Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a computed tomography angiography (CTA) for an evaluation of his coronary artery disease. Findings:  Two physician reviewers found that this patient had known coronary disease, including prior coronary stenting and presented with symptoms suspicious of recurrent coronary ischemia. In this circumstance, standard and established care in the medical community includes stress testing to both identify and quantify any coronary ischemia present. Coronary CTA only provides a rough assessment of coronary anatomy and does not evaluate the functional significance of any stenosis identified. In addition, artifacts from coronary calcium and stents during coronary CTA can sometimes preclude an accurate quantification of stenosis severity. According to a study by Miller and colleagues, CTA has been demonstrated to be less accurate compared to invasive coronary angiography and has the disadvantage of not being able to perform percutaneous revascularization during the same procedure, if clinically indicated. Current guidelines that are endorsed by several national organizations also do not definitively consider coronary CTA angiography appropriate in this patients particular clinical situation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested emergency services for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe the patient was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had been experiencing mild to moderate cold/flu symptoms of one to two days in duration. The patients mother reported a fever, but it had resolved two days prior to the emergency department visit. The patient was not experiencing any shortness of breath or any vomiting. Her vital signs were normal and she was not in any acute distress. She did not require any medication in the emergency department or any prescription medications upon discharge. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Melphalan autologous stem cell transplant for the treatment of his multiple myeloma. Findings:  Two physician reviewers found that there is a scant amount of data available regarding a third autologous stem cell transplant in this setting. National Comprehensive Cancer Network treatment guidelines indicate limited support for repeat autologous stem cell transplant. Two references were submitted with this appeal. A review of the published peer-reviewed literature revealed no other relevant studies. The submitted report by Jourdan and colleagues involves two patients who received a third transplant. The reference by Rokicka and colleagues reported on the planned triple transplant treatment of 13 patients who were quite ill with their myeloma. They were given modified doses of the high-dose chemotherapy and seemed to demonstrate reasonable, although not very long, responses. These patients are not representative of this particular patient in terms of patient history or the planned treatment. Furthermore, this patient experienced a shorter period of disease control after his second transplant procedure than after his first procedure. As such, it is expected that the period of disease control (if any) would be even shorter after a third transplant procedure. Moreover, there is a substantial risk of mortality associated with a third cycle of high-dose chemotherapy. In conclusion, there is insufficient evidence that the requested Melphalan autologous stem cell transplant will confer any benefit in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a Bioness NESS L300 functional electric stimulator for the treatment of her myelomeningocele. Findings:  The physician reviewer found that the Bioness device has been recommended in this case to allow for greater knee flexion during gait. However, the Bioness device has not been approved for this indication. There is no peer-reviewed scientific literature documenting the efficacy of the Bioness device in this particular setting.  The device has not been prescribed for its FDA-approved use, which is for the treatment of foot drop. This patients gait dysfunction can be adequately addressed through the use of a traditional static AFO combined with muscle exercises. All told, the medical necessity of the Bioness device has not been established in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested acute inpatient psychiatric hospitalization for the treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted clinical information demonstrates that acute hospitalization was medically necessary in this patients case. The patient was admitted on an involuntary basis with a diagnosis of schizoaffective disorder. As of the date of admission, she continued to display psychotic, isolative and withdrawn behavior. This was noted in one of the treatment records which describes the patient as agitated, psychotic, responding to internal stimuli, with bizarre staring at the provider. She was also described as impulsive and unpredictable with poor insight and judgment, and unable to care for self. She was withdrawn and isolative with flat affect and was easily agitated. Thus, given the patients continued psychotic behavior, impulsivity, agitation and inability to care for self, she required continued acute inpatient services during the period in question. The level of care provided was clinically indicated and consistent with Level of Care Utilization System guidelines and American Psychiatric Association treatment guidelines for acute inpatient treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested growth hormone therapy (Genotropin) for the treatment of his Prader Willi Syndrome (PWS) and adult growth hormone deficiency. Findings:  Two physician reviewers found that while growth hormone (GH) tests may not be as useful in PWS as in other disorders because of the confounding effect of obesity in these individuals, the use of GH therapy is well established. As noted in the references, there is evidence that GH is an approved therapy to maximize stature in patients with PWS. The records provided for review show no evidence that this patients growth plates have closed which lends even more support to the contention that he is likely to benefit from GH therapy. All told, the use of growth hormone therapy for treatment of patients with PWS is a medically appropriate indication, and the patient is an appropriate candidate for continued therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested dermabrasion to remove milia for the treatment of his milia. Findings:  The physician reviewer found that this patient is requesting coverage for dermabrasion treatment of the milia on his nose. Milia are considered to be inclusion cysts in the upper layers of the skin. While this structure is abnormal, its presence is not due to congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Nor is the procedure being requested to improve function or create a normal appearance as this is a minor skin condition that does not significantly impact function or appearance. Given that the condition does not significantly affect appearance, it is unlikely that more than minimal improvement in the appearance of the patient would result. Furthermore, the use of dermabrasion for the treatment of milia is not indicated under general concepts of medical necessity. As documented in the medical literature (George and colleagues and Berk and Bayliss) dermabrasion is a procedure used to treat a minor skin condition that does not affect functioning or severely impact ones life. All told, the proposed procedure is not indicated from a medical standpoint.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 69-year-old female enrollee has requested Synvisc injections (right knee) for the treatment of her osteoarthritis. Findings:  Two physician reviewers found that repeat administration of hyaluronic acid (Synvisc) is a safe, effective and valid treatment alternative. In this patients case, her only alternative to viscosupplementation would be total joint replacement. Review of her history suggests that she is still highly functional and that she does not feel her quality of life is so compromised that total knee replacement is her only option. She ambulates independently and has up to 130 degrees of knee flexion, with apparently full extension. Synvisc injections are a conservative alternative to knee replacement and are medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested daily interferon injections for the treatment of his mesothelioma. Findings:  Three physician reviewers found that the role of interferon in mesothelioma has not been demonstrated either in the resected adjuvant therapy or in metastatic/unresectable disease. It is not FDA approved, compendium listed or recommended by any expert consensus panel for this indication. The meeting abstract submitted with this appeal is a report of retrospectively treated patients who underwent resection followed by interferon therapy at the treating providers facility. While this unpublished report does demonstrate longer survival, interferon therapy still needs to be researched in a controlled, prospective study with larger numbers of patients and long-term follow-up data reported. Therefore, the therapy remains of unproven efficacy and superiority in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested a PET/CT scan for an evaluation of his metastatic extra-adrenal paraganglioma. Findings:  Two physician reviewers found that the use of PET/CT for monitoring treatment response in patients with extra-adrenal paraganglioma is not supported by the peer-reviewed medical literature. This is a rare tumor, and thus has not been well-studied. There is inadequate outcome data demonstrating the utility of PET/CT in this particular setting. Given the paucity of available scientific evidence, there is insufficient data to support the conclusion that the use of PET/CT is likely to be more effective for the purpose of monitoring this patients treatment progress than standard diagnostic modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine. Findings:  Three physician reviewers found that This patient has had chronic intractable migraine. The most recent and largest (and therefore most likely valid) studies of Botox as migraine preventive show benefit in patients with chronic migraine, even with ongoing medication overuse. Thus, there is adequate evidence that Botox is useful in a subset of migraine patients. It is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventive therapies. This patient has had trials of standard preventives, without sufficient success. She has had ongoing benefit with Botox therapy, and thus, it can be concluded that Botox is likely to be of greater benefit than standard treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested debridement of extensive eczematous or infected skin (extensive peeling of the skin (code 11000)), pelvic ultrasound, transvaginal (code 76830), and prophylactic/therapeutic injection of estrogen (code 96372) for the treatment of her medical condition. Findings:  The physician reviewer found that this patient received a variety of modalities for menopause relief. In terms of her therapy with compounded injectable and implantable estrogens, the American College of Obstetrics and Gynecology states, The steroid hormones most commonly compounded include dehydroepiandrosterone, pregnenolone, testosterone, progesterone, estrone, estradiol, and estriol ..Most compounded products have not undergone any rigorous clinical testing for either safety or efficacy, and issues of quality assurance regarding the purity, potency, and quality of compounded products are a concern. There is no scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens.The ACOG Guidelines for Womens Health Care states Compounded bioidentical hormones are plant-derived hormones that are prepared by a pharmacist and can be custom made for a patient according to a physicians specifications. Most compounded products have not undergone rigorous clinical testing for safety or efficacy, and issues regarding purity, potency, and quality are a concern. In this case, the patient is receiving non-FDA approved injectable estrogen therapy (as well as pellet therapy), and there is no indication as to what other FDA-approved estrogen products and methods have been tried. FDA-approved products and methods include oral, transdermal patches, gels and sprays, as well as vaginal administration. These therapies have proven results and are more appropriate in this setting than the injectable estrogen therapy that was provided. In addition, there may be safety issues with exposing menopausal patients to very high levels of estrogen on a chronic basis. As to the pelvic ultrasound performed, there is no medical documentation of any indication for the scan. The question being raised that day was relating to incontinence and a question of a fistula between the bladder and vagina. There were no findings on the patients pelvic exam or history of present illness that would have been elucidated by an ultrasound. There are other methods to look for a fistula, such as instilling fluid with a dye into the bladder.  Thus, the ultrasound was not medically necessary. As for the debridement of extensive eczematous or infected skin (extensive peeling of the skin (code 11000)), the only indication of this procedure is a note that in August of 2007 she underwent a mesh repair. The submitted records do not document the actual performance of the procedure. Nor is there detailed information in the submitted records documenting the indications for the procedure. As such, the medical necessity of this procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested endovenous chemical ablation and sclerotherapy for the treatment of her varicose veins. Findings:  Two physician reviewers found that general practice standards in the specialty of vascular surgery dictate that symptomatic varicose veins and venous insufficiency warrants invasive treatment when there are documented complications or chronic symptoms that interfere with activities of daily living despite a trial of conservative therapy. In this case, following the endovenous ablation procedure, there is insufficient documentation of significant ongoing complications or chronic symptoms. Additionally, chemical ablation and sclerotherapy is generally utilized for the treatment of residual veins after other more invasive procedures. The patient has not yet been treated for greater saphenous vein incompetence below the knee. The safety and efficacy of chemical ablation and sclerotherapy for treatment of incompetence of the greater saphenous vein has not been determined as compared to standard treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in this patient population. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of several modalities including speech therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language. As noted by Volkmar, research has shown that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Children with autism have deficits in speech and language, as well as social communication. Speech therapists are equipped to handle the myriad of communication challenges that face autistic patients. As such, speech and language therapy is medically indicated, and two hours per week is appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested an augmentative and alternative communication device for the treatment of the enrollees autism. Findings:  Two physician reviewers found that a child must be able to understand and express language in order for an AAC device to be helpful (Rhea Paul). As such, the Health Plan criterion requiring that the patient have comprehension and expression of language equivalent at least to that of a five-year-old is appropriate and consistent with the standard of care. Based on this patients age and developmental delays, he does not meet this criterion. Furthermore, as the Health Plan indicates, a patient should complete two years of therapy without improvement before being considered for an AAC device. In the case of this patient, the submitted evidence demonstrates the patient has been experiencing modest improvement and does not appear to have plateaued. All told, the patient is not an appropriate candidate for an AAC device at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Protopic 0.03% for the treatment of her lid retraction prior to surgery. Findings:  The physician reviewer found that the prescribed use of Protopic for this patient was not medically indicated. There is no evidence in the medical literature that the use of Protopic prior to eyelid surgery in an attempt to loosen the skin is as good as or better than alternative medications or no medication at all. Since there is no literature suggesting that loosening the skin before eyelid surgery is beneficial to the outcome of surgery, the pre-operative use of Protopic for this non-FDA supported indication in this patient was not medically warranted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested a PET/CT scan for an evaluation of his medical condition. Findings:  Two physician reviewers found that in the radiology literature PET scans for use in the diagnosis of head and neck cancer are far more accurate than MRI or CT scans alone. It is important to keep in mind that the oral pharynx and base of the tongue are very difficult areas to image well with conventional exams. The fact that head and neck tumors are metabolically PET-avid gives a definite advantage to the use of PET in cases where there is a strong clinical suspicion of head/neck tumor. In this particular patient, there was a high clinical suspicion of tumor based upon physical exam and history. The PET/CT scan guided the patients subsequent biopsy and was appropriate to fully evaluate his medical condition which would not have been possible with conventional exams.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested two psychotherapy sessions per week for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the clinical documentation submitted does not support the medical necessity of twice per week psychotherapy sessions for the treatment of this patients medical condition. As noted in the American Psychiatric Association Practice Guidelines for patients with major depressive disorders, the frequency of visits in the maintenance phase is determined by the patients clinical condition. A review of treatment notes submitted indicate treatment interventions consisted of  cognitive restructuring and anxiety management with insight-oriented psychotherapy, empathic listening and interpersonal psychotherapy. Crisis intervention was not listed or checked as a clinical intervention. Additionally, there were no mental state examination findings reflecting high-risk symptoms or behavior. Furthermore, Otto and colleagues also note the benefits of combined psychotherapy and pharmacology for patients with chronic depression and thus, medication adjustment may be appropriate. All told, the submitted documentation does not demonstrate that the patient meets clinical indications for two psychotherapy sessions per week.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested Oasis Neuromonics Therapy for the treatment of his tinnitus. Findings:  Three physician reviewers found that tinnitus is a common condition which affects many patients with hearing loss. A small number of patients find the tinnitus severe enough to affect quality of life. To date, there has been no recognized consistently successful treatment for this condition. Neuromonics therapy is a recent attempt to treat this problem and may prove successful with future trials. Currently, outcome data is limited and there is insufficient evidence to be able to conclude that Oasis Neuromonics Therapy represents an effective treatment modality for tinnitus. Larger scale outcome studies need to be performed before Neuromonics therapy can be considered beneficial. At this point, it has not been demonstrated that the proposed therapy will result in greater improvement in the patients symptomatology than standard alternatives in this setting.