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

A 44-year-old male has requested coverage for Afinitor (everolimus) for treatment of his grade IV anaplastic astrocytoma.  Findings:  Three physician reviewers found that this patient is diagnosed with an anaplastic astrocytoma. He has undergone multiple treatments, including surgery, radiation therapy, and temozolomide.  His physician recommends treatment with pazopanib, phenylbutyrate, erlotinib, and everolimus. Everolimus has shown some efficacy in the treatment of renal cell carcinoma and pancreatic neuroendocrine cancers. In several benign central nervous system lesions, it has also shown evidence of benefit. There is no data available in the peer-reviewed medical literature to support the use of everolimus in the treatment of anaplastic astocytoma. In addition, when considering combination therapy, such as that recommended in this case, it is not possible to determine whether the agents may be agonist or antagonists to each others, as there are no studies demonstrating the efficacy of these medications in combination. Overall, there is no support for the use of everolimus the treatment of anaplastic astrocytomas, as has been proposed in this particular case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested coverage for past computed tomography angiography (CTA) of the heart for evaluation of his coronary heart disease.  Findings:  Two physician reviewers found that the patient has a history of HIV infection, dyslipidemia and coronary artery disease.  He underwent coronary stenting to the left anterior descending coronary artery six years ago after presenting with chest discomfort. Follow up coronary CT scanning two years later was reported to show 50% stenosis in the left anterior descending coronary artery with ostial stenosis and ulcerative plaque in the left circumflex treated medically. A repeat coronary computed tomography angiography (CT angiography) was performed two years later with a documented indication of coronary artery disease and stents.  There is also reference to chest discomfort.  In this circumstance of known coronary artery disease and prior coronary stenting, coronary CT angiography is not considered an accepted practice in the medical community. Coronary stents often create artifacts on coronary CT angiography that preclude an accurate assessment of potential in-stent stenosis. In addition, coronary calcium is more common in patients with coronary stenosis and the presence of significant calcium can also impair accuracy in quantification of coronary stenosis. If assessment of coronary artery stenosis is thought to be necessary then invasive coronary angiography is preferred, due to its improved accuracy relative to coronary CT angiography (Miller, et al.) and the ability to intervene with coronary revascularization during the same procedure, if clinically indicated. Current guidelines that are endorsed by several national organizations do not consider coronary CT angiography appropriate in patients with known coronary artery disease and prior coronary stenting (Mark, et al.)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female has requested coverage for panniculectomy, abdominoplasty, and rectus diastasis repair for treatment of her excess skin following gastric bypass surgery.  Findings:  The physician reviewer found that the overlap of the lower abdominal pannus as seen in the photographs and clinically documented would be considered an abnormal enlargement of the abdominal skin. Obesity can be considered a disease and would thus have led to the abnormal overlapping of the abdominal skin that worsens with correction of the underlying disease. In addition, the requested surgery is being performed to improve function and would create a normal appearance to the extent possible. The patients records from more than one provider describe the presence of functional problems as a result of the overlapping skin. The photographs support this as well. The functional problems documented include rashes, dermatitis, malodor and causing discomfort with physical activity. Each of these complaints is a known problem associated with an abdominal pannus following severe weight loss. The American Society of Plastic Surgeons (ASPS) has addressed this issue and noted that, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Based on the documentation provided, there is no evidence that the requested surgery is being performed solely to enhance the patients appearance. Instead, the records indicate the procedure has been recommended to improve functional problems for the patients lower abdominal pannus. However, applying the recommendations from the ASPS, the diastasis rectus repair as well as treatment of the upper abdominal pannus would not be expected to treat a functional problem. As discussed above, the photographs show that the lower abdominal pannus is significantly overhanging, while the upper pannus is not as significant. Attempts to treat the functional problems have been documented as well, including topical antibiotics, steroids and other creams. The patient has functional issues related to the significant lower overhanging tissue, which can be reliably treated with a successful panniculectomy. Moreover, a panniculectomy would offer more than a minimal improvement in the appearance. The photographs show a significant condition and a panniculectomy would be expected to adequately treat this condition. Based on review of the available records, the panniculectomy should be covered as the likely source of the patients functional impairment. Diastasis rectus repair and upper abdomen pannus would not create much of a functional deficit and therefore have not been demonstrated to be reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested reimbursement for residential care provided for treatment of the enrollees substance abuse.  Findings:  The physician reviewer found that based on review of the available records, this patient is a relatively healthy young woman with a history of chemical dependence. She was successful in her remission of alcohol dependence but subsequently has used opioids for the last two years while suffering from the loss of her father as well as a painful urological condition. The records indicate that the patient was already stabilized on Suboxone and had no acute medical or psychiatric instability at the time of admission. Applying the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM) treatment guidelines, patients such as this are typically managed safely and effectively in an intensive outpatient program (IOP) or partial hospitalization program (PHP) so they can reside in a near normative environment while dealing with chronic co-morbid problems. Given the patients previous successful remission and her lack of acute medical or psychiatric issues, the residential level of care services provided were not medically necessary for management of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  for residential substance abuse treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the RTC progress notes document that the patient was experiencing anxiety attacks. The notes indicate frequent anxiety and Lexapro was increased. The patients affect was described as appropriate with euthymic mood. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care criteria and American Academy of Child and Adolescent Psychiatry (AACAP), RTC was medically necessary given the patients significant functional impairment, history of failed treatment at lower level of care, and presence of co-morbid disorders impacting treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old female has requested coverage for 60 sessions of physical therapy, at a frequency of 3 to 5 sessions per week for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that accepted guidelines (Centers for Medicare and Medicaid Services) for continuation of physical therapy indicate that there must be documentation of significant progress toward goals as well as an expectation of significant progress in a reasonable period of time. The documentation provided by the patients physical therapist is inadequate to demonstrate that the patient has made significant functional gains throughout her physical therapy. The progress report provided does not document that the patient has met her six month goals. Further, no standardized testing or comparison to baseline data is documented in the records provided. In the absence of such documentation, there is insufficient evidence demonstrating that the patient is likely to benefit from continued physical therapy. Thus, based on the clinical documentation submitted, the requested 60 sessions of physical therapy at a frequency of 3 to 5 sessions per week is not medically necessary. The patient should receive 6 additional physical therapy visits to thoroughly train the family on a home program and then receive quarterly monitoring to assess progress or regression.  (This decision partially overturned the denial)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.   The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, behavior, socialization, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  The current medical literature supports the requested therapy in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female has requested coverage for group speech therapy services in a group of at least three children for treatment of her autism.  Findings:  The physician reviewer found that the patient is currently receiving one hour weekly of individual speech therapy. In addition to the individual speech therapy, the patients parent has requested group speech therapy in a group of at least three children. The requested group speech therapy would be considered an adjunctive therapy for the patient, as socialization and pragmatic speech would be the goals involved in group speech therapy. Although, the medical literature supports speech therapy in the autistic population, there is no evidence in the peer reviewed medical literature indicating that speech therapy provided in a group setting augments individual speech therapy. In this case, the patients parent has requested coverage for group speech therapy in a group of at least three children. There is no scientific data demonstrating that the requested service results in improved outcomes in this patient population as opposed to individual speech therapy alone. As there is no evidence in the available peer reviewed medical literature establishing the value of combining both group and individual speech therapy in the treatment of autistic patients, the Health Plans denial of the requested group speech therapy as not medically necessary was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested coverage for gastric bypass surgery or consultation for treatment of her obesity, high blood pressure, sleep apnea, and knee and low back pain.  Findings:  The physician reviewer found that while there is conflicting information in the records provided pertaining to the patients height, regardless of the height utilized, clinically severe or morbid obesity is not documented at this time as the patients BMI is less than 35, with her most recent medically documented weight of 199 pounds. Medical notes explaining the height discrepancy, as well as verification of the patients new self-reported weight of 212 pounds needs to be documented. Bariatric surgery for low BMI is currently undergoing evaluation in clinical trials; at this time, it is not considered standard of care. The results of these clinical trials have not yet been published. In sum, the efficacy of bariatric surgery for patients with BMIs below 35 has not been documented in the peer-reviewed medical literature. There is no medical reason for the patient to undergo a bariatric surgery evaluation at this time, as she does not meet the qualifications for bariatric surgery.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient presented to the emergency room with a facial rash which was minimally itchy but not noted to be painful. The patient was afebrile, and the rest of his vital signs were normal. The rash was described by the treating physician as occurring in two patches on the right side of the face, being slightly erythematous, and having a papular component. It was not thought to be cellulitis or impetigo. The patient was given a prescription for an anti-fungal cream and discharged to follow-up with his primary care physician. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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.Review of the submitted documentation does not demonstrate the presence of any signs or symptoms that would cause a prudent layperson to believe he or she was experiencing an emergency medical condition. There is no documentation of severe pain, high fever, or dysfunction of the eye or jaw associated with the patients rash. While the patients parent was concerned about the rash being infectious, this could have been addressed by consulting the patients primary care physician. A prudent layperson would not have thought this to be an emergency medical condition for which immediate medical attention was required.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male has requested past and future coverage for transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient was diagnosed with onset of depression approximately 4 years ago. He was treated with various selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI), antidepressant medications as well as aripiprazole. He reports limited response to oral medications and indicates that daily alcohol and cannabis use calm him. He reports reduced ability to work or enjoy past hobbies and sports. The patients medical history is significant for cardiac bypass surgery and he requires assistance with continuous positive airway pressure (CPAP) mask during sleep. Transcranial magnetic stimulation (TMS) was first introduced as a novel method of non-invasive stimulation of the brain. The peer reviewed medical literature evaluating the outcome of treatment consists of varying reports on the efficacy, especially with regard to the long-term effects and potential side effect profile along with case selection. Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous but continued trials are required to advance this treatment from the experimental phase into standard therapy. Further, Lam and colleagues reported that for patients with treatment resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the relative lack of systematic follow-up suggest that further studies are needed before TMS can be considered a first-line monotherapy treatment for treatment resistant depression. Gershon and colleagues summary also recommends ongoing systematic testing of this treatment modality. Thus, based on the paucity of scientific data supporting the efficacy and safety of TMS, its use in this patients care is not likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male has requested coverage for a past colonoscopy and prospective coverage for annual colonoscopies due to his personal history of colorectal cancer.  Findings:  The physician reviewer found that for patients with rectal or colon cancer, a colonoscopy is recommended within a few months after resection.  In this patients case, he underwent resection and had a follow-up colonoscopy five months later.  This colonoscopy was negative.  Additionally, it is recommended that patients have a repeat colonoscopy one year after primary resection of colon or rectal cancer to exclude new lesions.  In this patients case, he underwent a follow-up colonoscopy a year later.  This was medically indicated per the current medical evidence for follow-up for this patient with a history of sigmoid colon cancer.  However, since this colonoscopy was negative, the current medical evidence supports follow-up colonoscopy in three years.  If the colonoscopy performed at that time is negative, then the current guidelines support a colonoscopy every five years thereafter.  All told, the colonoscopy obtained a year after the original follow-up colonoscopy was medically indicated for the evaluation of this patient.  Per the submitted documentation, the requested annual colonoscopies are not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female has requested coverage for intensity modulated radiation therapy (IMRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that the patient has been diagnosed with invasive and in situ carcinoma of the right breast. The tumor measured 1.7 cm on mammogram. A biopsy demonstrated grade 1 morphology. The tumor was estrogen receptor (ER) positive, progesterone receptor (PR) negative. A breast MRI did not reveal additional lesions.  A segmental mastectomy removed a grade 2, 1.5 cm invasive ductal carcinoma (IDC) tumor with 3 cm of high-grade ductal carcinoma in situ (DCIS).  Margins of resection were clear.  All 8 lymph nodes that were dissected were negative for tumor spread.  The patient was seen in a radiation oncology consultation following surgery, and intensity modulated radiation therapy (IMRT) was recommended.  IMRT is not standard in the treatment of breast cancer, but can be considered in some special situations (i.e., left sided breast cancer with significant heart in the field, central axis separation of 25 cm or more, adjacent previously irradiated area, etc.).  A review of the records and the colored printouts of the two treatment plans (IMRT and 3D) for this patient was completed. The patient does not meet any exceptional criteria requiring the use of IMRT in this case. Additionally, the listed dosimetric criteria do not appear to be dose limiting in any way for the 3D conformal radiation plan, as is suggested by QUANTEC, and the incremental benefits with IMRT are marginal.  The majority of data supporting breast IMRT is actually field-in-field forward planned radiotherapy, and the great majority of the supporting literature restricts treatment to tangent only or tangent like beams.  The treatment technique recommended here is arc-based IMRT, delivering radiation from 360 degrees, which has the disadvantage of being more prone to error with respiratory motion and increasing integral dose to the adjacent organs compared to the tangent or tangent-like treatment referred to above. Arc-based IMRT is generally felt to be outweighed by its disadvantages and has little support in the literature for the treatment of breast cancer. In sum, the use of IMRT in this case is not likely to be more beneficial than an optimal 3D plan (virtual wedge or field-in-field).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male has requested coverage for a past  consultation/evaluation and transcranial magnetic stimulation (TMS) treatments for his depression.  Findings:  Two physician reviewers found that the patient has a history of major depression and anxiety. He has been having symptoms of depression and had been tried on psychotropic medications including Cymbalta, Sertraline, Zyprexa, Abilify, Seroquel, Celexa, Effexor, Paxil and Wellbutrin. The patient was recommended for transcranial magnetic stimulation (TMS) therapy following consultation with his provider. This patient had a BDI, HAM, and MADRS and his scores were 44, 32 and 40 before TMS therapy and were reduced to 34, 13 and 26 respectively. This patient presents with a diagnosis of major depression and anxiety that has been refractory to numerous medication trials of antidepressant medications. Given his failure to respond to more than one pharmacologic agent, he was recommended for TMS by his treating psychiatrist. In the peer reviewed medical literature, TMS is described as effective and safe for patients who have failed to respond to previous therapies with minimal, if any, negative side effects. In addition, TMS has been approved since 2008 by the Food and Drug Administration. Consistent with these data, the TMS therapy was clinically indicated since he had not responded to conventional medications or procedures for the treatment of his sustained depression.