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

A 60-year-old male enrollee has requested a Real-Time Remote Heart Monitor for an evaluation of his paroxysmal atrial fibrillation. Findings:  Two physician reviewers found that there is no evidence that this short period of continuous monitoring is more effective than either standard periodic Holter monitoring or patient-activated ambulatory event monitoring. Since this patient was symptomatic, a self-activated event recorder to record heart rhythms during symptoms would have been more appropriate for evaluation of this patient. Additionally, recognition of asymptomatic intermittent atrial dysrhythmias at this time should likely not change the treatment approach based upon current practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Botox injections for the treatment of her chronic headaches and fibromyalgia. Findings:  Three physician reviewers found that although Botox is indicated in certain severe, frequent, refractory cases of migraine headache it should not be considered a first-line therapy for migraine headache.  There is ample literature demonstrating the benefit of prophylactic medications such as beta blockers, calcium channel blockers, amitriptyline, and antiepileptic medications (among others) for preventing migraine headaches. The literature provided demonstrates standard practice parameters (and the quality of literature supporting the use of each medication) for various age groups. These articles also reference additional literature regarding this subject. It is not clear that this patient could derive better or even adequate results from Botox.  Furthermore, the long-term safety and effect of Botox in a patient with medical problems such as this patient are not entirely clear.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested repeat Supartz injections for the treatment of her left knee osteoarthritis and pain. Findings:  The physician reviewer found that in this patients case the only alternative to viscosupplementation may be total joint arthroplasty. Based on her physical finding of anterior cruciate ligament deficiency and her x-ray report of tri-compartmental degenerative change, she is not a candidate for less extensive reconstruction surgery such as osteotomy or uni-compartmental arthroplasty. Total knee arthroplasty in a young patient such as this patient would commit her to at least 1-2 future revisional procedures, assuming she has no co-morbid conditions that would decrease her life expectancy. A third course of viscosupplementation in this patient is medically necessary to maximize non-operative management and further postpone a bridge burning procedure such as total knee arthroplasty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment services for the treatment of the enrollees substance abuse and major depression. Findings:  The physician reviewer found that there is insufficient evidence to support the contention that the patient required residential treatment of his polysubstance abuse and behavioral disorder. The patient met criteria for outpatient/intensive outpatient rehabilitation at the time of his evaluation at an outpatient treatment facility, as documented in his evaluation. He was participating in treatment. The notes document that he was confronting issues regarding his willingness to stay drug free and sober.  According to subsequent notes, the outpatient facility was notified by the patients mother that the patient was readmitted to an inpatient treatment facility. There is no documentation of a recommendation from the outpatient facility that the patient be admitted to an inpatient facility, nor any documentation to suggest that the outpatient facility was recommending a higher level of care at that point. It is not unusual for patients to have some episodes of drug/alcohol use during the rehabilitation process, and it is not indicative that the patient will ultimately have a poor treatment outcome. Further, these episodes provide an opportunity for analysis during therapy of the triggers that led to relapse. The notes subsequent to that incident indicate that the patient was developing some insight into the triggers of this behavior. The readmission note to the inpatient facility states that the patient was attending a seminar and walked out of it, so his parents decided to have him readmitted. This does not constitute medical necessity for the readmission.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment services for the treatment of the enrollees substance abuse and major depression. Findings:  The physician reviewer found that this young man has a history of polysubstance abuse, difficulty with anger management and acting out, and depression. His admission was his first attempt at residential treatment. There was no documentation of any prior psychiatric evaluation or substance abuse treatment or failure of prior outpatient treatment before the first visit. There was no documentation of trials of psychotherapy or medication for the depression. Upon admission, the patient initially was somewhat resistant to treatment but then became more engaged in the process. The patient had progressed through some stages of treatment involving working on his relationships with his family, and the documentation suggests the patient was expecting to return home with his family in early July following their visit. The documentation at that time showed progress in regulation of mood and compliance. However, there was little documentation of targeted treatment of the patients substance abuse, or its relation to his other problems. The Plan stated that the patients condition was such that continued outpatient treatment was appropriate. I concur with the Plans assessment. This indicates that the patient was able to regulate and improve his behavior when motivated. Following the Plans denial, the patient became more hostile and uncooperative. He expressed anger at having been left there. Subsequently the patient did not respond well to treatment. He was subsequently removed from treatment by his parents. There is no evidence to support that residential treatment beyond the last authorized date of service was medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested infliximab (Remicade) infusions for the treatment of the enrollees recurrent inflammatory myofibroblastic tumor of the stomach. Findings:  Three physician reviewers found that myofibroblastic tumors are rare tumors in children. Surgical resection is the mainstay of therapy for these children. Because there are a limited number of patients with this disorder, the medical literature studying this type of case is limited. The use of Remicade therapy has been reported in the literature. This therapy is likely to be beneficial for this patient and may result in regression of the tumor, thus allowing for a resection.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for Leukine therapy for treatment of his metastatic melanoma. Findings:  The physician reviewer found that this interest was provoked by the study by Spitler and colleagues. Their study involved 48 patients with completely resected stage III or IV melanoma who were given adjuvant granulocyte macrophage colony stimulating factor. These patients appeared to have superior disease-free and overall survival when compared to historic controls. The small number of patients as well as the fact that this was not a randomized study has cast doubt on the validity of this data. A randomized controlled trial was launched, but the data are not yet available. At the present time, there is a lack of data to indicate that there is clinical benefit to the adjuvant use of Leukine therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Neumega (oprelvekin) for the treatment of her cholangiocarcinoma. Findings:  The physician reviewer found that Neumega is a growth factor used only in rare situations to prevent severe thrombocytopenia from chemotherapy. For the most part, it is used when a prior chemotherapy cycle has already been demonstrated to lower the platelet count severely, (i.e., in the 20,000 range). Such is not the case with this patient, as the lowest platelet count seen (at least reported in the provided records), was 83,000, which is considered a relatively moderate impact on the platelet count. Thus, there is no evidence that the Neumega is medically necessary to continue the chemotherapy in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested a sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that there is a large and growing number of publications pertaining to this procedure as discussed by Deitel and colleagues who determined that sleeve gastrectomy (SG) is a rapid and less traumatic operation than alternatives. Deitel continues that the SG procedure has thus far shown a good resolution of comorbidities and good weight loss if a narrower channel is constructed than for the duodenal switch. Nocca and colleagues obtained good results in patients with laparoscopic sleeve gastrectomy (LSG) in terms of both weight loss and morbidity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested biofeedback and hyperbaric oxygen therapy for the treatment of her headache. Findings:  Two physician reviewers found that biofeedback has generally been accepted as having efficacy in chronic migraine and tension-type headache (Nestoriuc, et al.). In this case, there is no documented diagnosis of either migraine headache or tension headache, and in fact, the etiology of the patient's headache is not documented. In addition, the patient had tried some prophylactic medications but not all groups of medications with efficacy in chronic headache have been tried, most notably the beta blockers. Further medication trials were warranted as it is likely that these may have been beneficial. Given the current diagnosis, it is not likely that the biofeedback would be more beneficial than standard treatments for the patient's condition. Oxygen has been demonstrated to be efficacious in cluster headaches only. Hyperbaric oxygen has been demonstrated to have no greater efficacy as compared to high flow oxygen alone in cluster headaches (Nilsson, et al.). This patient does not carry the diagnosis of cluster headaches and does not have any of the typical vasomotor symptoms typical of paroxysmal hemi-cranial headaches. Standard therapies to treat this patients symptoms include trials of different prophylactic agents. Such therapies were likely to have greater efficacy in this case than hyperbaric oxygen therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Potaba 500mg for the treatment of his Peyronies disease. Findings:  The physician reviewer found that treatment of Peyronies disease can be challenging. Oftentimes treatment consists of both surgical and medical treatment, with medical treatment being a good initial approach. Potaba, among other drugs, has been used with variable results. The recommended dose is as indicated by the patients treating physician. Since medical treatment of Peyronies disease is a good initial approach as indicated in the article by Trost and colleagues, Potaba is medically indicated for this patient for treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested hyperbaric oxygen pressurization for the treatment of his necrotizing fasciitis. Findings:  Two physician reviewers found that HBO therapy in a monoplace or multiplace chamber is an accepted treatment in this setting. Topical HBO is investigational, but this is not the program that was recommended for this patient. The proposed therapy has established efficacy and is likely to benefit the patient as he has a Wagners 4 ulcer which has failed to respond to conservative care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Neuromonics TRT treatment for the treatment of his chronic tinnitus. Findings:  The physician reviewer found that although there are anecdotal reports of benefit, the safety and efficacy of the Neuromonics Tinnitus Retraining (TRT) program has not been sufficiently established. Studies conducted to date have only involved a small number of subjects and these studies have been open. Given the paucity of data currently available, Neuromonics TNT cannot be considered medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested computer assisted orthopedic surgery on her left knee for the treatment of her left knee arthritis. Findings:  Three physician reviewers found that the use of computer-assistance devices is considered to be investigational, and is still being studied at this time. Orthopedic peer-review literature fails to support that the use of computer-assisted devices result in superior improvements or outcomes. Long-term studies are still needed before the use of computer assistance can be determined to be efficacious.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested for residential treatment for treatment of his major depressive disorder, oppositional defiant disorder and cannabis abuse. Findings:  The physician reviewer found that he manifested no suicidal or homicidal ideation or behaviors. He did not attempt to elope, and even when placed on precautions, there were not elopement behaviors. Medication management was uncomplicated as the patient tolerated the dosage increases and showed no side effects.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment for the treatment of the enrollees panic disorder without agoraphobia, polysubstance abuse and major depressive disorder. Findings:  The physician reviewer found that she required 24/7 professional supervision in a structured environment. This could not be accomplished at any lesser level of care. When discharged earlier, she clearly decompensated and endangered her life. The patient was demonstrating a pattern of severe impairment of psychosocial function. Of note, the patient was unable to attend school due to her psychopathology. This patient required residential care for the period at issue. Any attempt to provide lesser level care could have compromised the patients safety.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient went to the ED at the direction of her primary care physician for complaint of sore throat and cough of several days duration. She was having no difficulty breathing, and her vital signs were normal. At no time during her visit did her condition deteriorate to an unstable condition. Her vital signs remained normal. Her condition could have been safely treated in a physicians office. There is insufficient documentation in the medical record to support the necessity of a visit to the ED.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for the treatment of his prostate cancer. Findings:  Three physician reviewers found that prostate cancer needs to be treated above toxicity (which is possible with IMRT), especially in this patient who has previously received full dose radiation therapy to his prostate. He then developed recurrent disease in his pelvic lymph nodes which were treated again with high-dose radiation. This was re-treatment to the adjacent area with possible overlap with previous radiation field. The appropriate treatment in this kind of complex situation is only possible with IMRT. The recurrent disease in the pelvic lymph nodes is generally irregularly shaped with concave and convex borders. IMRT is the only way to deliver an adequate dose to target, and at the same time, avoid high dose radiation to the neighboring bladder, rectum, and bowels.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested emergency services for the treatment of her abscess and cellulitis in her hip. Findings:  The physician reviewer found that when this patient presented to the Emergency Department with a complaint of hip pain and cellulitis, she did not exhibit any signs of systemic infection and had no known co-morbidities. She had been on a course of medication as an outpatient and the infection had not responded to it. The patient was admitted with a diagnosis of abscess, but there is no documentation of abscess. There is no record of any incision and drainage. The patient remained afebrile while in the hospital. Her infection was 6 cm x 6 cm, which is small in size. The patient did not require inpatient therapy for this infection.  Her condition could have been managed as an outpatient with 24-hours intravenous antibiotics and discharge on the appropriate oral regimen.  She also remained medically stable when she began to exhibit signs of opioid withdrawal. There is insufficient documentation in the medical record to support this admission at an inpatient level of care. Furthermore, a prudent layperson with an average knowledge of medicine and health would not have thought their health was in serious jeopardy had he or she not sought immediate medical attention for his or her complaint of redness and swelling in the hip.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Humatrope 6 mg for the treatment of his multiple medical conditions.  Findings:  The physician reviewer found that Dercums disease is a very rare disorder about which little is known but seems to be associated with hormonal problems, especially of the thyroid, but not exclusively so. There is reported objective shrinkage of the lipomas with human growth hormone as well as partial ameliorations of the pain, depression, and other symptoms associated with Dercums disease. The submitted documentation confirms that the patient has benefitted from the growth hormone and a superior alternative for the disabling symptoms of the patients Dercums disease has not been proposed in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female has requested authorization and coverage for a continuous glucose monitoring machine for the treatment of her diabetes mellitus. Findings:  The physician reviewer found that the majority of insulin pump patients use continuous glucose monitoring systems episodically in order to change their insulin prescription because they have not reached their glycemic goal or are having frequent unexplained hypoglycemia or hyperglycemia. This is particularly important for patients who have hypoglycemia unawareness. In these situations, several 72 or more hour readings may be needed several times a year. More frequent continuous glucose monitoring would not be medically necessary for most patients. This patient is likely to benefit from using the continuous glucose monitoring machine two to four times per year for a few weeks.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested spine manipulation with anesthesia and nerve block injections for the treatment of her chronic low back and left hip pain. Findings:  Three physician reviewers found that there is a lack of scientific literature in the standard, recognized journals that are peer-reviewed supporting anesthesia for chiropractic mobilization/manipulation. Based upon community standards, the requested services are not indicated or appropriate for treatment of this patient. The patient is likely to experience superior results from the use of standard pain management modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested laser treatment for the treatment of her fibrotic lymphedema of the breast and chest. Findings:  Two physician reviewers found that there have been many proposed treatments prescribed and tried for severe secondary upper extremity lymphedema throughout the years, most of these with minimal to moderate satisfactory results. Low-level laser therapy for the treatment of lymphedema has been studied for several years and was cleared by the Food and Drug Administration in 2006 for use to help treat chronic lymphedema. Many patients respond differently to various treatments. When a treatment shows encouraging results, it should be pursued. It has been shown that low level laser therapy is safe and effective. Although long-term data are not yet available, this should not preclude use of this therapy in this case when there is documented evidence that the patient is responding with encouraging results. Low-level laser therapy certainly adds to our armamentarium for treating this debilitating consequence of cancer treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Taclonex for the treatment of her psoriasis. Findings:  The physician reviewer found that this topical medication (Taclonex) has already demonstrated efficacy where others have failed, its coverage is reasonable and medically necessary. Taclonex is a safer option for this patient relative to systemic therapies which would be warranted with the extent of her psoriasis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The wife of a now deceased male enrollee has requested an extension of the skilled nursing facility (SNF) stay for physical and occupational therapy services for the treatment of the enrollees acute renal failure and multiple myeloma. Findings:  The physician reviewer found that the patient was functionally impaired on admission to the SNF. The skilled care he needed was to restore function. Skilled rehabilitation services are appropriate for patients with the functional capacity to participate and benefit from the services. Dialysis patients certainly can benefit as this patient demonstrated. Functional capacity, not diagnosis, determines benefit. Clearly, the patient progressed in a clinically appropriate and expected manner.  The services were ordered appropriately and provided appropriately. The skilled rehabilitation services were best provided on an inpatient basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested Rozerem for the treatment of her insomnia and nemaline myopathy. Findings:  The physician reviewer found that Rozerem showed few side effects and was unlikely to prove habit forming (Griffiths and Johnson). Ambien, Ambien XR, and Lunesta have a large number of well designed clinical trials that show both effectiveness and safety given appropriate clinical monitoring for untoward effects. It is reasonable for the Health Plan to recommend these agents as preferred agents, given their proven track record of safety and efficacy. Rozerem certainly has its own set of benefits, but none that are specifically required to be used in this patients case.