Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested compounded Versapro (topical estradiol, progesterone, testosterone) cream for treatment of her vasculitis, severe menopause and Churg-Strauss syndrome.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There is a lack of evidence in the medical literature that show compounded hormones are safer or more efficacious than standard FDA approved and tested options. In fact, because of issues related to compounding, dosing is frequently inconsistent. This may actually increase the risk of such treatments. According to the American College of Obstetricians and Gynecologists (ACOG) Guidelines for Womens Health Care, 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. Moreover, according to the Journal of General Internal Medicine, natural or bioidentical compounded estrogen preparations are being promoted to consumers as safe alternatives to conventional menopausal hormone therapy and as health-promoting tonics. No reliable data support these claims. Natural hormones, including estradiol, estriol, estrone, and progesterone, can be expected to have the same adverse event profile as conventional menopausal hormone regimens. Finally, the record is unclear as to whether the patient is receiving progesterone therapy along with her estrogen. Being treated with estrogen alone (without progesterone) increases the risk of developing endometrial cancer. Progesterone delivered in a cream form has not been proven to decrease that risk. For the reasons provided, the requested Versapro (topical estradiol, progesterone, testosterone) cream is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested surgery (CPT code 29916) for treatment of his hip pain. Findings:  Two physician reviewers found that in this case, the services at issue were not likely to have been of greater benefit than other available treatment options.  Surgical treatment for femoroacetabular impingement syndrome is supported in patients who have minimal degenerative changes of the hip, no other explanation for pain, and whose radiographs or testing document cam impingement.  In this patients case, there was another explanation for pain in light of his buttock pain and positive straight leg raise with possible radicular complaints associated with his L5-S1 degenerative changes.  Additionally, on the date indicated, a magnetic resonance (MR) arthrogram of the right hip documented moderate degenerative changes of the right hip.  In this clinical setting, the superior efficacy of the services at issue has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 3-year-old male enrollee has requested social skills group therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that ABA therapy was introduced by Lovass in the 1970s. Multiple peer-reviewed controlled studies have established that ABA is the mainstay treatment for autistic children. However, variations in therapeutic approaches have evolved over the years. Some approaches may utilize a highly structured program (discrete trial) (Myers, et al.) while other approaches are less rigid and less structured. These less structured operant training ABA programs are referred to by various names including Incidental Teaching, Natural Language Paradigm, Milieu Teaching, and the Denver Model - all of which follow the childs lead in initiating learning events. There are conflicting opinions about the merits of the various ABA approaches. To date, there is inadequate evidence demonstrating that a single program is superior to any other program. While this patients parents report the patient showed significant improvement in the 6 month treatment program at the specified facility, there is no evidence such gains would not have been achievable in an ABA program that utilized a different approach. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested transcatheter arterial chemoembolization (TACE) for treatment of her breast cancer with liver metastases.  Findings:  The physician reviewer found that in the medical literature, TACE has been shown to decrease liver progression and overall survival rates in patients with hepatocellular carcinoma (HCC) with liver metastases from colon, neuroendocrine, and breast cancer. One study from Li and colleagues comparing the efficacy of TACE versus chemotherapy demonstrated an improved response rate for patients following treatment with TACE (37.5%) compared to only 10% with chemotherapy alone. A study by Martin and colleagues evaluated the efficacy of TACE with DEB in a subset of patients with metastatic breast cancer and reported a response rate of 58%. Given that this patients condition has progressed despite multiple rounds of chemotherapy, her cancer is considered chemoresistant. Since TACE has been shown to be safe and effective in this clinical setting, the requested therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-month-old female enrollee has requested anorectovaginoplasty and urethroplasty for treatment of the enrollees congenital adrenal hyperplasia.  Findings:  The physician reviewer found that the question of whether the recommended procedures are appropriate care cannot be answered definitively until the remainder of the diagnostic workup reveals the level of the confluence of the urethra and vagina as well as the adequacy of the vaginal canal. The lack of vaginal obstruction eliminates any time pressure on the surgery to improve the vaginal introitus and elongation of the urethra. Additionally, the proposed procedures can be performed after the age of six months without any deficit in outcome. The Health Plan indicates surgery can be arranged once the patient is evaluated and further workup (genitogram) is obtained. The recommendation of the Health Plan is consistent with medically reasonable and appropriate care of the patients CAH related anomaly. For the reasons set forth above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested power knee (non-formulary bionic knee prosthetic (L5859)) for treatment of his left transfemoral amputation.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested equipment. The power knee is intended to mimic lost proprioception and muscle function to help patients experience the advantage of reduced effort and unequaled stability. It accomplishes this by providing motor-powered swing phase, stance phase, and sit-to-stand propulsion. Microprocessor-controlled prostheses use feedback from sensors to adjust joint movement on a real time as needed basis. Active joint control is intended to improve safety and function, particularly for patients who have the capability to maneuver on uneven terrain and with variable gait. The choice of the most appropriate design depends on the patients underlying activity level. These devices are equipped with a senor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds. The requested prosthesis is indicated for this patient as there is a demonstrated need for long distance ambulation at variable rates, a need for regular ambulation on uneven terrain and regular use of stairs. Furthermore, this patients physical ability, including the ambulation at faster than normal walking speed and his adequate cognitive ability to master use and care requirements for the technology make him an appropriate candidate for this prosthetic. For the reasons provided above, the requested power knee is medically necessary for the treatment of the patients medical condition. Therefore, the requested equipment should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested methadone for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has displayed aberrant behavior with opioid medications, including the use of THC.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  If there is any indication of aberrant behavior, then opioids should be weaned off or discontinued.  The current medical evidence does not support the requested medication in this setting.  Baron and colleagues reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao noted that prolonged use of high-dose opiates might induce abnormal pain sensitivity and tolerance.  All told, methadone is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested the real-time heart monitor for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other methods of evaluation.  There is a lack of studies demonstrating the superior efficacy of the services at issue as compared to standard loop or event monitoring.  Real-time remote cardiac monitoring has not been subjected to rigorous medical outcomes analysis.  Real-time remote cardiac monitoring may be considered an appropriate alternative diagnostic modality for patients with recurrent, intermittent symptoms and non-diagnostic yield using standard event monitoring.  Based upon the current medical evidence, use of the real-time heart monitor was not likely to have been more effective than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Botox injections for treatment of the enrollee, who has a history of facial pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  He has a history of facial pain.  However, his distribution of pain is unusual for typical trigeminal neuralgia.  A trial of amitriptyline was not beneficial.  There are multiple additional medications that are used for management of neuropathic pain.  For patients with classic trigeminal neuralgia, carbamazepine or oxcarbazepine are noted to be first-line therapy.  The data regarding the use of Botox for trigeminal neuralgia has yielded mixed results.  Botox injections may be an option for patients with medically refractory trigeminal neuralgia.  However, in this patients case, the records do not demonstrate trials of other medications which may be beneficial in this setting.  All told, Botox injections are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 9-year-old male enrollee has requested 30 hours per week of applied behavioral analysis (ABA) therapy  for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. However, when reviewing ABA as effectively applied to autistic older children, teenagers and adults, there is limited literature substantiating its favorable effect on these populations. In this patients case, his progress with ABA therapy has been limited. It has been documented that he only responds to his name being called one-third of the time. The available progress reports indicate behavioral improvement, but at a relatively slow pace. The requested frequency of 30 hours per week of ABA therapy is usually directed toward younger children who are just initiating therapy. Other than developing social skills, there is a lack of significant ABA literature guidance applicable to older children. Typically, rather than continue ABA therapy exclusively, the tendency is to expand social and behavioral skills in groups and school settings. The patients school is starting to place him into groups as he is now in group speech therapy. Thus, the Health Plans authorization of 20 hours of direct ABA services is sufficient for the continuance of ABA services. The requested 30 hours per week of ABA therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested inpatient or residential treatment program for the enrollees oppositional defiant disorder and depression.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of residential treatment services. The above cited clinical guidelines and patient placement criteria have been developed to assist providers with the complex determination process of finding appropriate level of care for patients with inattention, impulsivity, substance use, disobedience, and mood symptoms coupled with strained and enmeshed family dynamics and budding characterological traits. In this case, the patient has failed treatment in the outpatient setting. Furthermore, his pathological complex demanded an acute admission and involvement from the legal system. Residential admission by a facility providing 24-hour supervised care and comprehensive multi-disciplinary services and evidence-based therapeutic interventions is necessary to assist with the patients recovery and a healthy second individuation. In conclusion, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested residential treatment services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested right knee arthroscopy for treatment of his right knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is medically necessary for this patient to undergo the requested right knee arthroscopy for treatment of a meniscal tear as evidenced on MRI. The patients records document the patient initially had a bone contusion. The patients course of treatment was appropriate consisting of strict non weight-bearing with use of a scooter. This treatment for the osteonecrosis was successful as documented in a subsequent MRI. However, follow-up MRI also demonstrated evidence of a meniscal tear. Consistent with current guidelines, the next step in treatment is the requested right knee arthroscopy for management of this patients medical condition. Therefore, the requested service is medically necessary for treatment of the patients right knee pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested ChemoFx Assay   for evaluation of her ovarian cancer.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the testing at issue in this patients case.  The medical records indicate a de novo presentation of stage IIIc ovarian cancer.  In this clinical setting, the standard of care is to offer optimal surgery followed by chemotherapy.  One of the first determinations to make in relapsed patients is whether the tumor is platinum sensitive or resistant, and the longer the treatment-free interval, the higher the probability of response to platinum chemotherapy.  The paclitaxel/platinum combination has proven to be superior over single agent platinum therapy in several clinical trials.  A thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials.  The current medical evidence does not support the testing at issue in this clinical setting.  All told, ChemoFx Assay provided on the said date was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Metadate CD for treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold-standard psychopharmacologic intervention for attention deficit/hyperactivity disorder.  Metadate CD is a brand name, bimodal stimulant drug which has been approved for the treatment of attention deficit/hyperactivity disorder.  There is a generic equivalent to this brand name medication called methylphenidate extended release, and it is available in either a capsule or tablet.  When a generic medication replaces a brand name, there is a possibility that there are differences in potency.  This likely explains why this patient has needed more milligrams of the generic compound as opposed to the brand name.  However, the current medical evidence does not support the requested medication in this clinical setting.  There is no evidence in the medical record that the patient has been unable to tolerate the generic medication, and he has not reached the maximum typical daily dose of methylphenidate extended release.  Further, the common practice of decompressing or augmenting the stimulant load with the addition of guanfacine has not been trialed.  All told, Metadate CD is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested laser treatment for his rosacea.  Findings:  The physician reviewer found that the patients condition does not constitute an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor, or disease. Further, the requested therapy is not being requested to improve function. Although the requested therapy is being requested to create a normal appearance to the extent possible, the records do not indicate that the requested procedure will likely result in a more than minimal improvement in the patients appearance. Therefore, the requested therapy is not reconstructive in nature for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested chiropractic treatment for her primary immune deficiency syndrome.  Findings:  The physician reviewer found that the records suggest that the treatment was for maintenance as this patient has had ongoing chiropractic treatment since last year in 2012. This patient continues to return with exacerbations of her pain. According to the American Chiropractic Association (ACA), this patient received palliative care. The treatment notes do not document any physical examination and re-examination as required, or any condition that warrants ongoing chiropractic care. All told, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested Lamisil for treatment of her onychomycosis.  Findings:  The physician reviewer found that the patients medical condition, onychomycosis, would be most effectively treated with oral Lamisil. The relative efficacy and safety profiles of this drug, compared to other systemic antifungal drugs, justify the choice of continuous terbinafine therapy in this case. Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Various treatment modalities including topical, systemic and surgical have been used for onychomycosis. Topical drugs are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include Lamisil, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis (Gupta and Cooper). Lamisil is a synthetic antifungal in the allylamine class and has fungicidal activity against dermatophytes, molds, and certain dimorphic fungi, as well as fungistatic activity against Candida albicans. Following oral administration, Lamisil is absorbed rapidly and reaches peak plasma concentration within two hours. Lamisil has been proven to be standard therapy of onychomycosis as it is very effective, well tolerated, and has a relatively low potential for drug interactions. Consistent with these findings, the requested medication is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested magnetic resonance (MR) spectroscopy for evaluation of his prostate cancer. Findings:  Three physician reviewers found that in this case, the requested services are not likely to be more effective than other modalities for evaluating this patient.  There is a lack of support in the current medical literature demonstrating that superior efficacy of MR spectroscopy in this clinical setting.  Currently, peer-reviewed studies are limited and have not demonstrated benefit over current protocols of active surveillance which rely on PSA testing, digital rectal examinations, and repeat biopsies.  All told, the requested MR spectroscopy is not likely to be of greater benefit than other available options in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested the less invasive selective dorsal rhizotomy for treatment of the enrollees spastic diplegia cerebral palsy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has spastic diplegia cerebral palsy, and prior treatment has included physical therapy, bracing, and Botox injections into the lower extremities.  Despite prior care, the patient continues to remain symptomatic.  Although there is some support in the medical literature for the less invasive selective dorsal rhizotomy, there is a lack of class I or II evidence demonstrating that the requested services are superior to the open procedure.  While postoperative deformity is of concern after selective dorsal rhizotomy, there is a lack of supporting literature indicating that the incidence is significantly decreased by the requested procedure.  All told, the requested less invasive selective dorsal rhizotomy is not medically necessary for the treatment of this patient.