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

A 31-year-old transgender female enrollee has requested  facial laser hair removal for treatment of her gender identity disorder.  Findings:  The physician reviewer found that the removal of male pattern facial hair via laser surgery is necessary to create a normal appearance to the extent possible. As noted by Preston and colleagues, laser hair removal resulted in 77% satisfaction rate among study participants. These results are superior to satisfaction rates achieved with electrolysis or waxing. It is the consensus in the dermatology community that hair removal via laser surgery is more successful than any other method including electrolysis. As such, the proposed laser surgery is necessary to correct the presence of abnormal facial hair in this patient. Based upon the foregoing, the requested facial laser hair removal is considered reconstructive surgery as defined above and therefore is medically necessary for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested acupuncture for treatment of her corneal neuralgia.  Findings:  The physician reviewer found that in the medical literature, Shin and colleagues evaluated the safety and efficacy of acupuncture for ocular symptoms in dry eye patients. The authors reported that acupuncture may have benefits on the mid-term outcomes related to dry eye syndrome compared with artificial tears. However, the authors noted that verum acupuncture did not result in better outcomes than sham acupuncture. Despite this patients reports of temporary improvement obtained with prior acupuncture care, the requested additional acupuncture for the patients corneal neuralgia is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested radiofrequency ablation for treatment of her lung cancer metastasized to the liver. Findings:  Two physician reviewers found the medical records indicate the patient is currently symptomatic from her liver metastases, which has progressed while on crizotinib. Thus, the goal of her therapy is not to improve overall or progression-free survival, which is the usual endpoint in clinical trials of RFA, but to palliate her pain and improve quality of life. Moreover, second-line chemotherapy has a less than 10% chance of helping her with her pain. In comparison, the expected control rate of a metastatic liver lesion is up to 97% with RFA (Tanis, et al). Therefore, the request for RFA is likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested chiropractic care for treatment of her sciatica, lumbar spondylosis, and degenerative disc disease.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with low back and leg pain with MRI evidence of degenerative disc disease and disc bulges. The patients degenerative joint disease leads to mechanical and neurological pain from the discs and facet joints. In addition, the patient reports that a home exercise program and pain medications have not provided her with adequate pain relief. Applying the practice guidelines, this patient is an excellent candidate for treatment with chiropractic services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested authorization and coverage for fluoroguide for spine injections (lumbar/sacral) for treatment of his low back pain with sciatica.  Findings:  The physician reviewer found that in the medical literature, Vad and colleagues reported that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Botwin and colleagues found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. Rosenberg and colleagues noted that epidural steroid injections can offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis. An epidural steroid injection is indicated for pain associated with lumbar radiculitis/radiculopathy. Radiculitis is consistent with abnormal reflexes, straight leg raise, paraspinous tenderness and possibly motor weakness. This patients physical exam does not reveal these findings and there is no imaging demonstrating a disc bulge or nerve root compression. In addition, his pain and physical exam findings are not consistent with lumbar radiculopathy. Thus, the requested fluoroguide for spine injections (lumbar/sacral) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested i-limb prostheses by Norell Prosthetics for treatment of her quadrilateral amputations secondary to gangrene.  Findings:  The physician reviewer found that this patient does appear motivated to learn and adapt to the use of functional prostheses given her current state of dependence without prostheses. Treatment options include bilateral myoelectric prostheses, a myoelectric and body-powered prosthesis, or combinations that include hybrid prostheses (Behrend, et al). The records indicate the patient has either been provided upper limb prostheses that were malfunctioning, or she had a suboptimal therapeutic relationship with her treating providers. Functioning upper limb prostheses are appropriate and necessary for this patient to perform her basic activities of daily living. While some level of cosmesis is beneficial, optimizing function is the primary concern, especially since she is dependent for her care. However, there is inadequate published clinical literature demonstrating that myoelectric prostheses with i-limb terminal devices confer significant, marginal functional benefit in comparison to conventional myoelectric prostheses that are properly fitted for an individual patient. Further, the i-limb prostheses are expected to be less durable than a conventional body-powered or myoelectric prosthesis. For these reasons, the requested i-limb prostheses are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested occipital nerve stimulation for treatment of his headaches. Findings:  Two physician reviewers found that occipital nerve stimulation is not likely to be more beneficial for the treatment of the patients medical condition than other treatment modalities.  Per the peer-reviewed literature, anticonvulsant medications, antidepressants, beta blockers and triptans are considered to be safe and efficacious therapy for chronic headaches.   This patient presents with a more complicated picture of headaches than solely occipital neuralgia, and there is a paucity of peer-reviewed literature to support the requested services over standard therapy for chronic headaches.  Thus, the requested occipital nerve stimulation is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without dye for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the lumbar spine without dye.  The current medical evidence does not support the requested diagnostic procedure in this clinical setting.  There is no documentation that the patient has failed conservative therapy including anti-inflammatory medications, muscle relaxants, and physical therapy.  Additionally, physical examination does not demonstrate findings that would indicate that the patient is a candidate for surgery or an epidural steroid injection, including unequal reflexes or motor weakness.  All told, the requested MRI of the lumbar spine without dye is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested stereotactic body radiotherapy for treatment of his stage IV rectosigmoid adenocarcinoma. Findings:  Two physician reviewers found that the requested services are not likely to be more effective than other treatment options.  This patient has multiple sites of disease within the liver and in lymph nodes.  The current medical evidence has not demonstrated the superior efficacy of stereotactic body radiotherapy in this clinical setting.  There is some data supporting the use of stereotactic body radiotherapy in liver metastases from colon cancer with good local control and improvement in survival.  However, there is a paucity of published data on treating multiple sites of disease with stereotactic body radiotherapy.  Therefore, stereotactic body radiotherapy is not likely to be more beneficial than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Avastin and RU486 therapy for treatment of her malignant melanoma with metastatic disease to the lungs and liver. Findings:  The physician reviewer found that meningiomas are brain tumors arising from the dura mater of the brain. They typically grow slowly and are amenable to resection if pathologically classified as grade I. However, grade II and grade III meningiomas have higher proliferative rates and are usually only partially resected. Radiation therapy after complete surgical resection is the standard of care for atypical meningiomas based upon the available medical evidence (Jaaskelainen, et al). Systemic therapy is indicated for patients in whom surgical resection is not possible and in those with high grade disease. The medical evidence to support various chemotherapy agents is primarily comprised of observational studies (Newton). Since the disease is uncommon, one cannot expect rigorously designed randomized clinical trials confirming the use of chemotherapy. This patient has received the standard of care and the tumor has progressed. The patient is not considered a candidate for radiation treatment, which supports the use of systemic therapy. The patients provider has recommended combination therapy with Avastin and RU486. Therefore, the requested use of Avastin and RU486 in this patient is supported as appropriate and medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested gene test PCA3 expression test for evaluation of his elevated prostate specific antigen (PSA) and enlarged prostate.  Findings:  Three physician reviewers found that clinical studies have not demonstrated that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. If clinically indicated, repeating the biopsy or saturation biopsy may be useful if prior biopsies are negative. The records indicate that this patients enlarged prostate and elevated PSA levels was appropriately evaluated with biopsy, which was negative, and free PSA level monitoring. Consistent with these findings, the PCA3 testing provided to this patient was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested air ambulance transport services for evaluation of his medical condition. Findings:  The physician reviewer found that upon review of the submitted documentation, a prudent layperson would not have reasonably believed that the air ambulance transport services were urgently needed services. The patient was stabilized in a regional level III trauma center on the date of injury. Appropriate surgical treatment was available at this facility and follow-up care could have been coordinated. While the patient notes concerns about his aftercare, the evidence provided does not demonstrate that the patients health was likely to seriously deteriorate if he remained in the facility for treatment rather than returning to the state indicated so that he could be discharged to his home following surgery. Therefore, the air ambulance transport services were not urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a second gastric bypass surgery (lap band surgery) for treatment of her obesity.  Findings:  The physician reviewer found that revisional bariatric surgery for inadequate weight loss is a controversial topic with poor evidence to support the different approaches. There are several small case series describing outcomes of laparoscopic adjustable gastric band placement following failed gastric bypass. In general, these case series are small retrospective reviews with limited follow-up (Vijgen, et al). The American Society of Metabolic and Bariatric Surgery published a review on endoluminal procedures to induce weight loss following bariatric surgery that determined these procedures were well tolerated with limited efficacy (Dakin, et al). Approximately 10% of primary bariatric surgical procedures will fail, and most of these failures will present as weight recidivism. Most of these patients fail to maintain weight loss for reasons that are not surgically correctable (De Gara and Karmali). For the reasons provided, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested Remicade for treatment of his hidradenitis suppurativa.  Findings:  Three physician reviewers found that hidradenitis suppurativa (HS) is a debilitating inflammatory skin disease. Patients experience a significant reduction in quality of life and the need for new treatment modalities are urgent. In recent years patients with HS have been treated with TNF-alpha inhibitors, such as infliximab. Observational data, case reports, and the recent randomized, double-blind, placebo-controlled crossover trials demonstrated therapeutic efficacy. The patients HS has not responded to other therapeutic modalities. For these reasons, the use of infliximab is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested a bone growth stimulator for treatment of his Jones fracture of the fifth metatarsal.  Findings:  The physician reviewer found that a bone growth stimulator is not medically necessary for treatment of this patients medical condition. Although the patient has a Jones fracture, there is a lack of evidence of delayed healing as demonstrated by bone loss of 15 mm or less has no clinical signs or radiographic findings of delayed progress toward healing. This patients records indicate he has a non-acute left fifth metatarsal fracture with signs of progress toward healing. The most recent x-ray showed progressive union and the presence of new bone growth visible at the fracture site. Thus, the patient does not meet the Milliman Care Guidelines for a bone growth stimulator and the requested device is not medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested continued rehabilitative services for treatment of her multiple traumatic injuries. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The medical records indicate the patient has progressed well, making significant gains while in inpatient rehabilitation receiving PT, OT, ST and cognitive therapies. She no longer requires an inpatient setting and can safely receive continued therapies through outpatient programs. Moreover, the patients progress report assessed by her provider and therapists note the patient is appropriate for therapy in the outpatient setting. Therefore, continued rehabilitative services was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested surgical repair of discoid meniscus for treatment of his knee pain. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, the recommended conditioning physical therapy program and continued observation is medically appropriate for the management of the patients knee pain.  While MRI has revealed a discoid meniscus, it has not demonstrated any meniscal tears within the structure.  Discoid meniscus can be an incidental finding.  The medical literature documents that a discoid meniscus is more prone to tears but in the absence of MRI documentation of a tear and no more than small knee effusions, no documented instability, no flexion contracture and no specific meniscal signs, it is not likely to be beneficial for this patient to undergo a surgical exploration.  All told, the requested surgical repair of discoid meniscus is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested dosimetry collaboration  and intraoperative radiation therapy for treatment of her breast cancer. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other treatment options.  Accelerated partial breast irradiation is an acceptable treatment for select patients with early stage breast cancer.  Accelerated partial breast irradiation may be delivered using external beam radiotherapy, brachytherapy or intraoperative radiation therapy.  There is some support for accelerated partial breast irradiation delivered using intraoperative radiotherapy.  However, the current medical evidence has not established the superior efficacy of the services at issue in this clinical setting.  Thus, dosimetry collaboration provided on the date indicated and intraoperative radiation therapy provided on the subsequent date were not likely to have been more effective than other treatment methods.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested a full body positron emission tomography (PET) scan for evaluation of his pancreatic cancer.  Findings:  Three physician reviewers found this patient has known pancreatic carcinoma and mesenteric encasement. There is no report of a prior PET for staging. He has undergone chemotherapy and is being considered for resection. The records indicate the PET has been requested to evaluate the patient for distant metastases. The National Comprehensive Cancer Network (NCCN) guidelines acknowledge there is evidence PET with CT attenuation is valuable in the evaluation for distant metastases. For these reasons, the requested PET would be more valuable for this patient at this juncture than any other test available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Sovaldi with ribavirin for treatment of his hepatitis C genotype 2B.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has recently approved another drug for use in treatment of hepatitis C virus (HCV) infection which is sofosbuvir (Sovaldi), a nucleotide analog polymerase inhibitor. In addition, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) have crafted a nationally-recognized position paper that provides guidance on the recommended initial treatments for persons with chronic HCV infection who are naive to HCV treatment, as is the case with this patient. The patient has been recommended for HCV treatment, and thus AASLD/IDSA recommendations govern his present treatment alternatives. This treating provider has deemed the patient interferon-ineligible based on his aortic valve calcification. This is consistent with existing AASLD/IDSA guidelines that define a history of preexisting cardiac disease as grounds for interferon-ineligible status. Per AASLD/IDSA guidelines, the recommended regimen for HCV genotype 2 patients who are treatment-naive regardless of eligibility for interferon therapy is daily Sovaldi, and weight based ribavirin. In the absence of any other AASLD/IDSA recommended treatment regimens for this patients HCV genotype 2, the requested Sovaldi with ribavirin is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested individual therapy for treatment of her depression, anxiety and suicidal ideation.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients with depressive and anxiety disorders. Current practice is focused on aggressive treatment of mental health conditions, particularly in the acute phase of the illness in which weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Applying the American Psychiatric Association (APA) guidelines, although this patient is functionally impaired, there is no evidence of imminent threat due to her chronic symptom burden. The medical records indicate that she has been attending weekly sessions with some improvement. Further, the patient was planned to be treated with electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of mood disorders. Per the APA recommendation, treatment with electroconvulsive therapy should be adequate to determine a clinical outcome. In sum, individual psychotherapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested combination therapy with Sovaldi and Olysio for treatment of her hepatitis C genotype 1B.  Findings:  The physician reviewer found that with respect to the proposed combination treatment for this patient, once daily treatment with Olysio and Sovaldi, with or without ribavirin has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C, genotype 1, including patients with cirrhosis (Hagan, et al). In addition, the recommended combination regimen of Sovaldi and Olysio is consistent with the joint recommendation of the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) for treatment experienced hepatitis C genotype 1 patients who are interferon ineligible. Given this support, the requested Sovaldi with Olysio treatment regimen is medically necessary for treatment of this patients hepatitis C virus.