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

A 59-year-old female enrollee has requested deep brain stimulation for the treatment of her pain. Findings:  Two physician reviewers found that this patient is status post stroke with resulting right-sided weakness. She now has burning pain on the right side of the body that is not helped by any usual methods of treatment. She has requested coverage for deep brain stimulation. The Health Plan has denied this request, and this is the subject of the appeal. This patient has exhausted standard therapy for her pain. Deep brain stimulation has been used and has some efficacy, but also has significant failure, as noted in the scant literature about this condition. It is medically reasonable and appropriate to perform deep brain stimulation for this patients thalamic pain, as there is a lack of other options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine for an evaluation of his pain and osteoarthrosis. Findings:  The physician reviewer found that the patient clearly has a chronic set of symptoms which must have prompted the thoracic spine radiographs three years ago. The documentation in the medical record does not note any symptoms that would suggest a focal lesion that would require MRI for diagnosis (i.e., spinal tumor, epidural abscess, fracture, etc.). Further, the physical examination notes do not reveal any focal findings that would suggest a focal lesion. The Health Plans guidelines for the indications for MRI of the thoracic spine are consistent with good standards of medical practice. In addition, positive MRI findings are common, even in patients who are without symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested Orthovisc injections to the right knee for the treatment of his right knee condition. Findings:  Three physician reviewers found that the available medical literature reveals no evidence that Orthovisc injection is considered a viable treatment alternative for a diagnosis of chondromalacia. The proposed therapy remains of unproven efficacy for the patients diagnosis. There are standard therapies available which would be more appropriate for use in this setting than Orthovisc.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested the medication Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has uncontrolled diabetes mellitus type 2. It is reasonable and medically necessary for the patient to be treated with Byetta in addition to metformin. As noted by Nathan and colleagues, Byetta is indicated for the treatment of diabetes mellitus type 2 in combination with metformin. This patients endocrinologist has made the medical decision to add Byetta to this patients regimen based on their doctor-patient interaction. There is evidence that this patient was receiving Byetta in 2008, so this appears to be a continuation of therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Boniva for the treatment of her osteopenia. Findings:  The physician reviewer found that this patient has the diagnosis of osteopenia and therefore has a risk for osteoporosis. The Health Plan provides coverage for a bisphosphonate. Fosamax is effective in the prevention of osteoporosis as well as vertebral, nonvertebral and hip fractures in patients at risk for this condition. Fosamax is within the standard of care. The proposed alternative, Boniva, offers no better efficacy than Fosamax and furthermore has been shown to be ineffective in reducing hip fractures. Therefore, Boniva is not medically necessary for this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for a bunionectomy on her left foot for the treatment of her bunion. Findings:  The physician reviewer found that the submitted medical records reveal no documentation of conservative treatment options. Although the radiographic findings are not above the minimum acceptable values for surgery specified by the Health Plan, if the bunion is chronically painful and fails to respond to conservative treatment (i.e., oral non-steroidal anti-inflammatory drugs, physical therapy, steroid injections, orthotics and immobilization), then a bunionectomy would be medically necessary. Therefore, the patient should undergo a trial of the above mentioned conservative measures; if these measures fail to provide relief, then the requested bunionectomy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Provigil for the treatment of her fatigue secondary to multiple sclerosis. Findings:  The physician reviewer found that this patient has a diagnosis of relapsing-remitting multiple sclerosis (RRMS) with severe fatigue, a common and disabling condition in this patient population. She has reportedly tried other medications for this condition but experienced excessive negative side-effects. Provigil has apparently been beneficial and tolerated in the past, resulting in an improved quality of life. A thorough literature review demonstrates that Provigil is commonly used for RRMS-related fatigue, and can be of benefit. In this patients clinical situation, Provigil is reasonable and appropriate for treatment of her RRMS-related fatigue, and should be covered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-month-old male enrollee has requested a molding helmet for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that this patient has brachycephaly with a minimal amount of plagiocephaly. He has failed standard treatment recommendations for positioning and tummy-time. The measurements taken of his head revealed a cephalic index of 97.5%, much greater than the norm, and clearly representative of significant brachycephaly. Based on the guidelines, a molding helmet is medically necessary and appropriate for this infant to prevent future complications and permanent deformity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her major depressive disorder. Findings:  The physician reviewer found that psychiatric inpatient hospitalization was not medically necessary for this patient. She did not pose imminent risk to herself or others. She was not manic, psychotic or aggressive. There was no evidence of intoxication or withdrawal. She was not gravely disabled. Thus, based on American Psychiatric Association guidelines, the patient no longer required an acute inpatient level of care as of the last authorized date of service. She could have been treated safely and effectively in a less intensive treatment setting such as partial hospitalization.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested bilateral arthroereisis HyProCure implant surgery for the treatment of the enrollees talipes valgus. Findings:  Two physician reviewers found that because of the evidence provided, bilateral arthroereisis HyProCure implant surgery was likely to be more beneficial than standard aggressive debilitating rear-foot surgery for this patient. Scientific evidence demonstrates that the implant is non-aggressive, reversible and efficacious.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for Revlimid for treatment of her Non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Revlimid is a newer derivative of thalidomide. It has been approved for use in MDS as well as multiple myeloma and is being very actively studied in Non-Hodgkins lymphoma. Included for review is a reference to the paper by Wiernik and colleagues. In his report, 49 patients with aggressive lymphoma, all heavily pre-treated, were treated with Revlimid. Of these patients, 53% had diffuse large B-cell lymphoma (the same lymphoma this patient has) of which 35% had a response, with 12% being complete responses. The median duration of response was six months. Considering the degree of their pre-treatment, these data were felt to be quite good clinical results. Tempescul and colleagues have also reported a complete remission in a patient with heavily pre-treated mantle cell lymphoma.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for the treatment of her uterine fibroids. Findings:  Two physician reviewers found that this patient is clearly symptomatic from her fibroids and requires treatment. Hysterectomy, myomectomy, and now uterine artery embolization (UAE) are approved and supported in the medical literature as non-investigational treatments for symptomatic fibroids. MRI guided high intensity focused ultrasound ablation is a promising treatment for symptomatic fibroids. Short-term studies suggest it is safe and effective. However, studies are still underway to determine the procedures long-term safety and efficacy. At this time, there is not adequate data from which to conclude that MRI guided high intensity focused ultrasound ablation of fibroids is likely to be more efficacious in the long-term than the alternatives mentioned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Atlas Orthogonal Chiropractic Technique for the treatment of her cervical and thoracic spine deviation and spondylitic changes. Findings:  Three physician reviewers found that the chiropractic treatment at issue is not likely to be of any greater value for treatment of the patients condition than any available standard therapy. The records provided reflect the chiropractic services the patient received but the results are not impressive. The technique at issue, the Atlas Orthogonal Chiropractic Technique is only practiced by a handful of chiropractors and is not supported in the clinical literature as safe and/or effective. This patients examination and diagnostic findings are consistent with an arthritic spine. There is no indication why this patient could not be treated with the proven chiropractic techniques available for treatment of her condition. The requested technique offers no proven likelihood of additional relief greater than traditional chiropractic manipulation. The Cochrane Library Database and the Agency for Healthcare Policy and Research do not document that the Atlas Orthogonal Chiropractic Technique is any more effective than any other traditional chiropractic manipulative technique.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has been diagnosed with autism. By the age of seven, he has only vocalizations without understandable speech. However, he can carry out fairly complex commands indicating some degree of learning potential. His pediatrician has prescribed speech therapy. The speech therapist elected not to attempt to fully assess the patient until she had developed some understanding of his speech dysfunction. This did not constitute a failure to perform adequate pre-treatment evaluation, as it was well-established that the patient is aphasic. The plan of action with goals was a well-established program for speech therapy as noted in the article by Goldstein. Myers and colleagues state that most children with autistic spectrum disorder can develop useful speech, and chronological age, lack of prerequisite skills, failure to benefit from previous language and IQ scores should not exclude a child from receiving speech and language services. This patient has a five-year history of profound speech delay, and he does not need an extensive evaluation each time a speech therapy program is initiated. Speech therapy was and is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested breast magnetic resonance imaging (MRI) with computer-aided detection (CAD) for an evaluation of her medical condition status post lumpectomy. Findings:  Three physician reviewers found that the appropriate imaging studies for patients with breast pain are mammography and/or breast ultrasound. If there is an indeterminate finding on conventional imaging or physical exam, then breast MRI can be useful, as noted by the American Society of Breast Surgeons. The breast MRI study performed was done for diagnostic purposes for evaluation of left breast pain and not for screening purposes. There is no documentation of a recent mammogram or breast ultrasound prior to the MRI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Actiq for the treatment of her pain. Findings:  The physician reviewer found that Actiq is approved by the Food and Drug Administration for use in cancer pain patients, and the package insert specifically states its use is to be limited to cancer pain only. There are no randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are only case series and individual case reports in the literature. Its effectiveness in non-malignant pain has not been proven in randomized controlled trials. Simon noted that studies regarding the use of rapid-onset opioids in chronic, non-cancer pain that also measure patient function are needed. There are no prospective, randomized controlled studies of Actiq in abdominal pain. Additionally, this patient does not demonstrate any improvement in VAS scores while on opiates, which suggests that she is non-opiate responsive.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that this case involves a patient with severe headaches refractory to multiple standard first-line therapies for migraine headaches. In addition, she has a contraindication to other standard first-line therapies given her co-morbidity of asthma. Although Botox is not a first-line therapy for headaches, there is ample literature demonstrating its use for chronic headaches and it is a very good second-line therapy. Since this patient has failed multiple attempts with other more standard medications, the medical use of Botox in this particular case is indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested bilateral hip resurfacing (using Conserve Plus) for the treatment of his bilateral hip osteoarthritis. Findings:  The physician reviewer found that the requested hip resurfacing procedure using Conserve Plus is currently not FDA-approved. The differences between Conserve Plus and the 2 approved hip resurfacing implants (Birmingham and Cormet implants) are minimal and their track records are comparable. However, given the patients advanced age, his condition is more appropriately treated with a traditional large metal-on-metal type implant than hip resurfacing with the Conserve Plus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested Xifaxan for the treatment of her small intestine bacterial overgrowth. Findings:  Two physician reviewers found that while Xifaxan has been used quite often for small intestinal bacterial overgrowth (SIBO), the primary support for its use is literature promoted and supported by the manufacturer of the medication. Before Xifaxan, SIBO was successfully treated with a number of other regimens such as Bactrim with Flagyl. The conclusion of a study by Di Stefano, et al. is that Flagyl is more effective than rifaximin for the treatment of SIBO. Unless this patient has an allergy to all the other standard medications used in the treatment of SIBO (which is not documented in the submitted medical records), there is no evidence that Xifaxan is more effective in this setting than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Lipitor for the treatment of his coronary artery disease. Findings:  The physician reviewer found that this particular patient has been on Lipitor for two years with efficacious control of his hyperlipidemia. Lipitor was previously authorized by the Health Plan for treatment of this condition. It would not be medically appropriate to require the patient to switch statins at this point in time given the goods results he has achieved with Lipitor without any documented adverse effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested continued hospitalization for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient had no suicidal or homicidal ideation or psychosis on admission. She was not in medical jeopardy due to her eating disorder such that she required a 24-hour treatment milieu. She did need detoxification from various substances and required chemical dependency treatment but she could have reasonably been treated at a lower level of care such as chemical dependency rehabilitation treatment for her addiction. American Psychiatric Association guidelines support chemical dependency treatment for this patient as a first-line of treatment in lieu of 24-hour inpatient hospitalization.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested consultation and treatment with a neurologist that specializes in autonomic neuropathy for the treatment of her autonomic neuropathy. Findings:  The physician reviewer found that the submitted clinical evidence does not support the need for further neurologic evaluation with a specialist in autonomic neuropathy. The records provided indicate that the patient has had vague and continuous dizziness for years. Mild dysautonomia has been diagnosed clinically, supported by tilt table test results. Extensive testing has otherwise been unrevealing. Depression has been diagnosed, and the patient has not been responsive to standard therapies. A psychiatric evaluation would be more appropriate in this setting than further neurologic testing or consultation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the request for speech therapy is medically necessary. Since plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, it can be utilized to improve overall neurologic health. Specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. As such, the requested speech therapy is medically necessary for treatment of the patients medical condition. Regarding the requested occupational therapy, just as with speech therapy, occupational therapy can also be used to help induce brain plasticity in an attempt to retrain neural circuitry. Occupational therapy is medically indicated along with speech therapy to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities. This multimodal approach will allow the patient to derive therapeutic benefit. Therefore, I have determined that the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Botox injections for the treatment of her cervical dystonia. Findings:  The physician reviewer found that this patient has long-standing cervical dystonia with contraction of her posterior cervical muscles, sustained head tilt and a response to initial treatment with Botox documented in the medical records. The medical literature supports the use of Botox for cervical dystonia. There is sufficient evidence of the efficacy of Botox in this patient population to justify its use in this case. This patient has received Botox in the past with reported benefit. Thus, Botox is medically necessary and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested intraperitoneal heated chemotherapy for the treatment of her metastatic adenocarcinoma of the appendix. Findings:  Two physician reviewers found that the primary role of intraperitoneal heated chemotherapy has been in the setting of optimal debulking of peritoneal surface malignancy. There is mounting clinical experience in the literature with intraperitoneal heated chemotherapy without debulking for recalcitrant malignant ascites. The cited studies show that there have been excellent results with intraperitoneal heated chemotherapy without debulking in eliminating ascites. Because the volume of this patients ascites is so high that the patient becomes dehydrated with paracentesis, there are no other effective options for this patient. Given the absence of viable alternative therapies in this setting, the use of intraperitoneal heated chemotherapy is medically reasonable and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. She has a BMI of 64, and the pathophysiology and the surgical outcome of this patient population is very well-defined. This patient needs to get down to a weight of 189 pounds for her BMI to be 30. This represents a weight loss of 222 pounds. The best outcome for this patient with the Roux-en-Y procedure would be a weight loss of 144 pounds (65% of 222 pounds). At 267 pounds, she would still be morbidly obese with a BMI of 42. From an outcome point of view, the duodenal switch procedure achieves superior results in this patient population. The requested duodenal switch operation will likely have a better outcome for weight loss and result in the resolution of this patients co-morbid conditions. Duodenal switch bariatric surgery is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Botox injections for the treatment of her muscle spasms. Findings:  Two physician reviewers found that this patient has severe idiopathic torsion dystonia and has required multiple drug therapies and hospitalization. This patients symptoms are currently not well-controlled despite standard first-line care and multiple medication use. There is an abundant amount of literature citing the benefit of Botox for dystonic conditions. This patient will likely benefit from a trial of Botox. Botox therapy is considered a second-line therapy and is the standard in refractory cases such as the one presented here.