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

A 39-year-old female enrollee has requested a breast MRI for an evaluation of her breast lump. Findings:  The physician reviewer found that the American College of Radiology guidelines state that the recommended imaging procedures for a palpable breast mass are a diagnostic mammogram in conjunction with breast ultrasound. This includes patients with dense breast tissue. Breast MRI is not performed instead of mammography, but is utilized as an adjunct to mammography and breast ultrasound. On breast MRI, normal breast tissue, benign findings and breast cancer can have similar enhancement patterns leading to the false positives. The American Cancer Society advocates for screening breast MRI in patients with a strong family history of breast cancer (two or more first degree relatives) or those patients with a personal or family history of BRCA mutation.  The American Cancer Society does not recommend screening breast MRI for patients with dense breasts.  Breast MRI for diagnostic purposes includes patients with a new diagnosis of breast cancer or those patients with suspected implant rupture.  According to the American Society of Breast Disease, an MRI should not be used to distinguish a benign from a malignant process or to preclude biopsy of a clinically suspicious lesion.  This patient has not had a recent mammogram, which is the first-line imaging study for palpable breast mass in patients over the age of 30.  This patient does not have a documented strong history of breast cancer. There is only mention of a positive family history, with no specific details.  There is no history of personal or family history of BRCA mutation. There is no history of recent diagnosis of breast cancer or suspected implant rupture. The requested breast MRI is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for a positron emission tomography (PET) scan for evaluation of his gastric cancer.  Findings:  Two physician reviewers found that PET scanning is a functional scan that generally appears to be more sensitive in the evaluation of cancer than routine CT scans. It is becoming widely used in such situations. It is important to identify the objective parameters prior to chemotherapy so that one can evaluate the effectiveness of the treatment with the passage of time. Often a CT scan is sufficient for this purpose however in this case the CT scan did not demonstrate the metastatic disease, so a pre-treatment PET scan is very reasonable and likely to be of real benefit in this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested a battery powered nebulizer for the treatment of her asthma. Findings:  The physician reviewer found that metered dose inhalers (MDI) are used to treat acute episodes of bronchospasm and are quite effective. Delivery of albuterol by MDI is as effective as delivery by nebulizer in adults with acute asthma attacks. Although for some patients, nebulizer may be preferred, MDI is a safe, first-line treatment. In the case of this patient, there is no documented indication for use of a battery powered nebulizer as opposed to an MDI. The patient is on Advair, which contains a long-acting beta-agonist. Furthermore, it appears her asthma is mild and intermittent and she does not experience severe or frequent attacks. Thus, there is no evidence in the record demonstrating the necessity of a battery powered nebulizer. The requested equipment is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for skilled nursing facility services for treatment of her cognitive deficits. Findings:  The physician reviewer found that the patient did not require skilled nursing care, and any additional services could have been provided safely at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a total right knee replacement for the treatment of her right knee pain. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that all conservative treatment options have been exhausted by this patient. More intensive physical therapy, a home exercise program, additional weight loss, change in nonsteroidal anti-inflammatory drugs (NSAIDs) and viscosupplementation are all possible therapies that have yet to be adequately trialed. Further, there is no evidence of advanced joint disease necessitating total knee replacement surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested photodynamic therapy used in conjunction with aminolevulinic acid hydrochloride for the treatment of her actinic keratoses. Findings:  Two physician reviewers found that the treatment of actinic keratosis can be achieved with both surgical and medical modalities. A commonly used treatment is surgical (i.e., cryotherapy). A study by Kaufmann and colleagues comparing photodynamic therapy to cryotherapy showed photodynamic therapy had inferior efficacy for treatment of non-face/scalp actinic keratosis. With regard to non-surgical treatment, topical medication such as fluorouracil is often used with good results. The submitted documentation does not establish the patient has received adequate trials of standard topical agents. Furthermore, the available published studies do not support the contention that photodynamic therapy is better than the standard therapies used in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for Procrit injections for treatment of her chronic myelogenous leukemia. Findings:  The physician reviewer found that Procrit is indicated for anemia associated with the use of chemotherapy for the treatment of non-myeloid malignancies. Thus, it is not indicated for use in patients with chronic myelogenous leukemia. In addition, Procrit is generally used to maintain a hemoglobin between 10 and 12 g/dl.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Flomax for the treatment of his prostatic enlargement. Findings:  The physician reviewer found that this patient has taken the generic drug as requested in the formulary, and it was not effective. The patient reports that Flomax has been effective. Flomax is a selective alpha-1 blocker, and Cardura is a non-selective alpha-1 blocker. Both drugs work, but some patients do not tolerate the non-selective blockers and do respond to the selective alpha-1 blockers.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Vicodin for the treatment of her pain.  Findings:  The physician reviewer found that the Model Policy of the Use of Controlled Substances for the Treatment of Pain notes that there are two key elements that are required in the responsible prescription of narcotics. The first is consultation. The physician should be willing to refer the patient as needed for additional evaluation and treatment. The second key element is review. Specifically, continuation or modification of controlled substances for pain management therapy should depend upon the physicians evaluation of progress toward treatment objectives. Objective evidence of improved or diminished function should be monitored. The Health Plan is advocating for an acceptable standard of care which requires that the patient see a specialist when considering chronic opiate therapy. This requirement is medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested the Real Time Continuous Glucose Monitoring device and transmitter for the treatment of his diabetes. Findings:  The physician reviewer found that continuous glucose monitoring systems (CGMS) are now accepted and recommended by informed health care providers that specialize in diabetes management.  There is evidence in the literature about the benefits of CGMS in adults and children, and the device is accepted in the medical community that specializes in management of diabetes.  The device is used in the management of the patient's medical condition, and there is no equivalent alternative. Therefore, the Real Time Continuous Glucose Monitoring device and transmitter are medically indicated for this patient with brittle, long-standing type 1 diabetes complicated by frequent hypoglycemic events. This equipment can alert the patient when a severe glucose excursion occurs during the unattended gaps, which may be asymptomatic and not detected by his standard hand-held monitor. The requested equipment will prevent the patient from progressing into a life-threatening condition, such as hypoglycemic coma or diabetes ketoacidosis. In the long-term, the CGMS might be able to better control this patients diabetes mellitus and prevent diabetes-related complications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a computed tomography angiography (CTA) to detect coronary artery calcium scoring (calcification) for an evaluation of his risk for coronary artery disease. Findings:  Two physician reviewers found that CTA for detection of coronary artery calcification is not an accepted screening or confirmatory test in this patient subset and is not a medically appropriate alternative for other conventional screening tests that are within the standard of care such as treadmill stress testing. CTA is also not a medically indicated substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary disease in this patient subset has not been shown to be superior to the standard treatment protocol in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that there is a lack of evidence in the literature to show that proton beam therapy would be superior to highly conformal photon beam treatments using intensity modulated radiation therapy (IMRT).  There is no randomized trial directly comparing the efficacy of protons and photons in treatment of clinically localized prostate cancer.  The study by Tromifov and colleagues performed a dosimetric comparison of 10 patients whose treatments was planned with protons and photon IMRT to a dose of 79.2 Gy. This study found that IMRT actually yielded better dose conformity. The study by Hall and colleagues showed that the treatment with proton may result in an increase in total body dose to the patient from neutron scatter beyond the acceptable limits and actually lead to a higher risk of second malignancies than treatment with IMRT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Protonix 40 mg twice daily for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression and provide excellent relief of symptoms, and the healing of erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Although inter-patient variability of the efficacy has been seen, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The Health Plans formulary alternatives have similar efficacy and side effect profiles to Protonix. Therefore, the Health Plans recommendation of a trial with the preferred PPIs including omeprazole, Prevacid and Nexium is medically appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The patient was not experiencing fever or any other neurologic symptoms. His conditions had not changed suddenly according to the notes provided. The patient was described as without distress. Other than fluid in his middle ear, the patients examination was unremarkable. He was prescribed oral pain medications and discharged after obtaining a normal head CT scan. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Epogen for the treatment of her end-stage renal disease. Findings:  The physician reviewer found that the patient in question does have ESRD due to PKD, but did require ESA therapy to maintain her hemoglobin above 10 g/dl initially. However, after ESA therapy was initiated, her hemoglobin remained above 12 g/dl, which is a concern for two reasons. First, there is no proven benefit in controlled trials for hemoglobin above this level. Second, studies suggest ESA therapy may increase deaths and non-fatal heart attacks, strokes, heart failure and blood clots when the hemoglobin goal is higher than 12 g/dl. Thus, the patient qualified for initiation of ESA therapy, but as long as the hemoglobin is above 12 g/dl, does not qualify for continued therapy. The patient does have documented adequate iron stores, including transferrin saturations consistently greater than 20%. Thus, once her hemoglobin falls below 12 g/dl, ESA therapy at a reduced dosage from that previously given would be indicated to keep hemoglobin in the target range of 11 to 12 g/dl. ESA therapy has the risk of worsening outcomes if the hemoglobin target is above 12 g/dl, thereby negating any potential benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested health and behavior intervention for the treatment of the enrollees Ehlers-Danlos syndrome. Findings:  The physician reviewer found that this patient has well-documented chronic pain that did not respond to standard therapies for pain. Based upon documentation submitted, the patients symptoms were significantly reduced during her stay. Meta-analysis reviewing behavioral therapy for chronic pain determined that it is a useful treatment in managing pain. Given the acute reduction of pain, health and behavior intervention was medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested biofeedback and self-care home management training with therapeutic (group) procedures for the treatment of the enrollees hypermobility and dysautonomia. Findings:  Three physician reviewers found that this patients history documents pain since the age of six, consistent with symptoms associated with Ehlers-Danlos syndrome. The patient has not demonstrated adequate relief with prior therapies. The reduction of pain during her inpatient stay demonstrates that these modalities have been of greater benefit than previously tried therapies. In addition, although there are no studies specific to Ehlers-Danlos syndrome, there are multiple studies demonstrating pain reduction with these modalities in other disorders, such as chronic pain and spinal cord injury. Biofeedback and self-care home management training with therapeutic (group) procedures were medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested orthopedic shoes and insoles for the treatment of his foot pain. Findings:  The physician reviewer found that there is well-established, generally accepted criteria for coverage of orthopedic shoes and insoles for diabetic patients. Medicare requires that a patient must have diabetes and have one of the following complications: peripheral neuropathy with evidence of callous formation, history of pre-ulcerative callous, history of previous ulcer, foot deformity, previous amputation of foot or part of foot, or poor circulation. According to the submitted records, this patient does not demonstrate any of these risk factors or complications. After careful review of the progress notes and the literature, the requested orthopedic shoes and insoles are not medically necessary for treatment of this patients medical condition. A finding of pes planovalgus with arch pain does not constitute medical necessity for diabetic depth shoes and diabetic insoles. Research on therapeutic shoes and insoles for diabetes demonstrates their ability to reduce amputation rates by accommodating biomechanical deformities and reducing shear and frictional forces. However, this patient does not have any of the indications for the requested equipment based on the records provided.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-month-old female enrollee has requested a cranial remolding orthosis for the treatment of the enrollees brachycephaly. Findings:  Three physician reviewers found that this patient has documented plagiocephaly with a CI of greater than 80%. The gold standard for treatment of brachycephaly and plagiocephaly with synostosis is cranial orthosis therapy. The studies by Graham, et al. and Teichgraeber demonstrate the benefit of orthosis therapy with brachycephaly. Although these studies showed there was not a complete resolution of the brachycephaly, there was significant improvement.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested MR guided high intensity focused ultrasound (MRgFUS) ablation surgery for the treatment of her uterine fibroids. Findings:  Three physician reviewers found that this patient has symptomatic uterine fibroids. Hysterectomy, myomectomy and now uterine artery embolization (UAE) are approved and supported in the medical literature as non-investigational treatments for uterine fibroids. While MRgFUS ablation of uterine fibroids is a promising therapy for the treatment of symptomatic fibroids, only short-term results are available regarding its effectiveness and safety. Long-term studies continue to examine the safety and long-term benefits of MRgFUS. At this time, there is not adequate data from which to conclude that MRgFUS of fibroids is likely to be more efficacious in the long-term than the alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested the medication Enbrel for the treatment of the enrollees acne fulminans and SAPHO syndrome. Findings:  The physician reviewer found that since SAPHO is a rare syndrome, no randomized clinical trials of treatment have been performed or are likely to be performed. The preponderance of evidence as shown by a review of the literature is in favor of the use of TNF inhibitors in this syndrome. In most case reports, infliximab has been used although Enbrel has also been used with good results. This patient has a severe and potentially disabling condition which requires aggressive treatment of both his skin lesions and bone pain, and he has already failed other treatments including cyclosporine. Many published case reports describe prompt and dramatic relief of pain with TNF inhibitors such as Enbrel. As such, the use of Enbrel in this setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested Vital Stim therapy for the treatment of the enrollees anoxic brain injury. Findings:  The physician reviewer found that in the medical literature there is relatively strong evidence that Vital Stim therapy is beneficial in the stroke population. The most recent randomized clinical trial is from Permsirivanich and colleagues who found superior improvement in patients treated with neuromuscular electrical stimulation in lieu of rehabilitation therapy alone. In addition, Christiaanse and colleagues documented the safety and benefit in children treated with Vital Stim when compared to standard therapy. The use of Vital Stim for this patient with cerebral palsy is medically indicated. The possibilities include potential removal of the tracheostomy with secondary improvement in saliva control, and/or removal of the G-tube with improvement in independence with feeding which would enhance life expectancy. Thus, the proposed Vital Stim therapy is medically appropriate and indicated for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of her articulation disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has had articulation difficulties since the age of two. The patient is a product of a twin pregnancy and motor and speech milestones have been consistently at the lower limits of normal. This would suggest that neuronal cerebral development was congenitally impaired, which occurs at a higher frequency in twin pregnancies compared with single births. The patient has been recognized as having significant speech articulation problems by his second-grade teacher and his resource teacher. A formal speech evaluation indicated moderate articulation deficiencies and the patients articulation is below that expected of a five-year-old. Although recurrent otitis media with associated recurring hearing impairment can impede the development of speech, it is probable that this patients articulation deficit is congenital and related to delayed cerebral maturation. Thus, the patient has a medical condition that is congenital in its origin. The paper by Goorhuis-Brouwer and Kniff reports that speech therapy is highly effective for the treatment of articulation disorders in patients with specific language impediment. The paper by Law and colleagues is a meta-analysis of 13 published reports over 25 years that notes the efficacy of speech therapy in improving speech development articulation defects in children. These articles relate that speech therapy is effective for the treatment of articulation defects. This patient has a congenital disorder that is readily treatable by speech therapy. Speech therapy is medically appropriate and indicated for the treatment of this patients articulation defect.