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

A 57-year-old female enrollee has requested Reclast injections for the treatment of her medical condition. Findings:  The physician reviewer found that the medication has been granted FDA approval for the treatment of postmenopausal women with osteoporosis, and men with osteoporosis, as defined by a T score of less than -2.5, as well as for the prevention of osteoporosis while on glucocorticoid therapy and Paget's disease. It has not been approved for the prevention of osteoporosis. This patient did not meet the criteria for Reclast treatment under the FDA label.  Nor was the off-label use of the drug medically necessary as there is no evidence that other causes of bone loss were ruled out or that the patient had adequate vitamin D levels. A consultation with a specialist in osteoporosis for further evaluation would have been the next appropriate step for this patient rather than proceeding with Reclast therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee has requested  for tongue thrust therapy for treatment of her tongue thrusting/speech impairment.  Findings:  The physician reviewer found that Karacay and colleagues stated that tongue thrust usually develops in the presence of anterior open bite in order to achieve anterior valve function. As noted by Frasier, while it is frequently described as tongue thrust swallow, it is generally thought to be less associated with the act of swallowing and more the resting posture of the tongue. In this way, it either contributes to, or is the consequence of, the development of malocclusion. Myofunctional therapy is often prescribed in the orthodontic community to correct tongue thrust, but the recent literature is inadequate to demonstrate definitive improvement as concluded by Cayley and colleagues. The documentation does not demonstrate that the patients tongue thrust is the cause or result of a medical problem.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for a positron emission tomography (PET) scan for evaluation of her pheochromocytoma. Findings:  Two physician reviewers found that MIBG imaging is generally a well-accepted and accurate method of evaluating pheochromocytoma. A PET scan can sometimes find lesions that MIBG exam does not. The current standard of practice would be to perform the MIBG exam as the first line of imaging.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Leukine for treatment of her stage III metastatic melanoma.  Findings:  Two physician reviewers found that Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a cytokine that stimulates the production of a variety of immune cells. Relevant to melanoma, it is believed that GM-CSF stimulates the production of dendritic cells which are important in presenting antigen to the immune system. Since an early study in 2001, GM-CSF has been studied in melanoma. As noted in the appeal, Daud and colleagues gave GM-CSF, as an adjuvant to 42 patients mostly for the purpose of studying the impact on their immune system. At the time of analysis, 16 patients had relapsed but the authors felt the overall survival was greater than would have been expected from historical controls. On the other hand, Faries and colleagues reported on a randomized study wherein 95 patients were given a melanoma vaccine with or without GM-CSF. Unfortunately, the group receiving the GM-CSF had earlier recurrences than the group that received only the vaccine. Overall survival was thought to be adversely affected by the GM-CSF. In his letter, the patients provider states that the Mayo Clinic believes interferon is inferior to GM-CSF but that contention is not supported by the available medical literature. There is an ongoing randomized study of GM-CSF as an adjuvant in melanoma (ECOG Study), and until that study data is revealed, there is no convincing data available about the efficacy of GM-CSF in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for Xifaxan (rifaximin) for treatment of her Clostridium difficile colitis. Findings:  The physician reviewer found that there is sufficient evidence in the medical literature to support the use of Xifaxan in patients with C. difficile colitis. If left untreated, this disease can result in serious consequences and lead to recurrent hospitalizations and/or surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for artificial disc replacement at level C5-C6 for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that there is a lack of long-term studies supporting cervical artificial disc replacement over available standard treatment. Short-term studies are encouraging, but long-term results are needed before the efficacy of disc replacement can be established. Based upon the data currently available, the superiority of artificial disc replacement over standard interventions remains unproven at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for meniscal allograft transplantation for treatment of her internal derangement of medial and lateral meniscus. Findings:  Two physician reviewers found that the use of meniscal transplants has increased with the realization of the beneficial relationship between the meniscus and the articular cartilage. However, many of the studies reported focus on the survival of the graft, with less emphasis on the fate of the articular cartilage than on the survival of the transplant. There remains the need to examine the results over a longer time period. At present, transplantation is a reasonable option for the younger patient in need of salvage in cases of meniscal deficiency, but prospective studies comparing similar patients with and without grafts, and which follow patients for longer periods are needed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a Saunders Home Lumbar Traction device for treatment of his left sided sciatica and probable disc herniation.  Findings:  Three physician reviewers found that the medical literature includes articles about traction devices that range from quite elaborate systems to simple devices that depend on the individual providing their own power to support the pulling action of the traction. Some of the articles support the use of lumbar traction, while others were unable to demonstrate any benefit with a lumbar traction device. However, the available evidence does not establish that the at home use of a traction device such as the Saunders unit is superior to other modalities such as bed rest, physical therapy and/or medications. The medical literature simply does not suggest that a home traction device is more beneficial than any other available, standard treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for inpatient rehabilitation treatment for treatment of her bulimia nervosa and polysubstance dependence.  Findings:  The physician reviewer found that Fairburn and colleagues describe the effectiveness of cognitive-behavioral therapy for patients with eating disorders including a more complex treatment modality that also addresses mood, self esteem and interpersonal difficulties.  Crow and Petersons article mentions the benefit of cognitive behavioral therapy (CBT) particularly for bulimia nervosa. American Psychiatric Association practice guidelines note that treatment for eating disorders includes a range of services, such as intense outpatient or partial hospitalization. Hospitalization is usually indicated if there is a rapid or persistent decline in oral intake, medical instability or severe co-occurring psychiatric disorders that merit hospitalization.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested abdominoplasty and brachioplasty for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedures are reconstructive in nature. This patient has some hanging skin but no abnormal structure caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection and the amount of excess skin is not so great as to be considered abnormal. Thus, the proposed procedures do not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no photographic documentation of arm-related rashes, skin ulcerations, intertrigo or loss of range of motion. The abdominal photographs do document some hyperpigmentation, but do not document skin ulcerations, or loss of a functioning body part due to the excess skin. There is a lack of dermatology or primary care physician (PCP) notes which diagnose and treat skin related conditions with failure of conservative treatments over a period of months. All told, there is a lack of evidence of any physiologic dysfunction Therefore, the medical necessity of the proposed abdominoplasty and brachioplasty has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for Crestor (10 mg) for treatment of his hyperlipidemia. Findings:  The physician reviewer found that a great many well designed studies over the last 25 years have documented the benefit of lowering the LDL-C levels in individuals who have had a coronary ischemic event, or in individuals who have many risk factors of developing a coronary event. These different risk factors can be stratified giving predictive power to the specific recommendation for lowering a patients LDL-C. While there are a number of medications capable of lowering the LDL-C, the statins, as a group, are unequalled in the degree of LDL-C lowering (20% to 60%). Furthermore, statins are also the group of medications with the greatest tolerability for patients over time, (85% vs. 45% over the year of study). In other words, side effects are the least with the statins.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested bilateral breast reduction for the treatment of her breast, upper back, and neck pain. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. Breast reduction surgery removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with a patients body and to alleviate discomfort associated with overly large breasts. While the submitted photographs show a female with large pendulous breasts, the patients condition is not considered an abnormal structure of the body. There is no evidence of breast asymmetry or disease or infection affecting the breast tissue. The patients breasts are not excessively large so as to constitute an abnormal structure caused by a congenital defect, developmental abnormality, trauma, infection, tumor or disease. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. As for the medical necessity of the procedure, while a number of photos document shoulder grooves, the photos do not document intertrigo, skin ulcerations or rashes. The patient appears to have scars around the areola in a standard inverted T-pattern, consistent with prior breast surgery. The photos do not support the patients contention that her breasts are causing her back, neck, and shoulder pain. The proposed reduction of breast tissue in the amount of 300 grams would reduce the patients breast volume, but would not make a functional difference in terms of reducing her symptomatology, due to the small volume of removal. Furthermore, there is lack of documentation of workup of the etiology of the back, neck and shoulder pain, with no evidence of an orthopedic evaluation, physical therapy evaluation, diagnosis or conservative treatments with failure of those conservative treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested for skilled nursing facility level of care for treatment of her medical condition. Findings:  The physician reviewer found that the maximum rehabilitation potential at her current level of rehabilitation due to her NWB status on her left lower extremity. Her potential decline or deterioration can be prevented with a maintenance level of care which does not require skilled services, but can be accomplished with a rehabilitative nursing program 2-3 times per week.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for botox injections for treatment of her foot and ankle pain.   Findings:  Two physician reviewers found that Botox is not FDA approved for this patients muscle contractures. This patients muscle contractures are better suited to be resolved by tendon lengthening procedures. The literature in the medical community at this time does not support the use of Botox in this case. Thus, at this time the use of Botox in a case such as this remains investigational and/or experimental and is not likely to be superior to alternative standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for a computed tomography (CT) scan of the heart with coronary calcium evaluation for evaluation of her coronary calcification. Findings:  Two physician reviewers found that there are published consensus guidelines (see Greenland, et al.) regarding the appropriate use of coronary artery calcium (CAC) scoring. While the guidelines find that there are subsets of patients in which CAC may be reasonable, (such as low risk patients with atypical symptoms, or intermediate risk patients that are asymptomatic), this patient does not appear to fall into these subgroups.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested for Lunesta for treatment of his insomnia. Findings:  The physician reviewer found that Ambien CR and Ambien are essentially the same compound, but with different release mechanisms. It is not reasonable to require that the patient try the same medication, even if it is released in a different fashion, if he has already experienced a side effect from it.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for a follow-up positron emission tomography (PET) scan for evaluation of her recurrent ovarian cancer.   Findings:  Three physician reviewers found that are numerous articles in the peer-reviewed literature that support the use of PET scans for the evaluation of recurrent ovarian cancer. The Ovarian Cancer National Alliance has recommended that PET scans be utilized in the evaluation of recurrent ovarian cancer. Ebina, et al. notes that, PET scan may be the most effective means of detecting recurrence in ovarian cancer patients. Iagaru, et al. found good results of PET/CT for identification of recurrent ovarian cancer. PET/CT should be an integral part in evaluation of patients with high risk ovarian cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that documentation of a life-threatening weight related co-morbid condition such as hypertension, sleep apnea or diabetes mellitus, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for chiropractic services for treatment of his back pain. Findings:  The physician reviewer found that there is no documentation within the office notes of any injuries. The records also fail to show the evaluation of the patients condition in terms of identification of pain, tenderness, quality and intensity of pain visit to visit. The records do not document any aggravating or relieving factors to the case. The records fail to provide any musculoskeletal analysis or the specific subluxation and the type of chiropractic technique used.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for an open prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that the requested procedure is standard of care in this setting as set forth in the Management of Localized Cancer guide, which is based on recommendations from the Prostate Cancer Clinical Guideline Panel of the American Urological Association. It is appropriate for the patient to proceed with open radical prostatectomy at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for Gleevec (imatinib) for treatment of his Acute Myeloid Leukemia (AML). Findings:  The physician reviewer found that there is very little data regarding the use of Gleevec in AML, even those with c-kit mutation. There have only been small studies published over the past few years that do indicate some degree of activity in this situation (see Kindler, et al.). However, Chevallier, et al. published a particularly negative trial. Therefore, there is no convincing evidence that there is a sufficient likelihood of benefit from Gleevec for this patient when used as a maintenance therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for Aciphex for  her gastroesophageal reflux disease. Findings:  The physician reviewer found that Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. Interpatient variability has been seen with PPIs. However, 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for a spinal cord stimulator for her femoral nerve damage. Findings:  The physician reviewer found that there is ample evidence in the literature to support the use of spinal cord stimulation for peripheral neuropathic pain conditions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Levitra 20mg for treatment of her erectile dysfunction. Findings:  The physician reviewer found that Levitra is one of the FDA approved PDE-5 inhibitors available in the United States, and it is an appropriate medication for the treatment of erectile dysfunction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.  Findings:  Two physician reviewers found that the proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. They analyzed 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System) by a single satisfactory diagnosis. A rigid selection protocol was used including: 1) satisfactory diagnosis of the pathologic process resulting in pain; 2) corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, (i.e., vascular peripheral nerve, spine); 3) lack of satisfactory response to non-interventional pain management modalities by an interdisciplinary pain clinic; and 4) independent psychological evaluation, including a structured interview was performed by a psychologist specializing in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one patient with cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trials (3 cervical and 21 thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continued to use the stimulator. The same number would choose to receive an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography were documented in the patients with RSD. They concluded that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested for adolescent substance abuse sub-acute residential rehabilitation services for treatment of the enrollees cannabis dependence, hallucinogen abuse, alcohol abuse, obsessive-compulsive disorder and substance-induced anxiety disorder. Findings:  The physician reviewer found that the patient was in no acute distress at the time of admission to the sub-acute center. There was no evidence of suicidal or homicidal thoughts and no signs of psychosis. His drug use could have been effectively and safely treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for Renova 0.025% for treatment of her skin lesions.  Findings:  The physician reviewer found that the article by Gilchrest, Renova reduces fine wrinkles and skin roughness, and it produced changes histologically such as epidermal thickening, increased granular layer thickness, stratum corneum compaction and decreased melanin content. The article by Jeffes and Tang states that retinoids alone are probably not optimal immunotherapy in the treatment of actinic keratosis. The package insert for Renova indicates that it is used to reduce fine lines and wrinkles, and has not been demonstrated to have an effect on keratinocytic or melanocytic atypia. As such, there is no medical indication for the use of Renova and its use is cosmetic in nature.