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

A 48-year-old female enrollee has requested Botox injections for treatment of her headaches. Findings:  Three physician reviewers found that the use of Botox for chronic migraine following failure of standard preventive therapy is becoming widely utilized among headache specialists. A phase II study and two phase III studies have been completed, and the data is positive for reduction in headache episodes. These double-blind, randomized, placebo-controlled studies included over 3,000 patients and provide sufficient evidence of the effectiveness of Botox as a preventive therapy. Given the presence of chronic migraines in this case and the failure of multiple standard therapies, Botox injections are likely to be a superior treatment option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested an MRI of the brain and spine for evaluation of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation shows that the patients multiple sclerosis has been stable, with no evidence of a recent exacerbation.  The patient has not had any new or worsening neurological symptoms characteristic of multiple sclerosis. The use of an MRI in the evaluation of multiple sclerosis is widely accepted in the initial diagnosis of multiple sclerosis and to monitor response to therapeutic treatment. There is a lack of support in the peer-reviewed literature for the use of MRI for surveillance in patients who have stable multiple sclerosis symptoms. Per the Consortium of Multiple Sclerosis Centers, MRI of the brain is recommended for multiple sclerosis patients in order to evaluate an unexpected clinical worsening concerning for a secondary diagnosis, for reassessment of the original diagnosis and for reassessment before starting or modifying therapy. As this patient has no new neurological symptoms or physical findings to suggest an exacerbation of her multiple sclerosis, MRI of the brain and spine is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested a positron emission tomography (PET) and/or a single photon emission computed tomography (SPECT) scan for an evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that both PET and SPECT scans are routinely used to help evaluate patients with intractable temporal lobe epilepsy (TLE) who may need surgical resection of diseased brain tissue. SPECT scans have less utility than PET scans because of the relatively low temporal resolution and the frequent detection of both ictal onset zones and propagation pathways (which may still represent viable brain tissue). This patient, while potentially having historical features of TLE, has not met the criteria for intractable TLE. However, in a 2008 study by Boling and colleagues, it was shown that a careful, structural MRI with volume measurements of mesial temporal structures could clearly demonstrate atrophy, but when used in conjunction with fluorodeoxyglucose PET scanning, was superior in identifying patients with TLE. Thus, the use of PET, but not SPECT, is warranted to evaluate this patient and to help identify whether her episodes represent TLE, which would in turn argue for treatment with appropriate anti-epileptic drug therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for Cerezyme for treatment of the enrollees Gaucher disease. Findings:  The physician reviewer found that medical records do not include documentation of the patients genetic potential for height. Thus, it is not known if the patients growth is retarded compared to his genetic potential. Children with growth retardation may be at greater risk of bone complications.Cerezyme is medically indicated if there is documented evidence the patient has either growth retardation or bone lesions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested for sub-acute detoxification level of care in a residential setting for treatment of his alcohol dependence. Findings:  The physician reviewer found that an evidence-based instrument such as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is useful in determining necessary level of care to ensure a patients level of care meets their individual needs safely and effectively in the least restrictive setting possible. Per these guidelines, medically monitored non-residential services were appropriate in this situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for low back spinal fusion for treatment of her back pain. Findings:  The physician reviewer found that the role of spine fusion in the treatment of degenerative disorders of the lumbar spine has been the subject of much debate. Arthrodesis may be indicated as an adjunct to decompression of spinal stenosis, in the treatment of degenerative scoliosis or in the presence of iatrogenic instability, but has a poor success rate when used to treat back pain associated with disc degeneration seen on MRI. Lumbar fusion is rarely indicated for routine discectomy, abnormal radiographic results without appropriate clinical findings, or spinal stenosis. The ability to separate spinal from non-spinal sources on discography has not been clearly established, and the response of concordant pain may be less meaningful than assumed. Also, it is unclear to what extent positive pain reproduction corresponds with successful outcomes. All told, the clinical evidence does not demonstrate the patient meets indications for lumbar spine fusion
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female enrollee has requested weekly speech therapy for treatment of the enrollees childhood apraxia of speech and mixed expressive/receptive language delay. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of speech therapy. A mixed expressive/receptive language delay associated with Down syndrome has been documented and the patient has been assessed with apraxia. Speech therapy is generally considered medically necessary when performed for the purpose of improving functional skills. For patients such as this patient with mixed expressive/receptive language delay and apraxia associated with Down syndrome, speech therapy goals are focused on language-based skills; as such, speech therapy is not necessary from a medical standpoint. However, it should be noted that this patient also has a history of cleft palate and is status post surgical treatment, which may contribute to the apraxia. No standardized testing of articulation has been performed to correlate these issues. In the absence of identification of the specific factors that are affecting the patients expressive language/speech intelligibility via standardized testing of articulation, the medical necessity of speech therapy is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested cervicoplasty (removal of redundant skin and subcutaneous tissue from the neck with a lift) for treatment of her excess skin. Findings:  The physician reviewer found that with regard to whether the proposed surgery is reconstructive in nature, the documentation does not support the presence of an abnormal structure of the body in this patient. The skin is abnormal on a microscopic level, but the impact is only minimal at the macroscopic level, as the only symptom is some visibly lax skin. The excess tissue is not so great so as to be considered abnormal at a macroscopic visual level. In fact, the photographs do not show much more changes than are expected from the normal aging process. Thus, the California statute regarding reconstructive surgery does not apply. The proposed surgery is in fact a variant of a regular facelift. Concerning general concepts of medical necessity, the submitted documentation does not establish the presence of a functional impairment in this patient. The skin lesions and manifestations of pseudoxanthoma elasticum are asymptomatic. In the absence of evidence of infection, rashes, loss of skin integrity or so much excess skin that it restricts mobility, the removal of this skin would be cosmetic and not medically necessary. Therefore, the requested surgery cannot be seen as being performed to improve function.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department and reported four weeks of nasal congestion. She had seen her family physician the previous week and was treated with Sudafed, Zyrtec and Afrin nasal spray. The review of systems was negative. The patients vital signs were normal. There was no fever or hypoxia. Physical examination was normal, and the patient was discharged in stable condition. An emergency medical condition involves acute symptoms of such severity that the absence of immediate medical treatment would result in placing the patients health in serious jeopardy, seriously impairing bodily functions or causing serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patient was uncomfortable and unable to sleep, but she was not in respiratory distress.  The patient had normal vital signs, including temperature and pulse oximetry. Her symptoms were not acute, as they had been present for four weeks. 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 her health in this situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Supartz injections for treatment of his knee pain. Findings:  The physician reviewer found that the efficacy of viscosupplementation in the treatment of osteoarthritis of the knee has been accepted for years, with reduction in pain and improvement in function, as noted by Bellamy and colleagues. Some benefit has been found in a repeat course of injections, if there was a satisfactory response to the first course, per Waddell and colleagues. It has been suggested that multiple repeat courses of therapy might be of value, but additional well-designed, randomized, controlled trials of high methodological quality are needed to resolve the uncertainties remaining, as noted by Wang and colleagues. Clinical practice guidelines suggest that there be a progressive approach to treatment, utilizing pharmacological as well as non-pharmacological treatments, including the use of non-steroidal anti-inflammatory medications, acetaminophen, and other analgesics, and the use of steroid injections. In this case, there is no documentation of the use of treatments or medications other than an injection, presumably steroids. Physical therapy was suggested, but there is no documentation of the particulars of treatment or the results.  Further, there is no history of ulcer or gastrointestinal problem which would influence the selection of medications. All told, the submitted documentation does not demonstrate that the Supartz injections provided were clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested for an electromyography for evaluation of his toe pain. Findings:  The physician reviewer found that no evidence is presented to suggest a clinical diagnosis such as focal mononeuropathy, polyneuropathy or lumbar radiculopathy,
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Zometa (zoledronic acid) infusions for treatment of her medical condition. Findings:  The physician reviewer found that zoledronic acid is indicated for the reduction of skeletal related events in patients with metastatic solid tumors and multiple myeloma. It is also indicated for the treatment of osteoporosis. This patient has two indications for treatment with zoledronic acid. She is at very high risk for osteoporosis, given her early age of menopause, and she is already diagnosed with osteopenia. Zoledronic acid is compendia listed for bone loss from cancer treatment. This patient meets the criteria for this treatment. In addition, a phase III study has shown that zoledronic acid can reduce the risk of disease progression in pre-menopausal women, rendered post-menopausal as a result of treatment. This patient also meets this indication as well.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested computer-guided assistance during total knee replacement surgery for treatment of his medical condition. Findings:  Two physician reviewers found that computer-assisted navigation was designed in hopes of increasing the precision of total hip and total knee replacement surgery. However, this technology has not been widely adopted. Some studies have shown that there is no significant difference in post-operative component position and limb alignment between computer-assisted navigation and conventional surgical techniques. Other studies have demonstrated that there was a tendency towards improved component position and limb alignment in total knee replacement utilizing computer-assisted navigation. However, these studies (with short to mid-term follow-up) have not shown that the decrease in alignment variability resulted in an improvement in clinical outcomes. It is not possible to determine from these studies whether the relatively small degree of improvement in alignment translates into increased implant longevity and/or improved clinically relevant outcomes. The American Academy of Hip and Knee Surgeons, recognizing these study limitations and/or inconsistencies, has therefore concluded that `longer and more comprehensive follow-up of computer-assisted orthopedic surgery studies are needed to better understand the indications, limitations, and complications of the surgical procedure.` In this patients case, there is no indication of a special consideration such as severe femoral or tibial deformity that would warrant an exception to this conclusion.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for laparoscopic adjustable gastric banding for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 41, this patient meets the National Institutes of Health criteria for weight loss surgery. She has completed a thorough multidisciplinary evaluation that did not reveal any obvious medical, metabolic, dietary or behavioral barriers to surgery. Furthermore, she has failed conservative and supervised weight loss attempts. Additional attempts at conservative measures are not likely to be successful for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old female enrollee have requested for an inpatient hospitalization level of care for treatment with the medication Clozaril for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the need for inpatient hospitalization to initiate Clozaril treatment and to wean her off of her other medications is not medically necessary. There are no indications of any life-threatening behaviors or medical problems that would place the patient at risk, or any evidence that she is unable to follow an outpatient monitoring regimen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested  for mental health residential treatment for treatment of the enrollees bipolar disorder, developmental disorder, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining the necessary level of care for children, to ensure their level of care meets their individual needs at the least restrictive setting possible. Based upon these guidelines, the patient met criteria for residential treatment at admission. However, his progress in treatment indicates he was using coping skills and his behavior had improved through the course of treatment overall.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for Taxotere chemotherapy for treatment of her adenocarcinoma of the lung. Findings:  The physician reviewer found that Alimta has recently gained accelerated approval from the FDA based on randomized trials in which it showed equivalent survival when combined with cisplatin (cddp) compared to gemcitabine/cisplatin. In this study, there was a striking advantage to the Alimta/cddp regimen for those patients with non-squamous histology like adenocarcinoma. In the second study cited in the FDA label, Alimta was tested in the maintenance setting versus placebo and again it showed a survival benefit which was most pronounced for adenocarcinoma and non-squamous histology in general, as noted by Ciuleanu and colleagues. A more recent phase II study looked at 50 patients with stage IIIB/IV adenocarcinoma with Alimta/Avastin/carboplatin followed by maintenance Avastin/Alimta. The study was not randomized, but the overall survival times were impressive.  There is no evidence suggesting that Taxotere is likely to have similar results.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery for treatment of her back pain. Findings:  The physician reviewer found that there is a substantial increase in complications associated with increasing technicality in lumbar spine fusion surgeries (Fritzell and colleagues). The increasing morbidity experienced by individual patients by the application of more technically complex procedures was found by these authors to be a significant factor in their outcomes. In this particular case, a three-level fusion has been proposed. Spinal instability, demonstrated by flexion-extension studies has not been documented in this case. The studies performed to evaluate this patients lumbar spine condition (x-rays, CT scans, MRIs) do not describe spinal instability (a widely-accepted indication for spinal fusion surgery). In addition, although this patient has previously had some physical therapy treatment, it does not appear that she has exhausted conservative treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is a lack of evidence demonstrating that the patient would not be able to maintain sobriety at a less restrictive setting.Although psycho-social issues usually have an impact on substance use, there was minimal documentation of the strategies used to help the patient retain sobriety after she left treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested lumbar artificial disc replacement (at the L4-5 level) and lumbar fusion (at the L5-S1 level) for treatment of his low back pain. Findings:  Three physician reviewers found that artificial disc replacement has been the subject of much debate. Despite encouraging early results, there is still a need for results regarding the long-term outcome of these implants, and whether their use results in improved outcomes (Mirovsky and colleagues). This motion-sparing technology has not yet demonstrated efficacy with data (Madigan and colleagues). Further long-term study is necessary (Resnick and Waters) in order to confirm the benefits of artificial disc replacement as compared to standard alternatives. The role of fusion in the treatment of degenerative disease in the lumbar spine also remains a source of controversy. There is some evidence to support the use of fusion in cases with demonstrated instability, but further trials are needed to clarify the situation (Gibson and Waddell). The use of wide decompression or facetectomy may result in iatrogenic instability and thus may call for fusion (Resnick and colleagues). Trauma, tumor, infection, and spondylolisthesis may require fusion, but it is rarely indicated for routine discectomy or abnormal radiography without appropriate clinical findings. In summary, since there is no documentation of instability or other indication for fusion, the necessity for that procedure is not evident, and therefore the denial was appropriate. Further, since questions as to the efficacy of artificial disc replacement remain, the procedure is appropriately considered to be investigational and/or experimental in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Byetta for treatment of his type II diabetes. Findings:  The physician reviewer found that Byetta is presently contraindicated when prescribed with basal insulins, either Levemir, insulin detemir, or Lantus, insulin glargine. According to the providers notes, the basal insulin used in this case is Levemir insulin, once daily at bedtime. Neither the manufacturer of Byetta nor the Food and Drug Administration (FDA) has approved the addition of Byetta to an insulin regimen. A review of the latest information on the approved use of Byetta does not list this combination as being approved by the manufacturer or the FDA. At this time, there is insufficient peer-reviewed clinical data demonstrating that Byetta combined with basal insulin is safe and effective. Further studies are needed before the safety and efficacy of the proposed regimen can be determined.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a chemotherapy regimen to include nine visits/injections of Herceptin for treatment of her metastatic clear cell ovarian cancer. Findings:  Two physician reviewers found that Herceptin has been approved by the Food and Drug Administration (FDA) for the adjuvant treatment of HER2-overexpressing breast cancer. It has not been FDA approved for the treatment of ovarian cancer. Nor is Herceptin included in expert consensus panel recommendation for patients with recurrent ovarian carcinoma. Currently, there is a paucity of data concerning the use of Herceptin in ovarian cancer. Large scale phase three and four studies are lacking at this time. As a result, there is insufficient outcome data demonstrating that Herceptin is likely to be of any clinical benefit in this setting. The peer-reviewed clinical literature does not support the use of Herceptin in this clinical situation.