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

A 49-year-old female enrollee has requested sclerotherapy for treatment of varicose veins.  Findings:  Three physician reviewers found that while there are published reports regarding the use of this method, it is not yet considered standard of care. Even the physicians own treatment options with the patient reflect the possible use of endovenous laser and surgical ligation and stripping. These are traditional standard of care alternatives. In this case, the use of ultrasound-guided sclerotherapy did not offer an advantage over traditional methods such as endovenous laser or radiofrequency. In May 2004 the dermatologic surgery journal listed guidelines of care for sclerotherapy of varicose veins, and it is not indicated as first-line treatment for truncal veins with incompetence.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male has requested growth hormone (GH) therapy with Humatrope for treatment of growth failure.  Findings:  The physician reviewer found that a recent study of 35 children with achondroplasia who were treated with GH therapy for up to five years found that linear growth improved without significant side effects. This study confirmed previous studies involving achondroplastic children, which reported positive growth effects from GH therapy. In this instance, the patients growth has been severely impaired despite bone lengthening surgery. A one-year trial of GH therapy is clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Xyrem for treatment of sleep disturbance and pain associated with fibromyalgia.  Findings:  The physician reviewer found that review of the relevant medical literature does not support the use of Xyrem for the treatment of fibromyalgia. Xyrem is an agent with definite addiction possibilities, as well as concerns about abuse in non-therapeutic circumstances. It also has significant risks related to depression, both during treatment and following withdrawal. Xyrem has only been approved for use in treating a specific diagnosis (narcolepsy with cataplexy), which this patient does not have. There is very limited data from two short-term studies in patients with fibromyalgia which report favorable results. Longer-term studies are needed and are said to be underway. The current body of evidence supporting the use of Xyrem for treatment of fibromyalgia is inadequate to demonstrate long-term efficacy or safety. Use of this drug to treat fibromyalgia is not within standard practice at this time. This patient has reportedly been treated with numerous agents intended to treat fibromyalgia, but it is unclear from the provided list of agents whether full or adequate trials were undertaken. Given the lack of proven efficacy of Xyrem in this setting, further attempts with standard agents would be more appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of diabetes.  Findings:  Three physician reviewers found that research has shown that the CGMS can be helpful for patients such as this patient with hypoglycemic unawareness and wide variations in blood sugars. Standard diabetic management has not been optimal, and this device is the best alternative for improving the patients glycemic control.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested coronary CT angiography (CTA) for the evaluation of his cardiovascular status. Findings:  Three physician reviewers found that CTA is not, thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography cannot accurately confirm or exclude important coronary artery obstructions. The use of CTA in the diagnosis and prognosis of coronary artery disease or the assessment of by-pass graft patency, is an experimental/ investigational application of the technology.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Avastin for the treatment of his radiation necrosis. Findings:  Three physician reviewers found that Avastin is FDA approved for lung and colon cancer. It has shown intriguing early activity in high grade glioma of the brain. The role of Avastin in low grade brain tumors (ependymoma) has not been well studied. Additionally, Avastin has not been adequately studied in the setting of radiation necrosis. In a small pilot trial of 15 patients, there appeared to be radiological improvement in 8 patients. However, the improvement in patient symptoms, quality of life and the side effects in this setting have not been well characterized. We do not know from this small pilot study if there is sufficient clinical benefit to justify the risks of Avastin.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 14-year-old male enrollee has a bilateral mastectomy for the treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that this patient had gynecomastia that was not causing disabling pain or a functional problem. In addition, the records do not document a work-up for pathologic causes. The patients pubertal gynecomastia was likely to have resolved spontaneously and was not causing any health problems. Based on the submitted documentation, the patient did not meet the ASPS guidelines for surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female has requested a pulmonologist referral and pulse oximetry machine for treatment of shortness of breath and chest pain.  Findings:  The physician reviewer found that there are no findings to support the need for the requested pulmonology referral. It appears that at this point, pulmonary function testing would be appropriate. If the results show a need for further evaluation, a referral to a pulmonary specialist would be indicated. However, based upon the information presented at this time, a consultation with a pulmonology referral is not medically necessary. Furthermore, there is no clinical indication for a pulse oximeter in this case. The patients sleep study showed that her oxygen saturation is normal. There is no clinical utility to having the patient monitor her oxygen saturation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male has requested a speech and language evaluation for the evaluation of speech and language deficits.  Findings:  The physician reviewer found that The speech therapy evaluation identified expressive language delays, articulation delays and tongue thrusting. It does not appear these issues were previously identified or addressed during past therapy. In addition, there is a family history of dyslexia, indicating there may be an inherited component to the patients speech and language deficits. It is reasonable to re-evaluate when work begins with a new therapist and to establish appropriate treatment goals.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested Benicar for the treatment of his hypertension. Findings:  The physician reviewer found that there is no objective clinical documentation to suggest a true allergy to an ACE inhibitor. Overall, Accupril is well-tolerated. Despite the patients vague complaints of side effects to two other medications, there is no clear reason from a medical perspective to not consider a formulary medication in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested Gemzar and Taxotere for the treatment of his recurrent metastatic leiomyosarcoma. Findings:  Three physician reviewers found that the relevant medical literature including the articles submitted with this appeal demonstrates that there is sufficient support for the proposed regimen in this case. Gemzar and Taxotere is standard oncology practice for treatment of leiomyosarcoma. The patient is an appropriate candidate for the requested regimen.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of her diabetes. Findings:  Two physician reviewers found that the 72-hour continuous glucose monitoring system (CGMS) in contention was approved by the Food and Drug Administration in 1999. Since that time there have been many articles in peer-reviewed journals that have shown improvement in blood sugar control using this system. The device has been used in endocrinology practices as a standard of care for patients whose blood sugars are not well controlled despite frequent self monitored blood glucose by fingerstick. The use of CGMS in this setting was medically appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a computed tomography (CT) scan of the abdomen and pelvis for an evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scans of the abdomen and pelvis are often ordered together because it is difficult to demarcate the origin of pain as being from above or below the level of the iliac crests, which is where an abdominal CT scan would usually stop. Clinically, it would make no sense to have the patient receive oral and intravenous contrast and then possibly miss the source of the patients symptoms by a few centimeters. It is widely accepted that CT scan is an excellent diagnostic test to evaluate the abdomen and pelvis. For a patient with chronic pancreatitis and prior abdominal surgeries, there could have been ascites in the dependent pelvis or adhesions affecting the bowel in the lower abdomen or upper pelvis. A myriad of other possibilities also exist. The clinicians assessment was sufficient to justify this common diagnostic procedure
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested breast surgery (bilateral breast implant removal, bilateral capsulectomy, bilateral breast reduction and formal mastopexy) for the treatment of her breast deformity. Findings:  The physician reviewer found that the American Society of Plastic Surgeons position paper on reoperation for implants placed for cosmetic augmentation, the medical necessity criteria for reoperation includes (1) a broken or failed implant, (2) infection, (3) implant extrusion, (4) siliconoma or granuloma, and (6) interference with the diagnosis or treatment of breast cancer. Consideration is also given when pain is a factor. In this instance, there is no mammography or CT evidence of silicone granulomas. The records do not document painful capsular contracture or other functional problems. The operative note did not describe ruptured implants. It appears that the breast surgery was performed to improve the appearance of the breasts.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested Viagra for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted clinical information indicates the patient has erectile dysfunction (ED) that has responded to treatment with oral Viagra. The patient has a documented history of hyperlipidemia, though his current cholesterol levels are unknown. Regardless of the source of the patients erectile dysfunction, Viagra is considered a first-line therapy. It has apparently been an effective treatment for the patients ED. There are no contraindications to the medication based upon the information provided, and the patient should continue to receive Viagra for appropriate management of his ED.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 13-year-old female enrollee have requested Lexapro for the treatment of the enrollees depression. Findings:  The physician reviewer found that the black-box warning on SSRI medications, including Celexa and Lexapro, states that if discontinuing a medication that is known to be effective may increase the likelihood of transient suicidal ideation, in a patient with the history of suicidal ideation, while new and old medications are titrated, this factor should be considered in clinical decision making. Although it appears Lexapro was prescribed by a non-Plan provider, possibly unfamiliar with the Health Plans formulary guidelines, it is in the best interest of this 13-year-old patient to continue on Lexapro. Even if the risk of transient suicidal ideation is low, there is a risk nonetheless. A decision to discontinue a medication that is known to be effective in favor of a formulary medication that is likely to work, but may not, cannot be supported.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breasts for an evaluation of her fibrocystic breast changes.  Findings:  The physician reviewer found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative extent of residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient would be considered high-risk because of her personal history of breast cancer, which is a clinical indication for breast MRI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of his diabetes. Findings:  The physician reviewer found that the scientific evidence is clear that a CGMS will help to decrease the duration of hypoglycemic and hyperglycemic episodes and improve HgA1c values. Deiss and others also demonstrated that  extended use of the CGMS  resulted in lower HgA1c values. In a patient who is experiencing severe hypoglycemic reactions despite frequent monitoring, this device can definitely improve net health outcomes. However, no data from the patients blood glucose testing is provided. The patient indicates he is monitoring as often as 15 times per day, but the providers progress note indicates the patient frequently does not monitor before insulin boluses. As there is no objective evidence the patient is adequately monitoring his blood sugars, the CGMS is not clinically indicated at the present time. If the patient and his endocrinologist can demonstrate that the patient is experiencing extreme fluctuations in blood glucose levels, despite optimal monitoring, authorization of a CGMS should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the patient has chronic intractable pain in the back, neck, and extremities. Numerous narcotic and non-narcotic pharmacological agents have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300 mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies. Historically, medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown a measurable response to Lyrica over the past six months and continued treatment is medically indicated. Consideration might be given to prescribing a single higher dose tablet (150 mg) rather than two-half dose tablets. (75 mg x 2).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested Lyrica for the treatment of her neuropathic pain. Findings:  The physician reviewer found that the patient has chronic neuropathic pain and first-line therapies have been tried and have failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300 mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies. Historically, medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown a measurable response to Lyrica, and continued treatment is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Alimta (pemetrexed) to be administered in combination with Avastin for the treatment of her lung cancer. Findings:  The physician reviewer found that clinical trials have shown that pemetrexed has activity in metastatic lung cancer following prior chemotherapy. The study cited above suggested a benefit at six months for patients treated with Avastin and Alimta (Weiss, et al.). This was not a prospective trial and included only nine patients treated with this combination. Still, the results are encouraging and have prompted other studies. More recently, a phase II multicenter, randomized trial comparing chemotherapy alone with bevacizumab and chemotherapy (docetaxel or pemetrexed) or bevacizumab and erlotinib. This trial showed that the addition of bevacizumab was beneficial in terms of both progression-free survival and overall survival (Herbst, et al.). Currently, there is no standard of care in the treatment of metastatic NSCLC. However, these two trials provide a sound rationale for the use of Avastin and Alimta in combination. Additionally, each of these agents are known to be active in NSCLC when used alone, and their combined use is clinically reasonable at this stage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested bilateral inferior turbinate reduction for the treatment of her nasal airway obstruction. Findings:  The physician reviewer found that this patient was noted to have some difficulty breathing only when she has allergies which occurred primarily in the spring and summer months, and she was noted to have bilateral mild inferior turbinate hypertrophy.  Standard of care in determining whether a patient would benefit from surgical management of nasal congestion dictates that there be physical findings resulting in significant obstruction, i.e., prominent septal deviation, obstructive turbinate hyperplasia or nasal valve collapse.  In addition, failure of an adequate trial of medical therapy should be documented. Neither of these two elements are documented in this patients records. As such, medical necessity has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested monthly intravenous immune globulin (IVIG) therapy for the treatment of her multiple sclerosis (MS). Findings:  Three physician reviewers found that IVIG is not a first-line therapy for MS, but has been shown to benefit the relapsing-remitting MS population. This patient has failed first-line therapies, and is not a candidate for other commonly used agents. She had a favorable response to IVIG in the past. For this particular patient, the use of IVIG therapy offers the best opportunity for stabilizing her disease and is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested laparoscopic gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 40 and significant comorbid conditions, the patient meets the National Institute of Healths medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will ameliorate or eliminate her co-morbid conditions. With regard to the required six months of physician-supervised weight loss, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an acceptable candidate for the gastric bypass procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Lyrica for the treatment of her polyneuropathy. Findings:  The physician reviewer found that the medical record indicates that the patient had previously used Neurontin 1800 mg and  Elavil 25-75 mg. These medications were unsuccessful in managing her neuropathic pain. Subsequently, Lyrica 75 mg twice a day was prescribed by her treating neurologist and the patient had significant improvement. Given the patients inadequate response to Elavil and Neurontin, Lyrica was the next reasonable choice in treating her neuropathic pain. Continued treatment with Lyrica is medically necessary as it has relieved the patients pain without untoward side effects.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested non-surgical spinal decompression therapy for the treatment of his severe spinal stenosis. Findings:  Three physician reviewers found that the DRX 9000 is a type of spinal decompression traction device that is utilized primarily in chiropractic and osteopathic offices for non-surgical pain relief. There is insufficient evidence in the peer-reviewed medical literature supporting the safety and efficacy of this procedure. It is widely considered an experimental/investigational treatment as randomized controlled trials and outcome studies are lacking.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a stab phlebectomy for treatment of varicose veins.   Findings:  The physician reviewer found that the standard treatment regimen for varicose veins has several stages. Initially conservative therapy is offered to the patient, and if this is successful, then no further intervention is required. However, if conservative therapy fails, then high ligation, greater saphenous vein stripping or stab avulsions are generally recommended. New technologies are evolving to include radiofrequency ablation and endovenous laser therapy as treatment choices. In this instance, a three-month trial of compression hose with subsequent re-evaluation is a reasonable approach. The work up should include a duplex scan to rule out saphenous incompetence. Stab phlebectomy is not clinically appropriate at this stage.