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

A 69-year-old male enrollee has requested Oncotype DX testing for evaluation of his colon cancer.  Findings:  Two physician reviewers found the use of adjuvant chemotherapy in patients with resected stage II colon cancer has been a subject of controversy within the oncology community.  Clinical trials have provided varied conclusions as to the benefit of treatment in these patients, and consensus guidelines recommend that a decision to treat be based on the presence of certain high-risk features which predict a higher probability that these patients will experience recurrence.  The Oncotype DX assay has been shown to predict with some accuracy the risk of recurrence in patients with resected stage II colon cancer.  In this patients case, the requested Oncotype DX testing is likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested inpatient hospitalization services for treatment of her bulimia and depression, not otherwise specified. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the submitted documentation, acute hospitalization was initially indicated for her chronic mood symptoms and persistent eating disordered behavior despite intensive outpatient programming.  However, the medical records do not support the medical necessity of the admission during the specified time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested Synagis for treatment of the enrollees hypoplastic left heart syndrome, pulmonary hypertension, and chronic lung disease.  Findings:  Two physician reviewers found that most congenital heart disease studies have demonstrated the positive effect of Synagis in reducing the number of hospitalizations in patients under two years of age (Hussman, et al). Although there are guidelines for children under the age of two, there are no data on children over the age of two years that are not immunocompromised. Paes and Manzoni emphasized the difficulty of establishing control studies in older impaired children and thus the likelihood that such studies are not forthcoming. This patients severe cardiac, pulmonary, and cerebral impairments require continuous care and attention. Further, this patient is probably mildly immunocompromised from his inhalation steroids. Taken in its entirety, the requested vaccine may prevent this patient from experiencing further complications related to his medical conditions and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested continued intensive structured outpatient program services for treatment of the enrollees marijuana dependence and methamphetamine abuse.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the clinical notes, this patient has had sufficient intensive outpatient treatment to become established in group and 12-step treatment.  The medical records note a supportive home environment, and his family members were involved in his treatment.  Although patients may relapse during their movement towards sobriety, this does not always warrant ongoing treatment.  The current medical evidence supports community-based treatment in this clinical setting.  All told, continued intensive structured outpatient program services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested transurethral microwave therapy (TUMT) for treatment of his benign prostatic hyperplasia.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. The requested transurethral microwave therapy is not recommended for primary therapy for non-surgical candidates. Transurethral resection of the prostate (TURP) has been the gold-standard treatment for alleviating urinary symptoms and improving urinary flow in men with symptomatic BPH (Hoffman et al). Further, current peer-reviewed literature lacks adequate randomized controlled data to support the efficacy of TUMT for retention alone. In sum, there is a lack of medical literature that supports TUMT as a first-line management in this clinical setting. Thus, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested Cymbalta 20mg for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested medication. The record indicates that the patient has tried one dose of Effexor and discontinued it because of the reported side effects of nauseous, nervous, tired and trouble sleeping. According to the manufacturers prescribing information, Cymbaltas common side effects include nausea, dizziness, somnolence and fatigue. Both Effexor and Cymbalta are the same class and are likely to produce the same side effects. Therefore it is likely that the patient would experience the same issues with Cymbalta that she experienced with Effexor. In fact, most patients do experience these side effects at first, but they generally abate after about a week, and certainly within a few weeks.  Therefore, it is not medically necessary for the patient to receive Cymbalta based on the side effects experienced with one single dose of Effexor. Thus, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested genetic testing with the Verifi test for evaluation of her fetus for aneuploidy.  Findings:  Two physician reviewers found that per ACOG, The use of a cell free fetal DNA test should be an active, informed choice and not part of routine prenatal laboratory testing. The family history should be reviewed to determine if the patient should be offered other forms of screening or prenatal diagnosis for a particular disorder. A baseline ultrasound examination may be useful to confirm viability, a singleton gestation, gestational dating, as well as to rule out obvious anomalies. This patient meets several of the ACOG recommended criteria for prenatal fetal aneuploidy testing. Specifically, the patient is of advanced maternal age with a history of a prior pregnancy with a trisomy. Consistent with these findings, the diagnostic testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested kyphoplasty or vertebroplasty for treatment of his compression fracture. Findings:  Three physician reviewers found the requested services are not likely to be of greater benefit than other treatment options.  This patient has chronic back pain and was found to have a wedged vertebra on an x-ray at the time of his trauma.  Subsequently, an MRI did not show any bright signal in that vertebral body and this was deemed a chronic and not acute finding.  There is a lack of support for the requested services in this clinical setting.  The indications for kyphoplasty include acute osteoporotic compression fractures, painful vertebral fractures due to malignancy or painful hemangiomas.  The submitted records do not demonstrate these findings.  Additionally, there is a lack of support for the requested vertebroplasty in this patients case.  Thus, the requested kyphoplasty and/or vertebroplasty are not likely to be more effective than other option for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested inpatient detoxification services for treatment of his opioid dependence.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention in this case. The patient was experiencing acute-on-chronic polysubstance use (i.e., relapse) while in a treatment program. Thus, the severity of his condition was severe. Additionally, he had co-morbid medical concerns of cellulitis. According to the American Psychiatric Association Clinical Practice Guideline for the Treatment of Patients with Substance Abuse Disorders, ambulatory detoxification with co-occurring general medical conditions can be unsafe. As such, a prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Synvisc (Euflexxa) injections for treatment of her right knee osteoarthritis and degenerative joint disease.  Findings:  The physician reviewer found that the medical records provided for review evidence long-term care for multiple orthopedic conditions in the upper and lower extremities. At the knee, there is subjective documentation of medial compartment narrowing and patellar facet chondromalacia changes. X-rays demonstrated prior tibial tubercle transposition or Houser procedure. The records document a previous positive response to prior hyaluronan injections. However, there is limited or no benefit demonstrated in well-designed, double-blinded studies, but there is the possibility of acute local reactions. All told, the requested Synvisc (Euflexxa) injections are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested excision of right breast mass for treatment of the enrollees right breast mass.  Findings:  The physician reviewer found that based on review of the available records, a right breast ultrasound on the indicated date demonstrated fibroadenoma and was interpreted to be BIRADS category 3  probably benign finding, with short interval follow-up recommended. Clinical and ultrasound impression of a breast mass as fibroadenoma is only presumptive and requires confirmation by histology. In this patient, excision is also warranted to relieve pain. Thus, the requested excision of the right breast mass is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a functional electrical stimulator (FES) WalkAide device for treatment of her medical condition status post stroke with resultant foot drop.  Findings:  Two physician reviewers found that based on the clinical studies and available medical data, foot drop is generally managed with either a plastic molded AFO or double metal upright AFO depending on various clinical factors. However, several studies have demonstrated the efficacy of FES for the management of foot drop (Stein, et al). In some patients with foot drop, use of an FES unit may significantly enhance gait mechanics when compared with standard bracing techniques. The records provided for review lack documentation that the patient is able to tolerate use of the WalkAide or achieve an improved gait pattern with use of the FES unit when compared with use of a standard AFO. Therefore, based on a review of the medical records and peer-reviewed medical literature, use of a WalkAide is not likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested CombiPatch for treatment of her status postmenopausal.  Findings:  The physician reviewer found the submitted documentation supports the requested medication in this enrollee's case.  As noted by the American College of Obstetricians and Gynecologists Committee Opinion 556, medroxyprogesterone may have an increased risk of causing blood clots compared to some other progesterone preparations.  However, it was noted that the transdermal route may be less risky than the oral route.  In this enrollee's case, she has tried oral hormone replacement therapy and experienced side effects.  She reportedly has done well with CombiPatch.  There is sufficient support for the requested medication in this clinical setting.  All told, CombiPatch is medically necessary for the treatment of this enrollee.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Cialis for treatment of his erectile dysfunction.   Findings:  The physician reviewer found that based on review of the available records, this patient has erectile dysfunction due to cardiovascular disease. Cardiovascular disease is a common medical cause for erectile dysfunction. Treatment with a phosphodiesterase type 5 inhibitor such as Cialis, Viagra, or Levitra is appropriate and indicated. However, there is no documentation in the records provided for review that suggests the patient has tried and failed, or been unable to tolerate Levitra, which is approved by the Health Plan. Thus, the requested Cialis is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested computed tomography (CT) angiogram for evaluation of her abnormal electrocardiogram.  Findings:  Two physician reviewers found this patient had some coronary risk, no cardiac symptoms, a documented normal cardiovascular physical examination and a reported abnormal electrocardiogram.  In this circumstance, if the electrocardiogram were abnormal and suspicious for possible coronary ischemia or myocardial infarction, then stress testing would be the initial standard accepted practice.  Coronary CT angiography was not medically necessary in this circumstance since it only assesses anatomy and not the functional significance of any stenosis identified.  In addition, if an assessment of coronary anatomy were thought to be medically necessary, then conventional coronary angiography would be preferred due to its improved accuracy relative to coronary CT angiography and the ability to intervene with percutaneous coronary intervention during the same procedure, if clinically indicated.  Current guidelines endorsed by several national organizations also do not consider coronary CT angiography appropriate in asymptomatic patients with no known coronary artery disease.  Therefore, CT angiogram was not likely to be of greater benefit than other options for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested anterior optical coherence tomography (OCT) for treatment of his glaucoma suspect and narrow angles.  Findings:  Two physician reviewers found that anterior optical coherence tomography was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Anterior optical coherence tomography provides objective high-resolution images of the angle, and these images can be analyzed qualitatively and quantitatively. However, gonioscopy, a recognized method of angle examination, can give sufficient information about the potential for angle closure attack in an eye with narrow angles and is considered the gold standard. Although anterior optical coherence tomography is a promising development in the diagnosis of angle closure, it was not likely to be more beneficial than gonioscopy in this clinical setting. Based on the reasons provided, the anterior optical coherence tomography was not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested tendoscopy procedure to debride the peroneal tendons for treatment of her osteoarthritis of the right ankle. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. The requested tendoscopy procedure to debride the peroneal tendons is both medically necessary and likely to be beneficial for treatment of this patients medical condition. The requested procedure would have less morbidity than an open surgical incision and would be an appropriate technique to address the complications of this patients multiple prior ankle surgeries. Moreover, this approach is consistent with standards of care per the American Academy of Orthopaedic Surgeons. Therefore, for the reasons provided above, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested surgery using NanoKnife procedure for treatment of her colon cancer with liver metastases.  Findings:  The physician reviewer found that NanoKnife is a promising form of ablative technology which may improve upon current modalities. However, there is currently inadequate data to support its use outside of a clinical trial or institutional protocol. The records provided for review do not document that this patient has exhausted all non-surgical options. She may be a candidate for chemoembolization, spheres, or intensity modulated radiation therapy (IMRT), which have been proven more effective for treatment of metastatic disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested Remicade 400mg every four weeks for treatment of her ankylosing spondylitis.  Findings:  The physician reviewer found that based on review of the available records, there is a lack of objective evidence that the cause of the patients pain is ankylosing spondylitis. Per the physical examination documented in several progress notes, the patient presents with muscle spasm in the cervical and lumbar spine. However, there are no x-ray reports or laboratory studies such as erythrocyte sedimentation rate (ESR) for review. In addition, this patient has a diagnosis of fibromyalgia and is on multiple pain medications for that condition. Further, there is a paucity of data in the medical literature supporting the requested dose of Remicade for the diagnosis of ankylosing spondylitis and Remicade is not a pain medication. All told, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested hormone replacement therapy with pellet implants for treatment of her transgender hormone therapy.  Findings:  Three physician reviewers found the submitted clinical documentation reveals the patient has received hormone replacement therapy with pellet implants in the past. Her estrogen level while receiving implantable estradiol pellets was excessively high. There are significant potential risks associated with pellet implants. The increased estrogen dose administered via implantable pellet therapy is not likely to provide this patient with an improved health outcome over treatment with a lower dose of estrogen. All told, the requested hormone replacement therapy with pellet implants is not supported as likely to be more beneficial for treatment of this patients medical condition than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested therapies. The patient was diagnosed with autism at the age of 3 years. Autistic children have delays in communication, which is an essential component of the diagnosis and difficulties in motor skills. Although speech therapy and occupational therapy are standard therapies for the treatment of autism, there is no evidence in this case that the patient has recently been evaluated by a speech therapist or an occupational therapist. The medical records provided included a psychological assessment, however no evaluations were provided for either of the requested therapies. Formal assessment by a speech therapist and an occupational therapist is required to confirm the patients deficits. Based upon the lack of clinical documentation provided, specifically the lack of both a speech and occupational therapy evaluation for the patient, the requested therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested a neuromuscular electrical stimulation knee brace (Kneehab XP Quadriceps Therapy System) for treatment of her post left knee surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The mainstay of therapy following anterior cruciate ligament (ACL) reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility.  When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition.  If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored (Shelbourne and Klotz; Andersson et al).  There is no proven benefit of substituting or complementing therapy for this condition, including with concomitant conditions such as a post-partial meniscectomy knee, with a neuromuscular stimulation brace such as the Kneehab device in question. According to a review by Kim and colleagues, the authors noted that the effect of neuromuscular electrical stimulation `on functional performance and patient-oriented outcomes is inconclusive` for this condition. In a more recent systematic literature review, Kruse and colleagues concluded that such bracing `remains neither necessary nor beneficial.` The authors noted, moreover, that in general, `Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster` (Kruse et al). Although there are small studies that further explore this treatment intervention, there remains a lack of sufficient clinical data to support the use of this intervention for this patients condition. Given that the patient had already achieved significant levels of strength and range of motion prior to the use of the device, there were no indications that there was any impairment that would have precluded ongoing exercise and therapy to further strengthen the leg and improve function of the knee. Thus, the services at issue were not medically necessary.