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

A 32-year-old female enrollee has requested the replacement of the enrollees current spinal cord stimulator with an MRI-compatible stimulator for treatment of her back pain. Findings:  Three physician reviewers found that replacement of the patients current spinal cord stimulator with an MRI-compatible stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review fails to provide a rationale as to why MRI is required versus other traditional neuroimaging techniques. The peer-reviewed literature supports the use of imaging modalities such as traditional myelography, CT scan and/or CT myelogram for patients with a device or other contraindication to an MRI. Therefore, the request for replacement of the patients current spinal cord stimulator with an MRI-compatible stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested genetic testing for HNPCC for evaluation of her colon cancer.  Findings:  Three physician reviewers found that the hallmark of HNPCC is defective DNA mismatch repair which leads to MSI-H tumors. There are other cancers that may occur in patients with these abnormalities. Given this patients individual history and possible personal and familial consequences, it is appropriate to perform the requested genetic testing. In this patient, there is a reasonable possibility for a Lynch syndrome carrier diagnosis and the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Synvisc injection for treatment of his right knee pain. Findings:  Two physician reviewers found that hyaluronic acid injections are not recommended for indications such as chondromalacia patellae, facet joint arthropathy, osteochondritis dissecans, or patellofemoral arthritis, patellofemoral syndrome (patellar knee pain), and plantar nerve entrapment syndrome. These injections are not supported for use in joints other than the knee because the effectiveness of hyaluronic acid injections has not been established. All told, the requested Synvisc injection is not supported as 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 a wound vacuum for treatment of her wound. Findings:  Three physician reviewers found that in this patients case, use of wound vacuum was not and is not likely to be of greater benefit than other treatment options.  She has been treated with wound vacuum in the past, with unclear results.  There is a lack of support for the services at issue in this case, as the medical literature has not demonstrated consistent improvement of wound healing over standard therapy in this clinical setting.  Therefore, the services at issue were not and are not likely to be more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested therapy in this patients case.  This patient meets criteria for growth hormone treatment as the records document he was born small for gestational age with failure to catch up in growth by two years of age.  According to the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children with intrauterine growth restriction/small for gestational age is an indication for growth hormone treatment.  Provocative growth hormone testing is not required for diagnosis and treatment for this indication.  Small for gestational age or intrauterine growth restriction cause a pathophysiologic process in utero that adversely affects fetal growth.  Treatment with growth hormone in children with intrauterine growth restriction may stimulate substantial catch up growth during the first two years of treatment, followed by a slower but constant increase in growth.  All told, the requested Genotropin growth hormone therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a bilateral mastectomy for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  This patient has a strong family history that puts her at elevated risk for developing breast cancer.  Diagnostic mammography on the said date revealed bilateral dense breast tissue which limits the ability of radiologic surveillance for screening of breast cancer.  There are now multiple studies that demonstrate the benefit of bilateral prophylactic mastectomy in women who are at elevated risk of breast cancer due to a strong family history, even in the absence of genetic testing.  The records document the limited ability of mammography to screen her breasts for early cancer due to the dense tissue.  In this clinical setting, bilateral mastectomy has been demonstrated to be effective at risk reduction for lifetime development of breast cancer.  All told, the requested bilateral mastectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested intravenous immune globulin (IVIG) for treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP).   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested IVIG therapy. This patient has had progressive numbness and burning pain in the feet, and has been shown to have a mixed sensory-motor demyelinative and axonal polyneuropathy. He has been diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), and has had treatment with IVIG, which has not resulted in observed improvements. The preferred therapies for CIDP include IVIG, steroids, and plasmapheresis. An evidence-based guideline from the American Academy of Neurology (AAN) states that, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). Although this patient has been treated with IVIG without observed improvement, a longer trial is indicated to determine whether he will respond to the treatment.  Therefore, it is medically necessary to continue IVIG treatment for a span of an additional year to help define if the patient has actually responded, and to further clarify the diagnosis. While the patient has requested lifetime authorization of IVIG, neither the patients clinical findings nor the scientific literature support the lifetime use of IVIG. Thus, continued IVIG treatment for a one-year period is medically necessary and appropriate for this patient. The patient should be re-evaluated at the end of the one-year period to determine the appropriateness of further treatment with IVIG therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Pro Air inhaler #4, Promethazine with codeine cough syrup #2 and Norco 10/325 #180 for treatment of her chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that there is inadequate documentation to support the medical necessity of the requested Pro-Air medication. The patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates may be adjunctive to this therapy with close monitoring by a certified pain management physician (Fishman). Ballantyne and Mao reported that, prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. Consistent with these findings, the requested Norco, Promethazine with Codeine, and Pro Air inhaler, are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested spinal neurostimulator pulse generator for treatment of her lower back pain.  Findings:  Three physician reviewers found that spinal neurostimulator pulse generator is not likely to be more beneficial at this time for treatment of the patients medical condition than any available standard therapy. There is peer-reviewed evidence supporting the efficacy of spinal neurostimulation in select patients. In order to determine those individuals who are likely to benefit from the procedure, a pre-procedure psychological assessment is required as part of the standard diagnostic work-up. The patient has not had a psychological evaluation to rule out a psychogenic cause for her pain. As such, based upon the information provided, the requested spinal neurostimulator pulse generator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that during the course of treatment, the patient continued to struggle with self-defeating behaviors, emotional dysregulation and affective symptomatologies despite comprehensive therapies and psychotropic medication.  On the specified date, the patients mood was noted to be angry. He was upset with his grades.  He was procrastinating.  He was having disharmonious relations with family. The therapist was concerned about the recurrence of significant affective symptoms while the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  In sum, continuation of IOP services beyond the date indicated was consistent with current practice guidelines and relevant peer reviewed literature. Continued IOP services were reasonably expected to improve the patients condition and prevent a more serious health condition. Additionally, the services were safe, appropriate and consistent with good medical practice. Therefore, based on the documentation submitted for review, IOP services during a specified time frame were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-month-old female enrollee has requested Synagis for treatment of the enrollees prematurity to protect against respiratory syncytial virus (RSV).  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP), the Centers for Disease Control (CDC), and the American Committee on Immunization Practices, have invested a substantial amount of resources into determining which infants would most likely benefit from treatment with palivizumab (Synagis). The current recommendations are based on the evidence that demonstrates which children are most likely to be hospitalized with RSV. The majority of infants who are hospitalized with RSV have multiple risk factors, including prematurity and lung disease and/or heart disease. This patient does have a history of moderate prematurity but she does not have any other risk factors such as chronic lung or heart disease. Moderate prematurity alone is a risk factor when it is associated with being younger than three months old during the RSV season and having an exposure that would substantially increase the likelihood that the infant will be exposed to RSV. This patient was four months old at the start of RSV season and although she has a twin sister at home, her sister does not represent an increased risk for exposure to RSV. Therefore, there is no clinical indication for her to receive Synagis and the requested vaccination is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available treatment options. This patient is on a maintenance regime of TMS for the treatment of depression. There is a lack of medical literature that supports TMS in maintenance form beyond the acute phase for the treatment of major depressive episodes. In addition, there is a lack of studies in the medical literature that have systematically evaluated the treatment parameters and benefits of maintenance TMS (Janicak, et al). Furthermore, acute phase treatment of TMS is still less powerful in treatment refractory depression than ECT, and still does not have a top ranking in the treatment algorithm of major depression as does ECT. In sum, the TMS services from the time period specified were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old female enrollee has requested hydroquinone 4% cream for treatment of her post-inflammatory hyperpigmentation. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient developed post-inflammatory hyperpigmentation following an epidural steroid injection.  Post-inflammatory hyperpigmentation is due to the deposition of pigment in the papillary or mid-dermis.  Hydroquinone is a topical depigmenting agent that is useful for epidermal pigmentation, like melasma.  Hydroquinone is generally ineffective for the treatment of post-inflammatory hyperpigmentation as it does not penetrate to the appropriate depth in the skin.  Therefore, the requested hydroquinone 4% cream is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested hypertrophy liposuction for treatment of his gynecomastia.  Findings:  Two physician reviewers found that according to the photographs submitted, the patient has grade III-IV gynecomastia. Hypertrophy liposuction has been requested for treatment of the gynecomastia in addition to resection of glandular tissue. The peer-reviewed literature supports the use of liposuction as an adjunct to gynecomastia surgery to reduce the fibrous breast fat. A study by Hammond states that surgical treatment of gynecomastia is based on the underlying nature of the breast enlargement and ranges from direct surgical excision, to liposuction, to a combination of both, with skin excision performed as needed. In this patients case, the requested hypertrophy liposuction in combination with the approved direct excision is likely to be more effective in addressing both the glandular and fatty tissue. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 19-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that although acute hospitalization was initially indicated for this patient whose impairment encompassed the full-range of the bio-psycho-social-cultural model of conceptualization, as of the date indicated the medical record does not substantiate the need for continued inpatient psychiatric level of care. Despite requiring frequent redirection, the patient was not aggressive or violent in the milieu.  He did well with his behavioral plan on the unit.  He denied any suicidal ideation, homicidality or hallucinations.  He was future oriented.  He had been sleeping well and eating his meals.  He was tolerating his medications and the regimen was stable.  Although the patients chronically volatile relationship with his parents continued throughout the admission, these pervasive cyclical maladaptive behaviors were driven by the parent-child dynamic, not the result of an acute psychiatric syndrome. Thus, the acute services were not reasonably expected to significantly improve the patients condition or prevent a more serious illness. The services had become primarily custodial in nature while discharge planning continued. Accordingly, a less restrictive setting would have represented a safe and appropriate disposition consistent with current medical practice. Based on the documentation submitted for review and the relevant peer reviewed literature, it was not medically necessary for the patient to have been treated at an inpatient psychiatric level of care from the time frame specified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested testing using Tc-99 SPECT scan (IgG sub-class), punch nerve biopsy for small nerve neuropathy and Valcyte for treatment of his medical condition. Findings:  The physician reviewer found that although a recent study by Donta and colleagues refers to finding abnormalities in SPECT scans of patients with chronic Lyme disease, the study included no controls from which to compare the subjects. There is a lack of other recent studies demonstrating that SPECT brain scanning is valuable in the setting of Lyme disease. Per the medical records, a Tc-99 SPECT scan (IgG sub-class) is not likely to help diagnose any condition involved in this patients case.  The requested punch nerve biopsy for small nerve neuropathy is not medically necessary based upon the documentation provided. Peripheral nerve biopsy is not needed to diagnose the uncommon involvement of these nerves in Lyme disease. The requested medication Valcyte is not medically necessary for treatment of the patients condition. Valcyte is an antiviral agent and has no efficacy against bacterial organisms such as Borrelia burgdorferi. Based upon the documentation provided, the patient does not present with a condition that will benefit from use of Valcyte. There is no evidence that this medication is clinically indicated in this patients case.  In conclusion, testing using Tc-99 SPECT scan (IgG sub-class), punch nerve biopsy for small nerve neuropathy and Valcyte are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female enrollee has requested Lomotil for treatment of her pseudomembranous entercolitis. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. The patient has developed antibiotic associated diarrhea likely due to clostridium difficile. She was treated with Lomotil previously. She has had significant benefit from Lomotil without side effects. Although it is not optimal to use anti-diarrheals in the setting of clostridium difficile infection, the judicious use of anti-diarrheals is not typically associated with significant risk, particularly in mild cases. Furthermore, the patient has already received empiric treatment for clostridium difficile (Flagyl). Controlling diarrhea with Lomotil can prevent dehydration and electrolyte abnormalities. All told, the medical necessity of the requested medication has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Nutropin for treatment of her panhypopituitarism, chronic adrenal insufficiency, hypothyroidism, hyponatremia, growth hormone (GH) deficiency, and diabetes insipidus.  Findings:  The physician reviewer found that based on the documentation provided, this patient requires GH therapy, and Nutropin is supported as medically necessary. The American Association of Clinical Endocrinologists (AACE) noted the deleterious effects of GH deficiency in patient health and the benefits of replacement. The guidelines indicate that in the presence of organic disease (pituitary tumor followed pituitary resection surgery), the patient needs documentation of three pituitary hormone deficiencies and low IGF-1 with no stimulation test needed to establish the diagnosis of GH deficiency. The records indicate the patient has a low IGF-1 and has four noted pituitary deficiencies including thyroid, adrenal, gonadal, and antidiuretic hormone deficiencies. In this clinical setting, a stimulation test is not needed to confirm the diagnosis of GH deficiency. Thus, the diagnosis of GH deficiency is established and the requested Nutropin GH therapy is medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested brain DaT (SPECT) scan for evaluation of her hemifacial spasm.  Findings:  Three physician reviewers found the services at issue were not likely to have been more efficacious than other methods of evaluation.  The diagnosis of parkinsonism or Parkinsons disease is a clinical determination.  It is not standard of care to utilize a DaT scan to make this diagnosis.  A DaT scan may be beneficial when it is not clear whether a patient has an essential tremor or Parkinsons disease.  However, this was not the clinical scenario in this case.  Therefore, the brain DaT (SPECT) scan is not likely to have been of greater benefit than traditional diagnostic and clinical examination procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested Enbrel (etanercept) for treatment of his psoriatic arthritis. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be superior over other available treatment options.  The patient had a positive response to nonsteroidal anti-inflammatory medications in the past, and he has not had an adequate trial of conventional non-biologic disease-modifying antirheumatic drugs.  Treatment guidelines recommend nonsteroidal anti-inflammatory medications as a first-line treatment with non-biologic disease-modifying antirheumatic drugs as a second-line treatment.  If the number of joints found to be swollen on examination continues to grow or fails to respond to these medications, then a biologic disease-modifying antirheumatic drug such as Enbrel may be appropriate.  Therefore, Enbrel is not likely to be of greater benefit than other treatment alternatives in this clinical setting.