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

A 23-year-old female enrollee has requested residential treatment services and partial hospitalization program (PHP) services for the treatment of her eating disorder. Findings:  The physician reviewer found that the APA guidelines for the treatment of an eating disorder, specifically bulimia nervosa, states that a patient who can maintain her weight, has no electrolyte or EKG abnormalities and can reduce purging in an unstructured setting can benefit from continuing care at a community based program such as an intensive outpatient program. This patient has a psychiatric need for long-term treatment and would likely benefit from combined dialectical behavior therapy groups, family therapy and individual therapy with an experienced therapist. Her weight was close to her IBW, her electrolytes and cardiac statuses were not reported to be abnormal, and her binging and purging was controlled in a day setting.  The absence of life threatening behavior is also an indication for community based treatment. The patients long-term issues are amenable to treatment in the ambulatory setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a PET scan for evaluation of her breast cancer.  Findings:  The physician reviewer found that over the last decade, there have been many studies showing the efficacy of PET scan for staging breast cancer.  In October 2002, the Centers for Medicare and Medicaid Services (CMS) approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. PET scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. Furthermore, PET scan has been shown to be more sensitive, specific, accurate, and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases. PET scan has proven to have a significant impact on the care of breast cancer patients, influencing both clinical staging and management.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested continued acute inpatient rehabilitation for post subarachnoid hemorrhage treatment. Findings:  The physician reviewer found that a view of the record indicates the patient had multiple deficits involving cognition, communication, swallowing, head and trunk control and bilateral upper and lower extremity strength and movement. She has been receiving intensive, comprehensive neuro-rehabilitation with a multiple disciplinary approach. It appears from the record the patient has been participating in daily rehabilitation therapies and she has demonstrated steady small gains in communication, recall, right UE mobility and tolerance of oral feedings. She has also been decannulated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a robotic-assisted prostectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that radical prostatectomy is a good option for treatment of this patients condition. Laparoscopic radical prostatectomy has a similar oncologic outcome and probable lower morbidity compared to conventional open radical prostatectomy. There are no documented advantages to robotic assisted prostatectomy. This patient is a good candidate for a traditional laparoscopic radical prostatectomy and there is no evidence demonstrating he would have a better outcome with robotic assisted prostatectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested Provigil for the treatment of his shift work sleep disorder. Findings:  The physician reviewer found that the patient has a history of anxiety and depression. In addition to these diagnoses, he also suffers from shift work sleep disorder and is bothered by excessive sleepiness and difficulty sustaining attention. Provigil has been beneficial in this regard and its continued use is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested a wireless capsule endoscopy procedure for evaluation of her anemia. Findings:  Three physician reviewers found that a wireless capsule endoscopy is likely to be more beneficial for the patient than any available standard treatment. The patient has obscure, occult gastrointestinal bleeding. Recent literature suggests that wireless capsule endoscopy is superior to other studies for the detection of a small bowel source of bleeding.  The clinical decision in this case is to pursue a workup rather than empiric treatment with iron. Under the circumstances, wireless capsule endoscopy is the appropriate choice for evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Actiq for treatment of her breakthrough pain due to post-laminectomy syndrome. Findings:  The physician reviewer found that Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of opioid-resistant or allergic or intolerant breakthrough low back pain post surgery. The use of Actiq in this setting is not medically indicated and is not consistent with the community standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a magnetoencephalography (MEG) for evaluation of her epilepsy. Findings:  Three physician reviewers found that despite a comprehensive assessment, the patients seizure source remains obscure. Although it is still a relatively new technology, MEG has shown increasing benefit in localizing epileptic lesions. It has become a generally accepted diagnostic tool at major epilepsy surgery centers because of its ability to identify deep seizure foci that escape standard EEG. MEG is also helpful when MRI scans show a lesion that is discordant from EEG findings and MEG can map critical areas of brain function to optimize surgical planning. MEG should be considered a standard tool in the non-invasive, preoperative evaluation of potential candidates for epilepsy surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested Botox therapy for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that the severity of this patients symptoms will improve with Botox therapy.  In addition, the patients daily functioning will improve with Botox therapy. Furthermore, there is evidence to support the safety and efficacy of Botox therapy in the treatment of severe hyperhidrosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested pulsed radiofrequency (RF) nerve lesioning (and related services for treatment of her complex regional pain syndrome (CRPS).   Findings:  Three physician reviewers found that there is no documentation in the literature indicating pulsed RF lesioning is a standard therapy for CRPS. No single treatment is uniformly effective. Recommended therapies include physical therapy, pharmacotherapeutic agents (corticosteroids, tricyclic antidepressants, anticonvulsants, opioids and topical agents), sympathetic blocks, regional and neuraxial blockade and neuromodulation. The literature to date is limited to only a few controlled trials involving the treatment of trigeminal neuralgia and lumbar facet arthropathy. The use of pulsed RF lesioning in the treatment of CRPS is considered investigational. Studies are needed to determine the mechanism of action of this modality and to compare pulsed RF with conventional RF. The consensus to date is that successful treatment of this syndrome relies on an aggressive multidisciplinary approach that focuses on pain relief, physical rehabilitation and control of psychological dysfunction.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested a referral for annual follow-up visits at a liver transplant clinic for his post-transplant care.  Findings:  The physician reviewer found that based on the clinical evidence provided, the patient should be authorized for annual follow-up visits at UCLAs liver transplant clinic until he reaches the age of 18. Most transplant centers of excellence would consider standard of care/mandate their transplant patients to see them at least on an annual visit and it is appropriate for the patient to continue to be followed at UCLAs liver transplant clinic for purposes of continuity of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Januvia for the treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Januvia is approved for the treatment of type 2 diabetes. It is about as effective as the other oral medications the patient is taking to lower her blood sugar. Januvia is likely to  lower her hemoglobin A1c about 0.5-0.9%. The medication prescribed by the Health Plan physician, glipizide, is at least, or more effective in lowering blood sugar levels than Januvia. The patients most recent hemoglobin A1c concentration indicates that neither Januvia or glipizide is likely to adequately improve her blood sugars without additional help. This would typically involve a formal endocrine or diabetes team consultation in an effort to effect therapeutic lifestyle changes with diet and exercise to help control the patients blood sugar. Neither Januvia nor glipizide will help the patient to decrease her food intake or to lose weight sufficient to achieve a hemoglobin A1c below 6.5 or 7.0%  Another antidiabetic medication, exenatide (Byetta), is associated with decreased appetite and weight loss and has proven to be helpful for obese, type 2 diabetic patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested continued growth hormone (GH) therapy for treatment of his neurosecretory dysfunction.   Findings:  The physician reviewer found that before growth hormone therapy was initiated, the patients IGF-1 level was borderline low at 100ng/ml, his IGFBP-3 was normal at 5.0 ng/ml and his thyroid function test results were normal. Provocative GH stimulation testing after arginine and clonidine gave appropriate GH responses with a peak result of 15.8ng/ml. The patients bone age was delayed by approximately three years. His estimated adult height at that time would have been 58 exceeding the mid-parental height in the male tables of the Greulick and Pyle Atlas. The current mid-parental height estimate is 56.5. This patient appears to have a constitutionally delayed adolescence and would be expected to attain a normal adult height without GH therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested a CT angiogram for his chest pain.   Findings:  Three physician reviewers found that other approved alternatives could have been considered such as stress echo or single photon emission computed tomography (SPECT) imaging. In addition, there is no documented data to suggest a change in outcomes in this subset of patients. Currently, the CT angiogram is not a substitute for cardiac catheterization or nuclear SPECT imaging. The CT angiogram is not supported by the American Heart Association and a consensus statement in 2006 stated that the test is not ready for widespread use at the time. Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, and the need to use contrast, potentially nephrotoxic dye, as well as the radiation exposure. Furthermore, the clinical trials have been small.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested the medication Provigil for treatment of her depression.   Findings:  The physician reviewer found that there is growing support in the literature for the use of Provigil in the treatment of refractory major depression. The patient has tried various antidepressants and dosage adjustments without sustained improvement in her depressive symptoms. Alternative stimulant medications have also been tried. At this juncture, adjunctive Provigil is a reasonable approach and is known to be effective for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a STS continuous glucose monitoring system (CGMS) for treatment of her type I diabetes mellitus.   Findings:  Three physician reviewers found that Studies have demonstrated improved glycemic control with the CGMS. This technology is FDA approved and has been proven to alter the physiologic disease process, such as the frequency of hypoglycemia and the improvement in hemoglobin A1c values. There are few, if any, harmful effects. The CGMS is not considered investigational and this patient is an ideal candidate for the STS system. She has type I diabetes, had episodes of hypoglycemia and a hemoglobin A1c of 7.1% (goal = 6.5%) on insulin pump therapy. The patient had been checking blood sugars six to eight times daily, but this did not produce the same positive results as the CGMS. The patient is likely to benefit from long-term use of the STS system along with her insulin pump.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested the medication Provigil for treatment of his depression.  Findings:  The physician reviewer found that Provigil is FDA approved for the treatment of shift work sleep disorder, narcolepsy and obstructive sleep apnea/hypopnea syndrome. It is not approved for the treatment of depression. Although there is some data supporting the use of Provigil for the side effects of certain anti-depressant medications, it is not considered a standard medication for the relief of depressive symptoms. Furthermore, there are other more conventional medications available to this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a CTA for evaluation of coronary artery disease.   Findings:  Two physician reviewers found that there is no evidence the patient has had other forms of acceptable evaluation for risk stratification such as nuclear spect imaging or stress echo imaging.  In addition, the need to start statin therapy should not be based on CTA, but rather, the patients lipid profile, as the earlier has never been a clinical indication for such therapy. In this setting, other acceptable forms of risk stratification exist. Currently, CTA has not been shown to be of significant clinical benefit for patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested total ankle arthroplasty for treatment of her post-traumatic right ankle arthrosis.   Findings:  Two physician reviewers found that the American Orthopaedic Foot and Ankle Society has published a position statement regarding total ankle arthroplasty, which indicates the procedure is a viable option for the treatment of ankle arthrosis. The procedure has been shown to provide pain relief and restore motion in a severely arthritic joint. The patients treatment options were limited and it is not likely she would have experienced better results from other procedures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested a cochlear implant external processor replacement for treatment of her hearing loss.   Findings:  The physician reviewer found that the cochlear implant is useless unless there is a functional external processor that can be appropriately adjusted. The patients current processor outlived its usefulness. It was medically appropriate and indicated to replace that device. There was no alternative available for the patient and the processor at issue was integral to her hearing and was indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Lyrica for treatment of her radiculopathy.   Findings:  The physician reviewer found that the patient has a chronic pain syndrome and radiculopathy following spinal surgery. Presumably there are nocioceptive and neuropathic components to her pain. Alternative treatments including tricyclic antidepressants, anti-epileptic drugs and Cymbalta have been tried and were unsuccessful. There are no medications specifically approved for patients such as this one. Standard treatments have been sufficiently explored as well as invasive therapy with a spinal cord implant. Lyrica is approved for the treatment of diabetic peripheral neuropathy and post herpetic neuralgia. This medication is generally well tolerated and effective for these types of neuropathic pain. At this juncture, a trial of Lyrica is a reasonable clinical approach and likely to be beneficial in the management of the patients radiculopathy. If adequate dosages of Lyrica do not produce clinically significant improvement for this patient within two months, the trial should be discontinued.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The daughter of a 91-year-old female enrollee has requested continued stay at a skilled nursing facility (SNF) for treatment of a fracture of the humeral head and neck and two strokes.   Findings:  The physician reviewer found that the patient had a gastrostomy tube and received all of her nutritional support via the tube feedings. Her feedings were managed by the nursing staff and gastric residuals were checked each shift. This was a skilled nursing service. However, a gastrostomy tube and gastrostomy tube feedings are not part of usual and customary hospice care. As of the date in question, the patient was admitted to the hospice program and her skilled nursing care was managed by the hospice agency. The care provided by the SNF was custodial and more directed toward comfort than symptom management.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a mini gastric bypass for the treatment of morbid obesity.Findings:  Three physician reviewers found that National organizations such as the National Institutes of Health and the American Society of Bariatric Surgery have not recognized the mini gastric bypass procedure. There are only a few centers in the United States that are performing the procedure and the rates of bile reflux are a significant concern. The mini gastric bypass is not the standard of care and the procedure remains experimental. There is no clear indication that this patient could not be safely and effectively treated with standard bariatric procedures or that the mini gastric bypass offers a better surgical outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Botox injections for the treatment of task-specific focal dystonia (writers cramp). Findings:  The physician reviewer found that the safety of Botox has been sufficiently tested in other clinical applications and it was found to be safe. Botox therapy has clearly provided a benefit for this patient and continued treatment is consistent with the standard of care within the neurological community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested Penlac for the treatment of onychomycosis.Findings:  The physician reviewer found that the only medically appropriate treatments for fungus nail infections are oral antifungals, fungoid solution and Penlac.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested an MRI for evaluation of his neuroma.   Findings:  The physician reviewer found that MRI is the study of choice for assessing the internal auditory canals. This is widely known and is the standard of practice. Acoustic neuromas can slowly grow and serial imaging is indicated. Imaging should be performed on an annual basis for an indefinite period because some tumors (13.5%) can remain dormant for years before a growth phase. As such, an MRI of the brain is clinically indicated and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested thyroid surgery for treatment of her thyroid nodule.   Findings:  The physician reviewer found that the patient maintains that she has difficulty breathing and swallowing due to the nodule, however there is no objective documentation of this complaint and no evidence of this complaint until after surgery was requested.  There is no evidence that the nodule has enlarged to account for the new symptoms and the patient was not symptomatic when the nodule was initially discovered.  Finally, the patient has not been compliant with medical therapy for her hypothyroidism, which may in fact result in an overall decrease in the size of the thyroid gland and improve her described symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested breast reduction surgery without a six-month nicotine-free interval for treatment of her macromastia without a six-month nicotine-free interval.   Findings:  The physician reviewer found that recent studies support the premise that smoking (nicotine) increases the risk of surgical complications following breast reduction surgery. According to Chan and others nicotine is associated with a significant increase in wound healing problems. Moreover, the study by Bikhchandani, et al, reached the following conclusion: Stoppage of smoking in the peri-operative period should be adopted as an essential eligibility criterion for breast reduction. According to the literature, the likelihood of an uncompromised outcome is increased if the patient is nicotine-free for one month prior to breast reduction surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested percutaneous disc decompression for treatment of his degenerative disc disease.  Findings:  Two physician reviewers found that the patient has persistent complaints of low back pain. There is no mention of radiculopathy, nerve root tension or compression signs. The MRI demonstrated evidence of a posterolateral bulge at L4-5 with desiccation and diminished disc height and an annular fissure. There was no evidence of a disc herniation. Discectomy, either percutaneous, automated, or open, is performed for radicular pain of a neuro compressive etiology which has failed to respond to conservative treatment, or if there is a progressive neurologic deficit. In this instance, it appears the chief complaint is back pain and there is no indication of radiculopathy. A percutaneous discectomy would not be appropriate for the treatment of actual back pain which has been refractory to conservative measures.