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

A 27-year-old female enrollee has requested insertion of electrode for percutaneous tibial nerve stimulation and implantable neurostimulator electrode treatments for treatment of her interstitial cystitis.  Findings:  Two physician reviewers found that for patients with interstitial cystitis, multiple interventions are often necessary, with a combination of behavioral changes, pelvic floor physical therapy, counseling, oral medications, and bladder instillations. Hormonal manipulation in premenopausal women with menstrual flares may also provide benefit. Recently, continuous sacral nerve stimulation has been applied as an alternative, less-invasive therapeutic option for patients with lower urinary tract dysfunction not responding to conservative treatment. At this time, the current peer-reviewed literature fails to support percutaneous tibial nerve stimulation as an effective treatment for interstitial cystitis. This technique requires further study in order to establish its superior efficacy in this case.  Thus, the services at issue were not and are not likely to be superior over all other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested intensive outpatient therapy for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that in this patients case, intensive outpatient therapy from the date in question forward was and is medically indicated and is consistent with American Psychiatric Association guidelines. American Psychiatric Association guidelines indicate the percentage of ideal body weight should generally be greater than 85 percent for outpatient level of care, and patients should be self sufficient regarding eating and weight gain. Guidelines for a level of care higher than outpatient includes preoccupation with intrusive repetitive thoughts greater than three hour per day and a need for structure to gain weight, both of which are evident in this case.  The American Psychiatric Association guidelines indicate that patients who weigh less than 85 percent of their individually estimated healthy weight have considerable difficulty gaining weight outside of a highly structured program.  All told, in this patients case, the submitted documentation supports the medical necessity for intensive outpatient therapy from the date in question forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a liver biopsy and a Quad CT scan for evaluation of her focal nodular hyperplasia of the liver.  Findings:  The physician reviewer found that focal nodular hyperplasia is a benign lesion of the liver that has no malignant potential. A liver biopsy is not indicated in this case as two imaging modalities (CT and MRI) described pathognomonic features of focal nodular hyperplasia (feeding arterial vessel and a central scar). Furthermore, the size of these benign lesions do not present a risk. Thus, a liver biopsy is not indicated based on the patients imaging results. The liver biopsy will not alter the management of this patients care. Moreover, a Quad CT scan is not indicated as the patient has already undergone CT and MRI imaging which has resulted in a diagnosis of focal nodular hyperplasia. The results of a Quad CT scan will not have clinical utility in the care and management of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested cognitive rehabilitation (code 97532) for treatment of the enrollee, who is status post status epilepticus with resultant cognitive delay.  Findings:  Three physician reviewers found that in this patients case, cognitive rehabilitation is likely to be the most beneficial treatment for this patient. At issue is the notion that plasticity in the developing brain exists and can be utilized to improve overall neurologic health.  Thus, specific treatment, including cognitive therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process.  Given that the patients neurodevelopmental status was normal prior to the onset of her refractory seizures, cognitive rehabilitation may help her achieve independence in her activities of daily living by fully utilizing brain circuitry not affected during her status epilepticus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested Avastin combined with carboplatin and gemcitabine for treatment of his lung cancer.  Findings:  Three physician reviewers found that the tissue diagnosis was that of a poorly differentiated, focally keratinizing, superficially invasive squamous cell carcinoma.  The patient had a pleural effusion which did not involve tumor cells.  A mediastinoscopy showed a positive subcarinal lymph node making him stage IIIA.  Other scans did not show extrapulmonary metastases.  At this point, his oncologist stated that the patient would not be a surgical candidate and that chemotherapy would be the next step.  The provider has recommended Avastin combined with carboplatin and gemcitabine.  Avastin has been shown to prolong survival in patients when given in combination with paclitaxel/carboplatin.  It has also been combined effectively with docetaxel or pemetrexed.  However, a randomized phase II study by Johnson and colleagues showed that bleeding was a major adverse event which was correlated with squamous cell histology. Avastin is indicated for non-squamous non-small cell lung cancer.  Recent Avastin trials have excluded squamous cell histology.  Therefore, the requested therapy is not likely to be the most beneficial treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old male enrollee has requested Zometa for treatment of his multiple myeloma with spinal metastasis. Findings:  The physician reviewer found that biphosphonates are a class of drugs that appear to decrease bone resorption in situations such as osteoporosis as well as in metastatic cancer to bone. They have become standard therapy in many types of cancer including myeloma. In such situations, they decrease the rate of skeletal complications such as fractures or the need for radiation therapy. The issue in this case is the choice of biphosphonate: Zometa or pamidronate IV. Pamidronate is the older of the two drugs. It requires at least two hours of infusion time monthly. Zometa is given over 15 minutes monthly. Rosen reported on a randomized study of Zometa versus pamidronate involving 1648 patients with myeloma or breast cancer. Though in many endpoints there was equality between the two drugs, those who received Zometa had a significantly lower incidence for the need for radiation therapy as compared to patients receiving pamidronate. Thus, this study does provide some justification for the use of Zometa over pamidronate. Furthermore, myeloma patients on Velcade often have to visit their oncologists office more than once per week. The additional burden of a two-hour (or more) monthly infusion of pamidronate can be quite burdensome in this setting. Zometa has become the standard in most oncology practices. Its use in this particular case is medically reasonable and necessary and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Velcade for treatment of his primary effusion lymphoma.  Findings:  Two physician reviewers found that Primary effusion lymphoma is a very rare form of lymphoma ocurring predominantly in HIV positive patients.  The data regarding Velcade for the treatment of primary effusion lymphoma is very minimal.  This medication has demonstrated some in vitro activity against primary effusion lymphoma, usually when combined with other agents.  Siddiqi and colleagues reported a favorable response in one HIV positive patient who was treated with a combination of bortezomib, liposomal doxorubicin and Rituxan.  However, the contribution of bortezomib in that case is unknown.  At this time, there is a lack of data demonstrating the efficacy of Velcade in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Botox injections for treatment of her intractable migraine.  Findings:  Two physician reviewers found that this patient has continued to have daily headache despite treatment with multiple prophylactics, including lamotrigine, topiramate, amitriptyline, acupuncture, and elimination diets. She uses triptans as acute therapy.  Botox has been recommended.  Phase 3 studies of Botox for treatment of individuals with chronic migraine, not on other preventives, showed definitive statistical and clinical benefit in reduction of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox-treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives, suggesting that Botox may be more effective than standard preventives, even in individuals who have not tried and failed standard therapies. Therefore, Botox injections are likely to be superior over all other treatment options for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested rehabilitation services for treatment of his substance abuse.  Findings:  The physician reviewer found that the records indicate that the patient was able to achieve sobriety for several weeks prior to his admission to this program. There is no indication of serious medical sequelae related to his drinking or risk of withdrawal. He had not failed treatment in a less intense setting and there is no evidence that his living situation was subversive to sobriety. There were no documented behavioral issues which necessitated skilled observation and containment on a 24/7 basis. Furthermore the level of programming is not commensurate with intensity of services criteria for a 24-hour setting, as the patient received less than three hours of treatment per day. The data reviewed are inconsistent with American Society of Addiction Medicine guidelines and American Psychiatric Association guidelines as the patient could have been safely and effectively managed on an ambulatory basis during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested Intuniv medication for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that Intuniv is approved by the Food and Drug Administration (FDA) for the treatment of ADHD in children and adolescents 6-17 years of age. To date, the efficacy of Intuniv has been established in controlled trials (Sallee and colleagues) in more than one report. Intuniv is a long acting form of guanfacine (Tenex) and is not interchangeable with Tenex (Connor and colleagues). The authors state that, because of different pharmacokinetic guanfacine extended release is not substitutable on an mg for mg basis with immediate release guanfacine.  In addition, while commonly used off-label for treatment of ADHD, Tenex is an immediate release form of guanfacine and does not have FDA approval for ADHD. In addition, Tenex carries the risk of hypertensive crisis if stopped abruptly. Thus, it would not be in the patients best interest to discontinue Intuniv for a trial of Tenex when Intuniv which has been beneficial for the patients medical condition. For these reasons, the records provided have established the requested medication as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female has requested proton beam therapy for treatment of her pulmonary and spinal metastases secondary to progressive uterine leiomyosarcoma.  Findings:  The physician reviewer found that a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron).  Charged particles (such as protons and carbon) can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerators (LINAC), which deliver photon therapy (akin to high energy light), whereas protons (and other charged particles) are generated from a cyclotron. The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue.Certain conditions, such as base of skull and spine chordomas and chondrosarcomas, and pediatric central nervous system malignancies are well-suited to treatment with proton therapy due to the sharp dose fall off, allowing high dose delivery to the tumor, while sparing the neighboring normal tissue. For this patient, there is no compelling reason to treat her spinal metastases with proton therapy versus conventional therapy. The submitted evidence indicates this patient has already started a course of external beam radiation for her spine metastases. She is receiving appropriate, standard treatment for her spinal lesions. The use of proton therapy in this setting is not standard of care and there is an absence of literature supporting its use in patients with metastatic disease to the spine.  Likewise, there are no published reports on the use of proton therapy for lung metastases.  For patients with lung metastases who are undergoing treatment with radiation, stereotactic-body radiotherapy (SBRT) has become standard therapy. While SBRT can deliver photon or proton irridation, there is a paucity of literature studying the difference in the two approaches. A study by Georg and colleagues found minimal dosimetric differences between photon and proton SBRT. Furthermore, the only studies published to date involve primary lung cancer rather than metastatic lung disease, which is involved in this case.All told, review of the relevant scientific literature as well as the clinical documentation submitted with this appeal does not establish the medical necessity of proton therapy for treatment of this patients spinal and pulmonary metastases.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested an MRI of the lower extremities (feet/ankles) for evaluation of her bilateral foot pain. Findings:  Two physician reviewers found that this patient has disabling bilateral foot pain.  Her underlying diagnosis is consistent with unknown connective tissue disorder.  Her symptoms may reflect plantar fasciitis, but also could reflect other inflammatory conditions.  MRI is the best imaging choice with which to evaluate this patient in order to obtain a diagnosis and allow the clinicians to form a treatment plan which may be of benefit for her.  No other imaging test will offer as much information.  All told, the requested MRI of the lower extremities is likely to be the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested physical therapy, two times per week, for treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that extensive physical therapy may be necessary following anterior cruciate repair in order to achieve optimal clinical outcome. Closely supervised therapeutic exercise and neuromuscular training is critical to restoring knee joint stability and proper joint motion. There is evidence in the literature that younger patients, in particular, may require more prolonged courses of supervised therapy in order to insure adherence to their rehabilitation program.  In this patients case, the treating orthopedic surgeon has recommended that supervised therapy be continued due to the patients skeletal immaturity and the complicated nature of his surgical repair.  In the case under review, the inability of the patient to correctly perform therapeutic exercise without skilled supervision has been documented. Given his young age, complexity of the surgical repair and ongoing need for closely supervised treatment, continuation of skilled therapy was necessary.  All told, physical therapy, two times per week, was and is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested computer-aided detection (CAD), including computer algorithm analysis of magnetic resonance imaging data for lesion detection/characterization (CPT code 0159T) for evaluation of her right breast cancer. Findings:  Three physician reviewers found that there has been some debate in the literature concerning the efficacy of CAD streaming in the interpretation of breast MRI. Overall, the technique has gained considerable popularity among radiologists over the past few years. While CAD cannot replace the expertise of a radiologist in the interpretation of this complex examination, it has been repeatedly demonstrated that the use of CAD improves the efficiency of the reading radiologist and provides another set of eyes in the interpretation of the study. While some radiologists interpret this exam without CAD streaming, providers who use it find it very valuable in much the same way that CAD assistance helps in the interpretation of digital mammography. Thus, although the use of CAD is not absolutely necessary for the interpretation of breast MRI, it is a useful diagnostic adjunct and is no longer considered investigational for this indication.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a bilateral breast MRI for evaluation of the enrollees breast nodules. Findings:  Three physician reviewers found that this patient has bilateral, solid, probably benign lesions as determined by mammogram and ultrasound.  MRI is not indicated as a test in order to determine if biopsy is indicated.  If the lesions are suspicious, ultrasound-guided core biopsies are indicated.  Absent tissue sampling, follow-up ultrasound is also appropriate.  In this patients case, the requested bilateral breast MRI is not likely to be superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a thigh lift as well as excision of excessive buttock and back skin for treatment of his excess skin. Findings:  The physician reviewer found that in the absence of skin conditions, this pattern and severity of excess skin should not interfere with activities of daily living for this patient.  There is no documentation of a physical examination describing a skin condition related to the excess skin or office visits for treatment of such a skin condition in the reviewed records.  A thigh buttock lift or belt lipectomy lifts the thighs and buttocks by removing a circumferential segment of skin at the belt level. It is basically an abdominoplasty that is extended around to the back so the incision ends meet. The submitted photographs show little or no excess back skin, so the proposed procedure is the second half of a belt lipectomy and is primarily designed to lift the thighs.  Based upon the photographs, the patients condition does not constitute an abnormal structure of the body.  All told, the requested thigh lift as well as excision of excessive buttock and back skin is not reconstructive in nature and is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is a 40-year-old female who has requested a duodenal switch procedure for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient is morbidly obese, has failed supervised weight loss and has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery. The patient is requesting the duodenal switch, a standard procedure for treatment of morbid obesity that is approved by the American Society of Metabolic and Bariatric Surgery, the American Medical Association and the Centers for Medicare and Medicaid Services. There are no contraindications to the duodenal switch procedure based on the information provided. Therefore, the duodenal switch procedure is a medically appropriate and reasonable option for treatment of this patients morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Flector 1.3% patch for treatment of her ankle sprain. Findings:  The physician reviewer found that there is evidence in the literature indicating that patch usage as a drug delivery system may provide pain relief by a local action involving diclofenac accumulation, with a lower rate of gastrointestinal effects than noted with oral intake (Petersen and Rovati). The use of a gel offers similar pain relief to the patch in treating the pain associated with sports-related soft tissue injuries, and the most common adverse events noted were the skin reactions and gastrointestinal symptoms.  In this case, the problem is chronic rather than acute, and the patient implies that she anticipates continued usage of the patch rather than shorter term use for an acute problem. There is no mention of the use of diclofenac as an oral medication, nor any problems associated with oral intake of that medication. There is no report of other measures to reduce the problems associated with the use of other NSAID medications. There is no report of problems swallowing medications.  Since there appears to be a favorable response by the patient to diclofenac delivered by patch, and there is no documentation of a trial of the use of this medication in oral form, the medical necessity for the use of a patch is not demonstrated.  All told, Flector 1.3% patch is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested IVIG infusion and coverage for future IVIG infusions for treatment of her recurrent miscarriages.  Findings:  Three physician reviewers found that the American College of Obstetrics and Gynecology Practice Bulletin concluded that IVIG is not effective in preventing recurrent pregnancy loss.  A review of current literature and meta-analyses indicates inconsistent and very poor results with IVIG for recurrent pregnancy loss.  In addition, the only patients in whom there is a report of possible improvement are those with secondary recurrent miscarriage, or miscarriages following a successful pregnancy.  In primary recurrent miscarriage, where a woman has not had a prior successful pregnancy, treatment with IVIG has shown no improvement compared to placebo therapy.  Porter and colleagues concluded that IVIG treatment provides no significant beneficial effect over placebo in improving the live birth rate.  In conclusion, studies to date do not support IVIG as therapy for this condition, with results indicating no more efficacy than placebo.  In addition, it is not clear that other causes, such as chromosomal abnormalities, have been excluded.  Therefore, IVIG infusions were not and are not likely to be superior over all other treatment alternatives.