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

A 41-year-old male enrollee has requested Xifaxan 550mg, three times daily, for 14 days for treatment of his small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that after a review of the literature, the standard of care is to limit the dose to 1650mg per day of Xifaxan for seven days. The data suggests that at least 1600mg per day should be given for maximal efficacy in SIBO. Overall, about 80% of patients will have a negative hydrogen breath test when performed four weeks after seven days of treatment at 1600mg. This therapy is superior to monotherapy with either metronidazole or tetracycline derivatives. Pimentel and colleagues article discussion on use of a 14 day course was conducted in a population of patients with IBS. However, the endpoints were not the proportion achieving resolution of SIBO, but of symptoms of bloating and diarrhea. Therefore, many patients likely had resolution of their SIBO, but this number was far higher than the proportion who achieved significant improvement of their IBS symptoms. This may be due to the fact that many patients have diarrhea predominant IBS that has nothing to do with the gut microbiome. All told, one week of Xifaxan is usually sufficient to resolve SIBO in the majority of patients. Overall, there is not enough data to demonstrate that two weeks is more beneficial than one week in resolving SIBO and there is no data demonstrating that the longer course is better than the shorter course for symptom improvement. Consistent with these findings, the requested medication dosage is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 79-year-old female enrollee has requested vaginal vault suspension and anterior repair with suburethral sling and mesh placement for treatment of her uterine prolapse and cystocele.  Findings:  The physician reviewer found that in reviewing American College of Obstetricians and Gynecologists (ACOG) practice guidelines, pessary use may be considered prior to surgical intervention in patients with symptomatic pelvic organ prolapse. There should be a documented assessment by the surgeon regarding the option of pessary use, including the rationale for using or not using, such as patient discomfort, technical contraindications such as not being able to fit one, or patient refusal. However, pessaries have not been objectively demonstrated to improve incontinence symptoms. In addition, ACOG suggests that colpoclesis should be considered in patients at high risk for complications and who are not sexually active. All told, the requested surgical intervention is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested injections of Orthovisc for treatment of his left shoulder osteoarthritis. Findings:  Three physician reviewers found that the requested therapy is not likely to be more effective than other treatment modalities in this patients case.  Orthovisc is indicated for the treatment of pain due to osteoarthritis of the knee and temporomandibular joint in patients who have not responded to conservative treatment.  The superior efficacy of the requested therapy has not been established for the shoulder joint.  There is a lack of peer-reviewed data demonstrating the safety and efficacy of Orthovisc injections in this clinical setting.  Current clinical guidelines do not support the requested therapy for the treatment of shoulder osteoarthritis.  All told, three Orthovisc injections are not likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested osteochondral allograft transplant treatment of her two focal cartilage defects. Findings:  Two physician reviewers found that based on the medical literature, osteochondral allograft procedures are indicated for isolated lesion of the knee. This patient is noted to have several lesions, including one on the medial femoral condyle, one on the lateral femoral condyle, as well as grade 4 chondromalacia of a good portion of the patella. Given this global loss of articular/osteoarticular tissue, allografting is not likely to be a successful treatment option. Therefore, the requested services are 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 3-year-old male enrollee has requested speech therapy, applied behavioral analysis (ABA) therapy, and occupational therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has been proven to be an effective therapy based on multiple controlled studies (Turner and Stone). This patient has been diagnosed as autistic and ABA therapy remains the documented therapy of choice in this setting; therefore, ABA therapy is medically necessary at the requested frequency. The scientific literature also strongly supports the value of speech therapy in autistic children. Goldsteins paper discusses the multiple techniques that can be successful in teaching autistic children to communicate. A paper by Turner and colleagues is a controlled study comparing autistic children who did and did not receive speech therapy. Those who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the American Speech-Language Hearing Association states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. There is also strong scientific evidence supporting occupational therapy in autistic children. Pfeiffer, et al, reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism. In conclusion, it is medically necessary that this patient receive the requested 10 hours per week of ABA therapy with 20 hours of consultation per year, the requested speech therapy at a frequency of 30 minutes twice a week and the requested occupational therapy. All therapies should be continued for a minimum of six months with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested clonazepam (Klonopin) 3 mg per day (1 mg, three times per day) for treatment of his chronic fatigue syndrome. Findings:  The physician reviewer found that in a head-to-head study with fluoxetine, Clonazepam showed fewer adverse events and better efficacy for anxiety disorder than the SSRI. The documentation provided shows poor work-up and monitoring. The patient has failed SNRIs and other therapies. Klonopin protocol at 3 mg per day is a reasonable request given this patients anxiety and fatigue. Further, cessation of Klonopin could place the patient at risk for severe exacerbation of his anxiety and panic disorder, which may lead to worsening chronic fatigue. Klonopin improves this patients fatigue and anxiety and is therefore supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested excision of a benign lesion on the right mid upper arm for treatment of her skin lesion. Findings: The physician reviewer found that Nevus lipomatosis superficialis, also known as Nevus lipomatosis of Hoffman and Zurhelle, is characterized by soft, yellowish papules or cerebriform plaques, usually of the buttock or thigh, less often of the ear or scalp, with a wrinkled rather than warty surface (Rapini, et al). This is a benign lesion that does not have a risk for malignant transformation. Flesh-colored intradermal nevus is comprised by the nevus cells located in the dermis that may extend into the subcutaneous fat. Intradermal nevi are seen mainly after adolescence. Intradermal nevi are elevated, fleshy, and slightly or moderately pigmented papules. Dome-shaped lesions are the most common. Lesions vary in size from a few millimeters to a centimeter. The variety of shapes reflects the evolutionary process in which moles extend downward with age and nevus cells degenerate or become replaced by fat and fibrous tissue. Elevated nevi are exposed and prone to trauma from clothing and other stimuli, often causing them to bleed and inflame, influencing some patients to suspect malignancy (Bolognia, et al). Malignant amelanotic melanoma has been reported to develop from an intradermal nevus. Histopathologically, the tumor revealed benign nevus cells in the upper dermis and atypical malignant tumor cells in the deeper dermis. Wu and colleagues reported that immunohistochemistry using HMB-45 showed intensive positive staining in the deeper dermal tumor cells. All told, excisional biopsy of the lesion is indicated to rule out a possibility that an intradermal nevus harbors premalignant or malignant cells. The entire lesion should be excised to ensure that no abnormal cells are left in the skin. Consistent with these findings, the requested excision of a benign lesion on the right mid upper arm is a diagnostic procedure, which is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested BRCA testing for evaluation of her family history of cancer.  Findings:  Two physician reviewers found that the medical records note that she does not have a personal history of cancer.  The patients father was diagnosed with prostate cancer at 80 years of age, and her mother was diagnosed with breast cancer at 78 years of age.  Additionally, her grandfather was diagnosed with colon cancer in his 80s, a cousin was diagnosed with rectal cancer at age 62, and an aunt was diagnosed with breast cancer in her 60s.  BRCA mutations are associated with a high incidence of both breast and ovarian cancer.  Information regarding whether a patient is BRCA positive can have several implications with regards to patient management.  As to breast cancer, patients may consider more intense screening or bilateral mastectomies.  With regards to ovarian cancer, patients may elect to undergo bilateral salpingo-oophorectomy.  According to National Comprehensive Cancer Network Guidelines, women without cancer should be tested if there is a first-degree or second-degree relative diagnosed with breast cancer who also fulfills other criteria, such as young age, two breast primaries, or triple negative cancer.  In this patients case, she is Ashkenazi and her mother had breast cancer.  Per current recommendations, BRCA testing is not indicated at this time.  It is medically appropriate to undergo testing with an Ashkenazi panel prior to performing BRCA testing.  The medical records do not indicate that an Ashkenazi panel has been provided.  All told, the requested BRCA testing is not likely to be superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested coverage for Strattice (xenograft) for treatment of her incisional hernia.  Findings:  Two physician reviewers found that the patient is status post gastric bypass surgery. The patient has lost 65 pounds but remains obese. The records indicate that she developed an incisional hernia that could not be repaired by primary closure. The patient required component separation to allow primary closure. A posterior bridge was used to support the primary closure with xenograft (Strattice) mesh.  This patient presented to her provider with a symptomatic ventral hernia which required surgical repair. Per the records, the patient has at least one major risk for recurrence in the form of continued obesity. The provider noted that component separation was necessary to permit restoration of a functional muscular wall and closure of the hernia. Primary suture repair is associated with an increased risk of recurrence (Luijenddijk, et al). The use of mesh remains controversial, but the available data does support use of mesh as an underlay in well-selected patients. As with this patient, the mesh was placed intraperitoneally, which in most cases precludes use of a prosthetic mesh due to risks of adhesion. Patel and colleagues reported excellent results with Strattice without recurrence with follow-up at one year. Thus, in this patients case, the use of Strattice was likely to be superior to the use of prosthetic mesh.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested in-home nursing care for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that the requested skilled nursing services are not medically necessary for this patient. Review of the submitted documentation including a comprehensive assessment on the date indicated reveals that the patients needs are custodial in nature and do not necessitate skilled nursing services. Assistance with activities of daily living such as eating, grooming, dressing, and provision of certain medications are considered custodial care. Additionally, although safety concerns are documented, skilled nursing services are not medically necessary to respond to these concerns as such issues are typically addressed by non-skilled caregivers or other custodial measures. All told, there is a lack of evidence that the patient has functional or medical needs that require a skilled nursing level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested Botox injections for treatment of her chronic migraine. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services in this patients case.  This patient has a diagnosis of chronic migraine, with reported headaches greater than 15 days per month at baseline.  She has been on prior preventive medications, including antidepressants.  The patient reported significant benefit following Botox injections, with reduction of headaches by greater than 50%.  The medical literature indicates that Botox injections are effective for chronic migraine.  The current medical evidence has established the efficacy of Botox injections in this clinical setting.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested human growth hormone therapy for treatment of his myopathy.  Findings:  Three physician reviewers found that the superior efficacy of the requested human growth hormone has not been established in this patients case.  He has demonstrated drug-induced mitochondrial myopathy secondary to antiretroviral drug therapy.  In this clinical setting, standard treatment includes physical therapy.  There is a lack of double-blind, placebo-controlled trials demonstrating the efficacy of human growth hormone therapy in this case.  There is a lack of support in the medical literature demonstrating the effectiveness of the requested therapy for drug-induced myopathy.  Therefore, the requested therapy is not likely to be more effective than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested lumbar spinal fusion for treatment of her back and leg pain.  Findings:  The physician reviewer found that this patient has chronic back pain. However, the records do not document that her pain generator has been identified. Her MRI scans did not show any evidence of canal or foraminal stenosis, and x-rays did not demonstrate any instability. A patient at 54-years of age is expected to have some degenerative disc disease, as well as a positive nuclear study, as with this patient at L5-S1. In the medical literature, Chou and colleagues noted that provocative discography is not recommended as a procedure for diagnosing discogenic low back pain due to the high rate of false positive results. Further, Resnick and colleagues noted that discography should not be used as the decision maker for lumbar fusion. Bambakidis and colleagues discussion on indications for spinal fusion include infection, tumor, fracture, spondylolysis with spondylolisthesis, and spinal stenosis. None of these indications for spinal fusion are present in this patients case. All told, the requested surgery exceeds the needs for this patient and therefore is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested continued skilled nursing facility (SNF) services including physical therapy and occupational therapy for treatment of the his cerebral palsy.  Findings:  The physician reviewer found that the duration of therapy and interdisciplinary inpatient care for patients with tetraplegia has not been scientifically established (Teeter, et al). This patient has been unable to make any gains with two weeks of skilled therapy and has minimal residual function. Overall, a two week trial is a reasonable period of time to assess a patients response to rehabilitation (Albert, et al). While it is reasonable for the patient to continue a rehabilitation course, it is not medically necessary for him to have continued daily inpatient stay. The intensity of rehabilitation has not changed the patients outcome in a clinically significant way and intense therapy is not the method for addressing the patients spasticity (Kheder and Nair). All told, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female enrollee has requested  intravenous immunoglobulin (IVIG) therapy for treatment of her immune system dysfunction. Findings:  The physician reviewer found that the accepted treatment for IgG subclass 1 deficiency with evidence of recurrent infections and failure to respond to immunizations is replacement with IVIG, as was recommended by the provider in this case. On review of the available medical literature, there is inadequate justification for using prophylactic antibiotics or Plaquenil, as suggested by the Health Plan, as neither of these treatments has been proven to be effective in the treatment of IgG subclass 1 deficiency. Given this patients diagnoses, the requested IVIG therapy is supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested integrative medicine services for treatment of her metastatic breast cancer. Findings:  The physician reviewer found that although stage IV breast cancer is incurable, there is a lot of variability in patient survival times due to heterogeneous tumor behavior and treatment responses.  The steroidal and nonsteroidal aromatase inhibitors are important drugs that have benefit for stage IV patients in randomized clinical trials, although tumors may progress.  In the setting of tumor progression, the mammalian target of rapamycin (mTOR) pathway has been thought to account for resistance to endocrine therapy.  In the trial by Baselga and colleagues, patients with early and advanced hormone receptor positive disease were randomized to exemestane and everolimus, an mTOR kinase inhibitor, versus exemestane on its own.  Progression-free survival was the endpoint, and the analysis showed that the combination treatment arm had a median survival of 10.6 months compared with 4.1 months for exemestane alone.  This was highly statistically significant, showing improved progression-free survival in patients receiving both drugs.  The patient is being treated with the standard options, and she can receive the current regimen in-network.  In this patients case, the requested integrative medicine services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested uterine vein embolization for treatment of her pelvic congestion syndrome. Findings:  Two physician reviewers found that chronic pelvic pain is a common and disabling condition often affecting women of childbearing age. The condition may be caused by endometriosis, pelvic inflammatory disease, or referred pain. Pelvic congestion syndrome is a condition of chronic pelvic pain believed to be related to varices of the ovarian veins and can be of variable locations and intensity. Due to the variability of symptoms, diagnosis may be difficult. Treatment with vein embolization includes risks such as vessel injury, allergy, failure, and radiation exposure. Per the medical literature, the procedure is not supported by adequate scientific data as equivalent or superior to standard therapies. Overall, there is a paucity of studies demonstrating the long-term safety and efficacy of the procedure, especially compared to proven interventions. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested IVIG therapy for treatment of her history of herpes simplex keratitis. Findings:  Three physician reviewers found that the submitted medical records fail to demonstrate that IVIG therapy is likely to be more efficacious than other treatment options.  There is no laboratory support for a diagnosis of herpes infection, and there is no evidence of IgG deficiency.  Based upon the submitted documentation, the patients total IgG levels have been normal.  Per the current medical literature, there is insufficient support for the requested therapy for ocular herpetic infection.  Therefore, the requested IVIG therapy is not likely to be of greater benefit than other treatment options in this patients case.