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

A 32-year-old male enrollee has requested a lumbar spine MRI for evaluation of his back pain.  Findings:  The physician reviewer found that for patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma and no neurological deficits),  it is medically appropriate to undergo a trial of conservative therapy including NSAIDs and physical therapy prior to advanced imaging such as MRI.  This has been well-established in the medical literature. If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate. As there is no documentation of a recent trial of conservative therapy and this patient has uncomplicated back pain, the requested diagnostic procedure is not medically indicated in this patients case.  All told, the requested lumbar spine MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested laparoscopic ureterolysis-CO2 laser procedure for treatment of her obstruction and adhesion of the ureter. Findings: The physician reviewer found that urinary tract involvement through deep infiltrating endometriosis proves to be a rare condition with an incidence range of 0.3-5% and in about 0.08-4.6% of patients with endometriosis. Ureteral endometriosis can be differentiated into extrinsic or intrinsic disease. In the former and most frequent case, the endometriosis is in close proximity to the ureter, whereas in the latter it is characterized by the presence of endometriotic glands and stroma in the ureteral muscularis. The surgical management of deeply infiltrating endometriosis involving the ureter is a complex procedure that requires an accurate balance between the need for complete excision of endometriotic foci and the need to avoid any morbidity associated with radical surgery. Owing to the rarity of ureteral involvement in women with pelvic deeply infiltrating endometriosis, large-scale controlled, randomized studies on its surgical treatment are still lacking, and a clear surgical strategy for dealing with this condition has yet to be identified. Ureterolysis is the surgical technique in which extrinsic disease is removed. With the development of laparoscopic technique, ureterolysis may now be performed using a minimally invasive technique that respects the same principles as traditional urological surgery. Ureterolysis may be used as the initial surgical step for patients with ureteral endometriosis, and may be the only treatment if the extension of ureteral involvement is limited in length and there is no residual ureteral damage or dilatation. In this case, after the patients hospital stay, reports that endometriosis was present adjacent to the ureter. There is no documentation in the operative summary that there were endometrial implants adjacent to the ureter. The identification of the ureter apparently required some dissection in the area of the infundibulopelvic ligament and mid-pelvic sidewall. However, this surgical maneuver as described in the operative summary does not describe a ureterolysis procedure for endometriosis. It was also not a procedure of a complicated nature requiring extensive and advanced technique. Therefore, the procedure at issue was not sufficiently medically intensive to justify a separately billable service.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The guardian of a 64-year-old female enrollee has requested  inpatient mental health services for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that during the dates of service at issue, the patient was still disorganized and was unable to care for herself or be managed outside an institutional setting. However, there is no evidence of acute suicidality and there is no indication that the provider was directly assessing suicidal risk regularly. Although the patient required an institutional setting during the disputed period, there is no evidence that she was could not have been safely and effectively managed in an intermediate care facility from the date in question forward. Additionally, the treatment involved a non-evidence-based approach of using five different mood stabilizing drugs, with no apparent dose maximization and no consideration of a change to Clozaril despite the fact that the patient continued to be highly symptomatic. As such, the services provided were incompatible with American Psychiatric Association practice guidelines for managing bipolar patients. All told, inpatient mental health services provided from during the time frame were not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Lucanix for treatment of her metastatic non-small cell lung cancer. Findings:  Three physician reviewers found that Lucanix is an anti-tumor vaccine that inhibits transforming growth factor beta-2.  In 2006, Nemunaitis published a report of treatment of 75 patients with non-small cell lung cancer. In this study, the authors compared two doses and found that patients on the higher dosage had improved survival. There was no comparison of these patients with patients treated in other ways. The authors concluded that there was a suggestion that this inhibition might be of survival benefit, and that further study was warranted. The most promising results of vaccine therapy of non-small cell lung cancer involved patients with early or locally advanced stages of disease.  This patient has widespread disease (Gridelli and colleagues).  At this time, there is insufficient data demonstrating that Lucanix is likely to be of clinical benefit in a patient with advanced disease.  Therefore, in this patients case, Lucanix from the said date and forward was not and is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Celebrex 200 mg capsules for treatment of her rheumatoid arthritis, fibromyalgia and osteoarthritis. Findings: The physician reviewer found that the relevant medical studies on Celebrex in the treatment of patients with osteoarthritis and rheumatoid arthritis patients have demonstrated positive results. Celebrex is also FDA approved for use in osteoarthritis related and inflammatory pain. In addition, this patient has experienced severe adverse reactions to other NSAIDs including GI bleeding. Also, she has been on this medication, well monitored and with good results for at least six years. Thus, the requested Celebrex should be approved for this patient, due to significant contraindication to taking non-selective COX inhibitors, other adverse events noted in the medical record, and her reported relief with Celebrex.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for 12 months for treatment of the enrollees autism and global developmental delay. Findings:  The physician reviewer found that ABA therapy has been in existence for at least 30 years and has been widely used in the therapeutic intervention in autistic children. In clinical trials, Dawson and colleagues conducted the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of the ASD diagnosis. Further, when comparing patients treated with ABA therapy versus those who received standardized therapy, ABA is noted to provide a statistical improvement in cognitive, language, and adaptive behavior skills. Eikeseth stated that children who received ABA therapy made significant gains compared to those in special education. On average, the children who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, without further gains. On review of the new information provided in this patients case, she has not received three years of therapy as previously indicated by the Health Plan. In fact, she has only been participating in 30 hours per week of ABA therapy since said date. As reported by Lovaas in the peer reviewed medical literature, the requested 30 hours per week of intensive ABA therapy is required for at least one year in order for the patient to yield the maximum benefits from treatment. Thus, based on a recent progress report, the ABA therapy should be approved for this patient as medically necessary from the date requested and forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested ambulatory cardiac event monitor with mobile cardiac outpatient telemetry (MCOT) for evaluation of the enrollees transposition of the great arteries status post arterial switch with evidence of sinus node dysfunction with an accelerated junctional rhythm as well as occasional junctional escape rhythm with pacemaker placement.  Findings:  The physician reviewer found that evaluation with MCOT provides real-time remote heart monitoring and automatically transmits an electrocardiogram (EKG) to a center for analysis. The service offers a diagnostic advantage when the patient is unable to activate the device, as in the case of syncope, and may be experiencing a life threatening arrhythmia. In the diagnosis of patients with symptoms of a cardiac arrhythmia, MCOT provides a significantly higher yield than standard cardiac loop recorders (Rothman and colleagues) . According to this patients medical records, the index of suspicion is low that the chest pain is caused by palpitations. He has a history of tachycardia and no potentially life threatening symptoms such as syncope. As such, immediate intervention is not likely to be required. For these reasons, real-time remote monitoring in this patient with MCOT is not medically necessary. Further evaluation with standard loop event monitoring is adequate to diagnose whether this patient is having a significant arrhythmia causing his chest pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested anterior lumbar interbody fusion for treatment of his lumbar radiculitis at L5-S1. Findings:  The physician reviewer found that this patient has chronic low back pain with evidence of multilevel abnormalities on MRI scan. However, there is no history or findings on physical examination to implicate the L5-S1 disc to be his pain generator to warrant spinal fusion of that segment. He has no symptoms or findings of a lumbar radiculopathy (Tarulli and Raynor). He has no evidence of angulation, instability, scoliosis, spondylolysis, spondylolisthesis, recent trauma or infection to warrant spinal fusion at this time (Milliman Care Guidelines and Bambakidis, et al).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested epidural steroid injections for treatment of his pain.  Findings:  Three physician reviewers found that this patient had a documented lumbar MRI consistent with his pain. The patient has tried and failed to receive relief with NSAIDs.  He has participated in physical therapy and a home exercise program.  The patient reported exacerbation of his pain following physical therapy.  The pain physician has provided educational, and psychosocial support, as well as a trial of narcotic therapy.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy. The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Botwin and colleagues found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. Rosenberg and colleagues performed a prospective study to determine the effectiveness of transforaminal epidural steroid injections. They found that epidural steroid injections can offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.  In this patients case, the requested epidural steroid injections are likely to be more efficacious than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested outpatient psychotherapy at a frequency of two times per week for treatment of her major depressive disorder, panic disorder and eating disorder.  Findings:  The physician reviewer found that twice weekly outpatient psychotherapy from the date in question forward was not and is not medically necessary. The submitted documentation does not demonstrate the patients symptoms were at a severity level that required continued twice weekly sessions as of the said date. Although a risk assessment is not documented in the records provided, the progress notes do not reflect concern about the potential for suicide or decompensation. There is no evidence that the patient has been hospitalized in the past or was at risk for a higher level of care. American Psychiatric Association practice guidelines indicate that patients with panic disorder as well as major depression should be managed in the least intensive setting which is likely to be safe and effective. Based upon the submitted documentation, the patient could have been safely and effectively managed in the context of once weekly sessions as of the date in question. With regard to the medical necessity of twice weekly outpatient psychotherapy sessions going forward, transition to once a week sessions is medically appropriate at this time. Goals and time frames should be established with progress toward goals documented.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a computed tomography (CT) of the abdomen and CT of the pelvis for evaluation of her abdominal pains, nausea, dizziness, and headaches.  Findings:  The physician reviewer found that this patient presented with nausea and abdominal pain a few months ago. All labs were normal and her vital signs were unremarkable. The patients urinalysis was also normal and there was no documentation of fever or other sign requiring emergent imaging. In this instance, initial evaluation with plain x-rays (abdominal series) or ultrasound would be indicated. The CT scans of the abdomen and pelvis were ordered by the treating provider for evaluation of the patients condition, however there was no documentation of any sign, symptom or abnormal laboratory value which indicates the CT of the abdomen and pelvis was medically necessary at the time the studies were completed. All told, this patients records do not demonstrate the medical necessity of the diagnostic procedures at issue in this clinical circumstance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested a positron emission tomography with computed tomography (PET/CT) attenuation for evaluation of her appendiceal cancer.   Findings:  Two physician reviewers found that the patient has a very rare form of cancer that has no established guidelines. As the appendix is very close to the ascending colon, some providers may recommend application of colon cancer guidelines to guide the use of PET in cancer of the appendix. This may be especially the case when the diagnosis is adenocarcinoma and not a mucinous tumor. In this case, it was an adenocarcinoma with only a 5% focal mucinous component. There is limited peer reviewed medical literature on this topic, and there is no consensus as evidenced by the above references. However, the compelling justification for use of PET/CT imaging in this patient is that tumor was avid on prior PET/CT study. As the prior PET/CT was helpful in establishing this patients diagnosis it is likely to be a useful study in re-staging the tumor. For these reasons, the PET/CT scan performed on the date in question should be covered as it was more likely to provide useful data in the management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested a cardiac MRI for evaluation of his chest discomfort.  Findings:  The physician reviewer found that this patient has nonspecific symptoms that have been extensively evaluated and have yielded normal cardiovascular physical examinations, normal electrocardiograms, normal cardiac biomarkers, and several normal cardiac tests including echocardiography, stress echocardiography and coronary CT angiography.  In this circumstance, a cardiac MRI is not considered standard accepted practice in the medical community.  There is no clinical evidence of pericarditis or pericardial constriction (normal electrocardiogram, normal cardiac biomarkers, low jugular venous pressure, no pericardial rub, and no pericardial effusion on most noninvasive tests performed).  Since the pericardium has already been extensively imaged, additional imaging with cardiac MRI would not be of incremental value.  Current expert consensus guidelines do not consider cardiac MRI appropriate in this setting.  All told, the requested cardiac MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a combination of Victoza 1.8mg/0.1 pen injection/Janumet 50-500mg for treatment of his diabetes. Findings: The physician reviewer found that Victoza is a glucagon-like peptide 1 receptor agonist. Dipeptidyl peptidase-4 inhibitors such as Janumet slow the metabolism of glucagon-like peptide 1. Thus, in theory, the use of these medications both would raise glucagon-like peptide 1 levels. However, the use of the combination of Victoza and Janumet has not been adequately studied. There is a lack of medical studies demonstrating the safety of the combination of these two classes of medications. The current medical evidence does not support the use of the requested combination. In this patients case, either Janumet or Victoza is medically indicated and appropriate. However, the requested combination of Victoza 1.8mg/0.1 pen injection/Janumet 50-500mg is not medically indicated for the treatment of this patient. Thus, a portion of the requested medications is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested percutaneous tibial nerve stimulation for treatment of his nocturia.  Findings:  Three physician reviewers found that the etiology of lower urinary symptoms of frequency and urgency can be multifactorial in origin. The submitted documentation indicated that the patient has nocturnal polyuria. The urgency may be significantly affected by a large nocturnal urine production.  At this time, there is a lack of studies demonstrating the effectiveness of the requested services for the symptom of nocturnal polyuria. Percutaneous tibial nerve stimulation has been evaluated for urgency and other overactive bladder symptoms.  However, to date, these studies have not been evaluated over a long enough period to state its efficacy.  Therefore, the requested percutaneous tibial nerve stimulation is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested real-time remote heart monitoring for evaluation of her tachycardia.  Findings:  Two physician reviewers found that the patient has well-documented symptomatic supraventricular tachycardia in the setting of a structurally normal heart by cardiac MRI and stress echocardiography.  In this circumstance, additional cardiac monitoring adds very little information.  If additional monitoring were thought to be medically necessary, then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias.   Continuous off-line 24 to 48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.  Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient.  There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the patients condition.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias.  In this patients case, remote real-time heart monitoring was not likely to be superior over other tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested cardiac computed tomography angiography for evaluation of his chest pain.  Findings:  Two physician reviewers found that cardiac computed tomography angiography is not standard accepted practice in the medical community.  If chest discomfort symptoms are of uncertain cause, then stress testing is the standard and accepted procedure of choice since it provides a functional significance to any coronary stenosis identified angiographically, it quantifies any coronary ischemia that may be present and it links the patients symptoms to provokable ischemia identified. Additionally, it assesses for causes of coronary ischemia that may be caused by conditions other than fixed obstructive epicardial coronary disease identified angiographically, such as coronary vasospasm or small vessel disease.  Likewise, if symptoms are certain to be anginal and an assessment of coronary anatomy is thought to be medically necessary, then invasive coronary angiography would be preferred over cardiac computed tomography angiography due to its improved accuracy and the ability to intervene with revascularization during the same procedure, if clinically indicated.  Current expert consensus guidelines that are endorsed by several national organizations do not consider cardiac computed tomography angiography appropriate in patients with prior coronary stenting and new symptoms suspicious of coronary ischemia.  Thus, in this patients case, cardiac computed tomography angiography performed on the date in question was not likely to be more efficacious for evaluation than other methods of evaluation.