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

A 52-year-old female enrollee has requested for Yttrium-90 microsphere therapy/Selective Internal Radiation Therapy (SIRT) for treatment of her liver cancer.   Findings:  Two physician reviewers found that the results of SIRT are promising and have been reported as case-series for primary liver cancer, and metastases from colorectal origin. Only a few reports looking at safety included other diseases. The response rates and survival rates for liver tumors and colon metastases are promising, and have prompted the initiation of clinical trials to specifically evaluate whether there is an improvement in survival. Despite this, no data currently exists, particularly in regards to metastatic sarcoma. Furthermore, the data suggests that as a salvage procedure following chemoembolization, response rates are lower than with its use as an initial therapy. Thus, without adequate evidence to support the use of SIRT, especially in metastatic sarcoma, it remains of unknown benefit in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 22-year-old male enrollee has requested  for acute inpatient psychiatric treatment services for treatment of the enrollees opiate dependence with physiologic dependence. Findings:  The physician reviewer found that there was no clear cut indication that he had a specific plan or that he had actively attempted suicide. He was not psychotic or overly aggressive. He was experiencing signs of opiate withdrawal and was clearly in some discomfort. However, the magnitude of his withdrawal did not specifically demand inpatient care. His need for 24/7 professional observation was not demonstrated. The patient did not present a serious risk of harm to self or others. His functioning was impaired but not seriously deteriorated. The patient could have been safely and effectively treated at a lesser level of service.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested laparoscopic Roux-en-Y gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that with a BMI between 39 and 40 and early comorbidities, the patient meets the National Institutes of Healths criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested for residential treatment center level of care for treatment of the his substance abuse. Findings:  The physician reviewer found that the use of the PHP level of care will allow for further integration into the communitys sobriety oriented activities (such as community based 12-step work), would be less disruptive to the patients occupation as a student, and would also allow him to be evaluated for the use of ongoing Buprenorphine/Naloxone Treatment (see Ann Fam Med. 2007) as an adjunct to his treatment for opiate addiction.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for rehabilitation services for treatment of her condition. Findings:  The physician reviewer found that SNF-level rehabilitation services were no longer medically necessary as the patient was not and is not making further functional progress with continued therapy. She remains at the minimum and moderate assistance levels with lower extremity activities of daily living.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested for Avastin (bevacizumab) and Tarceva (erlotinib) for treatment of his metastatic hepatocellular carcinoma. Findings:  Three physician reviewers found that Hepatocellular carcinoma is a cancer that is generally resistant to conventional chemotherapy. This has led to a great deal of interest in using the newer drugs, particularly the anti-angiogenic agents. Nexavar (sorafenib) has been approved for use in this disease. This approval was based on a placebo-controlled trial of approximately 600 patients. This trial demonstrated a significantly better overall median survival time and time to progression in the sorafenib-treated group. Submitted with this appeal was the relevant reported trial of erlotinib (Tarceva) with bevacizumab (Avastin). The Thomas trial looked at such treatment in 29 patients, and did demonstrate responses, though there was no firm conclusion as to real clinical efficacy. There have also been other trials, with small numbers of patients, suggesting activity of either Tarceva or Avastin when used as a single agent.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested for an MRI of the right breast for evaluation of her breast mass. Findings:  Three physician reviewers found that there is also a smaller nodule located in this breast that has increased in size. Mammographic and sonographic analyses described findings highly suspicious for malignancy with BIRADS category 5 attached, meaning highly suspicious for malignancy and a biopsy is recommended.  No matter what an MRI would or would not show, a biopsy is indicated in this case. The findings on an MRI would do nothing to obviate the need for biopsy and surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a PET scan for an evaluation of her cognitive and psychomotor slowing. Findings:  Three physician reviewers found that there are no adequate standards by which to judge PET scan results in the differential diagnosis of cognitive impairment, as noted in the study by Matsuda. Furthermore, there are no therapeutic implications in this particular case which would be addressed by PET scanning as noted by Jagust and colleagues. In the absence of any evidence of clinical value in this setting, the proposed PET scan is not indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a bilateral breast MRI for an evaluation of her breast cancer risk. Findings:  The physician reviewer found that breast MRI can be utilized as a screening tool or as a diagnostic tool. This patient has no family history of breast cancer in a first degree relative. She has no history of radiation to the chest as a child and does not have Li-Fraumeni syndrome (both of these are indications for screening breast MRI). In regards to breast MRI for diagnostic purposes, breast MRI is mainly utilized to evaluate the contralateral breast in a patient with known breast cancer or to develop a surgical plan for patients with a new diagnosis of breast cancer. This patient does not have a personal history of breast cancer. The American College of Radiology guidelines for breast cancer screening include mammography with breast ultrasound if clinically needed. This patient has undergone both mammography and breast ultrasound. Both of these examinations showed no evidence of malignancy. As such, breast MRI is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested hernia surgery for the treatment of his abdominal wall atrophy. Findings:  The physician reviewer found that an attempt at repair is not medically appropriate given poor tissue and morbid obesity. Physician-supervised weight loss is appropriate. Component separation will not be tenable secondary to ileal conduit. Additionally, mesh will have a high risk of infection, especially given the conduit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 54-year-old male enrollee has requested continued skilled nursing services for the treatment of his complex cervical spine fracture with quadriparesis. Findings:  The physician reviewer found that the patient was not in pain and was not receiving treatment that required the skills of a nurse, such as wound management with dressing changes, frequent nebulizer treatments or intense blood sugar monitoring. The patient was turned every two hours, but this does not require a skilled nurse. He was not getting intravenous medications which would have required a skilled nurse. There did not seem to be an increased likelihood of an adverse event that required the daily monitoring from a nurse or a physician. In regards to rehabilitation services, both occupational and physical therapy services had been discontinued. Finally, there was an order from the physician to discharge the patient demonstrating the stability of the patient and the ability to manage him without continual physician or nursing care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested Duodenal Switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 47.9 and co-morbid conditions. The basis for the Health Plans denial of the Duodenal Switch surgery is not consistent with current studies. The available data does not establish that nutritional deraignment after the Duodenal Switch procedure is more prevalent or more serious than what is encountered with the gastric bypass operation. In fact, there is a large body of scientific evidence that shows superior short and long-term outcomes with the Duodenal Switch procedure when compared to the gastric bypass or the laparoscopic gastric banding procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested the OmniPod External Insulin Pump and monthly supplies for the treatment of his type I diabetes. Findings:  The physician reviewer found that there is no evidence demonstrating that switching to a different pump will change the frequency of the patients blood sugar testing or timing of his mealtime insulin bolusing. Further, there is no reason to believe his control will improve as there is nothing in the medical literature indicating that the OmniPod pump is superior to the Medtronics pump or other standard insulin infusion pumps. While the patient may have improved ease of use with the OmniPod, there is no evidence that this will have an effect on control. The choice of the Health Plan to authorize coverage for a standard replacement insulin pump over the OmniPod system is appropriate as there is no literature supporting the position that the OmniPod system is superior to other pumps, and there is no evidence that changing pump manufacturers will improve the patients outcomes.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested sub-acute residential eating disorder treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that despite the current residential treatment, the patient has not improved to any significant degree.  In addition, it seems unlikely that she will improve at Pacific Shores given what the submitted records report of her stay to date. The records are inconsistent and vague and do not indicate a clear, coherent, and thought-out plan of treatment. Her medications have been changed frequently, without an adequate therapeutic trial of a given medication or dosage. In addition, she was diagnosed with ADD at Pacific Shores, and was started on Adderall, a stimulant with significant anorexia as a side effect. She was also started on Provigil, presumably due to excessive sleepiness (which may well be a manifestation of her depression). Provigil is also a central nervous system stimulant that can cause or aggravate anorexia. Thus, there is limited potential for improvement at the current facility. The patient may well benefit from placement at an alternative residential treatment center that can provide intensive psychiatric treatment for her depression and obsessive compulsive disorder, as well as medication monitoring and necessary treatment for her eating disorder. The Health Plans current alternative is intensive outpatient treatment at the Pacific Shores facility. This alternative does not appear to be appropriate for this patient. She has not demonstrated stability at the current level of care (residential treatment) and her eating disorder has not stabilized to allow transition of care to a lower level of treatment. In addition, in view of the Plans concerns for the lack of patient progress at Pacific Shores, continued treatment at that facility at a lower level of care is not likely to lead to progress and would not provide the same level of structure which she is currently requiring. Therefore, since the current treatment is more appropriate for the patient than the Plan offered alternative, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested a duodenal switch with biliopancreatic diversion for the treatment of her morbid obesity. Findings:  The physician reviewer found that as bariatric surgery becomes safer and studies are carried out longer term, patients have multiple options in selecting their procedures. Consensus groups, including the National Institutes of Health and the American Society for Metabolic and Bariatric Surgery, recognize three options. These are Roux-en-Y gastric bypass, adjustable gastric banding and duodenal switch with biliopancreatic diversion. Many patients with significant hepatosteatosis cannot undergo Roux-en-Y gastric bypass due to the technical difficulty of a high gastrojejunostomy. In the case of this patient, her BMI is 47, and she requires NSAIDs.  Her hepatic span of 20 cm and relatively short height will make a laparoscopic Roux-en-Y gastric bypass procedure more difficult. As such, duodenal switch with biliopancreatic diversion is medically indicated for this patient and is the most appropriate surgical option.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested a NESS H200 (upper extremity functional electrical stimulation device) and/or the NESS L300 (lower extremity functional electrical stimulation device) for the treatment of his left-sided hemiplegia secondary to stroke. Findings:  Two physician reviewers found that the patient was plateauing with standard physical therapy and occupational therapy. The evidence base for functional electrical stimulation is difficult to clarify due to industry sponsorship and involvement within trials which at the time of publication was not as clearly defined as it is now. Having said this, the available literature does support the use of functional electrical stimulation in stroke candidates with continued late residual deficits. The articles by both Peurala and Kimberley demonstrate improved learning and evidence for cortical changes associated with functional electrical stimulation. Price and colleagues also evaluated the effects on shoulder pain and noted a demonstrated improvement as well. All told, there is sufficient evidence to support the use of electrical stimulation in this case. The patient will require the NESS H200 and NESS L300 plus the requested physical therapy and occupational therapy by a provider trained in the implementation of these devices.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested emergency surgery/stay in Mexico for the treatment of his condition. Findings:  The physician reviewer found that there is no evidence that the patient had to have the surgery in Mexico on an emergent basis, and or that he met prudent layperson criteria for emergency coverage. It appears the patient had an anterior cruciate ligament reconstruction with meniscal surgery in Mexico. This procedure is not considered an emergent or urgent service.  This type of surgery can be considered an elective procedure.  Based on the submitted evidence, the patient did not experience an acute onset of symptoms of sufficient severity such that a prudent layperson could reasonably expect the absence of immediate medical attention to result in serious jeopardy or serious impairment to bodily functions or of any body organ or part.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Cialis 20mg, once every three days for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that the issue at stake in this case is not regarding the medical necessity of the drug, but rather the quantity of medication that is being requested (one 20mg tablet every three days) versus the quantity that is already approved by the Health Plan (six 20mg tablets per month). The current prescribing limit of six tablets per month by the Health Plan is standard in the medical field and therefore is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested inflammatory bowel disease (IBD) serology 7 for the treatment of her irritable bowel syndrome. Findings:  The physician reviewer found that an IBD serology panel is recommended only as an adjunct to differentiate CD and UC in patients with a clinical diagnosis of IBD and non-diagnostic histology and radiologic findings. In accordance with the American College of Gastroenterology Practice Parameters Committee, pANCA and ASCA, Omp-C, `may be useful in the patient in whom all other clinical features do not allow a distinction between UC and CD.` Thus, this patient did not meet the recommended indications for the use of serologic IBD testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested an MRI/MRS (magnetic resonance imaging/magnetic resonance spectroscopy) scan for an evaluation of his prostate cancer. Findings:  The physician reviewer found that MRI of the prostate is a useful tool in the staging and restaging of prostate cancer. The use of MRS in conjunction with MRI in the evaluation of prostate cancer is evolving. Multiple studies have shown promise for MRS imaging in patients with elevated PSA (prostate specific antigen) and negative biopsy (See ASCO 2007 prostate cancer symposium). MRS, however, does have some limitations in the above described patient population. Cirillo, et al. states that MRS has limitations in the detection of prostate cancer within the prostate apex due to anatomical conformation of the gland.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 51-year-old female enrollee has requested residential treatment services for the treatment of the enrollees posttraumatic stress disorder, panic attacks and bipolar disorder. Findings:  The physician reviewer found that the patient was seriously ill at the time of admission to the residential facility. However, she clearly improved. She was no longer suicidal. Her mood was not substantively depressed, and her need for 24/7 supervision and care in a residential setting was not documented. The patient could have received all necessary psychiatric care at a lesser level of service. She could have been treated safely and effectively in a partial hospital program as of the last authorized date of service.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech and occupational therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that both speech therapy and occupational therapy are medically indicated for treatment of this patient. Plasticity in the developing brain can be utilized to improve overall neurologic health. Specific treatment, including speech therapy and occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic process. Based upon this patients diagnosis and current deficits, he is an appropriate candidate for the requested therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested for Synagis vaccination for treatment of the enrollees cyanotic hypoplastic heart.    Findings:  Two physician reviewers found that Synagis has been available for prevention or amelioration of the effects of RSV for the past decade. Its ultimate value remains under study, but it is in widespread use throughout the United States. Synagis is presently considered the standard of care as outlined in the 2008-2009 Guideline for use from the Division of Infectious Diseases of the Department of Pediatrics at the S.U.N.Y. at Syracuse (cited above). These guidelines are the same as those published by the American Academy of Pediatrics in 2003. In relevant part, a portion of the Guidelines read as follows: RSV prophylaxis is recommended for infants who are 24 months of age or younger with hemodynamically significant congenital heart disease. It is estimated that by 2 years of age nearly all children have been exposed to, and test positive for, RSV. Neither the safety nor efficacy of Synagis beyond the age of 2 years has been demonstrated by research. While there may be potential for benefit, at this point in time there is no confirmatory evidence to support the use of Synagis in patients older than 2 years even in the presence of significant congenital heart disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested subcutaneous hormone pellet implantation for the treatment of her menopausal symptoms. Findings:  Three physician reviewers found that this patient has peri-menopausal/menopausal symptoms. She would benefit from hormone replacement therapy (HRT). She requests subcutaneous delivery of bio-identical hormones. There is no evidence that bio-identical compounds are more beneficial than standard HRT. Furthermore, there is no evidence that subcutaneous pellet administration is superior to standard oral or transdermal delivery of HRT.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested sacroiliac joint injections for treatment of her chronic low back pain. Findings:  Two physician reviewers found that this patient could have other sources of SI pain that have not been investigated thoroughly. It is more appropriate for her to attempt other treatment options before proceeding to SI joint injections. The study performed by Maugars, et al. recommends SI joint injections to be considered in patients with contraindications or complications to NSAIDs (non-steroid anti-inflammatory drugs) or if medical treatment has been unable to control active sacroilitis (which this patient has not been demonstrated to have).