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

A 44-year-old female enrollee has requested an MRI of the pelvis for an evaluation of her uterine fibroids. Findings:  The physician reviewer found that this patient had a UAE for fibroids almost eight months prior to the request for an MRI. While uterine necrosis has been reported after UAE, it generally occurs within the first two months following the procedure, and the reported cases did not occur more than four months out from surgery. In the case of this patient, no documentation has been provided that other, more likely etiologies have been considered or investigated, such as chronic urinary infection, nephrolithiasis or even musculoskeletal conditions. There is no evidence that the patient is having problems or complications after UAE.  The records do not provide evidence of abnormal imaging from other imaging modalities, nor is there documentation to support the need for MRI pelvic imaging at this time.  The literature referenced above discusses the fact that pelvic MRI is not the standard of care for routine follow up after a UAE procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested epoetin alfa (Procrit or Epogen) for the treatment of his Friedreichs Ataxia. Findings:  The physician reviewer found that FA is currently a disease without a cure. There is current medical literature that supports the use of epoetin alfa for FA. This literature has shown that epoetin alfa can increase frataxin levels in vivo, thereby demonstrating its potential benefit for patients with FA. Furthermore, this patient has already demonstrated a functional benefit on this medication, making its use both reasonable and medically necessary.  A repeat evaluation at six months should be performed to ensure that this patient has continued to demonstrate clinical benefit on this medication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 80-year-old male enrollee has requested for CyberKnife Stereotactic Radiosurgery for treatment of his pancreatic adenocarcinoma.  Findings:  Two physician reviewers found that the CyberKnife System delivers the entire treatment in 5 sessions in 5 days. This consumes less of the patients time compared to traditional radiotherapy which is delivered in up to 40 sessions over a 6-8 week period. Furthermore, CyberKnife treatment results in much fewer acute episodes of GI toxicity and minimally impacts the patients quality of life. The data from the Stanford studies (Koong, et al.) showed local control in more than 90% of patients. An additional benefit of CyberKnife treatment is that there is less delay in treatment of systemic chemotherapy because overall treatment time is shorter and there is less acute morbidity compared to conventional fractionated radiation treatment. Dr. Gagnon presented his experience treating pancreatic cancer with CyberKnife at ASCO in 2006. Dr. Gagnon found that the CyberKnife System demonstrated high conformity and homogeneity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for spinal fusion surgery for treatment of her L4 to S1 spondylosis and discogenic low back pain. Findings:  The physician reviewer found that there is no instability, no significant degeneration, and she has had no previous spinal procedures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Boniva (150mg once per month) for the treatment of her osteoporosis. Findings:  The physician reviewer found that it is not medically appropriate to require this patient to use weekly Fosamax as a prerequisite to taking monthly Boniva since she had been on Actonel weekly and demonstrated GERD symptoms. The use of Actonel 75 mg daily on two consecutive days sounds medically reasonable. However, she had been on Actonel 35 mg weekly for one year and had to stop taking it due to her GERD. This patient has responded positively to Boniva (150mg once/month) and she should continue taking this medication and dosage in light of the absence of her GERD symptoms with this regimen.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested additional intravenous Rocephin for the treatment of her Lyme disease. Findings:  The physician reviewer found that this patient has no recorded history of a tick bite and has symptoms not especially suggestive of Lyme disease. The definitive serological tests for presence of Borrelia infection were negative. Intravenous Rocephin is not medically appropriate for this patient. Specifically, there is no need for intravenous Rocephin for a three month period. The maximum recommended therapy for proven joint or nervous system Lyme disease is 28 days of ceftriaxone, as noted in the guidelines presented by Wormser and colleagues. As the patient does not have clinical evidence of Lyme disease, there is no justification in this case for the proposed therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested inpatient detoxification treatment for the treatment of his alcohol dependence, opiate dependence and marijuana dependence. Findings:  The physician reviewer found that there was no clear indication for inpatient treatment. Additionally, the patient demonstrated motivation for treatment. He tolerated Suboxone well, and the therapies that he received could have taken place on an intensive outpatient program basis. The services at issue were not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested an MRI of the left breast for an evaluation of her left breast lump. Findings:  Two physician reviewers found that the American Cancer Society has developed guidelines for the use of MRI in breast cancer diagnosis and monitoring. It is used for screening in women at very high risk for breast cancer. It is also used for known breast cancer patients for determining the extent of disease or monitoring therapy. Breast MRI is also used for suspicious clinical findings or imaging results that remain indeterminate after complete mammography and sonography as well as clinical examination. This patient has a mass clinically and on mammogram. The decision for tissue excision should be based on these clinical and diagnostic impressions. MRI is not indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Duodenal Switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria for weight loss surgery as outlined by National Institutes of Health. She has a body mass index (BMI) of greater than 50. This places her at the super morbidly obese range. All of the referenced articles provided by the patient are clear that the Duodenal Switch operation is superior with regards to the percentage of excess body weight loss and sustained weight loss. Additionally, the Duodenal Switch is more efficacious when it comes to the potential resolution of the patients co-morbid conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested a consultation for bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient does not meet the National Institutes of Health (NIH) criteria for weight loss surgery. Further attempts at conservative weight loss methods are more appropriate for this patient than surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested laminectomy at L4 and release of neural roots, osteotomy of intercorporeal graft at L4-5 and fixation with transpedicular screws from L2 to L5 for the treatment of his low back pain. Findings:  The physician reviewer found that this patient has midline and unilateral buttock pain and no radicular pain. He has had a normal examination. MRI did not reveal significant stenosis, degeneration or foramen compromise. Dynamic studies showed no instability. Thus, the requested procedures are not medically indicated. There are no indications for the surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient was not diagnosed with autistic spectrum until the age of 11, which would imply relatively mild communication defects. Testing indicated relatively mild communication defects.  When retested, nearly all of his communication skills were in the normal range. The progress notes demonstrate that the emphasis was not on actual communication skills, but emphasized organizational efforts and intellectualizing skills (i.e., what to say and the way to say it). The emphasis was on a process to improve intellectual processing of language, rather than focusing on receptive or expressive language (i.e., not speaking, but prethinking what to say and organizing thoughts). Thus, the speech therapy rendered was not medically necessary for treatment of the patients condition. Furthermore, since the patients expressive and receptive language is in the normal range, additional speech therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a nine-year-old male enrollee have requested reimbursement and prospective authorization and coverage for neurofeedback (cognitive rehabilitation therapy) for the treatment of the enrollees history of traumatic brain injury. Findings:  The physician reviewer found that the clinical benefit of neurofeedback for mild traumatic brain injury (TBI) has not been conclusively established, as there is very little evidence in the published medical literature to support the use of this type of therapy for this patients condition. The article cited by the patients parent shows that mild, traumatic brain injuries can cause real problems, but it does not show that neurofeedback is helpful in this setting. Studies show that there is a need for more uniform and standardized assessments. At present, neurofeedback must still be considered an unproven modality for this patients medical issues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for continued skilled nursing facility (SNF) care for treatment of his end stage liver disease.  Findings:  The physician reviewer found that the patient does not require daily skilled nursing services for administration of parenteral medications, monitoring, or maintaining skin care (no stage 3 or worse skin condition was documented).  Further, the patient does not require skilled nursing care for routine care of rectal tube or condom catheter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested for continued skilled nursing facility (SNF) care for treatment of her Parkinsons disease, dementia, chronic obstructive pulmonary disease (COPD) and decubitus ulcer.   Findings:  The physician reviewer found that the patients condition as of this date required custodial care, which generally provides assistance in performing activities of daily living and does not require the continued attention of trained medical personnel.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 19-year-old male enrollee has requested for services for treatment of his second and third degree burns. Findings:  The physician reviewer found that there is nothing in the record that demonstrates that the patient is not stable for transfer. Nor is there any evidence that the services available at the in-network burn center are inadequate to treat the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has a laminoplasty to be performed along with a laminectomy for the treatment of her enlarging interdural lumbar tumor at this time. Findings:  The physician reviewer found that a laminoplasty may offer potential advantages over laminectomy. For example, posterior spinal elements are preserved with a laminoplasty and spinal stability can thereby (potentially) be better maintained. A laminoplasty is currently felt to be better-suited for young and active patients with mild-to-moderate central canal spinal stenosis in whom stability may be jeopardized by a standard laminectomy. The descriptions of the patient in the medical records indeed portray her to be relatively young and active. However, the clinical data give no indication that the patient has any degree of spinal stenosis, nor is there any data suggesting that the patient has any spinal stability issues. In fact, the most recent lumbar MRI specifically failed to reveal any evidence of spondylolisthesis. There is no compelling evidence that the patients condition necessitates a laminoplasty. A laminectomy is indeed the appropriate procedure for the patient given the absence of any evidence of spinal stenosis or impending spinal instability.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested neurofeedback (cognitive rehabilitation therapy) for the treatment of the her primary sleep disorder and post traumatic stress disorder (PTSD). Findings:  The physician reviewer found that the evidence supporting cognitive rehabilitation is not robust. The new information added for this review does not add any new light to the use of cognitive rehabilitation. According to the NIH (National Institutes of Health) consensus panel on rehabilitation of persons with TBI (traumatic brain injury), limited data is available on the effectiveness or cognitive rehab programs. Some studies support computer-assisted exercises. The role in mild TBI is not established. Ponsford, et al. found mild TBIs constitute 70-90% of all head injuries, most commonly the result of falls, motor vehicle accidents and sports- related injuries. The author found most cases resolve within 3 months, however, some patients continue to have difficulties (15-25%). The author found more uniform assessments needed to be established. There is insufficient evidence to support the use of cognitive rehabilitation in mild traumatic brain injury patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Transcatheter Arterial Chemoembolization (TACE) for treatment of his end-stage liver disease. Findings:  Three physician reviewers found that transcatheter arterial chemoembolization is a standard treatment for unresectable hepatocellular carcinoma. It is endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. The presence of a portocaval shunt is not a contraindication to this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Botox injections for the treatment of the enrollees chronic headaches. Findings:  Two physician reviewers found that chronic headache is one of the most challenging pain syndromes, and this patient has had an unusual set of clinical circumstances. His symptoms seem most clearly to be associated with elevations in intracranial pressure, and correction of that problem has alleviated his headaches on a number of occasions, albeit temporarily. The fact that he has improved following VP shunting and shunt revision is not consistent with a migraine component. Further, the fact that he did not have any (even transient) control with any of the triptans is also unusual. While there is conflicting evidence regarding the efficacy of Botox in the treatment of chronic migraine, there does seem to be a subset of patients who respond in the studies to date. However, the efficacy of Botox has not been shown in the treatment of chronic daily headaches or in medication overuse headaches. In addition, there are no studies that have been done demonstrating efficacy of Botox in headaches associated with elevated intracranial pressure or in patients with a history of head trauma or Arnold-Chiari malformation. Therefore, the use of Botox in this setting would be investigational, and not likely to be more beneficial to the patient than other standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for ProDisc-L Total Disc Replacement for treatment of his foraminal stenosis and intermittent L5 radiculitis.   Findings:  Three physician reviewers found that the ProDisc-L total disc replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than a superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The main conclusions of the study were that at 24 months, the overall incidence of adverse events occurring in the ProDisc-L group was no worse than in the control group, the number of device-related adverse events in the ProDisc-L group was no worse than in the control group, and the overall success rate of the ProDisc-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success. The results of this trial were published in 2007, but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler et al). There have not been any other randomized controlled clinical trials published to date. Given the unknown long-term safety and efficacy of the device, the FDA, in its approval, requested a post-approval study to obtain a total of five-year follow-up data from all subjects in the clinical study.Two published non-randomized case series of interest are those of Shim et al. and Tropiano et al. Shim et al. followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively), raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Tropiano et al. followed 64 patients with a mean follow-up of 8.7 years post-operatively. They found that prior lumbar surgery and an age less than 45 years were associated with slightly worse outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for acute skilled nursing facility care for treatment of her medical condition. Findings:  The physician reviewer found that there is no expectation that daily skilled rehabilitation will result in further improvement. As her brain continues to heal, she will make additional progress, but this progress depends more upon brain healing than upon skilled rehabilitation. Her needs can be met at a lower level of care (such as a rehabilitative nursing program).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for Erbitux (cetuximab) in combination with Camptosar (CPT-11 or irinotecan) for treatment of her recurrent progressive metastatic adenocarcinoma.   Findings:  Two physician reviewers found that cetuximab is one of a newer class of drugs, which has been approved for use in metastatic colon cancer as well as head and neck cancer, when used with radiation therapy. Submitted with this appeal were data from a few clinical trials. One of them demonstrated that when cetuximab is added to chemotherapy, as first line therapy of metastatic lung cancer, there was an approximately one-month increase in median survival, which was not statistically significant. There is not convincing data that when cetuximab is used in combination (i.e., with irinotecan) beyond first line therapy, that there is any statistically significant benefit.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for Selective Internal Radiation Therapy (SIRT) for treatment of her rectal carcinoma, metastases to the liver. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines for rectal cancer state that hepatic resection is a treatment of choice for resectable liver metastases from colorectal cancer. Furthermore, it states that ablative techniques may be considered when all known disease is amenable to ablation. These criteria are based upon the publication of Abdalla and colleagues. The guidelines for liver cancer include ablation or immobilization options. SIRT has been approved for both metastatic colorectal cancer to the liver as well as primary hepatocellular carcinoma. SIRT is a reasonable approach for this patient, and is likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested for Xopenex for treatment of his cystic fibrosis. Findings:  The physician reviewer found that the bronchodilators are in the same class as albuterol. Xopenex is associated with less tachycardia and tremulousness.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a Dynasplint brace for the treatment of her hallux limitus. Findings:  Three physician reviewers found that there is little evidence in the literature of the use of dynamic splinting devices, such as the Dynasplint, in the treatment of problems, such as is the case with this patient. There are some anecdotal reports of successful results, but a paucity of controlled studies. Some studies are in progress, but until they are completed, evaluated and reported, the use of the Dynasplint remains investigational in nature for this patients diagnosis. Therefore, the denial was medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested Botox injections for the treatment of his Parkinsons disease. Findings:  Two physician reviewers found that Botox is indicated for abnormal muscle tone related to neurodegenerative disease. This patients symptoms fit this classification.  In addition, Singer, et al. and Quirk, et al. support the use of Botox in scenarios such as this, making its use in this particular case medically reasonable, appropriate, and likely to be more efficacious for the patients symptoms than other available treatments.