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

A 51-year-old female enrollee has requested gene expression profiling test (Pathwork Diagnostics Tissue of Origin Test) for treatment of her malignant tumor unknown primary site.  Findings:  Three physician reviewers found that the requested service is likely to be more effective for this patient than other available treatment options. This patient presented with a carcinoma of unknown primary (CUP).  It is important to determine the tissue of origin so that the proper therapy could be applied. In retrospective studies, molecular profiling based on gene expression has proven to be highly accurate in determining the tissue of origin (Bender and Erlander; Varadhachary et al). The Pathwork Tissue of Origin Test is strongly supported by a large multicenter clinical trial (Monzon et al). In some small phase II studies, patients with CUP who were treated with drugs that were appropriate for their tissue of origin had better responses than those who were treated empirically (Varadhachary et al; Hainsworth et al). All told, the requested gene expression profiling test (Pathwork Diagnostics Tissue of Origin Test) is likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested an MRI of the right breast for evaluation of her medical condition.  Findings:  Three physician reviewers found both mammogram with tomosynthesis and breast ultrasound were inconclusive.  It is stressed in the MRI breast literature that mammography and MRI are complementary exams, and MRI should not be used as a substitute for mammography. As noted by Morris and colleagues, MRI should not be used as a substitute for screening mammograms; however, in individuals who have an inconclusive result utilizing conventional imaging, breast MRI with contrast may be indicated. In this patients case, a diagnostic exam was still indeterminant, and an MRI may help to target biopsy, and detect pathology earlier than waiting for a six-month follow-up. Therefore, the requested service is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested individual therapy for treatment of the enrollees depression.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapy. Current psychiatric practice is focused on the aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services, and greater community involvement, in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for transient once weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for affective disorders, especially for individuals with anxious-depression. Psychotherapies such as interpersonal therapy, cognitive behavioral therapy and family therapy are trusted interventions in the treatment of mood disorders in youth and are well-supported by the peer-reviewed evidence-based medical literature. The application of such therapies at a frequency of once a week in this patients case with unresolved medical issues, anxiety and recent concerning mood symptoms would be reasonable, appropriate and consistent with good medical practice.  Thus, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested lap band surgery (laparoscopic banding) for treatment of her obesity. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested lap band surgery (laparoscopic banding). The patient meets the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with severe co-morbid conditions. This patient has a BMI above the indicated criteria and hypertension, meeting the definition of clinically severe obesity. The patient has also failed dietary efforts and a completion of a multidisciplinary evaluation did not reveal any obvious barriers to surgery. All told, the medical necessity of the requested procedure has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested continued occupational therapy for treatment of his left distal humerus fracture status post ORIF.  Findings:  The physician reviewer found that compliance with an appropriate home program is expected to be a more significant factor in optimizing outcomes over regular, ongoing formal therapy given his needs to perform his exercises and on a regular basis in order to improve his range of motion and function. There is no proven significant, sustained benefit of formal passive modalities at this stage with respect to health or functional outcomes for this condition over palliative modalities that can be independently by the patient at home. The patient can perform his exercises and consult the provider every few weeks for adjustments to his home program as needed. Therefore, the requested occupational therapy services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male enrollee has requested a Kineret (anakinra) injection for treatment of the enrollees systemic onset juvenile idiopathic arthritis.  Findings:  Three physician reviewers found that Kineret (anakinra) is likely to be more effective for this patient than other available treatment options. The patient has systemic onset juvenile idiopathic arthritis manifested by high fever, rash and multiple joint arthritis. The patients symptoms have not been controlled with multiple previously tried agents that include steroids, methotrexate and anti-tumor necrosis factor agents. The patients symptoms were completely controlled and in remission while taking Kineret. The medical literature cited above supports the use of Kineret in this patients disease process as he has been significantly responsive to this medication.  Moreover, if left untreated, this patient will likely not be able to function on a daily basis secondary to severe symptoms and could also experience long term sequelae of this disease to include possible joint destruction and kidney failure. Therefore, the requested medication is likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of his hemorrhagic stroke.  Findings:  The physician reviewer found the records indicate that the patient sustained a severe stroke and that he is unable to participate in skilled therapy. His therapy consists primarily of passive range of motion, which does not require skilled nursing services. Continued daily skilled therapy is not indicated to improve or maintain his condition. He does not have daily skilled nursing needs as his condition is stable. All told, the SNF services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided from the date indicated forward was and is medically necessary for treatment of the patients medical condition. This is the patients fourth inpatient hospitalization in just over two months. There was only a 10-day period between his third and fourth admission. These facts evidence that the patient has very quickly relapsed absent the 24-hour structure of the program and requires a longer inpatient stay in order to prevent future relapse. In addition, the notes from the date indicated show that the patient was completely uncooperative with the simplest of activities, having vital signs taken. Thus, if the patient is unable cooperate with this activity, he would likely be unable to function in a less restrictive environment. The physician and parents both are concerned that the patient is not ready or able to attend school. In that regard, the physician has instituted a program of exposure therapy to gradually increase his tolerance so he will be able to function in a less restrictive environment without relapsing within a few days, which has previously happened. As such, the medical necessity of the disputed treatment has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested an excision skin abdomen, CPT code 15830, excision skin abdomen add-on, CPT code 15847, immediate insertion prosthetic following mastopexy, CPT code 19340, and excision excess skin tissue, CPT code 15832 for treatment of her excess skin.  Findings:  The physician reviewer found that the patients current condition does not constitute an abnormal structure of the body.  The requested surgery would not primarily improve function but would improve the cosmetic appearance of an otherwise normal appearance.  Therefore, excision skin abdomen, CPT code 15830, excision skin abdomen add-on, CPT code 15847, immediate insertion prosthetic following mastopexy, CPT code 19340, and excision excess skin tissue, CPT code 15832, are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a Flexitouch pneumatic compression device as opposed to the IC-BAP-DL Bio Arterial Plus device for treatment of her lymphedema, inability to control swelling, and compromised skin integrity.  Findings:  The physician reviewer found that the records submitted for review lack evidence that the patient would benefit from the requested Flexitouch pneumatic compression device over standard pneumatic compression devices. A standard pneumatic compression device has not been used due to concerns over skin integrity. However, the requested Flexitouch would likely present the same skin risks. Based on the records provided for review, there is inadequate documentation supporting the medical necessity of the requested Flexitouch pneumatic compression device.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested partial hospitalization program (PHP) as opposed to inpatient treatment for the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with signs of depression including passive suicidal thoughts, stating that he wished he could die, but that he would not hurt himself and put his family through the pain of his actions. Apparently, both the patient and the parent agreed that PHP is appropriate and that he would be attending voluntarily with his parents full support. The records indicate this patient meets the criteria for PHP, but does not at all meet criteria for inpatient level of care as he is not making suicidal threats, has no suicidal plan, has never made a suicide attempt, has never threatened to hurt himself, is not psychotic, and the patient and his family have been cooperative. All told, the records support the requested PHP level of care services for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested extensive decompression and fusion of the lumbar spine (L4-5 and L5-S1) for treatment of his degenerative disc disease and canal stenosis.  Findings:  The physician reviewer found that lumbar fusion is indicated for well selected patients with degenerative, traumatic, congenital, or post-operative spinal deformity, or single level documented discogenic back pain in the absence of radicular symptoms. The presence of back pain in addition to lumbar radiculopathy, in the setting of lumbar degenerative disease and spinal stenosis, does not support fusion during an initial operative intervention. The medical literature stresses the importance of careful patient selection for increasing success in complex clinical situations. The records submitted and reviewed do not provided adequate rationale or justification to support an extensive instrumentation and fusion surgery over a simple decompression as a first-line operative approach. Consistent with these findings, the requested decompression L4-5 and L5-S1 is medically necessary, while the requested fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-month-old female enrollee has requested cardiac catheterization procedure and associated surgery rather than cardiac surgery (and possible later catheterization procedure) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient needs relief of her right ventricular outflow tract obstruction (i.e., pulmonary stenosis). At issue is whether there should be an initial attempt to balloon dilate the pulmonary valve rather than to proceed with initial operative management. The proposed attempt at balloon pulmonary valvoplasty in the cardiac catheterization lab is medically appropriate as the initial procedure in this setting. If unsuccessful, surgical intervention can then be pursued. The proposed cardiac catheterization is less invasive and given the risks associated with surgery is medically reasonable and necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested cognitive rehabilitation treatment for her anxiety.  Findings:  The physician reviewer found that the patient has achieved subjective and objective benefits from cognitive rehabilitation treatment. In addition, there is evidence in the peer-reviewed medical literature demonstrating that this type of treatment helps patients to improve. Price and colleagues concluded that cognitive behavioral therapy is effective in reducing the symptoms of fatigue at post-treatment compared with usual care, and may be more effective in reducing fatigue symptoms compared with other psychological therapies. However, there is a lack of data supporting cognitive rehabilitation treatment for patients with CFS or Lyme disease. Therefore, the cognitive rehabilitation treatment at issue was not and is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested prostate cancer antigen 3 (PCA3) testing for treatment of his elevated prostate specific antigen (PSA).  Findings:  Three physician reviewers found that the PCA3 testing performed was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Clinical studies have not demonstrated that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. If clinically indicated, saturation biopsy is likely to be more useful if prior biopsies are negative. Given the lack of scientific evidence demonstrating the clinical utility of the disputed testing as well as the availability of proven alternative methods of detection in this setting, there is inadequate support for the use of PCA3 testing. As such, the services at issue were not and are 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 53-year-old female enrollee has requested Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more efficacious than other treatment options.  There is a lack of clinical documentation showing evidence of failure to respond to conservative therapy, including exercise, anti-inflammatory medications, acetaminophen or intra-articular steroid injections.  The current medical evidence has not established the superior effectiveness of Orthovisc injections in this clinical setting.  Additionally, as noted by Rutjes and colleagues, viscosupplementation is associated with an increased risk for serious adverse events in patients with knee osteoarthritis.  Therefore, the requested Orthovisc injections are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Butalbital-Aspirin-Caffeine (Fiorinal) 50-325-40mg oral tab and Butorphanol (Stadol) 10 mg/ml nasal spray for treatment of her headaches.  Findings:  The physician reviewer found that Baron and colleagues report high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and colleagues reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, it is in the patients best interest to wean off the requested medications. Therefore, the requested Stadol and Fiorinal are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested growth hormone therapy Humatrope (somatropin) for treatment of the enrollee, who has a reported decelerating growth velocity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patients height is not more than two standard deviations below normal.  His growth velocity is appropriate for a young male who is in early puberty.  The patients screening IGF-1 level is normal, and final adult height prediction, based on the bone age and height measurement, is 68.5 inches.  This is a normal adult height prediction and does not warrant growth hormone treatment.  The medical records are consistent with constitutional delay, not growth hormone deficiency.  All told, growth hormone therapy Humatrope (somatropin) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Provigil for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that in this patients case, the requested medication is not likely to be superior over other available treatment options.  The current medical evidence does not support the use of Provigil in this clinical setting.  The superior efficacy of Provigil as an adjunctive treatment in major depressive episodes has not been established.  All told, Provigil is not likely to be of greater benefit for the treatment of this patient than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested general anesthesia  for treatment of her hypertension.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the services at issue.  This patient has a history of hypertension.  However, general anesthesia was not medically indicated in this clinical setting.  The patient did not present with a significant history that would require general anesthesia.  Additionally, there is a lack of clinical notes documenting comorbid conditions that would place the patient at risk for complications requiring the need for general anesthesia.  The current medical evidence does not support the use of general anesthesia in this patients case.  All told, general anesthesia administered during the tooth extraction on the date indicated was not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested gastrointestinal (GI) tract wireless capsule endoscopy for evaluation of his history of GI bleeding lesions.  Findings:  Two physician reviewers found the request for a repeat capsule endoscopy is not consistent with the recommendations in the medical literature given the findings on the previous study. The standard practice is to follow the patient clinically for signs of recurrent or ongoing bleeding. This would include looking for melena and checking serial hemoglobin values. The records do not include evidence of ongoing bleeding that would require evaluation with an enteroscopy to assess and treat the ulcers. All told, the requested GI tract wireless capsule endoscopy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a consultation for bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested service. Bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. This is part of standard guidelines such as the NIH consensus guidelines for bariatric surgery. The submitted medical records do not document the presence of morbid obesity with a BMI of 40 or above or clinically severe obesity with a BMI of 35 or above with serious co-morbid conditions such as diabetes, hypertension, coronary artery disease or sleep apnea. Thus the request for a bariatric surgery consultation is not clinically indicated at this time. All told, the medical necessity of the requested service has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested a standing frame for treatment of his C6-7 spinal cord injury.  Findings:  Two physician reviewers found that there is evidence to suggest a clinical benefit from ongoing use of a standing frame for rehabilitation in persons with SCI (Harkema, et al; Boutilier, et al). The patient has demonstrated the ability to tolerate the use of a standing frame for stretch and range of motion. Further, it does not appear that standard therapy involving manual stretch and range of motion would be adequate to achieve a similar therapeutic effect. Therefore, it is likely that the use of the requested standing frame will be more beneficial for treatment of this patients medical condition than standard alternatives.