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

A 52-year-old female enrollee has requested for emergency work up for liver transplant and placement on liver transplant list for treatment of her acute liver failure.  Findings:  The physician reviewer found that most transplant centers follow an integrated approach designated to minimize the risk of alcohol recidivism, as it is currently the primary factor that jeopardizes transplant outcomes in patients with a history of alcohol consumption. To this end, thorough psychological and chemical dependency assessments are included in the transplant evaluation process. Lucey and colleagues note that a number of criteria are considered to predict abstinence after transplantation, including medical, surgical, and psychiatric assessment. Anantharaju and Van Thiel indicate that due to the shortage of donor organs, orthotopic liver transplantation (OLT) for alcoholic liver disease patients, remains controversial out of concerns that patients may resume drinking, thereby harming the transplanted organ. Some transplant centers have used contingency contracting as a method to improve long-term abstinence, but oftentimes, patients with a history of alcohol use are enrolled in an alcohol treatment program and may be required to submit to random alcohol testing while awaiting transplantation. Some researchers consider an abstinence period of six months prior to OLT a predictor of long-term abstinence, suggesting that patients who are abstinent for less than six months have a greater relapse rate. At present, the six-month abstinence rule is followed by most of the transplant centers in the United States, and patients are required to go through intensive alcohol rehabilitation prior to being listed. According to the submitted medical records, the patient has not been abstinent from alcohol for six months. Further, there is no documentation that she has participated in an alcohol rehabilitation program since last consuming alcohol.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested intensity modulated radiation therapy for treatment of her metastatic breast cancer. Findings:  Two physician reviewers found that there is a not a body of literature examining the use of intensity modulated radiation therapy for pancreatic metastases, since these are relatively uncommon. Intensity modulated radiation therapy is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution and minimize the dose to normal structures. Therefore, the literature for pancreatic cancer is relevant since the treatment would be similar. For this patient, radiation is indicated, given the growth and invasion of the tumor.  In this case, the treating physician is concerned about the expected kidney toxicity.  The kidneys are exquisitely sensitive to radiation, with renal damage occurring with doses in excess of 20 Gy. According to the said date, intensity modulated radiation therapy dose prescription sheet, the plan is to treat the tumor to a dose of 65 Gy. In order to prescribe this dose and maintain normal tissue dose constraints, the use of intensity modulated radiation therapy is required. Without intensity modulated radiation therapy, the prescribed dose would likely be sub-therapeutic. If this tumor progresses, it is likely to cause severe abdominal symptoms from biliary obstruction as well as abdominal pain. Intensity modulated radiation therapy is appropriate and indicated in this setting to prescribe the maximal effective dose, while maintaining normal tissue (bowel, kidney and cord) constraints.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested rhinoplasty for treatment of his nasal deviation. Findings:  The physician reviewer found that according to the records provided for review, the patients condition of traumatic nasal fracture has resulted in at least a slight asymmetry of the nasal dorsum. This condition can therefore be considered an abnormal structure of the body since it is not the normal state of the patients nose. In addition, the abnormal structure of the body was caused by trauma. However, the preferred surgery will not offer more than minimal improvement in the appearance of the patient according to the description given by the provider. Rhinoplastic surgery for this patient would result in only minimal change in the appearance of his nose, and therefore the proposed surgery does not meet criteria for reconstructive surgery as set forth by California law.With regard to whether rhinoplasty is medically necessary for this patient, the submitted documentation does not include evidence of a functional impairment. The follow-up notes from the patients otorhinolaryngologist do not include any reports of significant pain, discomfort or impaired breathing. Nor does the submitted plastic surgery consultation document any functional issues. As such, the medical necessity of the proposed surgery has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested dynamic posturography (vestibular research) for the treatment of the enrollees hearing loss, unsteadiness, imbalance and frequent falls. Findings: Two physician reviewers found that dynamic posturography is utilized in evaluating and defining different types of balance disorders. It may be useful in the study of patients who have otherwise normal results with standard tests such as videonystagmography, but who have problems with balance.  It may be used by physical therapists in assessing fall risk.  Most of the current literature indicates that dynamic posturography is used mainly as a research and laboratory tool.  This patient has balance problems. He also has a history of chronic middle ear disease and there is documentation in the provided records of a mild bilateral conductive hearing loss. A child with chronic recurrent ear infections may have balance difficulties based on obvious peripheral etiology. The addition of dynamic posturography to this patients evaluation was not likely to yield any additional clinically useful information.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Xifaxan 400 mg, 3 times per day for 10 days for the treatment of her small intestinal bacterial overgrowth. Findings:  The physician reviewer found that the medical literature does not demonstrate that a breath test must be performed to establish a diagnosis of SIBO. A review by Khoshini, et al. questions the adequacy of diagnostic testing for SIBO, as not all of these tests have been sufficiently validated. Thus, a negative breath test may not accurately exclude SIBO as a potential diagnosis. In the case of this patient, medical therapy is appropriate based on her providers recommendations, including the patients prior history of SIBO and response to treatment. Despite the propriety of treating this patient for SIBO, the scientific data does not support the use of Xifaxan as an initial treatment. Thus, it is reasonable for this patient to first be treated with three of the formulary antibiotic alternatives. If the patient tries three of the required formulary alternatives without success or with intolerable side effects, Xifaxan 400 mg, 3 times per day for 10 days would then be indicated and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  periodic pediatric neurology visits for treatment of the enrollees multiple medical conditions. Findings:  The physician reviewer found that the patient has an extremely complex multi-diagnosed history with diagnoses including autism, bipolar disorder, attention deficit hyperactivity disorder (ADHD), and Tourettes syndrome (TS).  Some of these drugs can cause significant side effects, including the exacerbation of the motor tics of TS, which is generally treated by a pediatric neurologist as it is a neurological motor movement disorder. Additionally, ADHD is frequently treated by a pediatric neurologist, often with psychostimulant medications which also can exacerbate tics. As noted in the article the multiple comorbidities of TS require very sophisticated medication management by a pediatric neurologist (Debes and colleagues).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested a bone anchored hearing aid for treatment of his unilateral hearing loss. Findings:  The physician reviewer found that this patient has unilateral congenital deafness and now has mild to moderate sensorineural hearing loss in the opposite ear. While the BAHA system was originally devised as a way to enhance hearing in ears that could not benefit from conventional aiding, (i.e., chronic middle ear disease, congenital malformation), the use of this system has expanded to include correction of unilateral hearing loss after resection of acoustic neuroma. These latter patients have presumably lost serviceable hearing in the operated ear, but continue to have a contralateral ear with fairly normal hearing. This patient has had unilateral hearing since birth. He now has gradually progressive worsening in his hearing ear. The BAHA device, although helpful in improving directionality, will not be of significant value in this setting since its efficacy will diminish as the patients hearing loss progresses in the hearing ear. There is no documentation in the submitted records that the patient has had a trial of conventional hearing aid use in the hearing ear. A trial with conventional amplification to the hearing ear is the next appropriate step in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the lumbar spine for evaluation of his low back pain. Findings: The physician reviewer found that there is insufficient justification for obtaining an MRI scan of the lumbosacral spine in this patients case. MRI imaging would be indicated if conservative therapy had failed. The records do not indicate that there has been follow through with recommendations for conservative therapy. Furthermore, the impact of MRI imaging obtained early in the course of a patients treatment has been reviewed in the literature (Chou and colleagues). This study was a systematic review and meta-analysis of two patient populations: one in which MRI was obtained early and one in which MRI imaging was delayed until a period of conservative care had taken place. The patient population was selected with criteria of low back pain without indications of serious underlying conditions. This study revealed that there was no statistical different in outcomes in the short-term or long-term (defined as six to twelve months). The authors concluded that lumbar imaging for low back pain without indication of serious underlying conditions does not improve clinical outcomes. The authors advised that clinicians should refrain from routine immediate lumbar imaging in patients with acute or subacute low back pain if they do not have features suggesting a serious underlying condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested rituximab for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the patient has a progressive form of multiple sclerosis with ongoing active inflammatory disease as demonstrated by gadolinium enhancing and new T2 lesions on recent MRI. This patient should be on active multiple sclerosis therapy. Rituximab is a therapy used to treat relapsing forms of multiple sclerosis and has been shown to be effective. This patient requires ongoing therapy for her multiple sclerosis. Rituximab is a medically appropriate option for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Sculptra injections  for treatment of his facial lipodystrophy secondary to medication.  Findings:  The physician reviewer found that the there is no evidence of a functional impairment that requires treatment with polylactic acid (Sculptra). Review of the submitted medical records reveals a lack of documentation of a loss of functioning secondary to HIV-associated lipoatrophy. The records provided do not demonstrate swallowing or gustatory malfunction, articulatory dysfunction or traumatic dysfunction of the oral cavity secondary to facial lipoatrophy. Thus, treatment with Sculptra for the patients HIV-associated lipoatrophy is not medically necessary to resolve or improve a functional deficit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the breast for evaluation of her breast mass.   Findings:  Two physician reviewers found that this patient is not in a high risk group of patients in which a breast MRI has been shown to provide a benefit. The patient has no known BRCA 1 or 2 gene mutation, no personal history of breast cancer, no history of ovarian cancer, and no family history of three or more affected first or second degree relatives that would give her a greater than 20% lifetime risk of developing cancer. In the absence of any of these findings, a breast MRI is not clinically indicated. Dense breast tissue is not an accepted indication for an MRI, nor would an MRI be beneficial for the evaluation of this patients breast mass.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for intensity modulated radiation therapy for treatment of her breast cancer.  Findings:  Three physician reviewers found that standard breast conservation and post-operative radiation is the standard of care and has proven efficacy. The use of IMRT for breast conservation therapy is appropriately considered when standard tangent therapy results in an unacceptable amount of lung or heart being in the treatment field or in patients with very large pendulous breasts with significant skin folds. In these situations, IMRT has been shown to reduce the volume of lung and heart exposure and reduce skin reactions. Thus, when there is a need to give Adriamycin-based chemotherapy and to treat the axilla, supraclavicle, and/or internal mammary lymph nodes, limiting the radiation dose to the heart and lungs is crucial to reduce the potential for pneumonitis and long-term cardiac toxicity. Based on the records provided for review, this patient is not likely to require systemic chemotherapy and there is no need to treat the axilla, supraclavicle, or internal mammary lymph nodes with radiation. As such, IMRT is not likely to be more efficacious for this patient than standard radiation therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for proton beam radiation therapy for treatment of his larynx cancer. Findings:  Three physician reviewers found that there is sufficient outcome data from well-controlled, randomized, peer-reviewed studies involving large numbers of patients which demonstrates that proton beam therapy is likely to result in a better outcome for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested  a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease in order to improve function and/or create a more normal appearance. The surgery must also result in more than minimal improvement in appearance to be considered reconstructive. In the case of this patient, the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease. While this patient has documented skin laxity, the amount of excess skin is not so great as to be considered an abnormal structure. Nor is there photographic evidence that the patients excess skin is visibly affected by disease or infection. As such, the submitted evidence does not demonstrate the patients condition meets the criterion of an abnormal structure as required by Californias reconstructive surgery statute. Thus, the proposed procedure is not reconstructive in nature. With regard to the medical necessity of the proposed procedure, panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions that comprise an abdominoplasty. Panniculectomy is medically indicated if the removed skin has a history of recurrent infections or is necrotic. With regard to the effects of the pannus on the lower back, the submitted evidence does not demonstrate the size of this patients pannus would likely result in lower back pain. In the absence of objective documentation of hampered range of motion, office visits for skin infections and response to such treatment for skin infection, or photographs that clearly show skin breakdown or rashes, the medical necessity of the proposed panniculectomy is not established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a wireless capsule endoscopy for evaluation of her gastrointestinal symptoms. Findings:  Three physician reviewers found that there is no documentation included for review that supports the use of a wireless capsule endoscopy in this case. The records provided do not support a diagnosis of gastroparesis and would not alone provide a basis for the diagnostic procedure at issue. The patients upper GI studies identified only reactive gastropathy, which is likely reflective of her use of prednisone. In general, wireless capsule endoscopy is reserved for use only in patients with obscure GI bleeding, inflammatory bowel disease, small bowel tumors, and refractory malabsorption. None of these factors are present in the instant case based on the medical records provided. The clinical value of wireless capsule endoscopy has not been established in this particular setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for a positron emission tomography/computed tomography (PET/CT) scan for evaluation of his pancreatic cancer.   Findings:  Two physician reviewers found that a prior PET/CT scan showed evidence of residual tumor, the patients most recent scan found him to be cancer-free. Careful surveillance for recurrent tumor is important in this patient with unresectable disease and evidence of local metastasis in the past. Conventional imaging alone is unreliable due to the inability to sort out post-operative change versus recurrent/residual tumor. The metabolic properties of the PET/CT scan provide radiologists with additional information which allows them to determine if abnormal tissue is likely tumor versus scarring. No other exam offers this advantage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Oncotype DX testing performed for evaluation of her breast cancer.   Findings:  Two physician reviewers found that the Oncotype DX assay is a 21-gene profile used for women with node negative, ER positive breast cancers between 6 mm and 4 cm in order to determine the risk of recurrence. It is intended to assist in making an appropriate decision regarding adjuvant chemotherapy treatment and has been found to be efficacious for this purpose. Based on this patients tumor size, ER positive and negative node status, she met clinical indications for the Oncotype DX assay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested a multi-chamber programmable lymphedema pump for treatment of her lymphedema.  Findings:  The physician reviewer found that intermittent compression devices have several configurations and are standard therapy for chronic lymphedema, as noted in an article by Morris. The most popular systems are non-programmable/non-graded multi-chamber sequential compression devices. However, some individuals will not be able to tolerate uniform pressures throughout the extremity. In these instances, the use of multi-chamber programmable lymphedema pumps is indicated so that different pressures can be set within each of the chambers. The submitted documentation demonstrates that this patient was unable to tolerate standard therapy with a non-programmable multi-chamber compression device due to pain. Therefore, the use of a multi-chamber programmable lymphedema pump was medically indicated for treatment of her lower extremity lymphedema.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested radiofrequency tissue shrinkage of the palate and base of the tongue for treatment of his obstructive sleep apnea.  Findings:  Three physician reviewers found that a polysomnography performed  showed an apnea/hypopnea index (AHI) of 43.7 and the patient was reportedly unable to tolerate the continuous positive airway pressure (CPAP) mask.  Based on the evidence provided, the patient only tried the CPAP machine once during the sleep study. Ideally, the patient should undergo an adequate trial with CPAP prior to resorting to other more invasive modalities of treatment such as surgery. Since this patients sleep apnea is moderate-to-severe, he is not likely to achieve superior results from surgical interventions. The best outcomes in this setting result from CPAP therapy.Although Eun and colleagues suggested that radiofrequency tongue base reduction in combination with radiofrequency palatal reduction can help patients with multilevel obstruction, this study was performed without adequate controls. Some studies have concluded that patients treated with uvulopalatopharyngoplasty (UPPP) fared no better when compared to patients treated with UPPP and radiofrequency tongue base reduction in terms of reduced AHI. In conclusion, the requested surgery is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested blepharoplasty, blepharoptosis repair and eye photography for treatment of the enrollees congenital ptosis. Findings:  The physician reviewer found that the medical necessity of the proposed procedures is not established. The submitted photographs do not demonstrate that the patients left upper lid is causing functional visual problems. Additionally, the visual field tests do not document a significant superior visual field loss that is corrected by taping the upper lids. Furthermore, the amount of astigmatism in the patients left eye is 0.50 diopters, which is not visually significant. Moreover, the patients astigmatism cannot be attributed to his ptosis with certainty. All told, the documentation provided does not establish that the patient meets clinical indications for the proposed surgical intervention.