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

A 29-year-old female enrollee has requested chemotherapy (Abraxane) for treatment of her lung cancer.  Findings:  The physician reviewer found that this case of NSCLC is complicated by the presence of pregnancy and the advanced nature of the disease. The patients initial treatment with carboplatin and paclitaxel showed a significant response. The patients imaging studies showed that she had an incomplete response that required more chemotherapy. At that point, she was switched to pemetrexed. This change in therapy is consistent with published medical literature showing an improvement in progression free survival with pemetrexed maintenance (Paz-Ares, et al; Ciuleanu, et al). Subsequently, the patient was switched to Abraxane. The clinic notes document neuropathy, so the continued use of carboplatin or paclitaxel would not have been advisable. A recent phase III study did report a better overall response rate with Abraxane compared with solvent paclitaxel in combination with carboplatin in metastatic NSCLC (Socinski, et al). The study also resulted in less neuropathy in the Abraxane treatment group compared with solvent paclitaxel. However, there is inadequate evidence for Abraxane monotherapy after pemetrexed maintenance for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested authorization an MRI of the lumbar spine and an MRI of the cervical spine for evaluation of her lower back and neck pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested MRI of the cervical spine. The patient has a history of progressive neck and arm pain consistent with radiculopathy. Additionally, the patients exam findings are consistent with myelopathy with hyper-reflexivity. Imaging of the cervical canal has not been performed. The patient meets accepted clinical indications for MRI imaging, specifically, subacute or chronic neck or radicular pain and clinical suspicion of cord compression or myelopathy (Milliman Care Guidelines). Furthermore, the patient is being considered for invasive injections. As such, the requested MRI of the cervical spine is medically indicated and necessary. The requested MRI of the lumbar spine is also supported as medically necessary in this case. The patients previous lumbar MRI shows a large L5/S1 disc herniation that seemingly resolved. Further herniation or return of the herniation on subsequent MRIs is possible in this setting, although this is not addressed by the available literature. In any event, the patient has progressive back and radicular symptoms. She has also failed many months of conservative measures and is being considered for invasive injections. The patients last MRI was over two years ago and her symptoms have changed. Additionally, the study by Al Nezari and colleagues emphasizes the point that the neurological exam has poor diagnostic accuracy for detecting clinically significant disc herniations. Based on review of the available evidence, the requested MRI of the lumbar spine is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested substance abuse services for treatment of his substance abuse.  Findings:  The physician reviewer found that based on review of the submitted medical records, this patient was in marked denial of the severity of his chemical dependence. The extent of the patients condition interfered with his ability to function at the workplace and required intervention. He was showing medical consequences of his illness such that a relapse would exacerbate his physical condition if not stabilized in a structured setting. As such, continued residential treatment level of care was medically necessary through the date indicated. Although the patient, transitioned to PHP level of care the following day, the records indicate he was sufficiently stabilized at that time to transition to an outpatient level of care, as he was no longer in denial of his condition and was compliant with treatment. Thus, the residential treatment center services provided from the time frame specified were medically necessary for treatment of the patients medical condition. However, the substance abuse treatment services provided from the time frame specified could have taken place in a more normative setting at home with the assistance of community services and therefore were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections to the left knee for the treatment of her knee pain. Findings:  Three physician reviewers found that the requested services are not likely to be superior over other available treatment modalities.  This patient continues to have knee pain following lateral meniscal repair and plica excision.  Physical therapy and cortisone injections have not been beneficial.  Per the current medical evidence, cortisone injections have been shown to provide short-term benefits for intra-articular knee pain.  However, the effectiveness of Botox injections in this clinical setting has not been established by the current medical literature.  The use of Botox injections in this setting has not been well-studied.  All told, the requested Botox injections are not likely to be of greater benefit than other treatment options.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A parent of a nine-year-old male enrollee has requested  emergency services for treatment of the enrollee's headache.  Findings:  The physician reviewer found that review of the submitted documentation indicates that the patient was seen in the emergency department for the recurrence of a headache that had been occurring episodically for a five-month period. On the date in question, the headache suffered by the patient was of sufficient severity such that absence of immediate medical attention could reasonably be expected to result in placing the patients health in jeopardy due to continued pain and suffering and possible progression of a potentially serious neurologic disorder. As noted by the parent, the patient had not responded to the medication administered at home and was in severe pain and appeared to be near syncope. Thus, the decision to seek immediate medical attention in an emergency department was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested Procrit (epoetin alfa) injections above 12 g/dL for treatment of her myelodysplastic syndrome.  Findings:  The physician reviewer found that although not currently listed as an indication by the Food and Drug Administration (FDA), the use of epoetin alfa injections has become standard of care for treating the anemia of myelodysplasia. As noted by Santini, et al. and Steensma, et al., a significant percentage of anemic patients respond to standard dose intramuscular injection and additional patients respond when the dose is increased. The drug is used to treat anemia and/or to render the patient transfusion independent (Balleari and Clavio). In the majority of cases of response, epoetin alfa injections were instituted for an Hb concentration of less than 10 g/dL and the Hb maintained between 10 and 12 g/dL (Balleari and Clavio). The rationale is that patients are anemic and usually symptomatic below 10 g/dL. The Hb of 12 g/dL is a normal level for women and in fact women qualify to donate blood at that level. An Hb of 12 g/dL is not anemic. There is no evidence that performance is enhanced by raising the hemoglobin above this level for people who do not live at extreme altitude, do not have deoxygenation from cardiopulmonary disease, or are not competitive endurance athletes. For that reason, patients are not generally maintained at an Hb greater than 12 g/dL, there is limited experience with such patients, and the adverse effects (if any) are unknown because of the lack of experience. The standard of care is to maintain the Hb between 10  12 g/dL. Therefore, the patients request for Procrit injections above 12 g/dL is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested BRCA1 and BRCA2 genetic testing due to her diagnosis of personal history of premenopausal invasive breast cancer and stated family history of cancer.  Findings:  The physician reviewer found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.Well-established guidelines identify those individuals in whom genetic screening is warranted. A personal history of breast cancer at age 50 alone is not considered a sufficient risk factor for BRCA gene mutation carrier status to justify testing, unless accompanied by other indicators of increased risk. These include, in part, a history of a first or second degree relative with ovarian cancer or breast cancer occurring at an age younger than 50, or belonging to a high-risk ethnic group such as Ashkenazi Jewish descent. The National Comprehensive Cancer Network (NCCN) guidelines also recommend testing individuals with a personal history of breast cancer and a limited family history, that is, where fewer than two close relatives, in either lineage, have survived beyond age 45. Review of the documentation provided does not demonstrate these qualifying conditions are met in this case. In sum, the clinical details provided regarding the patients BRCA risk factors is insufficient to justify BRCA mutation screening, as specified by the consensus guidelines described above.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested cryoablation of tumor for treatment of her left breast fibroadenoma. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more efficacious than other treatment options.  The current medical evidence supports the requested services in this clinical setting.  Cryoablation has been shown to be an effective treatment for breast tumors.  The medical literature has demonstrated the safety of these requested services for the treatment of this patients condition.  When compared to surgical excision, cryoablation has the advantage of little to no scarring.  Thus, cryoablation of tumor is likely to be more effective than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested buprenorphine SL tablet for treatment of his chronic pain and opioid dependence.  Findings:  The physician reviewer found that buprenorphine, a high-affinity partial agonist at the mu opioid receptor is approved for the treatment of opioid dependence and functions as a full agonist for analgesia and has no ceiling in terms of pain management. Buprenorphine comes in several preparations: Subutex sublingual (buprenorphine SL mono-tablet), Suboxone tablet and film strip (buprenorphine-naloxone combination), Buprenex (buprenorphine injectable) and Butrans (buprenorphine transdermal patch). Only the patch and injection forms are approved for treatment of pain. The preparation requested by the patient, (buprenorphine SL mono-tablet) is recommended only for pregnant patients and it is not approved for pain management by the Food and Drug Administration (Renner). While the submitted documentation notes concerns regarding the patients exposure to compounds that must be metabolized such as naloxone, there is no absolute contraindication to buprenorphine-naloxone combination therapy in a patient with hepatitis C. The combination tablet has the best support for co-occurring opioid dependence and chronic pain. Thus, based on the documentation provided and review of the relevant peer-reviewed literature, the requested medication, buprenorphine SL, is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested SAVI radiation therapy (internal radiation therapy) for treatment of her breast cancer. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  Based upon American Society for Radiation Oncology guidelines, partial breast irradiation is an emerging standard of care for women with low risk of recurrence.  Per these guidelines, suitable candidates for accelerated partial breast irradiation are older than 60 years of age, with small tumors, and negative margins.  As noted by Smith and colleagues, patients who are younger than 50 years of age are unsuitable for partial breast irradiation.  This patient is 44 years of age.  The current medical evidence has not established the long-term safety and efficacy of SAVI radiation therapy in this clinical setting.  Longer term follow-up is needed to ascertain if there is any risk or benefit with respect to late toxicity and long-term tumor control.  All told, SAVI radiation therapy (internal radiation therapy) was not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested emergency services for treatment of his throat pain.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date in question. The patient had severe throat pain, after a bout of documented tonsillitis/pharyngitis, has, in the differential diagnosis the potential to be a case of peritonsillar abscess or retropharyngeal abscess, both of which are life-threatening complications of tonsillitis/pharyngitis. Moreover, the determining factor in this case is the degree of pain that the patient was in, the fact that he had severe pain (9 out of 10) constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. The patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Xeomin (incobotulinumtoxinA) injections for treatment of her abdominal muscle spasms. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. There is a lack of published scientific evidence to support the efficacy of Xeomin in this clinical setting. The medical records note that the patient complains of abdominal muscle spasms and an MRI revealed she is found to have thoracic nerve root cysts. Per the manufacturers prescribing information, Xeomin is approved for the treatment of cervical dystonia, blepharospasms and wrinkles. Xeomin is not FDA approved or indicated for the treatment of abdominal muscle spasms secondary to neural foramen compression. Furthermore, there is a lack of peer-reviewed medical literature that supports the use of Xeomin for abdominal muscle spasms. Given the lack of scientific data demonstrating the efficacy of Xeomin for the requested indication, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of gastric bypass surgery in this case. The patient does not meet 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. Given the patients BMI of 31, she does not meet the standard definition of clinically severe obesity at this time. The risks of weight loss surgery outweigh the benefits in this patient population. Additionally, multidisciplinary clearance has not been obtained and there are pending behavioral compliance requests that have not been completed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested Xifaxan for treatment of her small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The medical records document small intestinal bacterial overgrowth by hydrogen breath test.  The patients symptoms include abdominal bloating and gas.  Her provider has recommended Xifaxan 550mg, three tablets per day.  The current medical literature has not established that Xifaxan is more effective than other antibiotics in this setting.  Per the submitted documentation, the patient has not tried other approved antibiotics for the treatment of this condition.  All told, Xifaxan is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested endoscopy sinus surgery (septoplasty/SMR/maxillary crest reconstruction, bilateral concha bullosa reconstruction with limited ethmoidectomy with possible balloon sinusotomy of the maxillary sinus) for treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation demonstrates the patient presents with the primary problem of sleep apnea and nasal obstruction. Based on the medical records examined, the nasal valve is not contributing to the patients symptomatology. The CT scan shows that the source of the problem is the septum/turbinates and concha bullosa. Therefore, the patient meets accepted clinical indications for septoplasty and concha bullosa reduction. The minimal maxillary/ethmoid findings seen on the CT scan are not contributing to this patients symptoms and therefore the ethmoidectomy and sinusotomy are not medically necessary. As such, a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested continued residential treatment center services for the enrollees major depressive disorder, moderate, recurrent, and posttraumatic stress disorder. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting as community interventions are thought to offer optimization of treatment gains.  However, individuals with anxiety and mood symptoms coupled with the burden of past abuse and strained family dynamics may require treatment in a more restrictive setting.  In this patients case, she has a history of anxiety and mood symptoms with recurrent suicidality, coupled with limited coping skills.  Like many other children of abuse, this patient lacks an internal locus of control and the ability to self-soothe, and this is compromising her developmental task of identity formation.  Per the submitted documentation, she has failed outpatient treatment and required acute care services on two separate occasions.  Currently, she is enduring mood and anxiety symptomatologies with somatic complaints while struggling with self-esteem and abandonment issues.  She also displays attention seeking behavior and entertains frequent thoughts of self-harm.  On the date indicated, both her antipsychotic and sleep medications were increased.  Per the medical records, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  All told, continued residential treatment center services from the date specified and forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy (72 hours per month of direct ABA therapy and 8 hours per month of supervision) for treatment of the enrollees autism.  Findings:  The physician reviewer found that in this patients case, he has been receiving extensive ABA therapy since the age of 3.  His language is limited to single words and the submitted records demonstrate the patient has made little substantive progress in social, language, or intellectual skills. While this patient has failed to demonstrate sustained and continuing improvement in the above noted areas, there are safety concerns that necessitate the continuation of ABA therapy at a reduced frequency. The submitted documentation demonstrates the patient is in constant danger of accidental injury. As such, it is medically necessary that he continue to receive ABA therapy in an attempt to allow him to develop sufficient insight to prevent accidental injury.  Safety concerns (e.g., crossing streets, avoidance of injury or trauma) necessitate ABA operant training to help prevent self-injury or accidents. Accordingly, 20 hours per month of direct ABA therapy limited to the objective of addressing safety concerns along with 2 hours of monthly supervision is medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested  speech therapy services and occupational therapy for treatment of the enrollees autism and speech and language delay.  Findings:  The physician reviewer found that the medical communitys standard of practice is to provide speech therapy to autistic children. Myers and colleagues found, People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. In light of the available scientific data, speech therapy at the requested frequency is medically necessary for treatment of the patients medical condition.With regard to the requested occupational therapy, Pfeiffer and colleagues compiled an extensive meta-analysis of the medical literature and concluded that occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism. Additionally, May-Benson and colleagues performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded the therapy was effective. Given the patients documented diagnosis and associated deficits, occupational therapy at the proposed frequency is medically necessary. For the reasons set forth above, it is medically necessary that this patient receive speech therapy and occupational therapy at the requested frequencies. Specifically, speech therapy services 2 times per week for 16 weeks and occupational therapy services up to 3 times per week (24 visits) in 15 minute increments are medically necessary.