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

A 49-year-old male enrollee has requested authorization a Quickie P222 group 4 power wheelchair for the treatment of his partial quadriplegia. Findings:  The physician reviewer found that this patient requires the use of a power wheelchair in order to perform his mobility-related activities of daily living. The Quickie P222 group 4 power wheelchair meets the patient's in-home needs for the performance of mobility-related activities of daily living. In addition, the requested wheelchair also allows the patient to continue to maintain gainful employment due to its capacity to traverse uneven terrain. The successful prescription of a power wheelchair should consider the entire individual and his or her specific circumstances. In this patients case, the prescribed wheelchair is medically indicated for in-home use.  It is not intended solely for outdoor, recreational or leisure use, and does not exceed the requirements of this patient's condition or circumstances.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patients earache had commenced gradually over two days. Although she had some congestion and sore throat, the patient was not experiencing fever, chest pain, or shortness of breath. There was no sudden decompensation or change in her condition. She was described in the medical record as being in no distress and her vital signs were normal. The patient did not require any testing or other medical intervention in the emergency department; she only required ear drops, and an oral antibiotic was prescribed. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe she was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees pervasive developmental disorder, not otherwise specified. Findings:  Three physician reviewers found that this patient presents with developmental delays with assessments indicating autism spectrum disorder symptomatology, a complex neurodevelopmental disorder. Speech and language therapy has been recommended. Medical records establish speech and language delays. As noted in the article by Myers and colleagues, the primary goals of treatment of autism spectrum disorder are to maximize the patients ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features. The article identifies speech and language intervention as an appropriate treatment modality in this setting. This is also consistent with the practice guidelines of the American Academy of Child and Adolescent Psychiatry, which state that the treatment of autism spectrum disorder requires the care of multiple providers with various treatment modalities such as pharmacotherapy, speech-communication therapy and behavior modification. All told, speech therapy is clinically appropriate and indicated for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested proton beam therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that the use of proton beam therapy is an accepted radiation technology that has proven efficacy and tolerability. Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies are best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. Outside of these specific settings, the use of proton beam therapy remains the subject of debate. While proton beam therapy is a safe and effective treatment modality for prostate cancer, the evidence does not demonstrate that it is any more beneficial than intensity modulated radiation therapy (IMRT), which is standard radiation therapy. In fact, with proton therapy for prostate cancer, often only two lateral beams are used, so as to eliminate beams entering through the bladder or rectum. IMRT can be delivered with innumerable beams (often seven to nine), which allows a similarly conformal plan to proton beam therapy. The use of daily ultrasound (image-guided radiation therapy) can improve normal tissue sparing with IMRT. Slater and colleagues in 2004 concluded, `Conformal proton radiation therapy at the reported dose levels yielded disease-free survival rates comparable with other forms of local therapy, and with minimal morbidity. Dose-escalation strategies are being implemented to further improve long-term results.` Furthermore, most reports, including a systemic review (Lodge and colleagues) conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation (i.e. IMRT). There is also the possibility that proton beam therapy is disadvantageous. The depth of proton delivery is more susceptible to changes in tissue density (such as changes of air in the rectum).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested treatment in an intensive outpatient eating disorder program for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient continued to experience various symptoms associated with multiple psychiatric diagnoses during the period at issue. However, the patients eating disordered behavior had significantly improved by the end of her participation in partial hospitalization. The cluster of symptoms she experienced during the period at issue would have been more appropriately treated outside of a IOP program that focused on her eating disorder per se. According to the American Psychiatric Association criteria for intensive outpatient eating disorder programs, additional psychiatric problems complicate eating disorders and coexisting psychiatric issues may require treatment at a different level of care. Based on the presence of comorbid psychiatric conditions as well as the fact that the patient had experienced significant improvement in her eating disorder, she did not meet clinical indications for the intensive outpatient eating disorder services at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old female enrollee has requested Procrit injections for the treatment of her anemia. Findings:  The physician reviewer found that this patient has multiple co-morbidities and has chronic normocytic anemia. The iron indices strongly indicate that the anemia is probably not due to iron deficiency. It is more likely due to chronic disease like chronic lower extremity infection. The patients ferritin level was 69 ng/mL and most studies performed in patients with chronic inflammatory conditions show that a level under 60ng/mL has a predictive value of 84% for iron deficiency anemia (Cook and Hansen, et al.). The Health Plan indicated that the patients iron stores need to be adequate in order for her to receive Procrit and that iron stores are measured by a transferring saturation of at least 20% or a serum ferritin of at least 80ng/mL. The ferritin level of 80ng/mL is an exceedingly high cutoff value for adequate iron stores. A high ferritin cutoff of 60ng/mL is used in the setting of an inflammatory condition. Ferritin is an acute-phase reactant which becomes elevated in conditions such as rheumatoid arthritis and cancer. Upon review of this patients hemoglobin, it appears that she has previously responded well to Procrit. Procrit is medically appropriate in anemia of chronic disease especially if the patient could be hemodynamically compromised by repeated blood transfusions (Pincus, et al). This patient has been managed with Procrit injections administered by a nurse and should continue to be maintained on Procrit therapy on an as-needed basis with periodic testing to ensure that her transferrin saturation is at 20% or above.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets generally accepted guidelines for bariatric surgery based on National Institutes of Health criteria. At issue is whether the duodenal switch procedure is medically necessary for treatment of the patients morbid obesity as opposed to available surgical alternatives. The duodenal switch procedure is a reasonable and appropriate treatment option for morbid obesity in the well selected candidate. It is a standard primary treatment for morbid obesity, and is approved by the American Colleges of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services. Duodenal switch is well-accepted as a safe procedure. Nutritional complications can be seen in both LRYGBP and duodenal switch. The randomized clinical trial by Skroubis, et al., as well as the 2004 study by Rabkin, et al. did not show that duodenal switch was associated with significant perioperative risks and postoperative nutritional complications. According to Skroubis, et al., There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD. The most common deficiencies encountered were of iron and vitamin B12. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl. The Rabkin study concludes, LapDS [duodenal switch] is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated. Clearly, all patients need to be followed closely and well selected to ensure compliance with lifelong follow-up. Furthermore, the duodenal switch procedure is likely to produce superior results than other procedures in this patient who has a BMI of 53. In general, it is well-accepted that for super obese populations, the duodenal switch affords the greatest weight loss of any weight loss procedure. Additionally, the duodenal switch is more appropriate in patients with joint pain who may require non-steroidal anti-inflammatory drugs (NSAIDs) which is a relative contraindication after LRYGBP. In conclusion, upon detailed review of the available scientific literature, the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested robot assisted laparoscopic abdominal perineal resection with lymph node dissection and colostomy for the treatment of her rectal cancer. Findings:  Three physician reviewers found that robotic surgery is the most recent development in the field of minimally invasive surgery, having been approved by the Food and Drug Administration for clinical use in 2000. The benefits touted by its proponents include a magnified 3D view of the operative field, increased manual dexterity, elimination of surgical tremor and decreased surgeon fatigue. The reported disadvantages include a steep learning curve with initial increased operative times. There are numerous reports in the medical literature showing that robot assisted laparoscopic rectal surgery is safe and effective, yet there is a paucity of evidence demonstrating that the procedure is superior to traditional laparoscopy. Patriti and colleagues noted that, Robot-assisted surgery is considered an evolution of traditional laparoscopy, but little data support any real benefits of the technology. Ng and colleagues stated: Although the laparoscopic approach in colorectal surgery has been shown to be beneficial and oncologically safe, its use is still not widespread. Hellan and colleagues indicate that future studies are still needed to determine the long-term oncological outcomes of robotic-assisted total mesorectal excision. Therefore, while this patient would likely benefit most from laparoscopic resection, the robotic assistance is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested a tumor imaging PET/CT scan for an evaluation of his multiple myeloma. Findings:  Three physician reviewers found that Medicare has revised the guidelines for PET imaging and now approves the technique for staging and monitoring treatment for most tumors, including multiple myeloma. The advantage of PET over MRI and CT is that known lesions are assessed for metabolic activity with PET. Even when successfully treated, the abnormal findings on CT or MRI would still be present. The clinician would have no way to assess the importance of the lesion without knowing if it is active. Therapeutic decisions would depend on the presence/absence of active tumor, and PET is the only tool enabling clinicians to perform such an assessment. All told, PET/CT scan would be more valuable to this patient than any other method of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a prophylactic bilateral mastectomy for the treatment of her fibrocystic changes. Findings:  The physician reviewer found that bilateral mastectomy is not medically indicated in this situation based on the patients risk of breast cancer as calculated by the Gail Model. By the Gail Model, the patient has a lifetime risk of breast cancer that is less than 10%, and a five-year risk of breast cancer of 1.6%. By these criteria, she would qualify for breast cancer chemoprevention with either tamoxifen or raloxifene. The patient has undergone frequent mammography, ultrasound and MRI evaluation. Screening ultrasound and MRI are both known to lack specificity and generate a significant number of false positive findings leading to unnecessary biopsies and patient anxiety. Screening ultrasound has been documented to identify on average only five to six additional cancers per 1000 patients screened, while generating false positive reports in 10 to 15% of patients. Finally, the pathology reports provided demonstrate benign findings and do not place the patient in an elevated risk category. She does not meet the criteria set forth by the Society of Surgical Oncology in the March 2007 position statement on prophylactic mastectomy, as she has tested negative for BRCA, has no family history of breast cancer and has no high risk pathology. As such, this patient does not meet medically necessary indications for prophylactic bilateral mastectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Enbrel 25mg, twice weekly for the treatment of her polymyalgia rheumatica. Findings:  The physician reviewer found that several studies support the use of tumor necrosis factor inhibitors in the treatment of both polymyalgia rheumatica and giant cell arteritis, a frequently associated condition. Catanoso and colleagues published an open label study of six patients with polymyalgia rheumatica who were able to reduce their prednisone dose significantly while on Enbrel. Similarly, the tumor necrosis factor inhibitor infliximab was shown in a pilot study and in case reports to reduce acute-phase reactants such as IL-6 and to reduce patient steroid requirements. High levels of IL-6 are thought to be associated with continued active disease and with prolonged high doses of steroids. In this case, the treating rheumatologist has documented both failure of steroids and oral steroid-sparing agents to control the patients disease, and clinical and laboratory response to Enbrel. Enbrel 25mg, twice weekly, is medically appropriate and indicated for treatment of this patients refractory polymyalgia rheumatica.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a coronary CT angiography (CCTA) for an evaluation of his coronary artery disease. Findings:  Three physician reviewers found that there is no indication for coronary CT angiography based on the documentation provided. The appropriateness criteria published by Hendel and colleagues only recommend CCTA in this setting for a negative or equivocal stress test. The literature does not support the contention that the risks of stress echocardiography are so great as to warrant a CCTA. There is also the question as to the diagnostic accuracy of CT angiography for evaluation of this patients coronary artery disease. As the study by Miller and colleagues indicates, The negative and positive predictive values indicate that multidetector CT angiography cannot replace conventional coronary angiography at present.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested acupuncture for the treatment of her post-surgical pain. Findings:  The physician reviewer found that there is no conclusive evidence in the medical literature documenting the effectiveness of acupuncture for post-operative pain. The medical literature does document that acupuncture and transcutaneous electrical stimulation have some benefit in decreasing symptoms of nausea. The adjuvant use of acupuncture for treatment and management of post-operative pain is recommended if conventional pain management treatments fail or there are severe adverse side-effects of such conventional treatments. However, in this case, the records do not document trials and failures of conventional pain management therapy or contraindications to such therapies. A study by Usichenko and colleagues concluded that the evidence that auricular acupuncture reduces post-operative pain is promising but not compelling. A study by Ernst found that the medical conditions that were improved by the use of acupuncture included chemotherapy-induced nausea and vomiting, post-operative nausea and vomiting and idiopathic headache. That study concluded, Cochrane reviews of acupuncture do not suggest that this treatment is effective for a wide range of conditions. All told, there is a lack of scientific evidence supporting the benefit of acupuncture in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested partial hospitalization services for the treatment of her bulimia nervosa and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient met American Psychiatric Association (APA) criteria for partial hospitalization on the dates of service at issue. She had daily repetitive thoughts about disordered eating and required structure and support to adhere to weight gain. She had skipped meals while at home on the weekend. She also had significant co-morbid psychiatric disorders impacting her recovery. All told, the patients clinical condition required the structure and monitoring available in a partial hospitalization setting during the period at issue. Without these services, there was significant risk of relapse and/or deterioration.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 70-year-old female enrollee has requested Botox injections for the treatment of her refractory post-herpetic trigeminal neuralgia. Findings:  Three physician reviewers found that this patient has post-herpetic neuralgia in the trigeminal nerve distribution, and does not have idiopathic trigeminal neuralgia. There are no surgical procedures that have been found to be effective in PHN. This patient has tried and failed at least four standard treatments. The only FDA approved therapy she has not tried is Cymbalta. The patient and her neurologist report a remarkable improvement in her facial pain from Botox injections. Botox has been utilized for a variety of chronic pain syndromes including occipital neuralgia, trigeminal neuralgia and post-herpetic neuralgia. There are case reports of Botox being beneficial in patients with intractable post-herpetic neuralgia. Botoxs mechanism of action suggests its potential to be effective in treating a variety of chronic focal neuropathic disorders. Given the patients failure on multiple standard therapies, the lack of effective alternative standard therapies, and her prior long-standing high response to intermittent Botox therapy, I find that Botox was and is likely to be superior to any standard therapies available in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical documentation does not demonstrate the medical necessity for continued acute inpatient/detoxification treatment. There is no report of a physical examination or vital signs documenting that the patient was unstable from a medical standpoint as of the last authorized date of service. In addition, although the records provide limited details regarding the detoxification protocol, it appears the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement. Thus, the submitted evidence does not establish that the patient was experiencing significant withdrawal symptoms during the period in question such that continued acute inpatient/detoxification services were required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the medication Xifaxan 400 mg for the treatment of the enrollees small intestinal bowel overgrowth. Findings:  The physician reviewer found that Rifaximin (Xifaxan) is an approved drug for the treatment of small intestinal bacterial overgrowth (SIBO). The medical literature does not support use of one of the formulary alternatives over the use of Xifaxan. Instead, the literature shows lower recurrence of SIBO with Xifaxan. Additionally, other antibiotics indicated for SIBO carry a higher risk for Clostriudium difficile. The use of Xifaxan is medically indicated for treatment of this patients condition. The proposed dose of Xifaxan 400 mg to be taken orally 3 times a day for 10 days is medically appropriate and does not pose any significant risk.