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

The parent of a 10-year-old male enrollee has requested Increlex for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that while the patient presents as a case of delayed puberty, the adult height prediction given by the endocrinologist falls well below the cut-off limit set by the FDA to justify GH therapy for idiopathic short stature. However, the FDA has not made any guidance about the use of Increlex for idiopathic short stature. The endocrinologists diagnosis of IGF-1 deficiency is presumed to imply a GH insensitivity state, inferred from the patients lack of positive response. If so, it would appear unlikely that he has the Laron phenotype, but rather would have a partial GH insensitivity state. If so, I could only find reference to a peak GH level of 5.1 after L-dopa in the materials provided, a level which is barely in the normal range and certainly not elevated as would be expected in GH insensitivity. Further, the initial IGF-1 was not deficient. The medical literature indicates that the definition of partial GH insensitivity remains to be established, and thus, IGF-1 therapy in this instance remains of unproven efficacy until appropriate studies have been completed. In the absence of evidence demonstrating the basis for the patients adult height prediction of less than 62 and documented evidence that the patients height continues to remain well below 64, the medical necessity of Increlex is not established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested submucous resection of the inferior turbinate for the treatment of his sleep apnea. Findings:  Two physician reviewers found that this patient has undergone multiple surgeries in an effort to alleviate his obstructive sleep disorder. He continues to have moderate OSA as documented by polysomnography. His complaint at this time is continued nasal congestion. There is no documentation that medical therapies (in the form of nasal sprays or allergy medications) have been attempted to any extent. While further turbinoplasty may help with this patients congestion and, possibly with his sleep apnea, no real trial of medical therapy has been undertaken. Thus, it is not possible to conclude that further surgery is likely to be more beneficial than standard therapy since we do not know what benefit medical therapy would have for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested surgery by a colorectal cancer specialist for the treatment of his colon and rectal cancer. Findings:  The physician reviewer found that the relationship of surgical specialization to cancer outcomes remains controversial. In the management of colon and rectal cancer, there are publications to support improved outcomes when patients are treated by specialists, but more recent papers have demonstrated that the improvement is likely related to surgeon and/or hospital volume rather than specialization (Borowski, et al. and Martinez-Ramos, et al.). That is, equivalent outcomes can be obtained by non-specialists who perform a high volume of the procedure and conversely, a specialist who performs a low volume of an index procedure can have inferior outcomes. In this case, no evidence has been provided that the practice volume of the in-network physician is inferior to that of the out-of-network physician. Thus, it should not be assumed that the specialization of the out-of-network physician will ensure better outcomes (operative morbidity, mortality, or cancer-related survival). Therefore, given the lack of evidence to directly support specialization as an independent predictor of improved outcome, and the availability of an in-network surgeon who appears to understand the management of rectal cancer (through the decision to refer the patient for preoperative therapy), the medical necessity of a colon and rectal surgeon is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for psychiatric residential treatment for treatment of the enrollees mental health conditions. Findings:  The physician reviewer found that the medical records also reflect ongoing medication management and family therapy. The ability to respond to intense residential treatment is evident. Discharge planning is included in the current plan of care, but this requires continued care at the present level of care, as well as intense planning and coordination (given this patients psychiatric history and major co-morbidities).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested Avita 0.025% gel for the treatment of his lentigo. Findings:  The physician reviewer found that lentigo consists of benign lesions that do not cause a functional deficit. These lesions do not pose a risk for skin cancer. The treatment of such lesions is generally considered cosmetic, as its purpose is to improve appearance. Based on the clinical information provided, there is no medical indication for Avita gel in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested Botox injections for the treatment of his myofascial back pain. Findings:  Two physician reviewers found that although Botox is certainly not a first-line therapy for back pain, there is sufficient medical literature that demonstrates its benefit in select populations. Although underpowered, the Lew study reported benefit in SF-36 scores compared to controls. This particular patient has failed multiple standard therapies and has shown some benefit to trigger point injections, thus further suggesting the benefit of Botox. A trial of Botox with a repeat assessment after treatment to evaluate response and determine future course of treatment should be granted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested Testim 1% gel for treatment of his hypogonadism. Findings:  The physician reviewer found that the medical records reflect an improvement of the bioavailable Testosterone after treatment with Testim. Total Testosterone is not sufficient to assess the androgen status of any male patient. Many co-morbid conditions will alter both Albumin and Sex Hormone-Binding Globulin levels resulting in different bioavailable Testosterone with the same Testosterone level. These conditions have been well studied and reported as seen in the references by Vermeulen cited above.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a Continuous Passive Motion (CPM) machine for the treatment of her knee (status-post surgery). Findings:  The physician reviewer found that there is a paucity of well-controlled studies in the peer-reviewed medical literature showing improved clinical outcomes from use of a CPM machine following any type of knee surgery. The literature does not clearly support the role of CPM after knee trauma surgery and does not sufficiently demonstrate that CPM improves long-term outcomes when compared to standard post-operative therapy measures. More outcomes data is needed to demonstrate the efficacy of CPM use in cases such as this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an additional 12 visits of physical therapy for the treatment of her knee condition. Findings:  The physician reviewer found that this patient has had extensive skilled physical therapy (PT) visits and has improved functionally. Her right knee active range of motion (ROM) is 0-120 degrees. She is ambulating independently with a single point cane. She continues to have strength deficits and requires continued strengthening exercises. However, this deficit does not require the services and supervision of a skilled physical therapist. She can improve her right knee ROM, quadriceps and hamstring strength, and ability to climb stairs with a home exercise or gym program. It is not well documented in the physical therapy notes how the patients right leg strengthening was being accomplished, why her strength had not improved, and what would be done differently in the additional 12 visits of physical therapy being requested to ensure increased strength, ROM, and function of her right knee.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested continued use of infusion/medication therapy for the treatment of her Lyme disease. Findings:  The physician reviewer found that there is no recorded history of the rash that is typical following a tick bite from a Borrelia positive tick. Additionally, the only serological evidence in the record is negative for the causative agent of Lyme disease (Borrelia burgdorferi).  There is no evidence of Babesia. Although the submitted photomicrograph has been reported to show Babesia, this is not a usual or established way of making the diagnosis of Babesia infection.  Standard serological testing for this organism is not included in the submitted records. Thus, there is inadequate evidence from which to conclude that the patient has Lyme disease or Babesia. Furthermore, there is no evidence that more than a month of therapy is needed for neurological Lyme disease. Additionally, intravenous tetracyclines are not widely used because they are associated with significant hepatic toxicity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested hyperbaric oxygen therapy (HBOT) for the treatment of her head pain secondary to mastoid ablation. Findings:  Two physician reviewers found that hyperbaric oxygen therapy has been utilized in the treatment of many disease entities, including chronic infection, osteomyelitis and chronic pain syndromes. However, there is no supporting scientific evidence that a patient with pain that appears to be secondary to chronic severe mastoid disease and possible cerebritis, would benefit from such treatment or that such treatment would be more efficacious than any other available treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Enbrel for the treatment of her rheumatoid arthritis and leukopenia. Findings:  The physician reviewer found that many rheumatologists who have a patient who has a relative contraindication to the use of methotrexate (such as mild leukopenia, or pulmonary disease) will use Enbrel alone because of the patients other risk factors for development of erosive, deforming arthritis. This patient has prognostic indications that suggest she will have aggressive RA, Enbrel is appropriate and should be used as soon as possible.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested mental health inpatient care services for the treatment of his major depressive disorder with psychotic features. Findings:  The physician reviewer found that the patient was chronically depressed and anxious and was prescribed multiple medications. He presented with no clear safety risk or psychotic features as of the last authorized date of service. The patient could have safely been discharged. The records provided document that as of the first date in question the patient was less depressed, less anxious and had decreased somatic preoccupation.  His degree of depression did not warrant mental health inpatient care services on the dates in question. As such, these services were not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested Nexium for the treatment of his gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that there is no documentation provided necessitating the requested Nexium therapy. The submitted documentation does not indicate the degree of GERD found on endoscopy; nor is there mention of erosions, ulcer, stricture, or presence of Barretts esophagus. This documentation is necessary because the degree of erosive changes on endoscopy may determine the dosing (every day versus twice per day) and duration of PPI therapy. There is no mention in the record of a trial and failure of an H2 receptor antagonist or prokinetic agents. There is no indication of the patient requiring referral for a surgical procedure for GERD control. All told, there is no documentation provided necessitating specific therapy with Nexium. The differences between the various PPIs are not significant. There is currently a lack of evidence to suggest superior clinical efficacy of one PPI over any other. The medications display similar dose-response relationships with similar potencies and efficacies at the equivalent dose. The decision to select one PPI over another is likely to be based on the drugs licensed indication and patient tolerability. Furthermore, PPIs should be used at the lowest effective dose for the minimum duration possible and attempts to step down to a lower dose or switching to an H2 receptor antagonist periodically, to achieve the goal of minimum effective dose should take place.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for intensity modulated radiation therapy for treatment of her pancreatic cancer. Findings:  Two physician reviewers found that there is abundant single institution data to suggest that IMRT for pancreatic cancer yields improved outcomes versus conventional radiation with respect to normal tissue sparing.  The studies by Milano and colleagues, Landry and colleagues and Spalding and colleagues demonstrate small bowel sparing.  In the study by Milano and colleagues, IMRT significantly reduced the volume of kidneys receiving greater than 22 Gy as well as significantly reduced the mean right kidney dose.  Several of these studies demonstrate IMRT to be safe and effective, including the studies by Ben Josef and colleagues and Milano and colleagues. The study by Yovino and colleagues demonstrated reduced gastrointestinal toxicity with IMRT when compared to conventional radiation therapy. In this particular case, there is a compelling reason to offer IMRT, since a therapeutic dose is unlikely to be safely delivered without IMRT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Omnaris 50mg spray for the treatment of her chronic sinusitis. Findings:  The physician reviewer found that Omnaris is a newer drug used in the treatment of allergic rhinitis and asthma.  Because it is administered as a pro-drug, it has been seen to have an improved therapeutic margin with no measurable effect on the hypothalamo-pituitary-adrenal (HPA) axis. On occasion, it has been prescribed at higher doses in patients with severe asthma. However, the use of this drug at the proposed dosage is not supported by the current literature. Given that the requested dosage is twice the dosage recommended by FDA guidelines and the effects of such dosage have not been studied, the Health Plans denial is medically appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested a CT scan of the abdomen for an evaluation of his condition. Findings:  The physician reviewer found that a CT scan is accepted as being medically necessary for abdominal and pelvic trauma, abnormalities noted on other imaging studies, abdominal inflammatory processes (such as abscess, pancreatitis, and colitis), palpable abdominal masses (not explained by other scenarios or other studies), and abdominal and pelvic pain (not explained by clinical features, examination, and preliminary imaging studies such as ultrasound of the abdomen). This patient had upper abdominal discomfort and an EGD revealed gastritis. The abdominal examination was benign with no tenderness, and no palpable masses. The liver panel was essentially unremarkable. The attending physician was suspecting fatty liver or NASH. A good quality ultrasound can be highly sensitive and specific in diagnosing fatty liver. The classic ultrasound findings are hyperechoic liver. An ultrasound of the liver should have been performed first to evaluate for possible fatty liver disease. A CT scan of the abdomen was not the appropriate next step in this setting, and as such, was not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested speech therapy for the treatment of her viral encephalitis. Findings:  Two physician reviewers found that there is medical literature that supports the use of cognitive rehabilitation therapy for patients with prior cerebral injury, such as what occurs in viral encephalitis. The above referenced articles provide examples of how cognitive rehabilitation therapy has been used in similar cases and the benefit that it provides to patients with cerebral injury. In clinical practice, these therapies are essential to help patients return to a near-normal functional lifestyle. This patient clearly has verbal symptoms and warrants such therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested hip resurfacing surgery for the treatment of her right hip degenerative joint disease (DJD) secondary to osteoarthritis. Findings:  Two physician reviewers found that there is a general agreement that more prospective studies of hip resurfacing surgery need to be completed. Hip resurfacing procedures have been performed for many years, but have been shown to have many problems associated with them. Changes in operative procedures and implant design and materials have led to an increased interest in resurfacing, since there are some theoretical benefits as compared to replacement, which has been the standard procedure for some 30 years. However, there are still questions to be resolved such as the longevity of the procedures results and the long-term effects of metal ionic spread, and the present metal-on-metal prostheses associated with this concern. In addition, patient selection is of great importance, since the choice of procedure can vary with age, sex, and bone stock and the majority of serious complications in a recent study occurred in women of all ages and men over the age of 55. All told, there is insufficient evidence of the efficacy of hip resurfacing to support its use at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested mental health acute inpatient treatment for the treatment of the enrollees anxiety and depression. Findings:  The physician reviewer found that the acute inpatient treatment services were medically necessary, as the patient required this level of care to effectively engage in treatment for severe anxiety and depression, and to initiate and monitor psychotropic medication. Her severe anxiety, withdrawn behavior, somatic complaints and inability to tolerate school even for one hour per week, significantly limited the patients ability to attend and engage in less restrictive services such as a partial hospitalization program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for an amniocentesis, ultrasound, fetal and maternal evaluation and office consultation with a perinatologist for treatment of her pregnancy. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology (ACOG) guidelines indicate that counseling regarding the risks of fetal aneuploidy and the risks and benefits for available screening and diagnostic tests should be offered to this patient. While amniocentesis is not performed prior to 15 weeks gestation, there is no reason to delay counseling until then. Both screening tests (first trimester screening) and diagnostic tests (chorionic villus sampling) are performed earlier (11 to 13 weeks gestation). Delaying the consultation until 14 to 16 weeks gestation would cause this patient to miss the opportunity to pursue these options. In addition, the National Society of Genetic Counselors recommends that counseling for the risk of aneuploidy and screening be performed as early as possible once pregnancy is confirmed. Finally, the patient has a clear diagnosis of hypothyroidism, a medical complication known to cause fetal effects if not adequately treated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for a whole body Positron Emission Tomography (PET) scan for evaluation of her possible lymphoma. Findings:  Three physician reviewers found that there is not a known diagnosis of cancer, or even findings from other imaging tests to assess metabolic activity in order to warrant a whole body PET scan. This patient has a perplexing set of clinical symptoms. However, all diagnostic tests have been negative to date. Also, no abnormal clinical findings (such as adenopathy or palpable masses) or prior scans exist to warrant evaluation by a whole body PET scan. Presently, PET scans are performed for specific reasons such as those listed, and there is no current medical literature to support the use of a whole body PET scan to evaluate peculiar or strange symptoms without a histological diagnosis of malignancy, or to evaluate a finding on another imaging modality to assess metabolic activity. For these reasons, a whole body PET scan in this case would likely be without benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested for continued intensive outpatient program services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that three hours per week of intensive outpatient program services is medically indicated for this patient.  This will allow treatment for social skills training, individual therapy and family therapy with his mother.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Vyvanse 100 mg for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the submitted documentation indicates the patients symptoms have improved since receiving the higher dosage of Vyvanse (100 mg), there are great concerns regarding the potential side effects of using a dose of Vyvanse in excess of the FDA approved dosage for this medication.  Upon review of the literature, both in children and adults, the maximum dose studied was 10 mg/day. In animal studies, higher doses caused abnormal behavior or death. In human studies, a long list of side effects exists, including self mutilation and risk of suicide. Patients receiving the proposed dose need to be on a research protocol with close supervision to denote side effects and prevent the ultimate adverse side effects. Until this study is performed, this patient should not exceed the maximum dose approved by the FDA.