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

A 44-year-old female enrollee has requested for the medication Zyrtec (not the generic version) for treatment of her allergies. Findings:  The physician reviewer found that generic products can sometimes have intrasubject variability.  Thus, for some patients, the generic equivalent may not be as effective as the brand version.  In this patients case, she has allergy symptoms that were not relieved with cetirizine, which is the generic form of Zyrtec.  The patient reported that she currently uses eye drops, nasal drops and inhalers to help with her allergies. Per the patient, this combination with Zyrtec has helped with her symptoms.  The submitted documentation noted that the only allergy medication that has worked for this patient is Zyrtec in non-generic form.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for bilateral breast magnetic resonance imaging for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that breast MRI is a useful adjunct to standard imaging (including mammography and breast ultrasound) in select patient populations. For screening breast MRI, the American Cancer Society (ACS) has published guidelines for the use of breast MRI in screening for breast cancer. These guidelines include patients with a strong family history of breast cancer, those with personal or family history of BRCA mutation and for those patients with a history of prior radiation to the chest as a child or young adult. The ACS does not support the use of screening breast MRI in patients with dense breast tissue and concluded that there is insufficient evidence to recommend for or against MRI screening in patients with heterogeneously or extremely dense breast on mammography. There is no family history of breast cancer and there is no history of recent diagnosis of personal breast cancer. For these reasons, this patient does not meet the published criteria for a screening or a diagnostic breast MRI.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested an MRI of the right breast for an evaluation due to her history of papillary thyroid cancer.  Findings:  Two physician reviewers found that this patient has an established diagnosis of thyroid cancer.  In her initial post treatment scan, there was a question of a metastasis in the right breast.  This requires further evaluation, as a metastatic lesion would require additional treatment.  However, the requested MRI is not the most efficacious method of evaluating this patient at this time.  In this clinical scenario, mammogram and ultrasound are indicated. MRI of the breast is not a first-line modality of choice in the evaluation of a breast lesion. MRI may be a useful complementary study when mammography and ultrasound fail to fully evaluate a finding.  In this patients case, the requested MRI of the right breast is not likely to be superior over other available methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for an annual PET scan for evaluation of the enrollee, who has a history of malignant fibrohistiocytoma, breast cancer and lung cancer. Findings:  Two physician reviewers found that there is no indication that this patient has received any treatment recently, or has any evidence of either elevation of tumor markers or clinical evidence of recurrent disease. PET scanning has an impact on patients who have suspected recurrence.  The role of PET scanning in terms of routine surveillance has not been supported in the literature.  In this patients case, there is no suggestion that a change in her treatment is anticipated depending on the results of the PET scan.  The submitted records do not indicate suspicion for recurrence to warrant a PET scan at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested for cognitive rehabilitation therapy for treatment of his Alzheimers disease. Findings:  Two physician reviewers found that studies of cognitive rehabilitation for acquired brain injury show varied results and have varied trial designs.  Available literature regarding the efficacy of treatment for Alzheimers disease endorses use of anticholinergic medications and memantine, and suggests that maintaining physical activity and cognitively stimulating activities may reduce the rate of decline in Alzheimers disease. A study of reality orientation therapy suggested that once trained, benefits were maintained by continuation of reality orientation therapy by the caregiver.  All told, there is not substantial evidence to show that cognitive rehabilitation therapy is effective in treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees Angelman syndrome. Findings:  The physician reviewer found that Angelman syndrome is a genetic disorder characterized by deletion of the maternal chromosome 15q11-q13 and paternal uniparental disomy. Features include severe developmental delay and/or cognitive delay, severe speech impairment and gait ataxia. Microcephaly and seizures are also common. The literature supports speech therapy and occupational therapy for patients with this syndrome.  The medical literature notes that management should include physical therapy, occupational therapy, and speech therapy with an emphasis on nonverbal methods of communication, including augmentative communication aids and signing. As noted by Guerrini and colleagues, cognitive, language, and orthopedic problems must be addressed with vigorous rehabilitation programs, including early physical therapy, which may help to develop communicative skills and prevent severe scoliosis and subsequent immobility. This patient has documented deficits in speech and language skills, as well as deficits in fine and gross motor skills. Standard of care includes speech therapy and occupational therapy intervention for children with Angelman syndrome to address these deficits. In this patients case, speech therapy and occupational therapy are medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested an abdominal hysterectomy for treatment of her uterine fibroid. Findings:  The physician reviewer found that the Health Plan has indicated that an endometrial biopsy to rule out endometrial pathology has not been performed. Per the American College of Obstetricians and Gynecologists, selected disorders or distortions of the uterine structure may enhance the risks associated with an endometrial biopsy or make success unlikely.  Another concern exists when areas of the myometrium are extremely thin, which may be the case in the presence of previous uterine surgery, such as cesarean delivery.  In these circumstances, there may be an increased risk of transmural thermal injury that could involve the adjacent bowel or bladder. This patients history is significant for a prior cesarean section. Additionally, an endometrial biopsy is of particular value if the menstrual pattern is that of anovulation where there is unopposed estrogen, which then increases the risk of endometrial cancer.  However, this patient has regular menses, which is the hallmark of ovulatory cycles.  She also has a normal appearing endometrial cavity on ultrasound.Although abdominal myomectomy is another option for treatment, as noted in the American College of Obstetricians and Gynecologists Bulletin pertaining to alternatives to hysterectomy, it is not definitive, may allow for recurrence, and is an option better suited to someone who wishes to preserve childbearing, which this patient does not.  All told, an abdominal hysterectomy is medically indicated for this patient. She is not an appropriate candidate for alternate conservative treatments and does not desire further pregnancies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested the medication Humira 40mg/0.8ml (quantity four) for treatment of her medical condition. Findings:  The physician reviewer found that the medical records submitted with this case do not document the patients diagnosis or the medication treatment plan. Although the requested higher dosage of Humira may be appropriate based upon clinical reasoning, the records supplied do not explicitly document the medical reasoning as to why the higher dosage of Humira has been requested or is medically necessary. Humira is a therapy that has potentially life-threatening toxicity and must be used under the direction of a physician for both on-label and off-label use. In the absence of clear documentation as to the patients medical condition and the necessity of the increase in Humira dosage frequency, the patients appeal should be denied.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a radiofrequency neurolysis at T10-T11 for treatment of her thoracic pain.   Findings:  Three physician reviewers found that there is some increasing evidence that radiofrequency ablation may be an effective treatment for facet joint pain.  However, most of the medical literature still indicates that the evidence in support of such treatment is only fair. There is better evidence that a facet block can provide temporary relief and aide in the diagnosis of facet arthropathy. The diagnostic criterion is 80% pain relief. In this patients case, she had a 50% reduction in pain after receiving a left T10-11 and T11-12 facet block with local anesthetics and steroid. Therefore, this patient does not meet the diagnostic criteria for facet arthropathy. Because there is only fair evidence in support of the use of radiofrequency ablation for the treatment of facet pain, in this patients particular case, radiofrequency ablation is not likely to be more beneficial in treating her not clearly diagnosed facet arthropathy than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested growth hormone Serostim for treatment of his HIV related lipodystrophy.  Findings:  Two physician reviewers found that there are two randomized, controlled trials for the use of Serostim for (HARS). The results of these are included in the FDA approved package insert for Serostim and show significant improvement in visceral adipose tissue in patients treated with Serostim. Of import, visceral adipose accumulation has been linked to dyslipidemia and increased risk of heart disease. The studies caution that some patients had significant adverse events with Serostim including elevated blood glucose levels, but overall, many patients had improved symptoms and sense of well being. Grunfeld and colleagues randomized trial concluded that Serostim can be effective in patients with HARS, and there are no other available treatments. For these reasons, the authors concluded that it is reasonable to approve a trial of Serostim for patients with careful monitoring for adverse events as it is likely to be more effective than other treatments. Another drug (recombinant hGH releasing factor) Tesemorelin is currently being considered by the FDA for approval however, to date there is no currently accepted or effective treatment for this condition. Therefore, Serostim is likely to be the most beneficial for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breasts for evaluation of her bilateral enhancing diffuse foci. Findings:  Three physician reviewers found that applying the National Cancer Institute (NCI) Risk Assessment Tool, this patient qualifies for screening with MRI at this time. This determination is based on the patients family history in addition to her documented dense breast tissue, which limits the sensitivity of mammography. Further, the recommendation for a breast MRI is also consistent with Saslow and colleagues discussion of the American Cancer Society (ACS) guidelines. This patient had a screening MRI that revealed some abnormality classified as BIRAD 3. The non-mass like enhancement was only seen on the MRI exam and since these findings are specific to MRI (i.e. cannot be assessed with mammography or ultrasound), it is reasonable to repeat this study within a short interval as advised by the interpreting radiologist. The study is likely to provide unique data in analyzing this patients risk for breast cancer, and therefore is not investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a Neuromuscular and Functional Electrical Stimulator (NMES) for treatment of his medical condition. Findings:  The physician reviewer found that Pomeroy and colleagues provide a comprehensive and thorough evaluation of recent medical literature evaluating the efficacy of neuromuscular electrical stimulation for the purposes of post-stroke motor recovery in the upper extremity. The authors concluded that electrical stimulation was felt to be better than no treatment, but felt this may be more an effect of the intensity of therapy, any form of therapy versus no therapy at all. However, when electrical stimulation was compared to conventional therapy, there was not a statistically significant difference between the two types of groups. Finally, there are no clear clinical guidelines as to which population of patients would benefit most from electrical stimulation, including amount of time elapsed from initial incident. While there appears to be some promise to the use of NMES in the treatment of post-stroke motor impairment, the authors concluded that there is insufficient robust data to inform clinical use of electrical stimulation for neuromuscular re-training.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the records indicate that her condition is stable. There is no indication of suicidal action, plan or intent, and the patient is denying urges to cut herself. There is no indication of psychosis or agitation. She is compliant with the program, and noted to be smiling except when told she could not go home. There is no evidence of risk to others. The records submitted indicate that the patients condition is incompatible with APA guidelines for treating depression and suicidal behavior in a residential setting and such a setting is not supported by the clinical evidence as being the most appropriate one for this patient. It appears that she can be safely and effectively managed in a lower level of care, such as an outpatient setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for continuous Euflexxa injections for treatment of her osteoarthritis.   Findings:  Three physician reviewers found that the submitted medical documentation does not detail how much conservative care (e.g., non-steroidal anti-inflammatory drugs dosage and duration, physical therapy type and duration, walking aids, home exercise program) has been tried and failed. All told, as evidenced by long-term, controlled and double-blind studies (see Benke and Shaffer, Chevalier and colleagues and Divine and colleagues) the medical literature to date has not demonstrated or validated the contention that viscosupplementation results in long-term efficacy from multiple re-treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested continued care, four visits per year, with a pain management physician for treatment of her medical condition. Findings: The physician reviewer found that the medical literature shows that PCPs have a primary role in the treatment of common conditions such as migraine, and that with appropriate education and support, they can be effective in that role. In general, the use of Fiorocet or opiates by migraine patients is discouraged due to the risk of the development of medication overuse and headache transformation, while triptans are considered a first choice for most migraine patients. If this patient requires the renewal of her ongoing medications, this service does not require the expertise of a pain specialist, and can be appropriately done by the patients PCP. All told, ongoing treatment by a pain medicine specialist is not medically necessary to treat this patients condition as the patients diagnoses can be appropriately managed by her PCP.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested the medication Nucynta (50 mg twice daily) for treatment of his diabetic neuropathy. Findings:  The physician reviewer found that in this patients case, there were no medical records submitted for review which indicate whether the requested Nucynta medication being requested is immediate or extended release. Moreover, there were no medical records submitted whatsoever. Lastly, the use of fluphenazine with Elavil has been shown to be an effective alternative for the treatment of painful diabetic neuropathy (Davis and colleagues). All told, in the absence of such medical documentation, the medical necessity of the requested medication is not supported.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for Botox injections for treatment of her migraines.   Findings:  Two physician reviewers found that a review of the medical records does not reveal that the patient has tried and failed all available standard therapies. In addition, Botulinum toxin has not been approved by the Food and Drug Administration to treat migraines. There is no evidence that botulinum toxin (Botox) is more effective in the treatment of migraines than other available medications. The latest study by Aurora and colleagues (2010) did not show reduction in the primary endpoint of headache.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested 30 intermittent uses of catheters per month and 30 indwelling catheters per month for treatment of his paraplegia and spastic neurogenic bladder.  Findings:  The physician reviewer found that this patient is documented to have a neurogenic bladder and the treating provider reports that the patient is not able to clean the catheters used for intermittent catheterization. The justification for the clean method assumes a patient has the functional ability to wash and clean the catheters, which is not an accurate description of this patients clinical scenario. Although many paraplegic patients are able to employ the clean technique for reuse of intermittent catheters, this patient has difficulty leaning over a faucet due to his spinal injury and brain damage. In addition to his impairment, this patient continues to work, which complicates his circumstances even further as he is away from home in a public restroom. However, this patients medical records do not provide sufficient documentation to establish the medical necessity for the requested indwelling catheters. The number of sterile catheters required per month should therefore be increased to replace the number of requested indwelling catheters. As such, the patients request for additional catheters should be approved with a maximum of 60 intermittent catheters per month based upon his functional status.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested 60 intermittent uses of catheters per month for treatment of her C5-6 quadriplegia and spastic neurogenic bladder.  Findings:  The physician reviewer found that, considering the extensive nature of this patients neurologic injury, which impairs her upper body strength and coordination, the necessity of the additional catheters is clinically indicated. In general, the clean technique works well for many paraplegics with normal upper body coordination and strength. The justification for the clean method assumes a patient has the requisite capacity and ability to wash and clean the catheters, which is not an accurate description of this patients clinical scenario. Rather, this patients situation makes it impossible to achieve the clean method with proper cleaning with soap and water. In addition to her impairment, this patient continues to work, which complicates her circumstances even further as she is away from home in a public restroom. According to the records provided, the patient is catheterizing between four to six times per day despite her inability to adequately practice the clean method to prevent infection. Therefore, her request for 60 catheters per month is medically reasonable.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient has a BMI of less than 40. She has none of the historical co-morbidities generally accepted as contributing to or caused by clinically severe obesity. These include hypertension, lipid disorders, diabetes mellitus, sleep apnea, etc. Given the patients BMI and the absence of such co-morbidities, weight loss surgery is not clinically indicated. Aggressive dietary and behavioral measures to manage weight loss are likely to result in a better outcome in this setting than weight loss surgery with its associated risks. There is inadequate evidence that surgical intervention is likely to be superior in this patient population as compared to further attempts at conservative weight loss measures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that the fact that Lyrica is not officially approve for the indication of trigeminal neuralgia by the Food and Drug Administration, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology. In addition, there is clinical experience supporting the use of Lyrica for this condition as a very effective medication.