Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her atypical ductal hyperplasia.   Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other available treatment options.  Most asymmetric breast densities are secondary to benign changes. In the context of a core needle biopsy, atypical ductal hyperplasia is considered an indication for a breast lumpectomy, also known as a surgical (excisional) biopsy, to exclude the presence of breast cancer. Since both the atypical ductal hyperplasia and the questionable distortion are located in the right breast upper outer quadrant, a lumpectomy or another core biopsy is preferable to a breast MRI. There is a lack of literature support demonstrating that a breast MRI is likely to be of greater clinical value in this setting than surgical excision/core biopsy. Therefore, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Intermezzo for treatment of his insomnia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This patient has been diagnosed with insomnia.  Intermezzo is a non-benzodiazepine hypnotic.  These medications have less overall risk of adverse effects but still may cause impaired memory and psychomotor retardation.  Non-benzodiazepine hypnotics used for the treatment of insomnia include zolpidem (Ambien), Intermezzo, zaleplon (Sonata), and eszopiclone (Lunesta).  The Health Plan indicates that generic zolpidem and Lunesta are the preferred drugs for the treatment of insomnia in the non-benzodiazepine class.  Per the medical records, this patient has not tried and failed the preferred medications.  The Health Plans formulary medications are medically appropriate in this clinical setting.  All told, Intermezzo is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested Remicade (infliximab) for treatment of the enrollees uveitis.  Findings:  Two physician reviewers found that in this patients case, the requested medication is likely to be more effective than other available treatment options.  Prior standard therapies, including steroids and methotrexate, have not resulted in improvement.  The patient has developed adverse sequelae to the long-term use of steroids.  There is sufficient support in the current medical literature for the requested medication in this clinical setting.  All told, Remicade is likely to be superior over other available treatment alternatives in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested Intacs procedure for treatment of her keratoconus.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Keratoconus is a degenerative disease of the cornea of the eye that causes the cornea to thin and change its curvature.  In extreme cases, the cornea becomes conical in shape.  Patients with keratoconus have symptoms such as blurred vision, sensitivity to light, eye strain, and the perception of multiple ghost images.  The visual symptoms experienced by keratoconus patients are often due to various forms of optical aberration induced by the irregular shape of the cornea.  Treatment of keratoconus generally begins with glasses or contact lenses.  Surgical treatment of keratoconus includes the insertion of intrastromal corneal ring segments, also known as Intacs, corneal transplantation, and deep anterior lamellar keratoplasty, a procedure in which only the outer layers of the cornea are replaced.  The published literature suggests that Intacs may prevent progression of keratoconus, may be useful in treatment of subclinical keratoconus, and may even be an option in patients with advanced keratoconus.  This patient no longer has adequate functional vision based on her visual symptoms despite the use of glasses and contact lenses, her corneas are clear, and the corneal thickness is adequate.  Because of its inherent risk and unpredictability, corneal transplantation is not a viable option in keratoconus patients such as this patient with good correctable vision but significant visual symptoms due to optical aberration.  Deep anterior lamellar keratoplasty has a similar risk profile to corneal transplantation.  All told, the requested Intacs procedure is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested plastic surgery for the removal of polymastia for treatment of her polymastia.  Findings:  The physician reviewer found that the requested bilateral axillary mastectomies and Z-plasty procedures are not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition. Although significant breast tissue within the axilla is considered abnormal, this is not demonstrated in the photographs. There is some fullness of the breast in the area of the axilla, but this appears to be within a normal range based on the patients body habitus. Lesavoy and colleagues noted that, aberrant breast tissue is usually present along the milk line above or below the normal breast location. Occasionally, it is found in unusual locations, such as the axilla, scapula, thigh, and labia majora. The abnormal accumulation of breast tissue within the axilla would be considered caused by a developmental abnormality. However, no clear functional deficit has been adequately established. Overall, the medical documentation and photographs do not support that more than a minimal improvement is likely. Therefore, the requested procedures are not reconstructive in nature. Overall, there is inadequate medical documentation that the patient has a functional deficit related to her axillary tissue. There is mention of tenderness with menstrual cycles, but this is not supported in the records. The patients axillary tissue is not likely to cause back pain. The patient indicated that she had lactation in these areas with breastfeeding, but this is not described in the medical documentation. Further, the photographs do not demonstrate the presence of significant excess of axillary tissue likely to cause symptoms or that would warrant resection. As documented by Down and colleagues, axillary tissue can be symptomatic. However, a clear functional deficit related to the axillary tissue has not been established in this patients case. Therefore, the requested procedures are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Testim 1% (50mg) gel for treatment of her menopause.  Findings:  The physician reviewer found that the records do not provide evidence that Testim is medically necessary for treatment of this patients medical condition. The records lack laboratory data confirming low testosterone levels and other medical documentation of consequences of testosterone deficiency, such as bone loss, that could benefit from replacement. In addition, there are few data regarding the safety and efficacy of testosterone therapy in women who are not using concomitant estrogen therapy or for the use of testosterone therapy for longer than six months. According to the North American Menopause Society (NAMS), clinically available laboratory assays do not accurately detect testosterone concentrations at the values typically found in women, and no testosterone level has been clearly linked to a clinical syndrome of hypoandrogenism or testosterone insufficiency. Basaria and Dobs reported that early results from small studies show that transdermal testosterone therapy results in moderate improvement in libido in surgically menopausal women on estrogen. However, the published data are of short duration and are limited to only 24 weeks. Based on the information provided for review, the requested Testim 1% gel is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a sacroiliac joint injection and possible rhizotomy if the injection is effective for treatment of his sacroiliitis.  Findings:  Two physician reviewers found that Sacroiliac joint injection and possible rhizotomy are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  The peer-reviewed literature supports the efficacy of sacroiliac joint injections and radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology only when patients are appropriately selected.  In reviewing the medical records, the patient is status post spinal fusion in the area to be treated.  The medical literature does not support the efficacy of these treatments at levels in which the medial/lateral branches are already disrupted such as that which may occur in spinal fusions.  All told, the current medical evidence has not established the superior efficacy of the requested sacroiliac joint injection and rhizotomy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested ChemoFx assay for treatment of her recurrent abdominal wall sarcoma.  Findings:  Three physician reviewers found that in vitro drug testing on an individual patients tumor cells prior to applying chemotherapy is an attractive idea, but difficult to put into clinical use. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology (ASCO) in 2004. In their thorough review of this technology, ASCO concluded that such in vitro drug testing should be limited to clinical trials. All told, the ChemoFx assay was not likely to have been more beneficial for evaluation and treatment of this patients medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) has now included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. This patients records indicate that he has been tried on antidepressants without benefit. However, there is no information in the record to document the specific antidepressants tried, what dosages were used and the duration. Further, there is no indication that augmentation strategies have been tried, such as mood stabilizers, thyroid, or stimulants. The patient has not reportedly received cognitive behavioral therapy (CBT) psychotherapy or electroconvulsive therapy (ECT) for treatment. In summary, although TMS is an approved treatment for treatment-resistant depression, there is inadequate documentation that standard available standard therapies were tried and failed prior to treatment with TMS.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested an MRI of the lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The submitted medical documentation does not demonstrate the patient meets accepted clinical indications for an MRI of the lumbar spine. Detailed documentation of the patients medical history, physical exam, history of treatment, and working diagnoses has not been provided. Furthermore, there is no documentation that the patient has had a trial of any specific treatment prior to consideration of an MRI. Such trials of treatment would include a program of active physical therapy or therapeutic injections. In the absence of the evidence listed above, the MRI of the lumbar spine is not clinically indicated. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested acute psychiatric inpatient services for treatment of her depression and eating disorder.  Findings:  The physician reviewer found that considering the robust affective, psychodynamic and characterological aspects of this patients condition, selection of the appropriate level of care and length of stay is challenging. Clinical guidelines and patient placement criteria have been developed to assist with such complicated determinations, and it is the task of the providers working directly with the patient to interpret and apply these tools. In this patients case, the documentation provided does not describe an acute psychiatric syndrome, significant disability, or medical illness that would necessitate services at the acute level of care. The patient was struggling with a formidable and enduring symptom complex that demanded comprehensive specialty care. However, she was not acutely suicidal, psychotic, or cognitively impaired. The patient had failed mental health treatments in the outpatient setting but had not pursued less restrictive subacute or residential care. Additionally, in reference to her eating disorder, she had an unremarkable physical examination. She had a normal heart rate and her electrocardiogram demonstrated normal sinus rhythm with a normal QTc interval. Although suggestive of menopause, her laboratory analysis was otherwise normal.  Although the patient had chronic underlying issues of significance including parasuicidality, ambivalence, self-defeating behaviors, characterological issues, mood symptoms and anxiety, and continued body distortionism, the patient was a candidate for treatment in a less restrictive environment and did not require the intensity and medical supervision provided at the acute level of care. All told, psychiatric services at the acute level of care provided from the time frame specified were not medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested home health care.  for treatment of his paraplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Patients with spinal cord injury are at high risk for pressure ulcers.  In addition, once formed, pressure ulcers can be difficult to heal due to metabolic and physiological changes in the tissues below the level of the spinal cord injury.  With respect to treatment, the key areas of focus remain ongoing appropriate pressure relief, optimizing nutrition, modifying behavioral factors such as smoking, and promoting an optimal wound environment.  In this case, the patient has multiple chronic wounds that have reportedly persisted for years despite extensive home health services.  He does not have any documented impairments that would be expected to preclude his ability to complete his wound care independently with an appropriate set up and training.  Home nursing notes document that he is able to perform his wound care.  The patient is not homebound and can follow-up in a wound care center for intermittent debridements, as needed.  All told, the requested home health care is not medically indicated 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 for 20 hours per week of direct ABA therapy (code H2019), 10 hours per week of parent training (code H0046) and 12 hours per month of supervision (code H0032) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the use of ABA therapy in young children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in young autistic children. However, there is limited scientific literature regarding the efficacy of ABA therapy as applied to older children or teenagers. The appropriateness of continuing ABA therapy in such patients depends upon the patients prior response to treatment as well as the likelihood of further benefit.In the case of this patient, he has had six years of intensive ABA therapy; despite this intensive therapy his present full-scale IQ is 46. The patient continues to present with poor attention/concentration skills, which has impaired his progress. While substantial gains are not likely, continuation of ABA therapy is medically appropriate in this setting to increase the patients social and peer related experiences. An article by Reichow and Volmar concluded that social skills can be improved by ABA therapy in older children Therefore, it is medically necessary that the patient continue to receive 10 hours per week of direct ABA therapy, 1 hour per week of parental training and 2 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested physical therapy sessions needed for maximum range, at least three times per week for one hour for treatment of her humeral shaft fractures.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  Loss of elbow range of motion following trauma can result in significant functional limitation.  Conservative measures, including physical therapy and splinting, are best applied in the early stages of contracture onset.  In this patients case, she sustained significant trauma to the distal left humerus in a motor vehicle accident.  There is no documentation of therapy or range of motion exercise for more than two months following her open reduction and internal fixation surgery.  She developed reduced range of motion at the left shoulder and elbow.  She underwent physical therapy and started to regain her range of motion.  Shoulder range of motion was ultimately restored to a level that her treating therapists rated as normal.  Elbow range of motion has improved more slowly.  The records do not support the medical necessity of ongoing physical therapy on a regular basis.  No marginally significant improvement in health or functional outcomes is expected with further therapy on a regular basis versus a home exercise and splinting program.  Compliance with a home program would be reasonably expected to be a more significant factor in optimizing outcomes over formal therapy at this point, given that the patient needs to perform her exercises and splinting on a regular basis in order to improve her range of motion and function.  There are no documented exercises that she is performing that could not be performed independently or substituted with independent exercise.  There is no significant, sustained benefit of manual therapy at this stage with respect to health or functional outcomes for this condition.  All told, the requested therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her diffuse large B-cell lymphoma.  Findings:  Three physician reviewers found that PET/CT scanning with F-18 FDG, an isotope of glucose, is an extremely helpful scan which can reveal areas of increased metabolism often associated with a wide variety of cancers, including high grade lymphomas. PET/CT has become a standard means of initial staging and for evaluating the effectiveness of treatment in many cancer types including lymphomas (Isohashi, et al; Juweid, et al). In this patients case, her initial staging PET/CT scan showed intense uptake in the areas of her lymphoma. Therefore, the requested follow-up PET/CT scan is likely to be more helpful to make clinical decisions for this patients care than any other testing or diagnostic procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested  continued psychiatric acute inpatient treatment for the enrollees medical condition.  Findings:  The physician reviewer found that on the date indicated, the psychiatrist indicated that the patient denied depressed feelings or suicidality and noted that the patient is medically stable, not immediately suicidal. As such, the acute psychiatric syndrome that prompted the admission to the acute level of care had resolved on the date indicated; the patient was appropriate for transfer to a less intense level of care on the subsequent date. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary beyond the date indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested Synvisc injections.  The medical records document early degenerative osteoarthritis and a past history of multiple injections of hyaluronan.   The current medical evidence does not support Synvisc injections in this clinical setting.  There is a risk of aseptic inflammatory reaction due to an allergic response.  The risk for this reaction increases with repeated injections and may also be increased by reason of an already present autoimmune disorder.  In this patients case, she has systemic lupus erythematosus.  Additionally, there is a risk of iatrogenic infection.  Rutjes and colleagues conducted a systematic review and meta-analysis assessing the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded that viscosupplementation is associated with a clinically irrelevant benefit and an increased risk for serious adverse events.  All told, the requested Synvisc injections are not medically indicated for the treatment of this patient.