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

A 38-year-old female enrollee has requested Provigil for the treatment of her depression and post-traumatic stress disorder. Findings:  The physician reviewer found that the Food and Drug Administration approval of Provigil supports the use of the drug for the treatment of four conditions: 1) narcolepsy; 2) multiple sclerosis; 3) sleep apnea; and 4) shift-work sleep disorder. Neither depression nor PTSD is listed as an approved indication for treatment with Provigil. At this time, there is inadequate peer-reviewed evidence demonstrating the efficacy of Provigil for fatigue associated with depression or PTSD. The article by Frye, et al. submitted with this appeal studied the use of Provigil in bipolar disorder which is not one of the patients diagnosed conditions. All told, the medical necessity of Provigil in this setting has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested chiropractic services for the treatment of his chronic back pain. Findings:  The physician reviewer found that the American Chiropractic Associations Council on Chiropractic Practices and Medicare guidelines state that a treating provider is expected to keep and maintain adequate case records which clearly show the progression of care, clinical impressions, assessments of the patients condition and treatment effectiveness from visit to visit. In this case, office visits were often once per month, with no documentation as to why the patient sought care or how the patient faired with the prior treatment. The records fail to indicate progression or regression of the patients complaints, fail to indicate provocative and/or palliative conditions, and fail to indicate any reduction in pain or improvements of functional capacity of the patients musculoskeletal system. Therefore, based on the information provided, the medical necessity of the services at issue is not supported.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested radioembolization using 90-Yttrium spheres for the treatment of his metastatic neuroendocrine tumor to the liver. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network recommend management of recurrent or unresected disease for patients who are deemed unresectable include a number of options. These include clinical trials, local ablative therapy (radiofrequency ablation, microwave and cryotherapy) and hepatic regional therapy (arterial embolization, chemoembolization and radioembolization). Therefore, local ablative therapy, including radiofrequency ablation, is listed as an option for patients such as this.  Radioembolization using 90-Yttrium spheres is medically appropriate and indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested the X-Stop interspinous implant procedure for the treatment of his lumbar spinal stenosis and lumbar radiculopathy. Findings:  Two physician reviewers found that the X-Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication.  These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain (with or without back pain) that was relieved with flexion (forward bending) and ability to walk at least 50 feet. However, FDA documents released before a public hearing on the product raised concerns that the X-Stop's effectiveness decreases over time, as studies found that about 15 percent of patients who had the implant reported symptoms returning. It appears that the X-Stop is effective for about one year and then begins to decline, according to the FDA. This patient does not have neurogenic claudication that is relieved by forward flexion.  He has multilevel stenosis.  This patient would have been most appropriately treated by nonoperative treatment or decompressive laminectomy and possible fusion. There is a lack of support from available literature demonstrating that the X-Stop device was likely to be more efficacious than any other standard therapy for this patient, and it is more likely associated with a high rate of failure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested right L3-4 microdecompressive lumbar laminectomy, removal of the lesion (tumor versus cyst) for decompression, provocative lumbar discogram and epidural for the treatment of his lumbar pain. Findings:  The physician reviewer found that of the services at issue, removal of the lesion for decompression and the right L3-4 microdecompressive lumbar laminectomy were medically necessary, but the provocative lumbar discogram and the epidural were not medically necessary. The excision of the synovial cyst through a technique of open micro-laminectomy with operating microscope was appropriate and indicated. The cystic lesion needed to be addressed surgically. The pathology report ruled out tumor. Although the pathology report did not confirm synovial cyst lining, the MRI diagnosis and clinical diagnosis demonstrate that the cyst was clinically significant in this patients pain experience. The microdecompressive lumbar laminectomy performed by minimally invasive technique is controversial as a surgical approach, particularly when combined with the excision of the L3-4 extradural spinal perineural cyst. In this case, the MRI studies documented erosive changes in the lamina. As an ancillary procedure to the primary procedure of excision of the perineural cyst, the microdecompressive lumbar laminectomy was medically appropriate in this particular setting and appears to have been efficacious in relieving the patients pain. The discogram and the epidural did not contribute to the surgical treatment provided. There was no indication for these procedures based on the information provided. As such, medical necessity for the discogram and epidural has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for a reconstructive duodenal switch to correct previous bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the long-term outcome of different weight loss surgical procedures is well-established. The duodenal switch operation provides the best long-term success rate. There is also ample scientific data that has documented the revision of failed gastric bypass to duodenal switch operation. The revision of other procedures to duodenal switch operation is proven and published in the weight loss surgical literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that the literature and experience of headache specialists supports the use of Botox for chronic migraine. It is currently used with some frequency in patients who have failed multiple standard therapies and have moderate to severe migraine-related disability. The records that this patient has provided do not document migraine and do not include mention of prior therapy utilization. In addition, the submitted documentation does not document response to Botox and does not document frequency and severity of current headaches. The patient does indicate that she has been under the care of a headache specialist, suggesting that at some point in time she likely had a severe and disabling headache disorder. The injection sites and doses suggest a cosmetic paradigm, although the treating physician indicates that it is for migraine. Given the lack of information about this patients headache disorder, it has not been demonstrated that Botox injections are likely to be more efficacious for this patient than alternative treatments.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested a left total ankle replacement for the treatment of her degenerative joint disease and osteoarthritis. Findings:  Two physician reviewers found that total ankle replacement procedures had many problems after the introduction of the procedure, but more recent designs have shown better initial results. However, there are few reports of results over time, and many of the reports have not been validated by independent and controlled studies. Several studies are in progress to evaluate the procedure and to compare it to fusion, but the results are not yet available.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Levaquin 500mg because she was traveling out of the country. Findings:  The physician reviewer found that Fluoroquinolones (e.g., Cipro) are known to cause gastrointestinal upset and sun sensitivity. While diarrhea is a common side effect of all quinolones, bloody or watery diarrhea may be a sign of a serious reaction to these antibiotics that can occur when certain bacteria overgrow in the colon. In this case, there was no documentation of intolerance to Cipro in the patients medical records, and no documentation of culture and sensitivity showing resistance to Cipro. Thus, Levaquin 500mg was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 10-year-old male enrollee have requested a partial hospitalization/therapeutic seven week summer program for the treatment of the enrollees bipolar disorder, not otherwise specified, generalized anxiety disorder and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that this patients level of functioning is not such to support treatment in the requested partial hospitalization/therapeutic program. While the patient does require continued therapy, the submitted documentation does not demonstrate that he is acutely impaired to the level that necessitates treatment in a partial hospital program. There is no mention in the records provided of family therapy as a treatment modality for this patient, which would be appropriate in this setting. The data available does not suggest that this patient would regress if not treated in the requested partial hospitalization program. His clinical need for the structure, monitoring and related services of a partial hospitalization program is not demonstrated. Continued care at a lesser level of intervention, such as an intensive outpatient program, is medically appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy services for the treatment of the enrollees condition. Findings:  The physician reviewer found that during the period at issue the patient presented with significant speech and language delay that adversely impacted communication with those around him. These difficulties prevent him from acquiring the usual skills of childhood. In addition to expressive language delay, he exhibits oral motor dysfunction, dysarthria, a motor planning disorder, and feeding difficulties. Speech therapy is imperative to treating these issues successfully. As the article by Nelson and colleagues indicates, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best  preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood. In addition to persistent speech and language-related underachievement (verbal, reading, spelling), language-delayed children have also shown more behavior problems and impaired psychosocial adjustment. In summary, this patient has significant delays in multiple areas, and has shown consistent improvement over time, as demonstrated during multiple assessments. He required continued speech and language therapy to maximize his skills in communication, oral motor function, and feeding. Speech therapy was therefore medically necessary and appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested the medication Qualaquin for the treatment of her nocturnal leg cramps. Findings:  The physician reviewer found that nocturnal leg cramps can be a very debilitating problem for many patients and quinine sulfate has been long recognized as an effective means of controlling such cramps. Historically, quinine sulfate was available as an over-the-counter medication for decades. However, in 1995 the Food and Drug Association (FDA) determined that quinine sulfate should require a prescription and more recently, the FDA has indicated that quinine sulfate is only appropriate for treating plasmodium falciparum malaria. The FDAs action was based on reports of serious adverse effects caused by quinine administration for leg cramps.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested permanent sacral nerve stimulation for the treatment of her interstitial cystitis. Findings:  Three physician reviewers found that there is no significant body of medical evidence that suggests sacral nerve stimulation is appropriate for patients with pelvic pain associated with IC. The paucity of data is reflected in scant literature with only a handful of patients studied. Additionally, there is difficulty in defining the pelvic pain syndromes with specificity. While some patients report good results from this therapy, there is insufficient data available to help determine which patients may derive benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for a return to a acute rehabilitation facility for an additional two weeks of treatment for treatment of his medical condition.  Findings:  The physician reviewer found that there is no significant change that would be expected from further inpatient rehabilitation that would alter his home care needs. Although he initially declined upon transfer home, once therapy was initiated he progressed. The patient is able to make further gains at home.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested intradiscal thermal annuloplasty for the treatment of her low back pain. Findings:  Two physician reviewers found that there are no large, scientific studies available to show that intradiscal thermal annuloplasty is efficacious and results in long-term relief of symptoms. A systematic review of intradiscal thermal annuloplasty by Singh and colleagues concluded that although the procedure has been in utilization for a number of years and numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials. Gibson and Waddell consider this procedure to be a research technique. Its superiority in this setting remains unproven.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested Levaquin for the treatment of his rhinosinusitis. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient was treated with a variety of antibiotics for several months for sinusitis that had been present. His condition did not appear to improve significantly and sinus surgery was performed. The organism recovered at that time (Stenotrophomonas maltophilia) is a recognized cause of respiratory disease and treatment of this organism was very appropriate. While antibiotics are not first-line therapy for sinusitis, in this case, the positive culture does indicate treatment was needed. The organism was reported as being sensitive to Levaquin and trimethoprim-sulfamethoxazole; thus, the use of Levaquin was a reasonable choice to treat the apparent infection. Note that no other quinolone was tested by the hospital laboratory against the Stenotrophomonas recovered at surgery. For these reasons, the Levaquin prescriptions prescribed after the organism was identified were appropriate and therefore medically necessary. However, the Levaquin ordered the following month was used for nasal irrigation which is not an appropriate indication for the antibiotic and was not medically necessary. Furthermore, the Levaquin prescription prescribed before the surgery does not contain cultural documentation and this drug was not clearly indicated on that basis and should be denied for reimbursement on grounds that it too was not medically necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over four days. She had a cough but no shortness of breath. The patient was described as non-toxic. Her lung sounds and oxygen saturation were normal. Varciella is a viral illness that is self-limited and usually requires only symptomatic treatment. While the patients symptoms may have warranted a medical evaluation, her symptoms were not such that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. Therefore, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested Remicade, or in the alternative, Humira for the treatment of her pulmonary fibrosis. Findings:  The physician reviewer found that treatment with anti-TNF medications has not been established to be indicated or medically necessary for this patient. The submitted records do not provide confirmation of the diagnosis of idiopathic pulmonary fibrosis. Based on the information provided, it appears the patient has nonspecific interstitial pneumonitis associated with dermatomyositis. There is no convincing evidence in the medical literature of the effectiveness of anti-TNF treatment for this patient's condition, and there are case reports suggesting the possibility of pulmonary complications from these treatments. In the paper by Dastmalchi and colleagues, 13 patients with refractory myositis were treated with infliximab (Remicade) infusions. Of the 9 patients completing this study, 3 patients discontinued the drug due to adverse events, and 1 because of a malignancy. There was no strong indication of drug effectiveness in the 9 patients who were able to complete the study. Ostor and colleagues describe 5 patients with rheumatoid arthritis treated with Remicade who developed pulmonary complications, and advise caution in the use of anti-TNF therapy in patients with rheumatoid arthritis with significant underlying lung disease. Furthermore, there is one report of a patient developing polymyositis while being treated for rheumatoid arthritis with Remicade (see Musial and colleagues). As such, there is insufficient evidence of the safety and efficacy of anti-TNF inhibitors such as Remicade and Humira to support their use in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Celebrex for treatment of her sacroiliitis.  Findings:  The physician reviewer found that Emery and colleagues noted that Celebrex has similar efficacy in terms of analgesic and anti-inflammatory efficacy when compared to other non-steroidal anti-inflammatory drugs (NSAIDs). There have been multiple studies, as reported by Silverstein and colleagues, which have shown a decrease in gastrointestinal toxicity with the Celebrex and other COX-2 inhibitors. However, Bertagnolli and colleagues data and that from other large, long-term studies, have associated use with an increased risk of cardiovascular problems, myocardial infarction and stroke. Since the COX-2 inhibitors have an increased cardiovascular risk, their use should be avoided unless the patient was at higher risk for gastrointestinal toxicity (i.e., 65 years or older; a prior history of ulcer disease or gastrointestinal bleeding; or concomitant use of Coumadin, Plavix, or glucocorticoids), of which there is no indication from the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested for a continuous glucose monitoring system (CGMS), sensors and related supplies for treatment of her diabetes.    Findings:  The physician reviewer found that the 2007 guidelines from the American Association of Clinical Endocrinologists recommend that providers arrange for continuous glucose monitoring for patients with type 1 diabetes mellitus with unstable glucose control; continuous glucose monitoring is particularly valuable in detecting both unrecognized nocturnal hypoglycemia and postprandial hyperglycemia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for percutaneous discectomy (nucleoplasty) for treatment of his L3-L4 herniation and low back pain.  Findings:  Three physician reviewers found that there is not adequate scientific data consisting of randomized, controlled large sample studies to show the efficacy of nucleoplasty. There are no comparative studies showing the safety and long-term effectiveness of nucleoplasty. The review by Manchikanti and colleagues only found level III evidence (lacking direct evidence) of the effectiveness of the procedure. Thus, based on the available scientific data, the superiority of nucleoplasty in this clinical setting has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for Hyalgan/Supartz injections for treatment of his osteoarthritis.  Findings:  Two physician reviewers found that an article by Conrozier and Vignon notes that although placebo-controlled studies are lacking, viscosupplementation for the symptomatic treatment of hip osteoarthritis (OA) may be effective. An article by Dagenais noted that the best available evidence suggests that viscosupplementation may offer symptomatic relief in patients with mild to moderate hip OA for whom other conservative therapies are contraindicated or have failed. However, the authors did note that currently this has not been determined conclusively. An article by van den Bekerom reported that viscosupplementation performed under fluoroscopic or ultrasound guidance seemed to be an effective treatment and may be an alternative treatment of hip OA.