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

A 40-year-old female enrollee has requested participation in a clinical trial for cardiac catheterization for placement of a Cheatham Platinum (CP) stent in the aorta for the treatment of her coarctation of the aorta. Findings:  Two physician reviewers found that this patient is an adult with a discrete aortic coarctation distal to and not involving the left subclavian artery. The anatomy of the coarctation described is suitable to a percutaneous repair (discrete and not involving branch vessels). Further, percutaneous stenting with a stent has the appeal of involving less risk when compared to open surgical repair. Stents provide support to help prevent recoil of the dilated segment and when used for coarctation is designed to provide a framework for endothelial cell growth and perhaps reduce the complication of aneurysm formation. Therefore, in older adolescents and adults with suitable anatomy, cardiac catheterization for placement of a stent is a reasonable and appropriate alternative to open surgical repair of aortic coarctation. The CP stent specifically is not yet FDA approved for this indication but there is preliminary data that suggests superiority of this stent over alternative stents. In addition, the patient is to become part of a clinical trial for study of the CP stent and is therefore going to be followed closely by the providers recommending the procedure with appropriate follow-up and monitoring of outcome. Thus, the proposed clinical trial represents a better alternative for this patient than surgical repair or the use of other available stents. All told, aortic stenting has become an accepted alternative treatment in the medical community and would be superior over surgery for treatment of this patients medical condition. Furthermore, there is adequate evidence to support the benefits of the CP stent to warrant the patients participation in the proposed clinical trial.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Real-Time Remote Heart Monitoring for an evaluation of his hypertension. Findings:  Two physician reviewers found that this patient has a history of hypertrophic cardiomyopathy and a new onset of symptoms of syncope and near syncope, thus longer term ambulatory ECG monitoring was indicated in this setting. To date, there are no large randomized data sets demonstrating which group of patients may benefit from Real-Time Remote Heart Monitoring. However, this particular patient has known severe structural heart disease and hypertrophic cardiomyopathy, which can carry significant risk for serious arrhythmias. The use of Real-Time Remote Cardiac Monitoring is recommended in patients with this type of structural heart disease and is most critical in the presence of syncopal-type symptoms in these patients. Thus, the services at issue were indicated and appropriate for this patient with significant underlying structural heart disease and significantly higher risk for severe cardiac arrhythmias.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested an excisional biopsy of an abdominal mole for the treatment of her medical condition. Findings:  The physician reviewer found that there are several factors that place patients at an increased risk for melanoma, one of which is a family history of the disease (Fisher and colleagues). The lack of early detection in this patient population is due in part to the subtle clinical features of early melanomas. Brochez and colleagues demonstrated that general practitioners have a lower accuracy in diagnosing thin melanomas than dermatologists. Goodson and Grossman related that the history of change in a moles shape is a red flag that may signal malignancy, and is noted at a significantly higher frequency in malignant than benign pigmented skin lesions. This patient demonstrates two risk factors for melanoma: family history and a mole that has changed in appearance. As such, the requested excisional biopsy is medically appropriate and consistent with the standard of practice in the dermatologic community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the Flector patch for the treatment of her sacroiliitis. Findings:  The physician reviewer found that the literature demonstrates that plasma concentrations of diclofenac in subjects treated with a Flector patch were significantly lower (less than 1%) than those treated with a single dose of oral diclofenac (50 mg). Therefore, the use of the diclofenac (Flector) patch does have an impact in the treatment of this patient who has a history of thrombocytopenia and therefore is at risk of bleeding complications with the use of systemic NSAIDs. Further, when this patient was exposed to oral ibuprofen, it caused ecchymosis resulting in discontinuation of the medication. The use of the Flector patch for management of this patients pain is therefore a reasonable medical option and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested removal of breast tissue (surgery and biopsy) for treatment of his gynecomastia. Findings:  The physician reviewer found that surgical removal of the patients excess breast tissue meets the definition of reconstructive surgery as defined by California law. The patients condition, asymmetric gynecomastia with enlarged left areola, is an abnormal structure of the body. The abnormal structure is caused by a developmental abnormality. While the requested surgery will not have an effect on function, it is being performed to create a normal appearance to the extent possible. Furthermore, based upon the photographic evidence provided, surgical excision of the breast tissue will offer more than a minimal improvement in appearance. As such, this patients condition meets the definition of medically necessary reconstructive surgery as defined by California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested an electric scooter for the treatment of his sternal, knee and back pain. Findings:  The physician reviewer found that this patient does not meet generally accepted medical necessity criteria (i.e., Medicare guidelines) for an electric scooter (or Power Mobility Device). This patient does not have a mobility related deficit that affects his ability to ambulate and complete MRADLs within his home in a reasonable time. He is at minimal risk of falls, which can be reduced with the use of a four-wheeled walker. The fact that this patient needs assistance with lower body dressing does not appear to be due to a mobility impairment. The patient was noted to have pain but was not observed to have shortness of breath during his most recent evaluation. All told, there is inadequate evidence to support the use of an electric scooter in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested stereotactic radiotherapy (SRT) with Novalis for the treatment of her olfactory neuroblastoma. Findings:  The physician reviewer found that the form of radiation therapy that has been proposed is stereotactic radiosurgery with Novalis. Various techniques of radiation have been utilized in this setting including 3D-conformal radiation and IMRT (which the Health Plan has proposed as an alternative). For this patient, IMRT is the preferred technique as the tumor is very close to the optic nerves, optic chiasm, eye and brain. Daily localization and verification of radiation fields can be done with IMRT. With regard to whether stereotactic radiosurgery offers any additional benefit over IMRT in this setting, there are no randomized trials comparing stereotactic radiotherapy and IMRT for rare tumors like olfactory neuroblastoma. Based upon the evidence available to date, there is insufficient evidence that stereotactic radiosurgery is likely to result in a superior clinical outcome as compared to IMRT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee is requesting a custom fit, functional, anterior cruciate ligament brace for the treatment of the enrollee, who is status post right knee anterior cruciate ligament reconstruction with hamstring autograft and lateral meniscus repair. Findings:  The physician reviewer found that although the use of braces following anterior cruciate ligament surgery is common, evidence of their efficacy is lacking.  No significant difference between braced and unbraced groups has been found in several randomized, prospective studies. Some decrease in postoperative swelling and pain has been seen with the use of rehabilitation braces. However, at final follow-up after one to two years, there was no difference in motion or strength, and no difference was found with the use of functional braces. There is a lack of evidence in the literature to indicate the necessity of the equipment at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a follow-up visit with an otolaryngologist (ENT specialist) for the treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that there is no mention in the submitted medical records that the patient is not tolerating CPAP or that there is a question of him having surgical treatment for his sleep apnea. As demonstrated by the literature, if the patient has questions about the CPAP device itself that his provider is not able to answer, a referral to a sleep medicine physician may be appropriate. Referral to an ENT specialist at this time is not appropriate unless there is a question of possible surgical intervention for this patient, which is not apparent from the records provided for review.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested 15 tablets of 100mg Viagra monthly for the treatment of the enrollee, who is status post radical prostatectomy. Findings:  Two physician reviewers found that this patient has undergone robotic-assisted radical retropubic nerve-sparing prostatectomy for moderately differentiated prostate cancer. He has requested authorization for the therapeutic use of sildenafil postoperatively to assist in the return of potency, despite the fact that a nerve sparing technique was utilized during the procedure. The Health Plan has denied coverage for 15 tablets of 100mg Viagra monthly, and this is the subject of the appeal. Postoperative PDE5 inhibitor therapy is used to hasten revascularization as well as to deter the possibility of fibrosis of the corpora cavernosa. This recommendation is routinely endorsed by the urologic community. A review of the current literature offers substantiation as to the efficacy of this approach. It is particularly useful in the younger patient, irrespective of whether nerve sparing was performed or not. It should be noted that sildenafil use for resurrection of potency is not an open-ended commitment and is usually administered over a finite period of time, approximating one to two years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female has requested Forteo for the treatment of her osteoporosis. Findings:  The physician reviewer found that this patient was treated with two bisphosphonates for documented osteoporosis. She failed both treatments due to the gastrointestinal intolerance. The leading cause of discontinuing bisphosphonate therapy is gastrointestinal causes. Therefore, it was not unusual that the patient would have experienced a similar result leading to cessation of treatment. Based on the bone mineral density results, the patient had significant osteoporosis that required treatment. The patient was not able to tolerate once monthly bisphosphonate. She was on Actonel for a three month period and had to discontinue this medication due to the gastrointestinal side effects. The literature supports alternative treatments with other medications when bisphosphonates have failed. The failure of the bisphosphonate was not due to a decrease in the bone mineral density, but was due to the gastrointestinal intolerance. Given this, an alternative form of therapy is reasonable to prevent significant morbidity from osteoporotic fractures. Forteo has a different mechanism of action than the bisphosphonates and could certainly be an option for this particular patient. Not treating the patient with a medication targeted for treating osteoporosis would not be an option given the failure of the bisphosphonates. The risk of fracture for this patient with its attendant morbidity and mortality would be great given the results of the DEXA scan showing severe osteoporosis. Forteo is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a panniculectomy and abdominoplasty for the treatment of her excess skin. Findings:  The physician reviewer found that an abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases, tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. This maneuver repairs a diastasis recti, which is a widening of the linea alba with separation of the rectus muscles.  It is not a medically necessary procedure. Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or is necrotic. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary. There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the hip for an evaluation of her hip problem. Findings:  The physician reviewer found that in most cases the evaluation of a patient with hip pain with history, physical examination, and plain radiographs, leads to a diagnosis (the American Academy of Orthopedic Surgeons (AAOS)). Erb suggested that when this assessment does not provide a diagnosis, an MRI may provide additional information of value, especially in detecting marrow-based abnormalities. However, as noted by Newberg and Newman, conventional plain radiography remains the key-role in the assessment of symptomatic hips. In this case, there is no documentation of any plain film study of the hip, noting only a reported finding six years earlier. There is a lack of documentation of any abnormal findings on examination of the hips. Since there is a lack of documentation of indications for an MRI of the hip, the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested Botox injections for the treatment of his chronic headaches. Findings:  Three physician reviewers found that Botox has been used for both episodic and chronic migraine with mixed results. The literature suggests a modest positive effect in refractory patients who have more than 15 headaches per month. There is also some literature that suggests that Botox enhances the response to narcotic medication withdrawal in patients with medication overuse headache. Most headache specialists now recommend Botox therapy for refractory chronic migraine patients. Given the patients refractory chronic daily headache and failure to respond to nearly all previously tried standard therapy, Botox injections are more likely to be efficacious than standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a deep brain stimulator for the treatment of his left arm brachial plexus injury. Findings:  Two physician reviewers found that this patient has had some relief with spinal stimulation. Pain medications affect his thinking, memory and recall and thus are not a good alternative. The medical literature suggests that for select patients, deep brain stimulation (DBS) is an alternative that is likely to provide pain relief. This patient fits the profile of those likely to respond to DBS since he has benefitted from spinal stimulation in the past. Based on the evidence provided, it appears that DBS is the most appropriate option for this patient; it is within the standards of good medical practice of the neurosurgical community and likely to produce the desired benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested a magnetic resonance imaging (MRI) of both knees for an evaluation of her bilateral knee pain. Findings:  The physician reviewer found that a thorough examination is not documented in the records provided. No treatments can be recommended or diagnostic studies ordered without first performing an adequate initial assessment. Once a physical examination and adequate history have been obtained, the next appropriate step would be to obtain standing antero-posterior (AP) and lateral x-rays of both knees and a patella tangential view of both knees. Should there be abnormal findings on plain x-ray, then additional studies and treatments may be considered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested a rheumatology referral for the treatment of her osteoarthritis. Findings:  The physician reviewer found that therapy for this condition is classified as either non-pharmacologic or pharmacologic therapy. Examples of non-pharmacologic therapy include self-management programs, such as the Arthritis Self-Help Course, aquatics programs, physical therapy, aerobic exercise programs and bracing. Examples of pharmacologic therapy include several treatments that the patient has already tried and topical analgesics such as capsaicin cream, topical anti-inflammatories and topical lidocaine patches. Exercise and weight loss have been shown to be beneficial in joint function and pain control in older adults. Randomized controlled clinical trials of physical therapy have shown improved clinical outcome in osteoarthritis, with particular benefits from quadriceps strengthening in patellofemoral arthritis. In view of the inadequate pain control in this patient and the lack of evidence in the medical record that important modalities such as physical therapy have been used, a referral to a rheumatologist is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) bone density scan for an evaluation of her osteoporosis. Findings:  The physician reviewer found that osteoporosis can be prevented, and the risk for fracture decreased with proper evaluation and pharmacological treatment. The National Osteoporosis Foundation suggests that providers evaluate and treat, younger postmenopausal women and men age 50 to 69 when there is concern based on their clinical risk factor profile and women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture or high risk medication. This patient is in menopause and has a family history of osteoporosis, which is a risk factor for osteoporosis. It is standard of care and consistent with the recommendations of the National Osteoporosis Foundation and the American Academy of Clinical Endocrinologists to order a DEXA scan in a postmenopausal woman with risk factors of osteoporosis. A baseline bone density study at onset of menopause is clinically indicated, (especially with risk factors such as family history) in order to counsel and determine whether pharmacological therapy is warranted. For this patient, a DEXA study of the hip and spine is medically necessary determine the proper management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested continued skilled nursing facility services for the treatment of his scleroderma. Findings:  The physician reviewer found that the medical necessity of continued skilled nursing facility services has not been demonstrated. This patient was admitted to skilled care and made documented functional gains. He is now able to transfer with minimum assistance to stand-by assistance. The progress notes do not demonstrate further skilled needs. The patient has multiple chronic conditions. He is currently stable and does not require skilled nursing care. With regard to his participation in rehabilitation, the level of therapy and degree of impairment are such that informal in-home therapies would be sufficient. Continued skilled nursing facility services are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Malarone for the treatment of her Babesiosis infectious disease. Findings:  The physician reviewer found that Malarone is a fixed drug combination of two agents (atovaquone and proguanil) that is FDA approved for treatment of malaria. It is not generally accepted therapy for Babesia infection. The report by Vyas and colleagues submitted for review is a study involving Malarone in one HIV infected patient. The article by Krause and colleagues reports on 14 immunocompromised patients with Babesia infection, where only two of the patients were treated with Malarone. The authors note resistance in Babesia to any of the standard treatment agents such as combinations of azithromycin, Clindamycin, doxycycline and quinine has not been reported. The peer-reviewed medical literature does not mention Malarone for treatment of Babesia infection. Mandells Infectious Diseases text does refer to the use of atovaquone in combination with azithromycin or Clindamycin. However, the combination of this drug with proguanil is designed specifically for malaria therapy and is not discussed for use in this setting. Malarone is not standard therapy for Babesia infection. It has been used in only a very few immunocompromised patients who have had relapsing disease. There is inadequate evidence of its efficacy to support its use by this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Procrit for the treatment of her renal insufficiency and/or undiagnosed autoimmune disease. Findings:  The physician reviewer found that Procrit is an approved medication for the stimulation of red blood cell production in patients receiving cancer chemotherapy or those with renal failure. The patients renal failure, despite being mild, is likely instrumental in her anemia. Although it is possible she has some sort of autoimmune process for which Procrit would not be helpful, there is no definitive diagnosis of such and her treating physician notes that she has anemia of renal insufficiency and chronic disease. Thus, there is sufficient clinical evidence to support the use of Procrit in this situation. Furthermore, Procrit appears to have been successful for this patient as her hemoglobin went from under 10.0 to greater than 11.0 during the period of use.