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

A 31-year-old male enrollee has requested the medication Actiq for the treatment of his back pain. Findings:  The physician reviewer found that although Actiq has only been approved by the FDA for cancer related pain, there are some clinical situations in which this medication can be appropriately used off-label for other forms of pain management. In the case of this patient, the submitted medical records do not outline in a prospective manner the failure of all the other forms of treatment tried and failed. Nor does the submitted evidence include objective medical record documentation which describes the benefit achieved from this off-label use of Actiq. In the case of chronic narcotic medication, such documentation should specifically include itemized functional improvements achieved by the patient from this medication in order to support its continued use. All told, the medical records provided contain insufficient documentation to support the medical necessity of Actiq, either retrospectively or prospectively.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested Nuvigil (armodafinil) 150 mg for the treatment of her bipolar disorder. Findings:  The physician reviewer found that because of the number and variety of medication trials that have been prescribed in combination for this patient, as well as a pattern of rapid adjustment and discontinuation, there is inadequate clinical data to support a reliable assessment of this patients response to medication treatment. In addition, the combination of multiple mood stabilizers (including Lamictal, at a higher than customary dose), multiple antidepressants, and a stimulant in the absence of a planned treatment protocol is not likely to result in a successful outcome and is not medically indicated. Furthermore, the differentiation between iatrogenic induced somnolence secondary to medication side effects and the somnolence that is caused by the psychiatric condition itself is not obvious in this case. All told, there is insufficient clinical rationale for adding Nuvigil in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a hydrogen breath test for the treatment of her gastrointestinal symptoms. Findings:  The physician reviewer found that the utility and specificity of hydrogen breath testing in patients with small intestinal bacterial overgrowth (SIBO) is not a settled issue among the gastroenterology community (Chey). The usefulness of a positive breath test in SIBO with diarrhea may have the same significance as a positive breath test in an individual with abdominal bloating and chronic constipation (Chey). Furthermore, in this case, there is no documentation which supports how medical therapy of the patients functional symptoms will be changed by a breath test result that is either positive or negative. The requesting physician has not stated that a negative breath test would mean that he would elect to not treat this patient with antibiotics for presumed small intestinal bacterial overgrowth or that he would use a negative test to explore other diagnostic possibilities for her symptoms. As such, there is inadequate evidence to support the use of a hydrogen breath test in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested an ultrasound or MRI for an evaluation of her breast microcalcifications. Findings:  The physician reviewer found that it is well-established in the medical literature that mammography is the appropriate imaging study for the evaluation of breast calcifications. This has been the standard of care for several decades. Further, it is well-documented in the peer-reviewed literature that ultrasound and MRI are not adequate for the evaluation of breast microcalcifications.  As noted by the National Cancer Institute, ultrasound is not used for routine breast cancer screening because it does not consistently detect certain early signs of cancer such as microcalcifications, and MRI also cannot detect microcalcifications. Breast calcifications fall into three categories, benign, indeterminate and malignant.  Those calcifications that are indeterminate or malignant in appearance are referred for biopsy. Benign calcifications are followed by mammography. If the calcifications are new, short-term follow-up mammogram is sometimes indicated. In regards to this patient, she was referred for a short-term follow-up mammogram to evaluate new benign appearing calcifications, which is consistent with the standard of care in this setting. Ultrasound and breast MRI are not medically necessary to evaluate breast calcifications as they have not been shown to be effective for this indication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested continued acute care stay for the treatment of her stage IV right breast carcinoma, metastatic to the bone. Findings:  The physician reviewer found that the patient underwent L3 to L5 laminectomy, resection of L4 inferior and partial superior facet joint, resection of pedicle tumor, dissection of lateral mass transverse process tumor right-sided, resection of L3 joint cyst lateral recess, decompression bilateral L4-5, posterior segmental fixation L3 to L5, posterior autologous bone graft and neural monitoring. This is a major spinal surgery which requires a substantial inpatient stay to achieve and maintain independent function. During the dates of service at issue, the patient was being transitioned from intravenous patient-controlled analgesia to oral pain medicine and required continued monitoring to determine if independent functioning and other capabilities remained. Thus, the acute care services provided were within generally accepted standards in this setting and medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested an X-Stop interspinous process decompression system for the treatment of his spinal stenosis. Findings:  Two physician reviewers found that although some studies of the X-Stop procedure have shown promising early results in limited numbers of patients (Zucherman and colleagues), other studies have not been as favorable and the need for randomized, controlled studies has been implicated (Siddiqui and colleagues). Studies of long-term outcomes and comparisons with laminectomy are in progress, but the results are not yet available. Until outcome data demonstrating the long-term efficacy of the X-Stop is published, the procedure remains of questionable benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested duodenal switch and laparoscopic cholecystectomy for the treatment of his morbid obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates that this patient meets generally accepted guidelines for bariatric surgery based on the National Institutes of Health criteria. At issue is whether the duodenal switch procedure is medically necessary for treatment of the patients morbid obesity as opposed to other surgical techniques. The duodenal switch procedure is considered an appropriate weight loss procedure by the National Institutes of Health, the American Society of Metabolic and Bariatric Surgeons, and the Centers for Medicare and Medicaid Services. Review of the relevant scientific evidence shows that duodenal switch is more successful in achieving and maintaining weight loss than gastric banding or Roux-en-Y gastric bypass surgery. Furthermore, dumping syndrome does not occur with duodenal switch. Moreover, given this patients need for NSAID therapy, Roux-en-Y gastric bypass would be contraindicated. Marginal ulcer formation is not a concern with the duodenal switch procedure and as such, NSAIDs may be utilized. All told, duodenal switch and laparoscopic cholecystectomy is the most appropriate option for this patient and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 4-year, 10-month-old male enrollee has requested applied behavioral analysis therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  Three physician reviewers found that the initial studies by Lovaas demonstrate the benefit of ABA therapy for patients with autism spectrum disorder. The research evidence for ABA is moderate to good, and is more reliable and reproducible than the research for many conditions which are not considered investigational. ABA is included in the standard treatment recommendations of most practitioners who treat patients in the early stages of autism. As the clinical research demonstrates, ABA is an integral part of an intensive approach for treating young patients with pervasive developmental disorder (PDD). Furthermore, the American Academy of Pediatrics supports ABA as effective treatment for pervasive developmental disorder and suggests early intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested an office visit and laboratory services for an evaluation of his medical condition. Findings:  The physician reviewer found that the patient has a history of hyperlipidemia and thus the lab tests to check his cholesterol levels were appropriate. Lipoprotein testing is also appropriate and indicated in patients with elevated low density lipoprotein cholesterol to further define a patients cardiovascular risk, in order to determine how aggressive their medical treatment needs to be (Katsouras and colleagues). In addition, a comprehensive metabolic panel is justified to monitor a patients baseline liver function prior to initiating, or while a patient is on statin therapy. In addition, because this patient has a history of anemia and fatigue, all of the following lab tests were medically necessary; complete blood count; thyroid; ferritin; vitamin B12 level; LDH, and; the DHEA testing. However, homocysteine testing (CPT 83090) was not indicated as the patient does not have a history of coronary artery disease, and there is inadequate evidence to suggest that screening and/or treatment of low homocysteine levels results in any clinical difference (Lentz and Haynes). In addition, there is no clear clinical indication for the uric acid testing (CPT 84550) or the phosphate testing (CPT 84100) based on the records provided. Therefore, these tests were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested psychiatric residential treatment services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the description of the patient reveals evidence of manic or hypomanic behavior considering her history of pressured speech, tangentiality and inappropriate affect at the time of this admission. The patient presented with substantial paranoia and anxiety, in addition to an unkempt appearance. After three weeks into the admission at issue, the patient was still manifesting paranoia and racing thoughts and coping with akathisia. The patient was having her medications actively titrated and she was discharged from this admission directly to another facility. This patient was an appropriate candidate for a residential level of care given her manic symptoms, paranoia, and long-standing substance use and dependence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested surgery for the treatment of her cervical intraepithelial neoplasia III. Findings:  The physician reviewer found that `urgently needed services` are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition for which treatment cannot be delayed until the patient returns to the plans service area. This patient had a diagnosis of cervical intraepithelial neoplasm (CIN) 3. In general, the progression of CIN 3 to cervical cancer can take at least several years to occur and this patients condition was not urgent. Therefore, the delay of several weeks for the rescheduled appointment did necessitate the performance of the surgery on an urgent basis. The procedure performed was not required to prevent serious deterioration of the health of the patient. It would have been medically appropriate for the patient to undergo the cold-knife conization procedure (or a similar procedure) at a later time after she consulted an in-network provider.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested residential treatment facility level of care services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient entered residential treatment with a body mass index of 17.8 at 88% of her ideal body weight. She was not losing weight rapidly or engaging in uncontrolled binging or purging behavior. She was not in metabolic danger. During residential treatment, there were no suicidal ideations, evidence of withdrawal or complications from anorexia noted. The patient did not have severe co-morbid psychiatric disorder, mania, suicidality, psychosis or aggression during the period at issue. She was not at risk of harm to herself or others and could have been safely and effectively treated in a less intensive setting throughout her stay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested inpatient detoxification services for the treatment of his substance abuse disorder. Findings:  The physician reviewer found that the detoxification services at issue were medically necessary. The patients family initiated the admission to the detoxification program in response to the patients threatening behavior which required police intervention. At the time of discharge from the detoxification program the patient was reported to have poor insight into his issues with substance abuse and on mental status examination, it was found that he rambles and is tangential. There were also concerns about the patients judgment and his potential to be harmful to himself or others. As a result, after he was treated in the detoxification program at issue, he was admitted to a 30-day inpatient treatment substance use disorder program, followed by a four-month stay in a sober living facility. Given this patients significant history of polysubstance abuse, threatening behavior, and the risk of harm he posed to himself and others, it was medically appropriate to admit this patient to a detoxification level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of his metastatic colorectal cancer.   Findings:  Three physician reviewers found that SBRT allows very high doses of radiation to be focused specifically to a specific tumor site, thus reducing excess radiation dosages to normal surrounding tissue. There are no guidelines for SBRT in relation to metastatic colorectal cancer to the lung, such as is the case with this patient. However, there is guidance regarding non-small cell lung cancer that states that SBRT can be considered for patients who are deemed medically inoperable, but who have a reasonable performance status and life expectancy. In addition, studies have shown the promise of increasing survivorship in patients treated with SBRT (Salama, et al. and Macdermed, et al.). In summary, SBRT is indicated and appropriate for this patient based on the following: he has had multiple cycles of chemotherapy as well as multiple surgical procedures; he has recuperated well from those surgeries and chemotherapy; he is still active, walking up to three miles at a time; and there are no other viable therapy alternatives in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested the medication Lamisil for the treatment of the enrollees onychomycosis. Findings:  The physician reviewer found that the submitted medical records confirms that this patient has a diagnosis of fungal infection with his culture report demonstrating the presence of trichophyton rubrum. The patient has experienced secondary infection (cellulitis) as a result of the onychomycosis which required treatment with antibiotics. Thus, systemic treatment with Lamisil is medically indicated in light of the cellulitis. Furthermore, the patient reports the infected toenails are painful which is likely to affect function. All told, the patient is an appropriate candidate for treatment with Lamisil and the medication should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested radiofrequency volumetric tongue reduction for the treatment of his obstructive sleep apnea (OSA). Findings:  Three physician reviewers found that this patient has a complex apnea, a combination of central and obstructive sleep apnea. There is no surgical treatment for central apnea. He has had multiple procedures for his obstructive sleep apnea. These have not helped to relieve the symptoms. As noted in the literature, radiofrequency volumetric reduction of the tongue base usually results in only mild improvement of obstructive sleep apnea symptoms. Furthermore, there is deterioration in these benefits over the long-term. All told, the proposed radiofrequency tongue base reduction is not likely to result in significant or sustained improvement in the patients symptomatology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested continued residential level care for the treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the medical records indicate that at the time of admission the patient was medically stable and exhibited no self-harm behavior. She was described as well developed and well nourished with no medical issues related to an eating disorder. She was noted to be without suicidal or homicidal ideation. The provider indicated that the patient made progress while being treated in a wilderness program prior to this residential treatment admission. Progress notes by the provider reflect issues related to trichotillomania and anxiety. The notes indicate the patient was working on self esteem issues and she was anxious but not sad. The provider notes that the patient was sleeping well, anxious and pulling her hair less. There were medication adjustments to address anxiety and hair pulling including Prozac, Zoloft, Neurontin and n-acetyl cysteine. The records reflect no documentation of binging, purging or restrictive eating. The patient was participating in family therapy and group therapy in a cooperative manner and was compliant with medication adjustments. Therefore, the need for 24-hour residential level of care is not supported by the medical documentation. Based on American Academy of Child and Adolescent Psychiatry (AACAP) and American Psychiatric Association (APA), treatment guidelines as well as Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines, this patient was appropriate for transfer to a less restrictive level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested enhanced external counterpulsation (EECP) for the treatment of his angina. Findings:  Two physician reviewers found that the use of EECP in the treatment of chronic angina refractory to medications in patients who cannot be safely revascularized is a generally accepted treatment modality. The current recommendations for treatment of angina remain anti-anginal therapy or revascularization as first-line therapy, with EECP reserved for those symptomatic patients who fail a reasonable trial of medications and cannot be revascularized.  Currently, to meet criteria for EECP, patients have disabling angina and must be refractory to maximum medical therapy and not readily amenable to revascularization.  In this particular case, the patient was on multiple anti-anginal agents, including carvedilol, amlodipine and isosorbide. This is considered maximal medical therapy. Partial revascularization was performed, and the documentation notes continued disabling angina. As the patient has continued class 3 angina despite maximal medical therapy and the partial revascularization of the patient was unsuccessful, EECP is the medically appropriate next step for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested residential treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the residential treatment services at issue were not medically necessary based on the following: there were no detoxification risks or co-occurring medical issues that required monitoring as the patient was detoxified during previously authorized days; there were no medical issues requiring monitoring as manifested by the absence of any post admission medical assessments, an absence of documented nursing monitoring and an absence of documented psychiatric monitoring; the patient was without any suicidal or dangerous ideation on admission and throughout this stay. She demonstrated no safety issues that required 24-hour monitoring or supervision. Furthermore, based on the available documentation, the patient did not meet American Society of Addiction Medicine (ASAM) criteria for a residential level of care. Under ASAM criteria, the patient was not noted to be intoxicated or to have any detoxification risks documented subsequent to the period she was in the sub-acute detoxification services. The patient was noted to have no major bio-medical issues that would complicate treatment. While she did undergo medical detoxification initially (during an authorized period of treatment), available documentation indicates she was seen only one time by a physician during this residential stay which falls well below the frequency of medical visits anticipated in a residential level of care. Thus, based on the established ASAM criteria, this patient did not require a residential level of care during the period at issue and could have been appropriately treated at a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested a spinal cord stimulator for the treatment of his lower back pain. Findings:  Three physician reviewers found that spinal cord stimulation is well accepted treatment for several pain syndromes. Long-term studies have validated its use. Kumar and colleagues published a case report with follow-up ranging from 6 months to 15 years. In that study, 58% of implanted patients, after careful trial selection, experienced continuous pain relief. Kumar and colleagues also documented satisfactory outcomes in a 10-year follow-up. Finally, North and colleagues have published multiple studies comparing the outcomes of spinal cord stimulation versus re-operation.  The authors noted spinal cord stimulation is more effective than reoperation as a treatment for persistent radicular pain after lumbosacral spine surgery. While spinal cord stimulation is a superior modality in this setting, the submitted evidence does not demonstrate this patient has undergone a psychological evaluation. Such evaluation is indicated prior to the procedure. Therefore, a psychological evaluation should be performed prior to this trialing in order to rule out underlying psychopathology that may compromise the potential success of this treatment.