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

A 58-year-old male enrollee has requested Zetia 10 mg for the treatment of his coronary disease. Findings:  The physician reviewer found that this patient has multivessel stenting and diabetes and is at very high risk of developing future coronary events and aggressive lipid therapy is warranted. This conclusion is consistent with the findings by Smith and colleagues and the American Heart Association/American College of Cardiology guidelines referenced above. Elevated homocysteine levels have been shown to put patients at higher risk of future atherosclerotic disease. Although further studies are needed, it is common clinical practice to attempt to lower homocysteine levels with medications in very high risk patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees selective mutism. Findings:  The physician reviewer found that selective mutism is a rare disorder in which a child refuses to speak in one or more social situations. Some consider it to be similar to social phobia. Speech therapy has been utilized successfully as part of a multimodal treatment approach because of the association with other speech and language disorders. The literature also supports the efficacy of speech therapy intervention for expressive language delay. In a large meta-analysis looking at studies of children with primary speech and language delay/disorder, Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary deficits. This patient suffers from multiple speech and language difficulties. It is important to address all of the co-occurring deficits with speech therapy now in order to improve communication skills, and prevent difficulties in the future that may not be so amenable to therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested  sensory integration based occupational therapy and/or sensory integration based speech therapy for the treatment of the enrollees sensory processing and integration difficulties. Findings:  Two physician reviewers found that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. The therapy at issue was and is medically indicated to allow this patient to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested a comprehensive evaluation and participation in a one-week outpatient program (including, but not limited to, allergens, skin testing, laboratory testing, oral food challenges and nutritional evaluation) for the treatment of the enrollees allergies. Findings:  The physician reviewer found that the submitted clinical records, parents letters and physician letters do not document the medical necessity of a full evaluation and extended food allergy testing performed. Records indicate the patient has undergone IgE RAST annually, as well as skin testing, with several strong reactions. The patient is avoiding these foods. The letter from the patients parents states the patient has experienced ingestion, inhalation and contact reactions. These types of reactions are not evidence of life-threatening anaphylaxis, and are not documented by physical findings. The patients parents are seeking extensive oral challenge testing to foods for which the patient has had equivocal test results. However, the submitted records do not document the presence of life-threatening anaphylaxis on any occasion, for which oral challenge testing in a carefully controlled setting may be considered warranted. In addition, the records do not document that the patient could not receive appropriate oral challenge testing from an in-network provider. There is no medical necessity to seek an additional evaluation for food allergies and the patients additional diagnoses of inhalant allergy, asthma and eczema at the outpatient program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a 59-year-old male enrollee has requested transfer to a facility with a higher level of care for the  treatment of the enrollees multiple medical conditions including Guillain-Barre Syndrome. Findings:  The physician reviewer found that this patient has had a severe paralytic illness, consistent with Guillain Barre Syndrome (GBS). The prolonged nature of his symptoms, along with observed atrophy, suggests axonal involvement as is seen in the acute axonal variant of GBS. CIDP is a chronic form of demyelinative neuropathy, reaching a nadir in more than eight weeks. IVIG can be beneficial for GBS, but does not always result in improvement. Plasmapheresis has been shown beneficial for GBS when given early in the illness. As with other inflammatory neuropathies, CIDP is treated with immunosuppressants with variable levels of evidence for the efficacy of each. The first line treatment for CIDP is accepted as steroids, IVIG or plasmapheresis. Electrodiagnosis may help differentiate CIDP and may show axonal loss. This could help clarify relevance of other immunosuppressive therapy. Although further evaluation regarding the possibility of CIDP may not yield different treatment options, the potential for improvement is greater at a higher level of care, where the diagnosis can be clarified, and treatment options fully assessed. In addition, wound care for a stage IV decubitus ulcer may require skin grafting, which is best done in an acute setting, rather than a rehabilitation hospital. Thus, transfer to a higher level of care at UCLAs acute-care hospital (which has expertise in GBS) is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Crestor for the treatment of her hyperlipidemia. Findings:  The physician reviewer found that patients with hyperlipidemia have several options available for therapy. Statin therapy has had the largest preponderance of positive data associated with decreased mortality and event reduction risk. There are many different drugs within the statin class, all of which are FDA approved for the treatment of lipid disorders, and intolerance is not a class effect. Therefore, intolerance to one or two statin drugs does not indicate intolerance to all statin therapies. The Health Plan formulary has choices of different FDA approved statins that may be as least as effective as Crestor without intolerant effects, and a trial of one of the formulary statins to assess for tolerance and efficacy would be a reasonable and a medically accepted clinical strategy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches and cervical dystonia. Findings:  Two physician reviewers found that this patient had a diagnosis of episodic migraine with an exacerbation period of several weeks. The records do not support a diagnosis of chronic migraine, or the addition of any migraine medications. This patient was already on multiple medications for her migraines and back pain when first seen by her neurologist. Furthermore, the records do not support a diagnosis of cervical dystonia. Botox was requested for this patient. However, this was the first time the chart notes mentioned any muscle spasm or abnormal neck position. The presentation is most suggestive of acute cervical muscle spasm and not cervical dystonia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a thallium stress test for the treatment of her sporadic chest pain. Findings:  Two physician reviewers found that the patient has little documented cardiac risk (only hyperlipidemia and a non-premature family history). She has atypical symptoms that are not likely due to coronary ischemia. She had a normal cardiac exam. In aggregate, there is a low pre-test likelihood of significant coronary disease, such that if stress testing were thought to be indicated, a routine treadmill test would suffice provided that the patients baseline electrocardiogram is normal and that she is able to ambulate adequately on a treadmill. Since there is no indication that the patient has a baseline abnormal electrocardiography that would preclude an accurate interpretation during exercise, and no indication of inability to ambulate on a treadmill, the usual criteria for augmented stress testing (i.e., thallium stress test) are not met. Current nationally endorsed appropriateness criteria for nuclear perfusion imaging (referenced above) also do not recommend performing a thallium stress test in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested transforaminal epidural injections for the treatment of his chronic lumbar back pain and degenerative disc disease. Findings:  The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) guidelines note that injections are not indicated in chronic low back pain in the absence of radicular symptoms or for treatment of any chronic problems. Review of the submitted clinical evidence reveals no indication of radicular symptoms, sciatic symptoms or symptoms of facet pain. Furthermore, a thorough search of the relevant medical literature revealed no support for the use of injections for chronic, midline, and axial pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-month-old female enrollee has requested a custom shaping cranial helmet for the treatment of the enrollees torticollis, right plagiocephaly and bilateral brachycephaly. Findings:  The physician reviewer found that this patient was born with cranial asymmetry as a result of intrauterine positioning. In addition, she experienced torticollis. She has failed standard treatment recommendations for positioning and physical therapy. The measurements taken of her head revealed a cephalic index of 98%, which is much greater than the norm and clearly representative of severe brachycephaly. Her cranial asymmetry was exacerbated by plagiocephaly, resulting in significant deformity. Based on the standard of care described above, orthotic therapy is medically necessary and appropriate for this infant to prevent future complications and permanent deformity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested a comprehensive evaluation and participation in a one-week outpatient program (which includes but is not limited to allergens, skin testing, laboratory testing, oral food challenges and nutritional evaluation) for the treatment of the enrollees allergies. Findings:  The physician reviewer found that the parent and physician letters do not document the medical necessity of a full evaluation and food allergy testing performed at the requested facility. Records indicate the patient has not undergone adequate skin testing, which must be performed before food challenge testing.  The letter from the physician states that the mother was interested in food challenges to nuts and seeds, and the plan was to perform skin tests first. There is no record that this testing was performed. The submitted records do not document the presence of life-threatening anaphylaxis on any occasion, for which oral challenge testing in a carefully controlled setting may be considered warranted.  In addition, the records do not document that the patient could not receive oral challenge testing at the clinic where she was being followed for her diagnoses or another in-network provider. Food allergy challenge testing may be appropriate for this patient, but only after performing and reviewing skin test results as recommended by her physician. There is no medical necessity to seek an additional evaluation for food allergies and the patients additional diagnoses of inhalant allergy, asthma and eczema at the requested facility.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested chemotherapy using Vectibix, Erbitux and irinotecan for the treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that this patient has tried and eventually progressed on several different chemotherapeutic regimens. The patient had a pronounced response to Tarceva, which, as his physician states, is indicative that the tumor is very sensitive to endothelial growth factor receptor (EGFR) inhibition. There is support for the use of EGFR inhibitors (including the monoclonal antibody Erbitux). Butts and colleagues demonstrated benefit from the addition of Erbitux to a chemotherapeutic regimen for patients with advanced localized or metastatic non-small cell lung cancer (NSCLC). In addition, the study by Hanna and colleagues involved patients who had prior treatments for their NSCLC, with 57% of the patients having two or more prior regimens. No patient had a complete response, but stable disease was achieved in 30% of the patients studied.  Irinotecan has been shown to be efficacious in the treatment of advanced and metastatic NSCLC, both alone and in conjunction with other medications. It has not previously been used in this patient, and the patient has not been treated with any medications with a similar mechanism of action. There is currently no data that supports the use of Vectibix, alone or in combination with the other requested medications, for the treatment of NSCLC. Given the patient's pronounced response in the past to Tarceva and the progression on his recent regimen, Erbitux and irinotecan are more likely to be beneficial for the patient than other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested CyberKnife surgery for the treatment of his colorectal cancer with liver metastases. Findings:  Three physician reviewers found that CyberKnife use would be controversial if it was used as an alternative to surgical resection or some other proven first-line intervention. That is not the case here. The use of CyberKnife is palliative in a patient who has exhausted the standard of care and the current literature shows it to have low toxicity. The use of CyberKnife therapy for this patient with liver metastases seems medically reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested a positron emission tomography (PET) scan for an evaluation of his adenocarcinoma of the pancreas. Findings:  Two physician reviewers found that this patient has known pancreatic cancer that has shown response to chemotherapy as documented on prior PET scans. PET scans have been shown to have increased sensitivity in comparison to computed tomography (CT) studies and have been shown to change management in patients with invasive cancer. Delbeke and colleagues state that PET scans are useful for detecting recurrence and monitoring therapy. Saif and colleagues found PET scans to be more accurate in the evaluation of metastatic disease than CT studies. The patients prior PET studies have shown metabolic active disease consistent with the patients known pancreatic cancer. A PET scan is medically appropriate for this patient at this time. The outcome of the PET scan will allow the patients physician to proceed with a proper treatment plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential psychiatric services for the treatment of the enrollees anxiety and attention deficit disorders. Findings:  The physician reviewer found that the patient does not meet medical necessity criteria for residential level of care during the timeframe in question. This determination is based on the medical records reviewed wherein there is no documentation to support that the patient was at any time in imminent risk of harm to herself or others. Additionally, there is no documentation to show the patient had any symptom or behavior that needed 24-hour monitoring. This patient does have emotional and mental health issues, but these could have been effectively and safely treated at a less restrictive level of care. There is no documentation to support that the patient was actively psychotic, or unable to take care of herself. The level of care provided was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested chemical dependency inpatient detoxification and chemical dependency residential treatment for the treatment of his chemical dependency. Findings:  The physician reviewer found that since the patient had no signs/symptoms of detoxification upon admission, there was no need for inpatient detoxification or any treatment requiring a 24-hour environment. The patient could have safely been treated at a lower level of care such as intensive outpatient treatment for chemical dependency. He had no medical or psychiatric co-morbid conditions and presented no risk of harm to self or others necessitating inpatient 24-hour medical supervision and management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested sub-acute residential psychiatric services for the treatment of the enrollees anxiety and attention deficit disorders.  Findings:  The physician reviewer found that the psychiatric services provided during the timeframe in question were not medically necessary at that level of care. At the time of the evaluation, the patient was not suicidal, homicidal, psychotic, or delusional and there is no documentation to support that there was any acute or imminent risk of harm to self or others. The suicide risk assessment clearly states this conclusion and the psychiatric evaluation performed also supports this conclusion. There is no documentation to support that the patient needed 24-hour supervision or monitoring. Evaluation of the patients suicidality, her diagnosis, medication management and academic testing could have been effectively and appropriately addressed at a less intense level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested acupuncture for the treatment of her temporomandibular joint (TMJ) disorder. Findings:  Three physician reviewers found that the literature does not support the notion that acupuncture was likely to be more beneficial than available standard therapies for this patients condition. There have been several randomized trials that have demonstrated a short-term beneficial effect from acupuncture for this indication. However, the size of the studies was small, and none of the studies employed a placebo arm to investigate the possible placebo effect. None of the studies looked for longer term benefits, and none of the studies compared the effectiveness of acupuncture with standard treatments for TMJ. Ernst and White concluded that the treatment may be beneficial, but that further studies are needed to demonstrate if there is in fact a beneficial effect compared with a placebo group. The Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested laparoscopic duodenal switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines set by National Institutes of Health for the treatment of morbid obesity with surgery. The American Society of Metabolic and Bariatric Surgery identified the duodenal switch operation as an option for the patient. The Health Plans reference does not objectively compare the two procedures. Gastric bypass patients do have significant nutritional deficiencies that are not present in duodenal switch patients. One example is Wernicke encephalopathy. After gastric bypass, patients have a high incidence of dumping syndrome, marginal ulcers and protein deficiencies. Although a duodenal switch operation may also result in nutritional deficiencies, the postoperative diet for a duodenal switch patient is much more normal since the anatomy of the stomach is reduced in a physiological way allowing proper functioning of its regulatory mechanisms. This patient should be offered the duodenal switch operation, since it has better long-term outcomes when it comes to the percentage of excess body weight loss.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested partial hospitalization program services for the treatment of her eating disorder. Findings:  The physician reviewer found that although her vital signs were stabilized following admission, she continued to ruminate daily about excessive weight and exercise. Additionally, the presence of a significant psychiatric comorbidity was well-documented in the medical records and impacted her level of motivation. Blunted affect, significant anxiety and poor eye contact were noted. Psychotropic medications were adjusted, resulting in an increase in certain medications. Family stressors were also present. All of these were impacting her recovery environment. The level of care received is also consistent with the American Psychiatric Association guidelines for the treatment of patients with eating disorders, and its effectiveness has been noted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested an endonasal tumor removal (endonasal transphenoidal approach) for the treatment of her suprasellar mass. Findings:  The physician reviewer found that the patient should have surgery to have this tumor removed. How it is accomplished is a matter of debate in the neurosurgical literature. The advantages of the supratentorial approach are that it is easier for most neurosurgeons and allows better removal of the tumor from the chiasm. The disadvantages are that it is more invasive and has the possibility of more complications. The transnasal endoscopic approach is less invasive, does not require mobilization of the brain and can decompress the tumor from below the chiasm and avoid manipulation of the optic nerve. It is a more complex procedure with a steeper learning curve and ideally should have better results in the hands of an experienced surgeon trained in the approach. It is medically reasonable for the patient to undergo a transnasal endoscopic approach.