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

A 53-year-old female enrollee has requested a positron emission tomography/computed tomography (PET/CT) scan  for evaluation of her medical condition.  Findings:  The physician reviewer found that it is well established in the peer-reviewed literature that CA-125 testing is not effective as a screening test for ovarian cancer. WebMD states that, The CA-125 test is not recommended as a screening test for ovarian cancer at this time because it often has false-positive results. Further, researchers for UpToDate report that, Ovarian cancer cannot be diagnosed based upon the results of a CA-125 test. Many women with early ovarian cancer will have a normal CA-125 level. For this reason, the authors concluded that, CA-125 is not recommended as a standalone screening test for ovarian cancer. It has also been shown that elevated CA-125 can be secondary to non-malignant conditions. Physicians writing for UpToDate noted that, non-cancerous conditions can cause CA-125 to be elevated, including endometriosis, uterine fibroids, pelvic inflammatory disease, heart failure, and liver and kidney disease. In addition, a review of the peer-reviewed medical literature returned a paucity of support for the utility of a PET/CT scan in the evaluation of patients with an elevated CA-125 but no personal history of cancer. All told, an elevated CA-125 in a patient with no personal history of cancer is not specific for cancer. Further, PET/CT scans are not medically indicated for cancer screening. For these reasons, the diagnostic PET/CT imaging done on the date in question was not medically necessary or reasonable for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested Dynasplint devices for treatment of her status post bunionectomy with first metatarsal neck osteotomy of both feet.  Findings:  Three physician reviewers found that the patient was treated with bilateral Dynasplint devices after surgery.   She received Dynasplint devices to aid in regaining full range of motion of her toes. The Health Plan has denied reimbursement for Dynasplint devices and maintains that the devices at issue were investigational, and this is the subject of the appeal.  At this time, there is insufficient clinical evidence to support the postoperative use of the Dynasplint device following bunionectomy.  The available studies do not demonstrate a change beyond usual care, as there is a lack of control groups as a comparison.  At this time, there is insufficient evidence supporting the use of a Dynasplint device in this patients case.  The medical literature has not established that the use of a Dynasplint device following bunionectomy is superior over other treatment alternatives.  Therefore, the Dynasplint devices at issue were not likely to have been superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested a biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the patients BMI was 40.4.  She has failed supervised weight loss and completed a thorough multidisciplinary evaluation.  Barriers to surgery were not noted by the patients provider.  This patient is requesting a standard procedure for treatment of morbid obesity.  The requested procedure is approved by the American Society for Metabolic and Bariatric Surgery and the American Medical Association based upon numerous published peer-reviewed articles documenting the safety, efficacy and durable long-term outcomes.  Current medical evidence supports the requested procedure in this clinical scenario.  All told, the requested biliopancreatic diversion with duodenal switch is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 79-year-old male enrollee has requested emergency transport for treatment of his medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have believed that emergency transport to the hospital was medically necessary. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The submitted documentation states that the patient was worried about pain in his chest. However, the paramedic notes specifically state that the patient denied any chest pain or shortness of breath. The patient complained only of nausea that commenced after eating breakfast. Upon arrival in the Emergency Department, the patient reported abdominal cramping. He then left the facility prior to evaluation by a physician. It is unlikely that a prudent layperson experiencing nausea after breakfast would reasonably believe his condition requires the emergency services that only an emergency ambulance transport can provide. This is supported by the fact that the patient then decided to leave the hospital prior to an examination or complete evaluation. While the patient is of advanced age, the submitted documentation does not establish that the patient was experiencing symptoms of such severity that they would cause a prudent layperson in his situation to believe emergency transportation was required to prevent serious injury.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Ixempra in combination with Avastin for treatment of her metastatic breast cancer. Findings:  Three physician reviewers found that the use of this combination of Ixempra with Avastin has not been demonstrated to be beneficial or safe in patients with breast cancer in the peer reviewed published clinical literature. Further, this combination is not approved by the Food and Drug Administration (FDA), compendium listed or recommended by the consensus expert panel guidelines. Given the lack of evidence of the effectiveness of the proposed combination therapy, there is inadequate justification for the use of the requested Ixempra and Avastin therapies in these circumstances.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested vagus nerve stimulation (VNS) through implantation of the VNS therapy system for treatment of his intractable epilepsy.   Findings:  Two physician reviewers found that although VNS is not considered a first-line therapy for generalized seizures, there is adequate literature supporting its use for refractory cases. As noted by Kostov and colleagues, VNS therapy is a favourable treatment option for patients with drug-resistant idiopathic generalized epilepsy. Further, these results are consistent with the recent findings published by Ghaemi and colleagues. In this particular case the patient has failed at least three primary seizure therapies. In addition, he is not thought to be a surgical candidate and his seizures appear to be progressing. Inadequately treated seizures place the patient at great risk of morbidity. Given the status of the available peer reviewed medical literature, a trial of a VNS is a reasonable and medically appropriate approach to this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Avastin (J9035) for treatment of her metastatic leiomyosarcoma with metastatic involvement of the lungs.  Findings:  Three physician reviewers found that Avastin is a monoclonal antibody targeting the vascular epithelial growth factor.  It has been approved for use in multiple cancers, particularly when combined with chemotherapy. The extent of the data regarding its use in soft tissue sarcomas is limited. In the study by DAdamo and colleagues, 17 patients with soft tissue sarcoma were treated with Avastin combined with doxorubicin.  Although there were a few responses, there was significant toxicity.  Accordingly, it was recommended that this approach not be further pursued.  There is a lack of data supporting the use of Avastin in this clinical scenario.  The current medical evidence has not demonstrated the benefit of the use of Avastin for patients with soft tissue sarcomas.  All told, Avastin is not likely to be superior over other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested Afinitor for treatment of his metastatic calcitonin secreting pancreatic neuroendocrine tumor.  Findings:  Three physician reviewers found that Afinitor is one of a relatively new class of drugs known as mTOR inhibitors, and mTOR is an enzyme that is significant in a number of pathways that appear to be important in neuroendocrine tumor growth.  Additionally, mTOR may regulate angiogenesis. Routine chemotherapy has been of limited benefit in this type of rare cancer, a metastatic neuroendocrine tumor.  Duran and colleagues studies 37 such patients and noted that although the response rate was low, 64% of patients had some degree of disease control.  Yao and colleagues also demonstrated some activity in these tumors.  In this patients case, the use of Afinitor is likely to be more beneficial than any other available treatment for this condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested Velcade in combination with R-CHOP for treatment of his diffuse large B-cell lymphoma.  Findings: Three physician reviewers found that the patients lymphoma is of non-germinal center origin and that this type of lymphoma does not respond well to the standard R-CHOP regimen. The patient has requested Velcade in combination with R-CHOP. The peer reviewed medical literature suggests that the standard therapy for advanced diffuse large B-cell lymphoma involves chemotherapy with R-CHOP. The addition of Velcade to this combination has not been demonstrated to be superior to this combination in randomized controlled phase III clinical trials published in peer reviewed clinical literature. It is not FDA approved, compendium listed, or recommended by consensus panel guidelines for use in this clinical setting. Thus, its use would not be expected to facilitate an improved health outcome in this patient beyond the results anticipated with the R-CHOP regimen alone.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested the Flexitouch System for treatment of her bilateral lower extremity lymphedema.  Findings:  The physician reviewer found that evidence in the peer-reviewed medical literature is lacking to support the use of lymphedema devices with truncal appliances. As reported by Wilburn in a small, limited pilot study comparing the clinical effectiveness of the Flexitouch device compared to conventional therapy. Overall, the author concluded that further investigation is warranted given this short-term evaluation of the device. In addition Ridner and colleagues concluded that, Patients using the Flexitouch system were satisfied with the device and perceived it to be beneficial in management of their lymphedema. Despite these findings, the outcome is questionable as there was no control group from which to draw comparisons. One study by Adams and colleagues found future clinical trials are warranted as the current published medical literature has not conclusively demonstrated the efficacy of the lymphedema compression pump devices with additional truncal garments, or the marginal efficacy of these devices over conventional compression devices without the additional truncal garments. With regard to this patient, the Flexitouch device was requested because she was not reportedly improving with conservative therapy. The provider also states that the requested device has a truncal appliance to treat truncal edema, and produces light pressures, which are more tolerable for users. The patients medical records, however, have consistently reported good results with conservative therapy as all documented physician examinations in the records documented no edema on examination. Therefore, the requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that review of the literature including the American Psychiatric Association Practice Guidelines indicates that residential treatment level of care is medically necessary and indicated for patients who are less than 85% of their ideal body weight. After her RTC admission, the patient was continuing to gain weight. While there is no indication of acute physiological compromise, the patient was not appropriate for discharge on the said date as this would have put her at significant risk and would have been inconsistent with current practice standards. The patient is showing significant progress in treatment and it is reasonable to expect that with continued residential treatment, she will continue to gain weight. Thus, continued residential services were and are medically necessary from the date in question onward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested residential substance abuse treatment for treatment of his substance abuse.  Findings:  The physician reviewer found that the records reviewed indicate the patient demonstrated a lack of motivation for recovery despite the fact that he had been in the residential treatment substance abuse program for two weeks. He relapsed immediately after discharge despite an identified treatment plan. The patients pervasive substance use indicates a lack of motivation to engage in treatment which is a necessary requirement for substance abuse treatment at a residential level of care. Further, American Psychiatry Association and American Society of Addiction Medicine guidelines indicate that patients should be managed in the least intensive setting that is likely to be safe and effective. Given this patients lack of motivation for recovery, continued treatment at a residential level of care was not likely to be more effective than a sober living situation with adjunctive partial hospitalization or intensive outpatient services. All told, the submitted documentation does not establish the medical necessity for residential substance abuse treatment services provided from the dates in question and does not establish the medical indication for completion of a 30-day residential substance abuse rehabilitation program
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested detoxification, substance abuse subacute/residential treatment center (RTC) services for treatment of his substance use disorder.  Findings:  The physician reviewer found that the records do not indicate that that this patient was previously enrolled in structured treatment or a lesser level of care for his alcohol dependence prior to his admission on the date in question. The providers notes suggest that the patient was stable and not experiencing any significant symptoms of withdrawal almost 2 weeks later when he was admitted to the treatment facility. The patients medications administered for depression were not altered during treatment and he was treated with a standard recovery based 12-step oriented 28-day treatment model. In general, patients with this degree of severity are usually safely and effectively managed at a partial hospital program (PHP) level of care. This patient could have received sufficient medical and nursing care for his depression and medications, and could be monitored for any post-acute withdrawal issues. For these reasons, the residential level of care services provided this patient on the dates in question have not been established as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a total disc arthroplasty and application of cranial tongs (22856) for treatment of his intractable left C5 radiculopathy attributable to new left paracentral C4-C5 disc herniation.  Findings:  Three physician reviewers found that In an assessment of the safety and efficacy of cervical disc arthroplasty, Matz and colleagues performed a systematic review of the literature. The authors examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF).  Matz and colleagues reported that the studies by Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric and colleagues (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or ACDF. These individual reports were subgroups of patients included in a larger randomized controlled trial. In these studies, both the arthroplasty and ACDF groups showed clinical improvement without significant differences between groups at 24-months postoperatively on NDI and SF-36.  However, the authors noted that these studies were graded Class II because it was not evident how randomization occurred and whether the assessments were done by blinded observers.Given the lack of Class I evidence, it cannot be concluded at this time that cervical arthroplasty is more effective than ACDF with plating for control of neck and arm pain. Also, longer term outcome studies are needed to assess whether motion is actually preserved following arthroplasty. As such, the superior efficacy of the requested procedure has not been established at this time. With regard to this particular patient, he has had previous surgery at C5-C6, and the requested procedure is contraindicated for patients with symptomatic cervical disc disease at more than one level. All told, the requested total disc arthroplasty and application of cranial tongs (22856) is not likely to be more efficacious than alternative treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested the WalkAide system (Code E0770) for treatment of her right-sided lower extremity hemiplegia due to incomplete spinal cord injury.  Findings:  Two physician reviewers found that the peer reviewed medical literature reveals a number of publications with preliminary results supportive of the WalkAide device as promising for patients with foot drop resulting from upper motor neuron disorders. Despite these initial outcomes, the studies are small and not blinded, and require longer follow-up. Wieler and colleagues reported that the results are encouraging in terms of decreased energy expenditure and increased walking speed, but further study is needed to determine the role, if any, of the WalkAide in this patient subset. Further, the benefit of the use of a WalkAide over an AFO in a patient with an incomplete SCI has not been established. Kim and colleagues compared use of an FES against an AFO and found the FES to only be superior in increasing foot-clearance value but not in walking speed or endurance. Per this patients documentation, she presents with right leg weakness including a right foot drop due to an incomplete SCI and uses a right AFO. The records indicate the patient is able to walk with a single point cane. Overall, there is no specific documentation of any specific problem related to the current right AFO. Since there is insufficient objective documentation the patient is unable to use an AFO, and there is inadequate evidence that a WalkAide is superior to an AFO in patients with an incomplete SCI, the WalkAide has not been demonstrated as likely to be more beneficial than any available standard therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Botox injections (200 units) for treatment of his cervical dystonia and Parkinsons disease.  Findings:  Three physician reviewers found that cervical dystonia, also called spasmodic torticollis, is the most common of the focal dystonias. In torticollis, the muscles in the neck that control the position of the head are affected, causing the head to twist and turn to one side. In addition, the head may be pulled forward or backward. Botox is an acetylcholine release inhibitor and a neuromuscular blocking agent indicated for treatment of cervical dystonia in adult patients. Multiple studies have demonstrated that Botox reduces the severity of abnormal head position and neck pain in this patient population. Further, through careful electromyographic (EMG) assessment of select muscles for injection, Botox therapy will frequently result in improved clinical benefit. This patient has documented evidence of cervical dystonia, which is not a manifestation of his Parkinsons disease. He has failed treatment with oral medications and Botox is FDA approved for the treatment of cervical dystonia. Thus, a trial with Botox is clinically appropriate in this circumstance and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested Apriso 0.375G capsule SR 24H 4 QD for treatment of her ulcerative colitis. Findings:  The physician reviewer found that there is a lack of evidence indicating that the ulcerative colitis is severe, as biopsy findings did not show active disease, except in the distal rectum.  Disease in the distal rectum is not controlled by Apriso. Moreover, there is a lack of data supporting the use of Apriso in cases of flares on mesalamine.  All told, the medical documentation demonstrates that the only segment with active inflammation is the distal rectum, and Apriso has not been shown to control flares in the distal rectum where mesalamine has failed. Apriso is medically indicated in cases involving maintaining response to mesalamine, and not in treating mesalamine failures.  Thus, the requested Apriso 0.375G capsule SR 24H 4QD is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested an electric scooter/wheelchair for treatment of his herniated lumbar disc with foot drop.  Findings:  The physician reviewer found that the records reviewed do not substantiate the presence of impairments that would preclude this patient from accomplishing his MRADLs within the home with the use of a right ankle foot orthosis and cane or walker, or with a manual wheelchair. The patient is not documented to have any significant neurological or musculoskeletal impairment or pathology affecting the upper limbs. In addition, he does not have any evidence of cardiovascular or pulmonary condition that is severe enough to preclude the use of a cane, walker or manual wheelchair. On the contrary, the patient has multiple chronic medical conditions that would benefit from increased physical activity. Consistent with the recommendations published by Keyser and colleagues, his limb pain and lack of strength or endurance should be treated with appropriate exercise and training, not with disuse. Overall, a power mobility device is not medically necessary for this patient applying the Medicare guidelines as reported by Dicianno and Tovey. In the absence of the requested equipment this patient would not be confined to a bed or chair. This determination is further supported by the occupational therapy evaluation on the date in question, which concluded that the patient did not qualify for powered mobility because he could safely ambulate with a cane or walker.