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

The parent of a 14-year-old male enrollee has requested past and future coverage for oral irinotecan hydrochloride (Camptosar).  Findings:  Two physician reviewers found that  adrenocortical carcinoma is a rare and difficult cancer to treat. The ideal therapy is complete surgical resection as noted in the National Comprehensive Cancer Network (NCCN) treatment guidelines. The main approach to the tumor has been surgical but at some point the tumor was inoperable and the oncologists tried cisplatin, mitotane, etoposide, IMC-A112, but the tumor progressed. He was then tried on oral irinotecan (Camptosar) based on testing for in vitro chemotherapy sensitivity. When chemotherapy is needed the recommended initial treatment includes combination therapy that includes mitotane. This patient was treated with this chemotherapy without substantial response. The NCCN guidelines also recommend evaluation for possible radiation therapy. This patients records do not describe if radiation was discussed but suggests that the patients tumor is in locations that would not tolerate higher doses of radiation. The NCCN does not offer guidance on further chemotherapy, and due to the rarity of the disease, studies have to be performed as large international trials. This patients treating oncologists are currently using a dose and dosing schedule based on previous experience in a number of diseases including Ewings sarcoma. Irinotecan has reportedly been used in a Phase II trial published in 2010 with an alternative dosing schedule with good results for stabilizing recurrent disease. Consistent with the findings reported in the Phase II clinical trial, the novel use of more frequent dosing of the irinotecan that provided stability of disease in many of the patients studied is adequate support for the use of Camptosar in this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for magnetic resonance spectrography (MRS).  The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee, who is status post gross tumor resection for a right sphenoid wing meningioma.  Findings:  Two physician reviewers found that the patient has a known right frontal lobe grade 2 oligodendroglioma.  The patient is  status post gross tumor resection for a right sphenoid wing meningioma, followed by re-resection for meningioma recurrence. He is status post external beam radiation therapy. Recently, the patient was noted to have an MRI suspicious for disease progression versus post-radiation effects.  The patient has requested authorization and coverage for a magnetic resonance spectrography (MRS).  This is a patient with a known prior oligodendroglioma who now has MRI changes of unknown significance.  Possibilities include a recurrence of his cancer versus radiation necrosis versus a non-neoplastic etiology.  There is adequate literature demonstrating the use of MRS for cases such as this.  MRS is a useful tool in differentiating cancer versus non-cancer.  Thus, it will substantially help guide management for this patient and potentially prevent unnecessary radiation or surgery.  In sum, the requested MRS is likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested authorization and coverage for brachytherapy.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with ductal carcinoma in situ of the breast.  Findings:  The physician reviewer found that as noted in a radiation oncology note, partial breast irradiation is typically reserved for patients with smaller lesions.  On this date, the provider noted that the patient would be a candidate for whole breast irradiation and external beam radiation therapy. The patient has declined this treatment and has elected to undergo brachytherapy. Partial breast irradiation is administered in several forms in an abbreviated treatment time.  Interstitial multi-catheter has been proposed in this case, and this is a method of partial breast irradiation.  This form of radiation is typically placed at the time of breast surgery, or shortly thereafter, and has resulted in positive data over the past five years in selected cases.  However, there is a lack of randomized comparison data to show that partial breast irradiation can reduce the risk of local recurrence as effectively as the current standard, whole breast irradiation.  The current medical evidence does not support the requested brachytherapy in this patients case.  This was a second ductal carcinoma in situ in the left breast. There is a substantial time interval from the initial diagnosis and biopsy to the lumpectomy, as well as a substantial time interval from the lumpectomy to present. The typical treatment in this clinical situation is mastectomy.  Additionally, the tumor size is greater than 6 cm, which is more than double the size typically reserved for partial breast irradiation.  All told, the requested brachytherapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested MitraClip for treatment of her mitral valve prolapse.  Findings:  Two physician reviewers found that this patient has clear indications for repair of her mitral valve deformity (Bonow, et al). She has increasingly severe symptoms of congestive heart failure (CHF) and pulmonary congestion given her diuretic therapy, orthopnea, recent onset atrial fibrillation, low normal EF, severe mitral insufficiency on ECHO and catheterization, low forward cardiac output, and thoracocentesis for recurrent pleural effusions secondary to pulmonary congestion. Moreover, due to her low blood pressure and orthostatic symptoms her providers have been unable to add significant vasodilator therapy to her medical regimen, making even medical treatment of the symptoms sub-optimal. Therefore, she meets the American College of Cardiology (ACC) Class I indications for mitral repair. In the absence of definitive repair, she will develop progressive CHF, congestive symptoms, left ventricular dilatation, and increasing cardiac rhythm disturbances based on the known natural history of this disease at this stage. For these reasons, the requested MitraClip procedure is likely to be more beneficial than standard therapies for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested for substance abuse sub-acute residential treatment services for treatment of the enrollees drug dependence.  Findings:  The physician reviewer found that he has not had recent intensive outpatient or partial hospitalization program treatment. There is no indication of behavioral issues requiring 24-hour containment, and his parents have been supportive of recovery. There is no evidence in the record that he is not currently motivated for treatment. Furthermore, the record fails to establish that the patient received treatment of sufficient intensity as to warrant residential treatment, as there is no documentation supporting the patient as having received active treatment, detailing implementation of the treatment plan, or describing his response or lack thereof.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested coverage for lumbar spinal fusion surgery. The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees spondylolisthesis at L4-5 and degenerative disc disease.   Findings:  The physician reviewer found that in the medical literature and Milliman Care Guidelines, the clinical indications for spinal fusion include moderate to severe lumbar spinal stenosis associated with lumbar spondylolisthesis or with evidence of spinal instability, either pre-existing or anticipated due to the need for bilateral decompression or wide decompression involving facetectomy or resection of the pars interarticularis. In addition, spondylolisthesis with progressive deformity or neurologic compromise with persistent and significant symptoms despite an adequate trial of non-operative care may also require fusion. In this case, the patient has spondylolisthesis stenosis with evidence of instability. Therefore, the requested fusion and instrumentation is indicated by both pre-existing and probable iatrogenic instability. With supporting medical evidence for the role of fusion in this patients medical condition, the requested surgery has been demonstrated to be medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested authorization and coverage for MILD (minimally invasive lumbar decompression).  The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees clinically symptomatic lumbar spinal stenosis.  Findings:  Three physician reviewers found that the patient has clinically symptomatic lumbar spinal stenosis.  The submitted documentation noted that the patient has low back pain. He has not obtained relief with pharmaceutical management, conservative treatments, and physical therapy.  The patient has requested authorization and coverage for MILD (minimally invasive lumbar decompression).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  The concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based.  At this time, there is a lack of evidence supporting minimally invasive lumbar decompression in this clinical situation.  The current medical evidence has not demonstrated the superior efficacy of the requested procedure.  All told, the requested procedure is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for exploratory laparotomy with possible hernia repair with preperitoneal mesh and computed tomography (CT) of the abdomen and pelvis for treatment of her inguinal hernia.  Findings:  The physician reviewer found that hernias can be subtle, particularly Spigelian and Trocar site hernias, and often are not appreciated on physical examination or cross-sectional imaging. This has resulted in differing opinions as to whether this patient in fact has a hernia. There is no confirmation of a hernia on imaging with computed tomography (CT) or magnetic resonance imaging (MRI), but the providers evaluation and review reported the presence of a hernia. In addition, if a hernia is found it should be repaired. Since additional imaging with CT is inadequate to diagnose and treat this patients condition, the requested surgery without the additional imaging has been shown to be medically necessary in this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested genetic testing for arrhythmogenic right ventricular dysplasia for evaluation of his history of dilation of the right ventricular, fibrofatty tissue infiltration and arrhythmias.  Findings:  Three physician reviewers found that arrhythmogenic right ventricular dysplasia is an inherited cardiomyopathy involving the ventricular myocardium with fibrofatty replacement, leading ultimately to right ventricular dysfunction.  There is propensity for malignant ventricular arrhythmias with sudden cardiac death.   In 50% of arrhythmogenic right ventricular dysplasia cases, the disease is transmitted in an autosomal dominant fashion.  Genetic testing for this condition has about a 50% detection rate for the known mutations which have been associated with this disorder.  In addition to confirming the diagnosis of arrhythmogenic right ventricular dysplasia in patients with suspected disease, genetic testing allows for early identification and diagnosis of individuals at greatest risk for developing arrhythmogenic right ventricular dysplasia, prior to the expression of typical clinical manifestations.  If a pathogenic variant is identified in a preclinical individual, regular follow-up is indicated.  Fressart and colleagues concluded that genetic testing was strongly supported as a clinical tool in this clinical situation and also suggested its use had prognostic impact.   Overall, per the current medical literature, the requested genetic testing for arrhythmogenic right ventricular dysplasia is likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for individual psychotherapy treatments for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the APA states that, Cognitive-behavioral therapy is a time-limited treatment (generally 10-15 weekly sessions) with durable effects. Further, Cognitive-behavioral therapy for panic disorder generally include psycho-education, self-monitoring, countering anxious beliefs, exposure to fear cues, modification of anxiety-maintaining behaviors, and relapse prevention. All told, individual psychotherapy is likely inadequate to assist this patient through the difficult issues of anxiety disorders including anxiety, panic, phobia and sleepwalking. For these reasons, the patient appears to be appropriate for a partial hospitalization program (PHP) and the medical necessity of the requested outpatient psychotherapy has not been established in her care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure. Panniculectomy involves removal of the lower abdominal skin via periumbilical and lower abdominal incisions.  This procedure is medically necessary if the removed skin has a history of recurrent infections or if the skin is necrotic. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  This patient had documented intertrigo of the pannus in 2011 despite chronic antibiotic therapy. She also has a pannus that hangs below the pubic symphysis. The current medical evidence supports the medical necessity of the requested procedure in this clinical scenario. All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested for brachial plexus surgery for treatment of her left brachial plexopathy and neuropathic pain.  Findings:  The physician reviewer found that adult brachial plexus reconstruction remains a dilemma to the reconstructive microsurgeon, especially when attempting to reconstruct cases of total root avulsion. A significant improvement in results has been achieved by a better understanding of various methods of reconstruction and prolonged postoperative rehabilitation. In the medical literature, Chuang concluded that brachial plexus surgery, consisting of primary nerve and late palliative reconstruction, is now a worthy surgical pursuit that makes a useless limb useful. For these reasons, the medical necessity of the requested surgery has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested authorization and coverage for Protopic 0.1% ointment.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis.  Findings:  The physician reviewer found that the patient has a history of severe atopic dermatitis.  While the topical calcineurin inhibitors are successful in treatment of atopic dermatitis with minimal side effects, the higher strength form of Protopic (0.1%) has not been FDA approved for 12-year-old patients.  The information provided does not indicate that the approved lower strength form (Protopic 0.03% ointment) would be ineffective for this patient.  While it has been tried in the past, the documentation does not demonstrate that prescriptions have been written for Protopic in the six-year interim between 2005 and 2011.   The submitted medical records do not demonstrate that Protopic 0.03% would be ineffective at this time, given that the severity of atopic dermatitis can change considerably with age.   The medical records do not show that intermittent topical steroid use has been ineffective recently.  In this patients case, the medical documentation provided does not demonstrate the medical necessity of the requested Protopic 0.1% ointment.  All told, the requested Protopic 0.1% ointment is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested positron emission tomography/computed tomography (PET/CT) scan for evaluation of her anal squamous cell carcinoma.  Findings:  Three physician reviewers found that this patient has a history of anal cancer with known recurrent carcinoma.  There is ample support in the peer-reviewed literature for the use of PET/CT scan in the evaluation of possible recurrent or metastatic anal cancer.  As noted by Grigsby, the requested diagnostic procedure is an imaging modality which greatly affects the management of patients with anal cancer.  Conventional imaging such as MRI and CT cannot provide the metabolic information of a PET scan.  Conventional studies may show normal-sized lymph nodes.  However, on a PET scan, the lymph node  may show increased uptake indicating recurrent/metastatic disease.  The outcome of the requested PET/CT scan in this patients case will have a direct impact on the treatment plan.  In sum, the requested PET/CT scan is likely to be more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient level of care provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on review of the available records, the acute inpatient services were medically necessary from the dates at issue. This patient already had two prior inpatient psychiatric admissions within the previous six months of this admission. The providers notes indicate the patients diagnosis was questioned and his previous treatment with Risperdal, Depakote and lithium was changed. The provider also noted that the patients behavior was cooperative on the unit which was a sharp contrast to the description of his aggressive and uncontrollable behavior at home. The treatment course was to discontinue all of the patients current medications and start him on a different course with Concerta to address any untreated symptoms associated with ADHD. Thus, the inpatient treatment for the dates at issue was clinically indicated as abruptly discontinuing the patient from his current regimen could have precipitated a significant reaction in terms of acute deterioration in function as well as withdrawal symptoms. Further, the difference in the patients behavior on the unit versus at home required observation outside the home to separate the psychiatric component of the patients illness from his contributing family situation. The providers needed skilled observers to record the patients behaviors on the unit to compare them with the described behaviors at home. For these reasons, the acute inpatient services provided for the dates at issue were medically necessary for management of the patients medical condition. As the patients records end at discharge, there is inadequate documentation available to support the medical necessity of acute inpatient services beyond the discharge date.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, five-month-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of approximately 68% and a delay in receptive speech of 28%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.