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

A 23-year-old male enrollee has requested transcranial magnetic stimulation for the treatment of his depression. Findings:  The physician reviewer found that the treatment of depression with transcranial magnetic stimulation is relatively recent. It falls into a form of psychiatric therapy called somatic treatment. For several years, the psychiatric literature has reported the development of this procedure. In October 2008, the US Food and Drug Administration determined that it is indicated for the treatment of major depressive disorder in adult patients who have failed to improve following use of one prior antidepressant medication at or above the minimal effective dose and duration. Since this patient has not responded satisfactorily to both Remeron and Prozac, he seems to meet these specific requirements. The records show that the patient has been tried on at least two different classes, since Remeron and Prozac are in different classes. Moreover, the stimulants the patient used constitute adjunctive treatment. Additionally, having two comorbid diagnoses does not necessarily preclude proper treatment of the patients depression by transcranial magnetic stimulation, or by any other approved treatment of depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested sacroiliac joint injections for the treatment of her low back pain. Findings:  Two physician reviewers found that this patient was diagnosed with sacroiliac joint dysfunction based on examination. There are multiple journal articles that have been written to substantiate sacroiliac joint injections and sacroiliac joint arthrography. There is substantial scientific evidence to support the utility of the procedure. However, in this patients case, there was not sufficient basis to proceed with a sacroiliac joint injection for a presumptive diagnosis of sacroiliac joint dysfunction. The patient had acute onset of pain just a few days prior, without associated trauma. She was noted to be tender in the lumbar region and to have lost considerable weight. Based on the history of acute pain onset and tenderness in the lumbar region on examination, pain origination from the lumbar spine and not the sacroiliac joint was quite possible. Moreover, the patient did not have an adequate trial of more conservative treatments for possible sacroiliac joint dysfunction prior to the injection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested sacroiliac joint injection for the treatment of his sacroiliac joint dysfunction. Findings:  Three physician reviewers found that the sacroiliac (SI) joint injection was not likely to have been more beneficial than standard therapy for treatment of this patients condition. Physical therapy, manual therapy and non-steroidal anti-inflammatory drugs (NSAIDs) have not been demonstrated to have been trialed or were not used for an adequate length of time. The patient was only given one week of treatment for the pain before receiving the SI joint injection. The Passor Guidelines state that SI joint injection is indicated for patients with arthritis pain who fail to respond to conservative treatments and have had the pain for at least four weeks. Also, Staal and colleagues indicate that there is not strong evidence for any type of injection therapy for patients with subacute or chronic low back pain. Rupert and colleagues reviewed studies of SI joint injections and concluded that there is only level II-2 evidence for diagnostic SI joint injections and therefore the therapy remains of uncertain efficacy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested selective internal radiation therapy (SIRT) for the treatment of her neuroendocrine cancer with liver metastases. Findings:  Three physician reviewers found that this patient presented with neuroendocrine tumor metastatic to the liver. There is no effective chemotherapy for metastatic disease to the liver. This patient is not a surgical candidate for surgical resection of tumor in the liver. There is adequate literature support for SIRT for liver metastasis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested reimbursement for PLIF at L5-S1 with microdiscectomy at L3-4 for the treatment of her spondylolisthesis and stenosis at L5-S1 and herniated disc at L3-4 on the left side. Findings:  The physician reviewer found that the definitive procedure in this setting is the anterior-posterior fusion which was offered by the Health Plan. The anterior-posterior fusion offers better success than the PLIF procedure. The anterior-posterior fusion does involve two separate incisions and is a larger and more morbid procedure. However, it does provide a greater probability of solid bony arthrodesis and therefore was more appropriate for this patient. As such, PLIF at L5-S1 with microdiscectomy at L3-4 was not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for the treatment of the enrollees myasthenia gravis. Findings:  The physician reviewer found that the documentation from the patients mother indicates the patient is currently stable and they are not requesting coverage of IVIG at this time. The request for IVIG is for a preauthorization for use if the patient develops myasthenic crisis. The use of IVIG acutely is standard therapy for myasthenic crisis with proven results. As the study by Chiang and colleagues indicates, juvenile MG is different from adult MG and IVIG is often the only therapeutic intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for the treatment of her breast cancer. Findings:  Two physician reviewers found that the scientific literature does not demonstrate that IMRT confers additional benefits over standard radiation therapy for patients with breast cancer. For radiation to the right-sided chest wall, heart dose would be minimal, regardless of technique. This is the case following comparison of dose volume histograms to both plans. The planning target volume appears similar as well. Lung dose reveals a slight improvement utilizing IMRT. However, in reviewing the cross-sectional isodose distribution, this could be attributed to the placement of the medial field edge. In the IMRT plan, the medial field edge is lateral to the sternum, allowing for shallower lung field. In the 3-D plan, the medial edge is more medial, allowing for more lung dose. A similar lung dose with the two plans could be achieved with a slight modification of the medial edge of the 3-D plan in moving this a few millimeters more lateral. Based upon the submitted documentation, there is no evidence that conventional 3-D conformal radiation would lead to unnecessary radiation exposure in this case. Thus, the submitted documentation does not support the superiority of IMRT over 3-D conformal radiation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested growth hormone treatment (Nutropin) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the purported growth failure is not apparent from the submitted growth chart. The patients growth remains well within the normal range. In addition, the patient had normal GH dependent insulin-like growth factor (IGF-1) and IGFBP-3 levels and a normal brain magnetic resonance imaging (MRI) scan. He had two GH stimulation tests which showed peak GH levels near the cut-off values of 10 ng/ml. Given these findings, there is insufficient evidence the patient is experiencing GH deficiency. Accordingly, GH therapy is not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested emergency services for the treatment of her rash. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson would have sought immediate medical attention for the rash. The patient used hair dye that day and subsequently developed a rash. While the patient was uncomfortable, there is nothing in the medical record that indicates that her health was in any jeopardy or that would have caused a reasonable person to believe that their health was in jeopardy if they did not seek immediate medical attention. The patient had normal vital signs and she had no difficulty breathing. She could have safely waited until the next day to be treated. Her complaint does not meet the prudent laypersons definition of an emergency condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested an increase in Levitra to 12 tablets per month for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that this patient had difficulty with erections prior to surgery for prostate cancer (venous leak). This is generally nonresponsive to vasoactive medications. The patients request for 12 tablets of Levitra per month is not medically indicated. The standard of six tablets of Levitra per month would be adequate coverage for a patient with organic impotency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 15-year-old male enrollee has requested an additional four hours of psychological testing for an evaluation of the enrollee to rule out Aspergers disorder. Findings:  The physician reviewer found that psychological testing is appropriate in this setting and should include assessment of cognitive ability, verbal and non-verbal IQ and adaptive skills (American Academy of Child and Adolescent Psychiatry Practice Parameters). The article by Troth and King indicates that a comprehensive assessment is needed for Aspergers syndrome and should include a detailed developmental history, direct observation, evaluation tools specific for autism diagnosis, a review of school records and a consultation with the patients teachers (particularly around peer interaction). Assessment of intellectual, language, adaptive and neuropsychological functioning may be part of a comprehensive assessment. Autism spectrum disorders are complex and require a comprehensive evaluation. This can include neurologic and genetic assessment with in-depth cognitive and language assessment. Verbal and non-verbal strengths and weaknesses and assessment of independent living skills are important areas to assess. An additional four hours of psychological testing to evaluate the patients medical condition is medically necessary and consistent with standards of practice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a user adjustable heel height component for her prosthesis for the treatment of the enrollee, who is status post amputation. Findings:  The physician reviewer found that the patient has low back pain. However, the diagnosis of scoliosis and its severity has not been established in the documentation provided. If the patient does have scoliosis, a user adjustable heel height component should not be used, as changing the length of the lower extremity will increase pain. Thus, the user adjustable heel height component was not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested emergency services provided for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The patient states that he was experiencing a fever of 103 F. Despite this, his symptoms had been of gradual onset over the past three days. He was described as being in no distress and was not experiencing any chest pain or shortness of breath or other life-threatening symptoms. Although he was treated for influenza, his rapid influenza test was actually negative. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested blue light photodynamic therapy for the treatment of her rosacea. Findings:  The physician reviewer found that the patient is requesting coverage for blue light photodynamic therapy for treatment of her permanent telangectasias associated with chronic rosacea. This patients medical management of rosacea has not been optimized.  There is no indication from the medical records that the patient has been treated with low dose oral antibiotics including doxycycline, which is a standard approach to reduce inflammation in patients with this condition according to Modi and colleagues. In addition, Korting and Schollmann suggest topical treatments including sodium sulfacetamide-containing washes or creams, and topical azaleic acid creams that can reduce inflammation. There is no objective documentation of recent trial and failure of these therapies in the records provided for review. The use of blue light photodynamic therapy is not supported in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested Rituxan for the treatment of his chronic inflammatory demyelinating polyneuropathy. Findings:  Three physician reviewers found that although Rituxan is not first-line therapy for CIDP, there is literature that supports its use in this population. In this particular case, the patient has failed multiple prior standard first-line therapies and some second and third-line therapies. The patients neurologist is rightly concerned about the patients disease progression and the long-term effects of IV steroid use. Given this clinical history, it is medically reasonable to treat this patient with Rituxan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested peripheral nerve stimulation via neurostimulator facial implants for the treatment of her atypical trigeminal neuralgia. Findings:  The physician reviewer found that the medical literature yielded limited information regarding the use of peripheral nerve stimulation. However, there is evidence of a paper published by Slavin and colleagues in their 2006 publication which presents an algorithm for surgical management of face pain. The authors suggested, If the patient is diagnosed with trigeminal neuropathic (not neuralgia), and maintains some degree of sensation in the area of the pain, and the pain is localized to distribution of the supraorbital or infraorbital nerves, the treatment of choice is trigeminal branch stimulation with peripheral nerve stimulation technique. This patient appears to meet the aforementioned criteria for peripheral nerve stimulation. As such, she is an appropriate candidate for the proposed procedure. Given the severity of her condition and the lack of effective treatment modalities, peripheral nerve stimulation via neurostimulator facial implants is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested adult psychiatric residential treatment services for the treatment of her major depressive disorder and anorexia nervosa. Findings:  The physician reviewer found that this patients history of intense abandonment issues, her past suicidal attempts including a gesture while in residential treatment, her history of psychotic decompensation and past acute hospitalizations, there was a need to maintain the level of care provided to avoid further decompensation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children and may lead to difficulties establishing relationships, navigating the educational system and ultimately navigating the work force. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in children with autism spectrum disorder. The deficits identified and goals established for this patient are based upon conventional occupational therapy principles. Incorporation of sensory integration techniques to augment other occupational therapy techniques does not represent a deviation from standard practice. Occupational therapy is an integral part of treating children on the autistic spectrum with deficits in fine motor skills, balance and sensory integration, and it is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the medical records indicate a diagnosis of autism with gross motor and fine motor deficits, along with sensory motor deficits. The American Academy of Child and Adolescent Psychiatry notes that autism requires the care of multiple providers and various treatment modalities. The article by Myers and colleagues notes that occupational therapists play a role in the treatment of autism and can help promote self-help skills in addition to addressing fine motor and gross motor deficits. Occupational therapy utilizing sensory integration is often indicated in the treatment of youth with autism spectrum disorder and is a widely accepted intervention supported by practice guidelines and the literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a bariatric surgery consultation for the treatment of her medical condition status post gastric bypass surgery. Findings:  The physician reviewer found that this patient has a medical condition that is correctable with the appropriate surgical procedure. While details about the initial procedure are not known, the patient has obviously experienced a poor outcome with weight regain, which is a complication of the gastric bypass procedure. Further, the patient reports that she has dumping syndrome. This is also a complication of the initial gastric bypass operation that requires surgical treatment. A bariatric surgery consultation is medically appropriate and indicated to evaluate the patient and educate her on the available surgical options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Sirtex radio embolization for the treatment of her cholangiocarcinoma. Findings:  Two physician reviewers found that although the medical literature is sparse on this topic and current NCCN Guidelines are somewhat limited in their recommendation, cholangiocarcinomas are relatively rare tumors and are not well studied. In this particular case, SIRT has been recommended by the patients multidisciplinary team as the best approach. I concur with this assessment as there is no evidence that any alternative standard therapy will be superior in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested selective internal radiation therapy (SIRT) for the treatment of her colon cancer. Findings:  Three physician reviewers found that the current National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer include criteria for resectability of metastasis and local regional therapies. These guidelines indicate that ablative techniques (such as SIRT) may be considered alone or in conjunction with resection. In addition, the medical literature shows a significant response of hepatic metastases to SIRT treatment. The use of SIRT in this case is medically reasonable and is consistent with national guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a PET scan and/or a lung biopsy for an evaluation of her lung nodules. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient had a CT scan of the chest. The only pulmonary indications for a PET scan are a solitary pulmonary mass for evaluation of lung cancer or restaging of a patient with known cancer after treatment. This patient has a 5 mm nodule that is unchanged and multiple bilateral pulmonary nodules with no documentation of change. There are no indications present that demonstrate the medical necessity of a PET scan or a lung biopsy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that during her stay, several psychotropic medication adjustments were required. The overall medical documentation supports the level of care provided. The patient remained at risk for self harm, she was also highly anxious with nightmares and insomnia. The services provided are consistent with the recommendations of the American Psychiatric Association (APA), the level of care guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP) and the Association of Community Psychiatrists.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the left eye, upper eyelid, soft tissue area, and tear duct for an evaluation of her left eyelid condition. Findings:  The physician reviewer found that the submitted clinical evidence does not establish the medical necessity of the disputed MRI. There was no indication by history or examination that suggested soft tissue pathology in or around the orbits. The patients symptoms were vague, but more consistent with an external ocular issue. It is not likely that the foreign object could penetrate tissue and move around to different areas. It would have been possible for the object, if it was still present, to become embedded and have a granulomatous reaction around it, but that would have been seen on examination. In addition, a computed tomography (CT) scan had already been performed which did not suggest any pathology in or around the area of concern. An MRI of the deep tissues around the orbit was not likely to be clinically useful in this setting, and as such, was not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested chemotherapy regimen Alimta and gemcitabine for the treatment of her stage IV colon cancer. Findings:  Three physician reviewers found that the use of Alimta and gemcitabine in metastatic colorectal carcinoma has not yet been studied and found to be effective or safe for this condition. This combination is not FDA approved, compendium listed or recommended by expert consensus panel opinion due to the lack of peer-reviewed published reports from clinical trials. At this time, there is inadequate data to conclude that the proposed therapy has any efficacy in the treatment of metastatic colorectal cancer.