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

A 49-year-old male enrollee has requested rehabilitation at a skilled nursing facility for the treatment of his medical condition. Findings:  The physician reviewer found that the medical literature indicates that recovery after stroke occurs fastest in the first three months. Later recovery (up to one to two years after stroke) is also possible, especially between three to six months. Therefore, continued rehabilitation is generally appropriate for a patient who has had a recent stroke (within the last three months). While this patients condition was somewhat limited by his medical problems, he demonstrated some improvement during his stay in the skilled nursing facility and was continuing to progress.  In light of his capacity for further improvement, his continued stay during the time period in question was medically appropriate and indicated. Further, it is reasonable to provide the patient with additional skilled nursing facility services at this time. While the patients progress has been slow, there continues to be potential for improvement. Moreover, a skilled nursing setting will allow the patients medical problems to be addressed thus maximizing the amount of therapy that he can tolerate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested high intensity focused ultrasound (HIFU) for the treatment of his prostate cancer. Findings:  Three physician reviewers found that the standard treatment alternatives for prostate cancer vary according to stage, grade and age of the patient. Also relevant are any co-morbid conditions present at the time of diagnosis. The accepted and proven therapies for localized prostate cancer are radical prostatectomy and radiation therapy. HIFU is a more recent development with some positive reported attributes in short-term studies. However, the lack of randomized trials with sufficient long-term (greater than two years) follow-up prevents HIFU from being proven to have equal or superior outcomes when compared to the existing standard treatments of surgery or radiation therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested the medications Abraxane and Avastin for the treatment of her metastatic melanoma. Findings:  Two physician reviewers found that there are few therapies available for patients with metastatic melanoma and no treatment has been found to be curative. In this clinical setting, it is appropriate to devise a reasonable treatment plan based upon the available medical data and experience. There is increasing published data on the use of carboplatin and paclitaxel in the treatment of metastatic melanoma. These agents have been found to be well-tolerated with good clinical activity. Extrapolating from this experience, clinicians have substituted Abraxane for paclitaxel. This albumin bound form of the native paclitaxel has been found to be both more tolerable and effective than the native compound in Cremophor. There has been promising phase II data regarding the use of this agent in metastatic melanoma. Avastin is a drug of interest in many tumor types. It is of great interest in melanoma, due to the highly vascular nature of these tumors. Phase II data evaluating Avastin in combination with carboplatin and paclitaxel, as well as with Abraxane are available. These studies have shown promising activity with acceptable toxicity. This particular patient had an excellent clinical response to this combination therapy, demonstrating the value of this regimen in this case. In summary, there is no standard therapy for this patient. Current research is focused on the agents at issue. The phase II data for these agents is good in a very difficult to treat disease (Perez and colleagues and Hersh and colleagues). In addition, this patient experienced a good response to this chemotherapy regimen to date.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for lipoprotein diagnostic testing for evaluation of her risk for cardiovascular disease.   Findings:  Three physician reviewers found that there is no documentation of coronary artery disease or mention of other cardiac risk factors in the records. As discussed by Brunzell, the American Diabetes Association and the American College of Cardiology Foundation guidelines for the diagnosis and management of dyslipidemia and cardiovascular risk currently to not recommend routine performance of specialized lipid-associated tests. The author notes that modifications to treatment based on the results of routine screening with specialized lipid tests has not been shown to improve outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. The only circumstance where specialized lipid testing may be considered appropriate is in selected cases of secondary prevention where standard risk factors are not present to a sufficient degree to explain cardiovascular event occurrence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested the medication Levaquin (500 mg daily) for the treatment of his pulmonary infections. Findings:  The physician reviewer found that continuous daily antibiotic treatment with Levaquin 500 mg is not medically necessary for this patient. The recommended dose for exacerbation of chronic bronchitis is 500 mg daily, but not on a continuous basis. The recommended duration of antibiotic therapy for respiratory infections is 5 to 14 days. Furthermore, there is evidence that longer durations (seven days versus five days) of antibiotic therapy are not more efficacious in treating exacerbations of chronic obstructive pulmonary disease (COPD) (Falagas). All told, there is no convincing peer-reviewed evidence that continuous daily antibiotic therapy reduces the frequency or severity of respiratory infections, prevents exacerbations of COPD or is effective for any other respiratory condition such as restrictive lung disease, interstitial lung disease, or bronchiectasis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested partial hospitalization treatment for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient has had numerous treatment failures in the past. In this patients case, when her treatment programs were prematurely ended, she relapsed quickly. Her condition would have likely deteriorated if she would have been moved to a lower level of care.  She has a long history of bulimia and has had multiple relapses. Her treatments in the past have not resulted in long-term success.  Due to her comorbid substance abuse issues, the literature supports the fact that she is in a difficult-to-treat subset of patients. Partial hospitalization treatment provided during the dates of service at issue was clinically indicated for this patient. During the dates of services at issue, the patient met American Psychiatric Association criteria for partial hospitalization program level of care as she needed further intensive services due to her comorbid conditions and history of treatment failure with rapid relapse/decompensation in the past.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested hydrocodone/acetaminophen for the treatment of his neck and back pain. Findings:  The physician reviewer found that it is possible to achieve pain control for chronic spine pain with long-acting opioids such as Kadian, without the need for breakthrough (short-acting) opioids such as Vicodin/Norco. Devulder and colleagues reported that long-acting opioids have a pharmokinetic profile resulting in more sustained and stable plasma opioid concentration compared to short-acting Vicodin/Norco. It is this pharmokinetic profile of long-acting opioids that improves adherence to the therapeutic schedule and prevents rebound pain. In addition, the use of short-acting opioids for chronic pain increases the risk for opioid tolerance and dependence. The development of opioid tolerance may cause a patient to take more medication than prescribed, in an attempt to treat their pain. This practice, in turn, may lead to opioid dependence. One study reported that prescribing short-acting opioids for chronic recurrent pain may put the patient at risk for both under treatment, and drug tolerance (Hermos). An article by Rauck reviewed 12 chronic pain studies that compared short-acting opioids and long-acting opioids head-to-head. His review found that many patients receiving long-acting opioids showed improved treatment responses and better perception of quality of life over patients receiving short-acting opioids. In addition, the group of patients receiving long-acting opioids had better focus on daily activities, rather than on their pain, thereby improving therapy adherence and reducing pain related activities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for osteochondral allograft of the left ankle with arthroplasty, bone graft, application uniplane and application multiplane for treatment of her left ankle post-traumatic arthritis. Findings:  Two physician reviewers found that remains the standard treatment option for ankle arthritis, there has been interest in other modalities. As noted by Lalonde and Conti, allograft transplantation has been explored.  Although some reports have been encouraging, others have reported a high rate of failure with evidence of radiographic failure and need for revisions. As noted by Berti and colleagues, there is a need for longer follow-up of osteochondral allograft of the ankle in patients with post-traumatic ankle arthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested for treatment by a podiatrist every four (4) weeks treatment of his foot condition. Findings:  The physician reviewer found that the documentation provided does not demonstrate the presence of a complex condition that requires monthly follow-up. The services rendered to this patient are primarily focused on basic care of his lesion. There are multiple treatment alternatives available for this condition including topical agents, which the patients provider has apparently initiated. The patients response to treatment can be appropriately monitored at eight week intervals. There is no evidence the patients condition has deteriorated during the period he has received podiatry visits at eight-week intervals. All told, the submitted documentation does not establish the need for consultation with a podiatrist more frequently than at eight week intervals.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested the medication Tracleer for the treatment of her pulmonary arterial hypertension. Findings:  The physician reviewer found that this patient does not meet the standard indications for treatment with Tracleer. Specifically, there is no convincing evidence that she has Class III or Class IV symptoms. There has been no further investigation (such as cardiac catheterization) to confirm the presence or degree of her elevated systolic pressures. While the patient has been diagnosed with lupus, the submitted medical records do not document a level of disability that would preclude a simple right heart catheterization. Furthermore, the patients left atrium was slightly enlarged on echocardiogram and left ventricular hypertrophy (LVH) was also present. This left-sided pathology remains unquantified and could conceivably relate to her mild pulmonary hypertension. All told, there is insufficient evidence that the patient meets clinical indications for treatment with Tracleer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Nexium 40 mg twice per day for the treatment of her medical condition. Findings:  The physician reviewer found that proton pump inhibitors (PPIs) are the main stay and backbone of therapy for the management of patients with gastroesophageal reflux disease (GERD) and Barretts esophagus. Reducing the acidity of gastric juice ameliorates reflux symptoms and allows esophagitis to heal. Most patients require a once a day dose of a PPI such as Nexium, Protonix, or Prevacid, etc. However, in a small group of patients a twice a day regimen is required. Clinical trials are lacking with respect to the efficacy of proton-pump inhibitors as a twice-daily regimen for refractory symptoms, though such dosing is sometimes used in practice. In this particular patient, the medical records do not document that she has tried and failed a trial of Nexium 40 mg once per day for 30 days. The Health Plans requirement that the patient undergo a documented trial of Nexium 40 mg once per day for 30 days prior to seeking coverage for Nexium 40 mg twice a day is medically appropriate and consistent with standards of practice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested bariatric lap band surgery for the treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient does not meet the generally accepted BMI criteria (BMI greater than 35) for adolescent bariatric surgery. In addition, the patient is eight years old and has not obtained near full growth stature. Furthermore, there are no randomized, controlled trials in the peer-reviewed literature which document the safety, efficacy and long-term outcome benefit of bariatric surgery for patients of this age with a BMI below 35. Further, there is no peer-reviewed evidence demonstrating that bariatric lap band surgery is a well-established and effective treatment modality for children with insulin hypersecretion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested acupuncture treatments for the treatment of her hormonal imbalance. Findings:  The physician reviewer found that the condition of hormonal imbalance relates to changes in the levels of estrogen and progesterone (Goroll and Mulley). An imbalance can result in allergy symptoms, depression, endometriosis, fibrocystic breasts, hair loss, facial hair growth, headaches, low sex drive, osteoporosis, premenstrual syndrome, incontinence, uterine fibroids, weight gain, water retention, bloating and dry skin. The documentation indicates that the patient also had issues related to premenstrual syndrome. Based on the submitted documentation, the only previous treatment she received was oral contraceptives. Per Fauci and colleagues, there are multiple accepted treatments for the patients condition, which include treatment trials with antidepressants (SSRIs), NSAIDs, diuretics, oral contraceptives and Depo-Provera. There has also been reported benefit from phytoestrogens and herbal remedies as well as supplementation with calcium, magnesium, Vitamin B6 and Vitamin E. Acupuncture is not an accepted standard therapy in this setting. While there is peer-reviewed evidence demonstrating the efficacy of acupuncture for the treatment of certain conditions such as chronic osteoarthritis and nausea and vomiting associated with chemotherapy, the use of acupuncture for the treatment of hormonal imbalance and/or premenstrual syndrome has not been shown to be effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for a CT scan and MRI for evaluation of her pain. Findings:  The physician reviewer found that it has been shown in multiple studies and is well-documented in clinical guidelines that uncomplicated back pain is best treated with conservative therapy. Uncomplicated back pain is described as back pain with no associated red flags. According to the American College of Radiology guidelines, indications of a more complicated status include recent significant trauma, or milder trauma, age greater than 50, unexplained weight loss, unexplained fever, immunosuppression, history of cancer, intravenous drug use, prolonged use of corticosteroids, osteoporosis, age greater than 70 and focal neurologic deficit with progressive or disabling symptoms. Per an article by Kinkade, in the absence of red flag findings, four to six weeks of conservative care is safe and appropriate, and imaging is not indicated. The author also noted diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. Therefore, imaging should be used in carefully selected patients and interpreted with appropriate clinical correlation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  for tilt-table testing for evaluation of the enrollees orthostatic symptoms.   Findings:  Two physician reviewers found that the literature suggests that orthostatic hypotension associated with postural tachycardia syndrome (POTS) cannot be diagnosed by using sitting and standing blood pressures, and instead requires performance of a tilt table test. This makes sense when one considers the multi-factorial nature of dysautonomia that may be involved in patients with POTS. This may include significant dysregulation from a variety of factors, including but not limited to baroreceptor dysfunction, vestibular inputs, carotid body function, as well as the potential conditioning that may occur in experiencing near-syncopal symptoms. Many potential stressors are simply obviated with having the patient quickly stand after sitting, but not all can be eliminated without the use of an operator-assisted tilt table.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested coverage for occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that evaluation of fine motor skills showed grasping was good and pronation/supination was within normal range of motion. With regard to gross motor skills, it was noted that the patient is walking, is able to hop on one/two feet and able to climb, throw and catch/kick a ball. Oral motor skills were noted as normal, with the patient described as eating using standard utensils, drinking from a cup and feeding himself.  Based on the evidence, the patients deficits are not functionally based and therefore the patient does not meet clinical indications for occupational therapy. While the patient does have sensory issues, these issues are best addressed in conjunction with other treatment modalities. Accordingly, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for a functional electrical stimulator (FES) Bioness L300 for treatment of his foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that functional electrical stimulation is used to prevent or reverse muscular atrophy or electronically provide function in a paralyzed/paretic limb. It has been used for some time in the setting of stroke and spinal cord injury and more recently, has been proposed for patients with multiple sclerosis. The 2008 publication by Stein cited above, studied functional electrical stimulation in patients with non-progressive conditions (e.g., stroke) and progressive conditions (e.g., multiple sclerosis) of the central nervous system. The authors found that in non-progressive conditions, therapeutic increases were seen up to at least 11 months of use. However, the authors noted that in progressive disorders such as multiple sclerosis, the progression of the disease eventually overcomes the early therapeutic effects. At this time, the use of a functional electrical stimulator such as the Bioness L300 has not been shown to be more beneficial than usual and customary care (the use of an ankle foot orthosis) for patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested artificial disc replacement at L5-S1 using ProDisc II for the treatment of his back pain. Findings:  Three physician reviewers found that a study by Chou and colleagues indicates that, Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease, insufficient evidence exists to judge long-term benefits or harms. Although artificial disc replacement has been performed for many years as an alternative to lumbar fusion, mostly for degenerative disc disease causing chronic low back pain, the authors concluded that additional studies with greater follow-up are still needed to fully assess the outcomes of patients who undergo artificial disc replacement surgery. The conventional surgical treatment for recurrent disc herniation with radiculopathy is redo-discectomy. Since the medical literature fails to demonstrate the equivalence or superiority of artificial disc replacement, the requested surgery remains experimental. This patients problem is apparently his recurrent disc, which can be removed adequately with a re-operation discectomy and foraminotomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested for bilateral digital hearing aids for treatment of his hearing loss. Findings:  The physician reviewer found that digital signal processing allows manufacturers to create hearing aids with enhanced processing and features. Current digital hearing aids use this capability to perform loudness growth and threshold testing in order to obtain fitting information specific to an individual patient's ears.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements. This patient has a body mass index of greater than 50. There is no scientific evidence that pre-operative diet and exercise plans improve or predict the outcomes of the weight loss surgery. There is evidence that shows a far better outcome with management of the co-morbidity of diabetes with weight loss surgical procedures (metabolic surgery) than any of the medical regimens available for the treatment of diabetes (see Sjostrom and colleagues).