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

A 55-year-old female has requested approval for nerve conduction velocity (NCV) studies and testing, electromyography (EMG), genetic marker testing, Minnesota Multiphasic Personality Inventory (MMPI), 16 PF Questionnaire (Personality Factors), Milan Multi Axial Clinical Inventory 2, a face-to-face neuropsychological screening, and a second opinion outside of Loma Linda University Healthcare System for evaluation of her behavioral health issues.   Findings:  The physician reviewer found that the available medical records provided for review support the medical necessity of a second opinion from an independent neurologist for evaluation of the patients movement disorder. However, the records do not support a request for NCV testing, EMG, genetic marker testing, Minnesota Multiphasic Personality Inventory, personality factor test, Milan Multi Axial Clinical Inventory 2, or face-to-face neuropsychological screening. The records indicate the patient has movement disorder which has been assessed by the provider as a myoclonus condition. A second opinion is appropriate in order to assess and provide opinion as to the neurologic basis of the patients condition and confirm etiology as this is not established in the medical records provided for review. As the records do not document any abnormal motor, sensory, or reflux abnormalities, the NCV testing or EMG are not clinically indicated. In addition, these tests are not necessary for the general evaluation of a tremor or myoclonus. Further, the requested psychological or psychiatric evaluation is not supported with regard to evaluation of the patients myoclonus or neurologic condition. The patient has an established diagnosis regarding her psychiatric condition. Additional personality and psychological testing is not supported to evaluate for any neurological condition and is not supported for evaluation of myoclonus. Therefore, the requested second opinion with a neurologist in regard to the reported movement disorder is supported as medically necessary, while the additional services are not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested a breast MRI for evaluation of her right breast lump.  Findings:  Three physician reviewers found that the patient has a palpable abnormality in the right breast apparently increasing in size. Mammography showed very dense breast tissue and an ultrasound revealed a simple 3 mm cyst corresponding to the area of palpable concern. There is no known genetic predisposition to breast cancer in this patient. This patient has a palpable abnormality, which has been shown to be a simple cyst by ultrasound. If there is a clinical suspicion of breast cancer due to the increasing size and palpable nature of the mass, then a biopsy would be the best procedure to exclude malignancy. Although the patients breast tissue on mammography has been described as extremely dense, which limits the value of mammography there is no noted genetic predisposition. In this case, the request is for evaluation of a clinically suspicious palpable abnormality. Since there is still concern about the mass following ultrasound, a biopsy would be more beneficial than any other test for evaluation and possible treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron).  Charged particles including protons and carbon can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerator (LINAC) which delivers photon therapy, while protons are generated from a cyclotron. The difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. In practice, the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability in certain conditions such as base of skull chordomas and chondrosarcomas and pediatric tumors, due to the sharp dose fall off, allowing high dose delivery to the tumor while relatively sparing the neighboring normal tissue. The current status of the peer reviewed publications is unsettled with regard to the safety and efficacy of proton therapy in terms of outcomes when compared with conventional radiation therapy. Most providers support proton therapy as having some role in the treatment of well selected patients, including some patients with prostate cancer (Vargas, et al). The two most respected therapeutic proton facilities in the U.S. have researched the potential of proton beam therapy in prostate cancer (Zietman, et al; Slater, et al). In their 2004 paper, Slater and colleagues concluded that, Conformal proton radiation therapy at the reported dose levels yielded disease-free survival rates comparable with other forms of local therapy, and with minimal morbidity. Dose-escalation strategies are being implemented to further improve long-term results. However, the issue of whether proton therapy for prostate cancer affords any advantage over intensity modulated radiation therapy (IMRT) remains controversial. Most reports, including the article from Vargas and colleagues systematic review, assert that patients treated with proton therapy fare comparably to patients treated with IMRT. Further, the authors found that proton therapy yields improved normal tissue sparing as compared to IMRT. Of note is that other accepted technologies such as image guided radiation therapy (IGRT), with daily computed tomography (CT), imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing and were technologies that were not investigated in that analysis. With the limited data, it is possible that proton therapy is actually disadvantageous as the depth of proton delivery is more susceptible to changes in tissue density. Thus, despite the fact that proton therapy for treatment of prostate cancer is not experimental, other treatment approaches including IMRT with or without IGRT have been proven to be highly effective and well tolerated. All told, there are insufficient compelling data to suggest that proton therapy is superior to or more beneficial than IMRT for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female has requested 4 sessions per month of individual therapy and 2 sessions per month of family therapy for treatment of her mood disorder, not otherwise specified, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that current psychiatric practice is focused on the aggressive treatment of anxiety and depression, particularly in the acute phase of the illness, followed by less frequent services, and greater community involvement, in the maintenance phase to foster patient autonomy and recovery.  The current evidence suggests that a short-term increase in services can be effective at decompressing morbidity and improving functionality.  The modalities of both cognitive behavioral therapy and family therapy are trusted interventions in the treatment of mood disorders and anxiety in children and adolescents, and are well-supported by scientific evidence. In this patients case, considering that treatment gains have not been consolidated with the current plan of care, a 3-month course of 4 sessions of individual therapy per month (12 total sessions) and a 3-month course of 2 family therapy sessions per month (6 total sessions) are medically necessary. The patient should be evaluated at the end of the three-month period to determine if additional therapy beyond the three-month period is indicated. As such, a portion of the requested therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female has requested radiofrequency lesioning for treatment of shoulder pain.  Findings:  Two physician reviewers found that the patient developed the pain after a fall. She has been treated with epidural injections along with suprascapular nerve blocks, physical therapy, and opioid therapy. She was determined not to be a candidate for suprascapular nerve decompression. Her diagnosis includes a multitude of problems including cervical radiculitis and thoracic outlet syndrome. The patient has requested authorization and coverage for radiofrequency lesioning, which has been denied by the Health Plan as investigational. The proponents of suprascapular nerve block consider it to be an important procedure and have described its technique (Fernandes, et al). However, there is a paucity of support for neurolytic procedures in the medical literature (Liliang, et al). Pulsed radiofrequency lesioning of the suprascapular nerve has been reported in case reports and only preliminary reports (Keskinbora and Aydinli). However, there have not been any properly performed studies showing the effectiveness, and indications for radiofrequency thermoneurolysis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested surgery consisting of uvulopalatopharyngoplasty (UPPP)  for treatment of primary snoring and sleep related non-obstructive alveolar hypoventilation.  Findings:  The physician reviewer found that this patient presents with snoring and non-apneic hypoxemia. The medical literature supports the efficacy of UPPP as a treatment for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). As concluded by Hou and colleagues of their five year study, combined midline glossectomy and UPPP can be an effective treatment for subjects with Friedman stage II or III OSAHS and substantial stenosis around the base of the tongue. However, the data indicates that the requested UPPP will not improve the alveolar hypoventilation in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested diagnostic genetic testing for evaluation of her stage IV ovarian cancer.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing is indicated for patients with a diagnosis of epithelial ovarian cancer. In addition, the U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) endorse the utility of diagnostic genetic testing to assist in treatment planning for patients with epithelial ovarian cancer. All told, the requested diagnostic genetic testing is supported as medically necessary in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female has requested Oxycontin 60mg for treatment of lumbago status post back injury with fracture.  Findings:  The physician reviewer found that based on the records provided for review, authorization and coverage for Oxycontin 60mg, three times per day is not medically necessary for treatment of this patients medical condition. Such narcotics and at the doses prescribed are presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and if controlled release narcotics are indicated, treatment should be closely monitored by a certified pain management physician (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  As high dose opiates may also cause adverse outcomes, the patients request for Oxycontin 60mg three times per day is not clinically indicated. It would be in the patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. Any opioids as requested by the enrollee for her chronic pain would be in my opinion, contradictory to providing safe and effective health care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male has requested Xifaxan-Rifaximin 550mg for treatment of irritable bowel syndrome.  Findings:  The physician reviewer found that this patient follows the typical course of IBS as his symptoms tend to alternate over time. One treatment strategy for IBS is to use antibiotics for possible bacterial overgrowth. In the medical literature, standard antibiotics, such as metronidazole and TMP-sulfa, are proven to be effective. This patients records do not document the presence of bacterial overgrowth at this time. Further, the patient is variably compliant with Amitiza and current diarrhea, cramping, and bloating may be a side effect from using this drug. All told, the requested Xifaxan-Rifaximin 550mg is not supported as medically necessary in treating this patients medical condition based on the records provided for review
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female has requested acupuncture (voice acupuncture) for treatment of her spasmodic dysphonia.  Findings:  The physician reviewer found that  based on review of the available records, this patient presents with a condition for which she underwent acupuncture care in the past with significant benefit. Botox injections are a more aggressive type of treatment, with more possible complications than the additional acupuncture requested by the patient. In one study, acupuncture was compared to Botox therapy, with demonstrated equivalent benefits. As this patient has experienced benefits with previous acupuncture treatment for her diagnosis of adductor spasmodic dysphonia, and the peer-reviewed medical literature supports its use, the requested acupuncture care is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Amerge 27 tablets per 30 days for treatment of her migraine.  Findings:  The physician reviewer found that based on review of the available records, this patient has a long history of migraine. Given the high frequency of headaches, her condition is consistent with chronic migraine. She is not on reportedly on preventive therapy, and is noted to be using multiple acute medications, including up to 27 Amerge per month. Use of abortive medications more than two days per week on average can be associated with development of medication overuse headache. The American Migraine Prevalence and Prevention Study demonstrated that, transformation is most likely to occur with 5 days of butalbital use per month, 8 days of opioid use per month, 10 days of triptans or combination analgesic use per month, and 10 to 15 days of non-steroidal anti-inflammatory use per month. Acute migraine treatment should be limited to 2 or fewer days per week. Optimal therapy should involve assessment of factors such as obesity, possible sleep apnea, and medication overuse, and treatment along with refinement of preventive therapy. All told, the records support the medical necessity of Amerge up to two tablets per day, two days per week, for a total of 16 tablets per month, for treatment of this patients medical condition. Therefore, a portion of the requested medication dosage is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression and anxiety disorder.  Findings:  The physician reviewer found that the body of medical literature supporting the use of transcranial magnetic stimulation (TMS) in the treatment of refractory depression continues to demonstrate positivism for this intervention. Researchers such as Ueyama and colleagues have identified a possible mechanism for the antidepressant effect of TMS. Most compelling in support of its application, TMS has been approved by the Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of patients with depression. In this particular case, the patient is experiencing an acute, recurrent major depressive episode that is causing significant morbidity and functional impairment. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice in the United States. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested approval for past use of compounded lactose powder 600mg and domperidone 5.5gm for breastfeeding.  Findings:  Two physician reviewers found that the patient adopted a premature infant and wanted to produce breast milk to feed the baby. There is a request from her provider for coverage of the compounded product. The coverage request from the provider states that Reglan had been tried and had failed. She noted that domperidone is not FDA approved, but stated she did not wish to use an FDA approved medication such as metoclopramide (Reglan), because of potential risks, stating that the domperidone did not have any side effects. The patient reported that the medications were successful. There are limited studies on various medications and herbal supplements used to increase milk supply in nursing mothers who have had a decrease in milk production. There are even fewer publications on the topic of using these medications to induce lactation in women who have not given birth. One FDA approved medication, metoclopramide, is often used to increase milk supply. According to Gabay, galactogogues are medications that aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Metoclopramide remains the galactogogue of choice due to its documented record of efficacy and safety in women and infants. Osadchy and colleagues noted that, There is a controversy within the medical community regarding the role of domperidone as a galactogogue and the drug has been removed from the US market owing to safety concerns. In addition to an FDA warning against the use of domperidone for lactation, the patient was taking oral contraceptives during this time period, which would be inconsistent with trying to breastfeed. All told, the medications at issue were not likely to produce an equivalent or superior health outcome when compared with standard alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old female has requested approval for 10 hours per week of applied behavioral analysis (ABA) therapy and 8 hours per month of supervision for treatment of her autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Granpeesheh, et al). Evidence-based studies also have demonstrated improvement of function in older children with autism spectrum disorders using intensive ABA interventions. The goals for older children often are to identify and remediate particular deficits. Treatments based on operant principles of learning were noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey and Hastings). In addition to this patients maladaptive behaviors of communication, noncompliance, and screaming, her social and language skills should be addressed in an effort to increase her functional life skills. ABA therapy is a necessary and appropriate modality to address these concerns.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female has requested approval for duloxetine (Cymbalta) 60 mg capsule for treatment of her lumbago.   Findings:  The physician reviewer found that the patient in this case has two FDA approved indications for the use of Cymbalta at the 60 mg per day dose. Per the records, she has been on Cymbalta for the past five months, and she had a diagnosis of generalized anxiety disorder and musculoskeletal low back pain. The study by Pergolizzi and colleagues reported statistically significant improvement in objective outcomes for depression, anxiety, muscle pain, low back pain, and neuropathy. Thus, Cymbalta is indicated and there is no mention of any contraindication in the clinic notes. Based on review of the available information and the patients diagnoses, Cymbalta is medically necessary at the requested 60 mg dose.