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

A 63-year-old male enrollee has requested for intensity modulated radiation therapy for treatment of his stage IIBX lymphoma. Findings:  Three physician reviewers found that IMRT has been recommended. Comparative IMRT and 3D conformal plans were submitted. These plans indicate significant dosimetric benefits in renal and kidney sparing with IMRT versus 3D conformal radiation therapy in this case. Thus, IMRT is likely to be a more beneficial treatment alterative for this patient than the 3D conformal radiation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his major depression. Findings:  Two physician reviewers found that although the safety of transcranial magnetic stimulation has generally been established, its efficacy has not been documented for this clinical situation. The medical literature indicates that transcranial magnetic stimulation has been shown to be effective in those patients who have not responded to a single antidepressive agent. This patients clinical course, as described in the medical records, does not clearly demonstrate that this patient was not responsive to pharmacotherapy with or without more conventional adjunctive treatment. Furthermore, even if the patient derived no benefit from antidepressant medication, according to the FDA approval for transcranial magnetic stimulation, its efficacy has not been established in patients who have failed to receive benefit from two or more prior antidepressant treatments. As such, there is inadequate scientific evidence to support the efficacy of transcranial magnetic stimulation in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the literature demonstrates that speech therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function. The patients deficits are not solely educationally based issues. The issues of pragmatic language, behavior and cognition affect functional skills regarding dressing, bathing and other age appropriate activities of daily living. This patient regressed from using a spoon and making requests to being unable to perform these activities. In comparison, patients who have an acquired brain injury receive speech therapy as standard of care for cognition and language skills to address functional deficits (not related to laryngeal pathology or swallowing dysfunction). Patients with autism have similar needs and are likely to derive benefit from individual speech therapy. For the reasons set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested C5-6 cervical disc arthroplasty (ProDisc) for treatment of his cervical degenerative disc disease. Findings:  Three physician reviewers found that cervical disc arthroplasty is not likely to be more beneficial for this patient than ongoing conservative care and/or fusion. At this time, there are unresolved issues concerning cervical disc arthroplasty. These issues include whether or not improved range of motion will in fact be maintained over time, or whether fibrosis and heterotopic ossification will diminish range of motion over time. There are also unresolved issues with regard to adjacent segment degeneration. It is not clear whether changes adjacent to an area of fusion are determined primarily by intrinsic factors related to cumulative micro-trauma and aging, as opposed to a simpler explanation that disc replacement will decrease compensatory motion at adjacent levels as compared to fusion. The role of posterior facet joint changes is also relevant to this case, as is the effect of intrinsic changes within the spinal nerve roots creating a more diffuse type of syndrome. These factors are not positive prognosticators for cervical disc arthroplasty.In addition, non-case specific issues remain including the long-term implications of cervical disc arthroplasty. These issues include wear-loosening, subsidence, dislocation and re-operation. Concerns have been raised over particulate wear debris and the resultant inflammatory response and will require study over a longer duration of time than has been available to date. At this time, there is insufficient published data to assess the long-term safety and efficacy of cervical disc arthroplasty in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.The parent of a five-year-old male enrollee has requested 30 hours per week of applied behavioral analysis therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that applied behavioral analysis (ABA) is an established medical treatment modality widely accepted in the practicing community and by centers specializing in treating ASD. According to an article published in the October 2008 edition of Child and Adolescent Psychiatric Clinics of North America, ABA is a state of the art treatment modality for this medical disorder. The authors note that ABA utilizes methods derived from scientifically established principles of behavior and intensive treatment is needed, usually between 20-40 hours per week. The National Institute of Mental Health also acknowledges that ABA has become widely accepted as an effective treatment for autism. This finding is consistent with the Surgeon Generals report on Mental Health. Granpeeshehs July 2009 article notes that ABA treatment programs are supported by scientific evidence and are recommended for individuals with autism. Review of the submitted clinical evidence reveals that the patient has made progress with ABA therapy. All told, there is adequate evidence demonstrating that ABA services at a frequency of 30 hours per week are likely to be superior to any other available treatment for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a continuous passive motion device and synthetic pad for treatment of his right knee status post total knee replacement surgery.  Findings:  The physician reviewer found that there have been several studies of CPM devices after total knee arthroplasty. A review of peer-reviewed Level 1 and Level 2 studies in the current medical literature does not support the use of a CPM device in the home following this procedure. Chen and colleagues studied 51 patients who were assigned randomly to physical therapy or physical therapy plus CPM. The study revealed that there was no difference between the two groups. The authors concluded that the use of CPM offered no added benefits. Subsequent studies have not demonstrated a significant increase in range of motion in the long-term from the use of a CPM machine following total knee replacement surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for continued adolescent mental health inpatient treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient has recently failed less restrictive treatments and continues to experience severely disabling depressive symptoms. His symptom severity does not allow him to fully cooperate with his treatment in the hospital, and he would most likely deteriorate in a less restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested stereotactic radiosurgery (CyberKnife) for treatment of his metastatic lung cancer. Findings:  The physician reviewer found that although radiosurgery to a brain metastasis resection cavity is generally a reasonable option, the risk-benefit ratio of the treatment must be assessed based on the individual patients clinical situation. This patient has experienced a local recurrence in an area that has been resected twice, and has received both whole brain radiation and stereotactic radiosurgery. Given that the patient has a Karnofsky Performance Score of less than 70, the potential risks of repeat salvage radiosurgery outweigh the benefits. It is not clear that repeat radiosurgery will delay disease progression. Further, the procedure would put the patient at high risk for radiation necrosis and its subsequent complications. Given this patients extensive treatment history and risk profile, he does not meet clinical indications for stereotactic radiosurgery with CyberKnife.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 84-year-old female enrollee has requested a PET scan for an evaluation of her adenocarcinoma of the upper lung. Findings:  Three physician reviewers found that PET scans are a medically accepted imaging study for the initial staging and restaging of patients with non-small cell lung cancer. Medicare coverage guidelines allow PET scans for both initial and restaging purposes in patients with non-small cell lung cancer.  Multiple studies in the peer-reviewed literature also support the use of PET scans for restaging purposes in patients with non-small cell lung cancer. Joshi and colleagues noted that PET scanning is useful in differentiating between malignant and benign disease, fibrosis and recurrence, staging and in changing patient management to more appropriate therapy. The outcome of the PET scan in this patient will have a direct impact on the treatment plan. PET scans are more sensitive and accurate than standard CT scans in the evaluation of residual tumor, nodal disease and distant metastatic disease. Thus, in this patients case, the requested PET scan is likely to be the most efficacious method of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox therapy has been shown to be helpful in select patients with migraine, its use is typically reserved for treatment after the patient has failed at least one agent from several classes of prophylactic medications (anti-convulsants (such as Topamax), antidepressants (such as Elavil and Trazodone), and/or cardiovascular agents (such as Inderal and verapamil)). In this patients case, the submitted documentation does not establish that she has had any trials of the many prophylactic agents available. Since the use of Botox as first line therapy is not supported by the scientific evidence, this patient does not meet appropriateness criteria for the use of Botox for treatment of her migraines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested Celebrex 200 mg, two tablets twice per day for treatment of her osteoarthritis. Findings:  The physician reviewer found that Celebrex is a selective COX-2 inhibitor indicated in the treatment of osteoarthritis, rheumatoid arthritis and familial adenomatous polyposis at doses of 200, 400 and 800 mg/day respectively. The requested dose of 800 mg per day of Celebrex exceeds the dosage recommended by the Food and Drug for treatment of osteoarthritis. The risk of cardiovascular events appears to increase with higher doses. In addition, there have been reports of gastric ulcers in patients being treated for osteoarthritis in doses higher than the FDA recommended daily dose. Moreover, the analgesic effects of higher doses of Celebrex were not shown to be better in a population of patients with ankylosing spondylitis. In sum, there are no studies that support the safety and efficacy of a dose of Celebrex of 800 mg/day for the treatment of osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested selective internal radiation therapy (SIRT) for treatment of his colon cancer with metastases to the liver. Findings:  Three physician reviewers found that this patient has multiple liver metastases; it is not possible to treat all of these lesions with the proposed radioembolization with Yttrium-90 microspheres (SIRT). In addition, it is too early to assess the patients response to his chemotherapy regimen, and whether or not he is refractory to such treatment. Finally, in this case, there is possible evidence of progressive disease outside of the liver as there is some increase in the size of his para-aortic lymph nodes (which would not be treated by the proposed SIRT procedure). In light of these factors, the medical literature at this time does not support the use of SIRT in this patients particular clinical situation. Vente and colleagues noted that although the clinical results of SIRT are promising, overall response and survival are not yet known and the impact on patient survival will not be established until the results of phase III studies are published.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested real-time cardiac monitoring for an evaluation of her medical condition. Findings:  Three physician reviewers found that event recorders of the type invoked are much more likely than standard approaches to detect culprit arrhythmias, since the latter have a notoriously high rate of missing such events. It was therefore appropriate for the cardiologist to order this type of monitoring in this situation since the patients symptoms were of sufficient severity, on more than one occasion, to result in her hospitalization. This method is commonly used among the cardiology community and has been documented to be of significant clinical value.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Three physician reviewers found that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity. The safety and efficacy of the sleeve gastrectomy has been sufficiently studied.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 75-year-old male enrollee has requested for emergency medical services and the placement of a pacemaker required on an emergent basis. Findings:  The physician reviewer found that The patient presented with symptomatic, third-degree heart block, or complete atrio-ventricular dissociation. This is considered a medical emergency as the clinical condition of a patient in complete heart block can deteriorate without warning. The standard of care is to emergently admit such patients to the hospital and apply trans-thoracic or temporary trans-venous pacing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for continued stay at a Rehabilitation Center for treatment of the enrollees medical condition. Findings:  The physician reviewer found that while the patients medical condition was becoming more stable, he continued to improve in his stair negotiation, so further improvement in a reasonable time was expected. The patient also demonstrated improvement in his activities of daily living.  Therefore, because the patient continued to benefit from skilled physical therapy at the skilled nursing facility, his continued stay was medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Avodart for treatment of his prostate cancer and benign prostatic hyperplasia with urinary obstruction. Findings:  The physician reviewer found that this patient presents with benign prostatic hyperplasia and prostate cancer. His provider has prescribed Avodart indicating that the patients enlarged prostate and irritative and obstructive voiding symptoms may interfere with potential brachytherapy for treatment of his prostate cancer. The Health Plan has offered Proscar as an alternative for this patient. Proscar and Avodart are two 5-alpha reductase inhibitors blocking the conversion of testosterone to the active form dihydrotestosterone. This action results in decreased glandular activity. The decreased glandular activity results in decreased prostate volume over many months. The Health Plans requirement that Avodart be approved only after treatment failure with Proscar is medically appropriate. There is a lack of evidence suggesting that Avodart has a clinical superiority over Proscar for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his esophageal cancer. Findings:  Two physician reviewers found that IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the radiation doses to normal structures. IMRT is of use when there is concern about sparing normal tissues from high-dose radiation exposure. There is a growing amount of literature on the use of IMRT for esophageal cancer, with most studies demonstrating a dosimetric advantage (Zhang and colleagues and Chen and colleagues). However, there is little clinical outcome data available. There is also a growing amount of literature supporting the use of IMRT in patients with gastric cancer, albeit a slightly different clinical situation than with this patient as gastric cancer patients generally undergo radiation after gastrectomy. Nevertheless, the principles of using IMRT to spare normal tissue from radiation do apply for both gastric cancer and esophageal cancer. The volume of heart, bowel and cord receiving in excess of 45-50 Gy correlates with acute and late toxicity to these organs. Reducing the high-dose radiation exposure to these organs is known to reduce toxicity. IMRT is a tool that enables the reduction of dose to surrounding organs. As the patients physician indicates, the heart and spinal cord are in close proximity to the target tumor. Given the proximity of the target tumor to critical structures, IMRT is clinically warranted in this patients particular situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a replacement artificial anal sphincter for treatment of her fecal incontinence. Findings:  Two physician reviewers found that  replacement of the artificial anal sphincter represents one of the few remaining options for preserving or improving this patients fecal continence. In this patients case, a permanent colostomy is the alternative. In most cases, patients with artificial anal sphincters have excellent short-term results, and moderate long-term results, often with the need for re-intervention, as this patient is requesting. As noted by Mellgren, reports have demonstrated excellent results with good functional improvement and a significant improvement in quality of life. The medical literature supports the use of an artificial anal sphincter for end-stage fecal incontinence in selected patients who do not have other treatment options, except for colostomy. Thus, a replacement artificial sphincter is the preferred method of treatment in this patients case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had eaten food and later experienced throat swelling and a rash. Although no respiratory distress was noted in the Emergency Department upon arrival, she had been experiencing throat edema just prior to arriving at the hospital. Symptoms of throat swelling, tightness or itching can be signs of acute anaphylaxis, the course of which is quite variable. In this patients case, exercise-induced anaphylaxis would be a prime consideration due to the temporal relationship between the patients food ingestion and onset of symptoms while exercising shortly thereafter. The prudent course is to proceed to the Emergency Department for an emergent evaluation and immediate treatment, as these initially mild symptoms may progress to airway compromise. As such, the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health in this situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested 8-10 catheters per month for treatment of her urinary incontinence. Findings:  The physician reviewer found that when a patient is unable to void due to neurogenic bladder, the patient either self catheterizes or wears an indwelling Foley catheter. The preferred method of self catheterization is the intermittent clean technique, which does not require sterile equipment each time. The catheters are reusable. This technique is associated with a low rate of infection and is well accepted in the urologic community. The average life of a catheter is one week. Patients who use this technique usually carry a small kit when they are out in public and wash and reuse the catheters. While this patient reports that she needs additional catheters for travel purposes, the requested number of catheters per month are not necessary from a medical standpoint. The quantity authorized by the Health Plan (4 catheters per month) is appropriate and consistent with Medicare guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a follow-up bilateral breast MRI with/without contrast for an evaluation of her breast cancer. Findings:  Two physician reviewers found that the recent MRI of the breast showed probably benign findings within both breasts.  The standard of care when a probably benign finding is identified on breast imaging is a short-term follow-up study. This short-term follow up study is performed using the breast imaging study that showed this finding. Most short-term follow-up studies are performed at a six-month interval. Articles in the peer-reviewed literature do support the use of short-term follow-up breast MRI studies. As this patients probably benign findings were found on a breast MRI, the short-term follow-up study should be a breast MRI. The requested follow-up bilateral breast MRI is likely to be of greater clinical value than any other method of evaluating this patient.