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

A 62-year-old male enrollee has requested an F-DOPA positron emission tomography (PET) scan of the brain for an evaluation of his progressively worsening tremors. Findings:  Three physician reviewers found that although an F-DOPA PET scan is not a standard test for the diagnosis of Parkinsons disease, it is indicated and medically appropriate in this particular case. This patient has refractory progressive symptoms. Currently, the patients neurologist is considering the diagnosis of conversion disorder as opposed to Parkinsons disease. The use of the proposed study will be very useful in differentiating between these two conditions and is supported by the medical literature. In this case, this imaging study is crucial as it will help provide a diagnosis and guide future therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Remicade IV infusion for the treatment of her sarcoidosis. Findings:  Two physician reviewers found that this patient's recent biopsy confirmed sarcoidosis in the left thumb. It appears she has not had adequate response to prednisone, which is first-line therapy. Conventional therapy in this setting would include a trial of immunosuppressant therapy, such as methotrexate, as the next appropriate step. There is no evidence to suggest that Remicade, a TNF antagonist, is more efficacious for sarcoidosis than immunosuppressant agents. Therefore, a trial of Remicade is not indicated for this patient until attempts at more conservative therapies have been exhausted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested the Exogen 4000 Ultrasonic Bone Stimulator for the treatment of her fractures. Findings:  Two physician reviewers found that this patients fractured third metatarsal failed to heal after over six weeks of immobilization. She is also osteopenic, which is a risk factor for bone healing. The articles demonstrate statistically significant bone healing capabilities with use of the device at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested residential treatment services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient has a very serious eating disorder, and she has required inpatient hospital care. She was admitted to an in-network facility, but she did not respond favorably to treatment. The facility discharged the patient for noncompliance. The patient then sought treatment at an eating disorder facility that was out-of-network. The patients need for inpatient care was fully established when she was initially admitted to the in-plan facility. In-plan physicians and reviewers did not deny the patients need for such care. This facility discharged the patient for noncompliance. This patient continued to need residential care. She was discharged from the Health Plans facility and admitted to the out-of-network facility shortly after. The second admission is only ten days subsequent to the first admission. She was discharged because the facility was not able to effect compliance, not because she did not need such treatment. This patient required residential treatment services. Such care was medically indicated and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested right total ankle replacement surgery for the treatment of her right ankle pain. Findings:  Three physician reviewers found that total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis (fusion) remains the subject of debate. For arthritic conditions regarding the ankle, there are a number of peer-reviewed articles comparing fusion with ankle replacement in the short- and intermediate-term, and both procedures have good results. The patients provider has recommended total ankle arthroplasty over fusion due to concern that the patient is at risk of developing arthritis in other joints, which can occur with fusion. This rationale is medically prudent and sound. The procedure chosen by the patients provider is likely to produce the best outcome for the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested revisional band over bypass bariatric surgery for the treatment of her post surgical complaints. Findings:  The physician reviewer found that the medical literature shows that 5-10% of patients fail to lose adequate weight (greater than 50% of pre-surgical weight) after LRYGB. In some cases, this is due to a maladaptive behavioral eating disorder. However, it is also possible that poor results are a result of anastomotic failure. In the case of this patient, the submitted documentation does not include definitive proof of anastomotic failure of the previous LRYGB. Furthermore, it does not appear an endoscopy has been performed to evaluate the pouch and the size of the gastrojejunal anastomosis. Until such evidence is obtained, the medical necessity of revisional bariatric surgery is not established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox has been used in select cases of migraine headache, it is not considered a first-line therapy for migraine prevention. While this patient has used Imitrex and Maxalt for abortive therapies, there is only evidence of a trial of one prophylactic medication, amitriptyline. There are many other better studied and proven migraine therapies that have not been attempted by this patient. The American Academy of Neurology Quality Standards Subcommittee practice parameters for headache care suggest that there are more standard alternatives that may prove efficacious for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested an electromyogram and nerve conduction study for an evaluation of her carpal tunnel syndrome. Findings:  The physician reviewer found that this patient clearly has carpal tunnel syndrome. EMG/NCV studies are typically indicated in this setting for adequate evaluation of carpal tunnel and consideration of surgical intervention. It has been more than two years since the patients last EMG/NCV studies were performed. It is medically reasonable to recheck these studies with the passage of time. In a case such as this in which a patients condition is clearly worsening, surgical therapy may now be desired. However, if significant improvement is found, the patient may wish to continue with conservative therapy. It is within the standard of care to repeat EMG/NCV studies for carpal tunnel syndrome evaluation. Such studies will be clinically useful in the ongoing management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested Alinia for the treatment of her toxoplasma gondii and bacterial overgrowth. Findings:  The physician reviewer found that Alinia was prescribed in this case to treat toxoplasma positive serology (toxoplasma gondii) and bacterial overgrowth as indicated by the provider. A review of the peer-reviewed scientific literature revealed no evidence supporting the use of Alinia for treatment of these conditions. Alinia is not approved for either diagnosis and there are more standard alternatives. Moreover, positive toxoplasma serology without laboratory confirmation is not sufficient to confirm a diagnosis of toxoplasmosis. The symptoms described are not those of toxoplasma, nor do the patients history and labs support such diagnosis. There is no confirmatory evidence to support toxoplasma positive serology and bacterial overgrowth. Even if these conditions were present, they are not indications for Alinia treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a Meniett device for the treatment of her Menieres disease. Findings:  The physician reviewer found that the nature of Menieres disease, with a highly variable clinical presentation, lack of pattern or often a provoking reason for the attacks, makes management difficult. The pathology is understood as an increase in pressure in the fluids of the inner ear, but the cause of that pressure increase in unknown. The Meniett device invokes a theory that by increasing air pressure in the middle ear, fluid in the inner ear will be displaced and Menieres symptoms will reduce. While a few early studies showed some benefit in the treated groups in reduction of dizziness, objective criteria, such as the hearing loss that accompanies Menieres disease, remain unimproved. In the case of this patient, based on the most recent treatment notes provided her symptoms are dominated by tinnitus. A review of the literature shows no evidence that the Meniett device is successful in reducing tinnitus. The patient also suffers from headaches which have been diagnosed as migraines, which may be a contributing factor in the dizzy spells. All told, there is insufficient evidence to support the use of a Meniett device is this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Voltaren 1% gel for the treatment of her bilateral tarsal tunnel syndrome.  Findings:  The physician reviewer found that Voltaren gel is a topical presentation of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) and is indicated for the relief of osteoarthritis of the joints amenable to topical treatment. Voltarens mechanism of action is related to the inhibition of cyclooxygenase, an enzyme involved in the conversion of arachidonic acid into prostaglandins which are mediators of inflammation and pain. The amount of systemic absorption of Voltaren gel is approximately 6% compared to the serum levels achieved with oral administration of the oral presentation. Although the cardiovascular and gastrointestinal risks are not completely eliminated with Voltaren, the possibility of such side effects is decreased. This particular patient has a history of renal surgery and therefore is at a higher risk of renal complications with oral NSAIDs. As such, the use of Voltaren in this particular setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Hyzaar for the treatment of her hypertension. Findings:  The physician reviewer found that patients with hypertension have several options available for therapy within the standard of care in clinical medicine. The Health Plan formulary has choices of different FDA approved antihypertensive agents that may be as efficacious without intolerable effects. However, this particular patient has been on a specific antihypertensive agent (Hyzaar) for several years with an efficacious control of her hypertension. Since this patient has no reported side effects and has been able to achieve and maintain control of her hypertension with Hyzaar, it is medically appropriate for this patient to continue use of this medication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested oral contraceptives for the treatment of her irregular bleeding. Findings:  The physician reviewer found that although oral contraceptive can be used to treat abnormal uterine bleeding, it is only one form of treatment for the problem. When the decision to use oral contraceptives is made, the relative risks and benefits need to be reviewed. If medical problems are present that create a significant risk, then alternate therapies should be prescribed. The American College of Obstetrics and Gynecology issued a practice bulletin which stated that combination oral contraceptives should only be prescribed with caution to smokers who are over age 35. There is a significant increased risk associated with the use of oral contraceptives in women who are over 35 years of age who smoke. Thus, the use of oral contraceptives is contraindicated in this patient given that she is currently a smoker. Additionally, there was no pathology report in the record showing that the endometrial cavity was adequately sampled during her biopsy. Such testing would be the next indicated step to determine the most appropriate treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a home sleep study for the treatment of her sleep apnea. Findings:  Two physician reviewers found that the American Academy of Sleep Medicine published criteria and recommended portable devices type II, III, and IV for sleep monitoring to diagnose sleep apnea. Additionally, Centers for Medicaid and Medicare (CMS) supports coverage of type I through IV portable sleep monitoring devices. While there is evidence to suggest that portable monitoring can effectively diagnose sleep apnea in some cases, it may not be as accurate as polysomnography in certain patients, especially those who have mild apnea. Furthermore, the question at issue in this appeal is whether the proposed home sleep study is likely to be more beneficial than any standard therapy (e.g., an attended level one polysomnography). Review of the peer-reviewed scientific literature does not demonstrate that superior results are achieved with a home study as compared to an attended polysomnography. In fact, re-evaluation via polysomnography is needed if the results of the home study are negative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested inpatient treatment for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the evidence demonstrates the medical necessity for continued treatment of this patient in a 24-hour treatment setting. The patient continued to have difficulties with insight regarding relapse, there was minimization of the severity of his addiction, and there was anxiety and ambivalence on his part. Overall, there was significant potential for relapse with services at a lower level of care; thus, continued treatment in a 24-hour subacute setting was medically necessary and consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) criteria and American Psychiatric Association (APA) practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested mental health intensive outpatient treatment for the treatment of the enrollees pervasive developmental disorder, not otherwise specified. Findings:  The physician reviewer found that this patient had been in intensive outpatient treatment for one year. An updated summary from the provider indicates that the patient has made progress in several areas, and his adaptive functioning was described as only moderately impaired. Other documents indicate that his emotional outbursts are less frequent. The school also reports progress and notes that he is able to handle transitions better. A behavior plan is in place. He continues to need ongoing support and redirection, especially with social interactions. He engages in hair pulling and has episodes of anxiety and frustration. The patient has academic difficulties. There is no documentation of ongoing high risk behavior. He continues to have challenges with change in routine, social interactions and flexibility. Goals of treatment from the intensive outpatient program include such goals as increasing relational capacity and social and family functioning. These appear to be ongoing and not specifically related to a major decline in overall functioning. This patient has a supportive environment, a capacity to participate in treatment and a low risk of self-harm. Therefore, current treatment goals could be addressed in regular outpatient therapy. This is consistent with the American Academy of Child and Adolescent Psychiatry practice guidelines and CALOCUS level of care guidelines. Thus, based on the patients level of functioning, continued mental health intensive outpatient treatment was no longer indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested eyebrow corrective surgery for the treatment of his eyebrow loss. Findings:  The physician reviewer found that this patient had a brow lift via superciliary brow incisions. He has visible unsightly incision scars above each brow that are not totally correctable by any means. It cannot be covered over by hair grafting because it lies at the edge of the eyebrows where the hairs are normally sparse. Filling it with sufficient grafts to hide it would result in a very unnatural looking eyebrow. The current condition does not constitute an abnormal structure of the body, such as a mutilated digit. The requested surgery would be done to improve appearance rather than improve function, and will likely not end up improving appearance. Improvement, if any, will not create a normal appearance or offer more than a minimal improvement in appearance. The requested procedure is not medically indicated and the California statute relative to reconstructive surgery does not apply.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patient has a diagnosis of ADHD for which Vyvanse is an FDA approved medication. Vyvanse is a prodrug of dextroamphetamine and offers certain advantages such as longer duration. Both efficacy and safety have been observed in the medical literature as noted in the article by Findling and colleagues. These determinations are also discussed by Najib in his publication regarding the use of Vyvanse in the treatment of ADHD. This patient has already responded well to Vyvanse as reported by both the provider and the patients parent. Vyvanse is medically appropriate in this setting and should be approved for treatment of his ADHD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested Voltaren 1% gel topical (100) for the treatment of his right pes bursitis and osteoarthritis. Findings:  The physician reviewer found that the request for Voltaren 1% gel topical stems from the patients desire to avoid having to take additional oral medications. The records from the patients physician do not document a swallowing defect. Nor is there data to substantiate the contention that the use of topical medication will negate the risks posed by oral NSAIDs. Per the Manufacturers Prescribing Information, use of Voltaren 1% gel can increase the risk of hyperkalemia, especially in patients with diabetes mellitus. The associated risks are similar to those of oral NSAIDS. Given the absence of evidence of an intrinsic swallowing defect, the necessity of Voltaren 1% gel has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested acupuncture for the treatment of her medical condition. Findings:  The physician reviewer found that Acupuncture is understood as an alternative complimentary medical technique of treatment. Its underlying rationale is based on the premise that the essential energy called Qi flows through the body along invisible lines called meridians. Stimulating points along these lines either with pressure or needle intervention corrects the flow of Qi to optimize health and impact pain. While literature support is somewhat lacking, there is evidence to suggest there can be significant benefit from conservative, non-operative modalities such as acupuncture. However, in the case of this specific patient, she reported that acupuncture had provided only minimal relief of her neck and knee pain and migraines headaches. There is inadequate documentation in this case to demonstrate the patient had significant response to acupuncture to support the necessity of the past or future treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for the treatment of his morbid obesity. Findings:  Two physician reviewers found that sleeve gastrectomy as part of a staged procedure is the most appropriate option for this patient. In a super morbidly obese patient, a standalone malabsorptive procedure such as Roux-en-Y gastric bypass and duodenal switch are more difficult to perform and carry greater risk. Furthermore, a lap band procedure involves less weight loss and will not achieve adequate results as a standalone procedure. Nor is it easily converted to a second procedure, as a gastric resection has to be done. For patients with sleeve gastrectomy, gastric resection has already been performed prior to the second surgery. All told, laparoscopic sleeve gastrectomy as the first stage of a two-phase surgery is likely to be superior to any other bariatric procedure.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested emergency room services for the treatment of his medical condition. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe the patients health to be in jeopardy without immediate medical attention. Based on the medical records provided for review, the patient did not have exhibit any symptoms or signs that would constitute an emergency. Upon presentation to the emergency room, the patients condition was stable. His vital signs and physical examination were normal. His symptoms of mild dysuria and penile discharge had been present for one week. It is not likely that these circumstances would cause a prudent layperson to reasonably believe that his health would be in serious jeopardy in the absence of immediate medical attention. It appears that a prudent layperson in this situation would make the decision that this was a non-emergent presentation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested intravitreal Lucentis injections for the treatment of his macular edema. Findings:  Three physician reviewers found that this patient has vision in only one eye. He has been receiving intravitreal Lucentis injections from a retinal specialist who feels they are warranted due to the decreasing vision in his only seeing eye. The Health Plan has denied coverage for intravitreal Lucentis injections, and this is the subject of the appeal. Lucentis has shown effectiveness in treating macular edema in other conditions aside from its original role in the wet phase of age-related macular degeneration. Based on its use in other settings, it is medically reasonable to pursue this line of therapy for the patient due to his monocular status and lack of alternative therapies for treatment of his progressive condition. There is no evidence that any other therapy will have superior efficacy in this patient who will lose his remaining vision without effective treatment.