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

A 65-year-old female enrollee has requested Lunesta for the treatment of her insomnia. Findings:  The physician reviewer found that Lunesta was and is medically appropriate for this patient. The patient experienced significant side effects on Ambien. Lunesta has been safe and effective for this patient. Additionally, improved safety of Ambien versus Lunesta in patients over 65 has not been demonstrated in peer-reviewed scientific studies. As such, it is medically reasonable and appropriate for this patient to continue taking Lunesta for treatment of her insomnia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that long-acting medications are almost always preferred, when appropriate. Long-acting medications prevent dosing multiple times per day, have less potential for addiction and diversion, and side effects are often lessened due to a more continuous and even dispersion of medication throughout the day. The patients physician documents that a long-acting medication, Adderral XR, is no longer effective for the patient. Vyvanse is another long-acting medication for the treatment for ADHD. Vyvanse is FDA-approved for ADHD and has much lower abuse and addiction potential than other ADHD medications. The patients physician reports that the patient is currently on Vyvanse with success` and thus it is medically appropriate to continue him on the medication at this time. The literature supports that Vyvanse is a safe, effective, appropriate, and FDA-approved treatment for this patients ADHD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Qualaquin for the treatment of his leg cramps. Findings:  The physician reviewer found that the FDA issued a statement of concern about the use of Qualaquin (quinine), for the off-label treatment of leg cramps due to the risk of serious side effects such as arrhythmias. There are other medications that are useful for the treatment of leg cramps which are not documented in the records submitted as having been tried and failed. Alternative medications include verapamil and gabapentin which have been shown to be effective in studies by Baltodano and colleagues and Serrao and colleagues respectively.  A trial of one of these drugs for treatment of this patients leg cramps would be more medically appropriate than Qualaquin, given its safety risks.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested an MRI of the right shoulder for an evaluation of her shoulder problem. Findings:  The physician reviewer found that this patient has numerous medical problems, including muscular pain. Review of the submitted clinical evidence reveals no documentation of recent evaluation of her neck and right upper extremity pain. There is no evidence of recent radiographs of the right shoulder in the records provided. As this patient has no documented recent physician concern of a rotator cuff abnormality or labral abnormality, there is a lack of medical evidence to support an MRI of the right shoulder. The patient does not meet clinical indications for an MRI of the shoulder at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested intrastromal corneal ring segment for the treatment of her keratoconus. Findings:  Two physician reviewers found that patients with keratoconus have very poor vision with spectacle correction due to the large degree of irregular astigmatism induced by the warped cornea. This patient had become contact lens intolerant. Therefore, the only options remaining to provide functional vision were implantation of intrastromal rings and penetrating keratoplasty. Intrastromal corneal ring segment implantation has been approved by Medicare to correct and stabilize keratoconus. The device at issue is within the standard of care in this setting and was a medically reasonable option for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested an H-wave system/treatment (rental) for the treatment of his neck/cervical injury. Findings:  Two physician reviewers found that H-wave (electrical stimulation therapy) does not currently have high-grade medical literature support. The scientific literature demonstrates only weak preliminary evidence of support (e.g., anecdotal reports, case series, and survey studies) for the H-wave machine.  A 2006 study by Blum and colleagues (submitted with this appeal) was a cross-sectional survey of 6774 subjects with chronic soft tissue injury or neuropathic pain using a Customer Service Questionnaire that evaluated user responses (subjective) to the H-wave device. A majority of users reported favorable results using the H-wave device in pain and function on the survey. A 2008 industry-sponsored meta-analysis (Blum and colleagues 2008) identified five studies in the literature. Given the large size of the 2006 survey in comparison to the other studies, the results were basically a re-iteration of the 2006 survey results. Multiple, significant limitations of the research were identified by the authors, including the very heterogeneous nature of the included studies, the subjectivity of the majority of the data, a lack of data collection with regards to adverse effects, and a lack of formal examination findings, test results or laboratory results. Overall, there is insufficient data from disinterested, evidenced-based, peer-reviewed studies published in the medical literature to establish the efficacy of this modality for the patients conditions. There is no literature support of any efficacy over self-directed exercise and basic palliative modalities such as self-applied thermal modalities (i.e., heat or ice).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch is an appropriate and standard primary treatment of morbid obesity. This patient is super morbidly obese and takes NSAIDs, which in a chronic fashion would generally be a contraindication for Roux-en-Y gastric bypass and can cause marginal ulceration (Felix and colleagues). The duodenal switch maintains the pylorus and therefore there is less risk of marginal ulceration. The duodenal switch is approved by the American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Metabolic and Bariatric Surgery (ASMBS) and Centers for Medicare and Medicaid Services for use in the treatment of morbid obesity in the well-selected patient. The procedure has been well-studied with long-term outcomes over 10 years. As with any weight loss procedure, there are associated risks. However, duodenal switch is generally safe and effective. Furthermore, it is well-accepted in the field that for super obese populations, the duodenal switch generally affords the greatest weight loss of any weight loss procedure. All told, the duodenal switch procedure is the most appropriate weight loss procedure in this particular setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested ambulance transportation for the treatment of her medical condition. Findings:  The physician reviewer found that the issue is whether the patients condition met the prudent laypersons definition of an emergency medical condition. Emergency medical condition is defined as a medical condition with symptoms of sufficient severity such that the absence of immediate treatment would result in placing the patients health in serious jeopardy, serious impairment of bodily functions and/or serious dysfunction of any bodily organ or part.  In this case, the patients condition does not meet the definition of emergency medical condition. The patient had experienced these symptoms on several occasions previously. When the ambulance arrived to pick her up, the emergency medical services team described her as ambulatory and in no distress. Her vital signs were normal. There was no complaint of chest pain. She did not require cardiac monitoring or medical intervention en route to the hospital. The patient could have been safely transported to the hospital by other means, such as a private vehicle. She had experience with this constellation of symptoms. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a referral to an orthopedic specialist for an assessment of her hemangioma. Findings:  The physician reviewer found that the development of the MRI scan has led to the identification of many asymptomatic incidental hemangiomas of the spine (see Hiari and colleagues). Hemangiomas are benign tumors, involving about 10% of the world population, and generally remain asymptomatic throughout the entire life of the individual (see Bandiera and colleagues). Regular follow-up monitoring of asymptomatic hemangiomas is unnecessary unless pain or other problems develop at the appropriate level (see Fox and Onofrio). Only 1% of vertebral hemangiomas are symptomatic (see Murugan and colleagues). In this patients case, the submitted records do not document the presence of pain or other neurologic findings which would indicate the need for further evaluation of the patients hemangioma at this time. Therefore, the Health Plans denial of the request for a referral to an orthopedic specialist is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a referral for consultation with an allergist/immunologist for the treatment of her rhinitis. Findings:  The physician reviewer found that patients with persistent symptoms despite standard medical management and environmental avoidance should be referred to allergy specialists for further identification of responsible allergies. The UptoDate guidelines referenced by the Health Plan state, Primary care physicians treat the majority of patients with allergic rhinitis, and often initiate therapy empirically, identifying triggers only through the clinical history. This approach may be adequate for many patients, although those whose symptoms are severe or refractory to therapy should be referred to an allergy specialist for a more definitive evaluation. Based on the submitted evidence, it appears this patients symptoms have been refractory to trials of several medications. Furthermore, although the results of the patients RAST testing were negative, Williams suggests in his publication that RAST results have been demonstrated to be less sensitive than those of percutaneous skin tests. Generally, skin testing is considered the optimal way of determining allergic sensitivity and is endorsed widely throughout the medical community. Consistent with Wallace and colleagues practice parameters, the clinical records presented for review, and the relevant scientific evidence, this patient should be referred to an allergy specialist for additional evaluation of her symptoms and further testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested speech therapy for the treatment of his dysfluency. Findings:  The physician reviewer found that stuttering is generally diagnosed as language skills develop in children.  In 80% of cases, this is thought to be a developmental problem, although the exact underlying cause is not completely understood. Spontaneous remission is noted approximately 70% of the time.  As noted in the study by Block and colleagues, although some short-term efficacy has been seen in adults who receive additional behavioral and speech therapy, relapse in the long-term is common. There is insufficient evidence that any immediate gains will be maintained over an extended period. Given that the long-term efficacy of speech therapy in adult patients with this condition has not been demonstrated, speech therapy is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 67-year-old female enrollee has requested acellular dermal sling (AlloDerm) for the treatment of her post-mastectomy wound infection and complications associated with chemotherapy in a staged breast reconstruction plan. Findings:  Three physician reviewers found that the use of acellular grafting is medically indicated in breast reconstructive surgery after cancer surgery and is not investigational. The description of the procedure in the published medical textbooks and well recognized peer-reviewed medical journals supports the safety and efficacy of its use. Further, the U.S. Food and Drug Administration (FDA), which regulates the use of AlloDerm, refers to it as banked human tissue and not a device. AlloDerm is intended for use in replacement or repair of damaged or inadequate integumental tissue. The FDA makes no distinction for its use in terms of body part or type of surgical procedure. In breast reconstruction surgery, AlloDerm is commonly used with tissue expanders as an inferolateral cover for the submuscularly placed expander to decrease the risk of implant exposure or displacement. Directly relating to this patient, these risks are inherently greater since she has already undergone radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested Oseltamivir to reduce his risk for contracting H1N1 virus and passing it to his pregnant wife and/or newborn child. Findings:  The physician reviewer found that this patients request is not consistent with recommendations for the prophylactic use of oseltamavir. The Centers for Disease Control and Prevention (CDC) indicates that antiviral agents are discouraged for prevention of illness in healthy children or adults based on potential exposure in community, school or other settings. The document also notes limited safety data for these drugs in healthy adults. Even if used for treatment purposes in the event the patient develops influenza-like symptoms, prevention of transmission is not absolute as patients with H1N1 influenza are contagious for one day prior to onset of clinical symptoms. Thus, the proposed use of a prophylactic antiviral to prevent H1N1 influenza in the patients high-risk spouse and/or newborn child is not recommended by CDC guidelines, nor has it been studied to determine its efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that while vertical sleeve gastrectomy is gaining support as a primary procedure, it has traditionally been used as a component of a staged procedure in super morbidly obese patients or as a primary procedure in patients with esophageal motility disorders or other contraindications to Roux-en-Y gastric bypass (RYGB) or adjustable gastric banding (Lap-Band). This patients records do not demonstrate any evidence of esophageal dysmotility or other contraindication to RYGB or Lap-Band. The American Society for Metabolic & Bariatric Surgery (ASBMS) indicates that a new position paper is pending, but without further information, the efficacy of sleeve gastrectomy remains unclear. This conclusion is further proven by Tucker and colleagues requirement in their 2008 study for institutional review board (IRB) approval, which suggests this specific procedure is still being studied. This patient should achieve good results with the standard surgical alternatives of RYGB or Lap-Band as suggested by her provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested a bunionectomy for the treatment of the enrollees bunion on the left foot. Findings:  The physician reviewer found that the requested bunionectomy is medically reasonable and necessary for treatment of this patients condition. The patients initial complaint upon visiting the provider was foot pain. There was mention in his notes of the patient trying different shoes and complying with the Health Plans requirements without positive results. Bunions are congenital deviations at the first metatarsal phalangeal joint (MPJ), and can only truly be corrected with surgery. At 15 years of age, this patients growth plate should be closed, enabling her to undergo bunion correction. The standard of care in this setting is surgical correction if the bunion remains painful and does not respond to conservative care. The records indicate that this is in fact the situation with this patient and therefore surgical correction is warranted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested radiofrequency treatment (radiofrequency neurolysis) of the neck for the treatment of her recurrent cervical facet pain radiating to the head and shoulders. Findings:  Two physician reviewers found that interventional procedures such as radiofrequency neurolysis have been described in the medical literature for purposes of diagnosis and treatment of cervical facet pain. They are indicated if conservative treatments have failed to provide adequate pain relief. Such is the case with this patient. Further, she reports that the radiofrequency treatment was very effective and lasted from four to six months. Radiofrequency neurolysis has allowed her to decrease her pain medications and increase her activity level. Based upon its demonstrated efficacy in this case, radiofrequency treatment (radiofrequency neurolysis) of the neck was and is medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an 11-month-old female enrollee has requested evaluation and treatment of swallowing dysfunction and manual electrical stimulation (e-stim) therapy for the treatment of the enrollees dysphagia. Findings:  Two physician reviewers found that this female patient has complex medical problems and disabilities resulting in significant feeding difficulties. She is currently receiving comprehensive feeding therapy, involving multiple modalities, including the use of e-stim. She has shown improvement as a result of this intensive therapy. The literature supports the use of e-stim for patients with dysphagia and feeding difficulties. Carnaby-Mann and Crary (2007) noted, Transcutaneous electrical stimulation involves the application of electrical current across the skin to excite nerve or muscle tissue during a functional task and concluded, this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES [neuromuscular electrical stimuation] for swallowing.  Numerous speech and language pathologists utilize this modality in their treatment of patients with dysphagia. The same authors in 2008 noted that, a systematic therapy for chronic pharyngeal dysphagia using adjunctive neuromuscular electrical stimulation (e-stim) produced improvement in clinical swallowing ability and functional oral intake without significant weight loss or complications. Finally, Shaw and colleagues concluded, VitalStim therapy clearly has a place in the management of dysphagia. In sum, the literature supports the adjunctive use of e-stim in the treatment of patients with dysphagia and feeding difficulties in this patient population.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested Propecia for the treatment of her alopecia. Findings:  The physician reviewer found that Propecia (finasteride) was used in a research study of pre-menopausal women with female pattern hair loss who were also receiving oral contraceptives (Iorizzo, et al.). Although there was improvement seen in their alopecia, it was not clear whether the results were due to the contraceptives or due to the higher dose of finasteride used in the study. In another study of post-menopausal women with androgenic alopecia, finasteride (one mg/day taken for 12 months) did not increase hair growth or slow the progression of hair thinning (Price, et al.). While there have been some reports of improvement in androgenic alopecia in the subset of women with documented hyperandrogenism (Shum, et al.), further studies are needed before its efficacy can be established. Furthermore, based on the information provided, it does not appear this patient has undergone evaluation of her androgen levels. All told, there is inadequate evidence to support the use of finasteride for treatment of androgenic alopecia and further studies are needed before this medication can be established as safe and effective in this setting. In addition, there is considerable risk involved in the use of this drug in women of reproductive age (Bowman, et al).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested allogeneic bone marrow transplant for the treatment of his chronic lymphocytic leukemia. Findings:  Two physician reviewers found that this patient has high-risk chronic lymphocytic leukemia (CLL). He has poor prognosis molecular features (CD38 positivity) and high-risk clinical features including lymphocyte count greater than 200,000, rapid lymphocyte doubling time, and short response to initial therapy. Given these features, standard therapy is very unlikely to be effective. The patient has good performance status, has no serious co-morbidities, has poor risk disease and has not demonstrated drug resistance. As such, he meets current clinical criteria for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with CLL. This patient is an appropriate candidate for treatment with HSCT and is more likely to respond to the therapy than any standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Nutropin AQ for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that while it appears that the patients growth slowed significantly, there is no evidence of a recent IGF-1 and bone analysis, no documentation of clear growth rates, and no recent adult height prediction against his expected mid-parental height of 59.5. In the absence of such evidence, it is not possible to confirm a neurosecretory GH deficiency that would necessitate the use of GH therapy. All told, the submitted evidence does not demonstrate that the patient meets criteria for growth hormone therapy at this time.