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

A 40-year-old male enrollee has requested extracorporeal shock wave therapy for the treatment of his plantar fasciitis. Findings:  Three physician reviewers found that there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects of ESWT. In addition, there have been some conflicting results among the randomized controlled studies; a recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time there is nothing to indicate that the requested ESWT is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for Avastin and Alimta for treatment of her metastatic lung cancer.   Findings:  The physician reviewer found that Avastin has been found to be of some benefit when used in first-line chemotherapy with carboplatinum and taxol in patients with advanced non-small cell lung cancer. It has not been demonstrated to be of benefit when added to second and particularly third-line chemotherapy, as would be the situation in this case. Furthermore, its usefulness, even in first-line chemotherapy, has actually only been in patients with adenocarcinoma histology. This patient has squamous cell carcinoma. Many studies preclude the use of Avastin in patients with squamous cell histology, as discussed in the article by Sandler and colleagues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested for Vivitrol injections for treatment of his alcohol addiction. Findings:  The physician reviewer found that he did not tolerate the brief trial of naltrexone and the trial of Campral showed both side effects and ineffectiveness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old male enrollee has requested for growth hormone therapy (Nutropin AQ) for treatment of his short stature. Findings:  The physician reviewer found that he has experienced a marked fall off in growth and has had repeatedly low IGF-1 levels that could also be consistent with growth hormone deficiency. This makes a positive growth response after growth hormone therapy more probable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a breast lift and reduction for the treatment of her symptomatic macromastia. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the procedures at issue were reconstructive in nature. Breast reduction removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with a patients body and to alleviate discomfort associated with overly large breasts. While the presurgical photographs show a female with large pendulous breasts, the patients condition is not considered an abnormal structure of the body. There is no evidence of breast asymmetry or of disease or infection affecting the breast tissue. The removal of only 250 grams from each breast demonstrates that the patients breasts were not excessively large so as to constitute an abnormal structure. As such, this patients condition did not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Thus, the procedures at issue do not meet the definition of reconstructive surgery as defined in California law. Concerning general concepts of medical necessity, the reduction of 250 grams of tissue from each breast falls below the Schnur Sliding Scale Chart guidelines. According to Schnur, the volume of reduction can be used to distinguish cosmetic from functional breast reduction surgery. The reduction of 250 grams per breast falls below the 22nd percentile. Reductions above the 22nd percentile are considered medically necessary. Although the patient reported she was asymptomatic following surgery, it is unlikely that a reduction of only 250 grams of tissue from each breast will provide long-term relief from her musculoskeletal pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested cryosurgical ablation for the treatment of her benign fibroadenoma. Findings:  Two physician reviewers found that there is literature to support the use of cryoablation for symptomatic breast fibroadenoma. Clinical studies support the validity of ultrasound-guided cryoablation as a treatment option for this particular patient. According to the American Society of Breast Surgeons, the following criteria establish a patient as a potential candidate for cryoablation of a fibroadenoma: the lesion must be sonographically visible, the diagnosis of fibroadenoma must be confirmed histologically and the lesion should be less than 4 cm in largest diameter.  This patient met these criteria. Cryoablation was medically indicated and appropriate for this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested continued outpatient psychotherapy for the treatment of her major depressive disorder, posttraumatic stress disorder and dissociative identity disorder. Findings:  The physician reviewer found that this patient does indeed have a complex grouping of psychiatric symptoms that appear to have improved with relatively limited psychopharmacotherapy and relatively frequent psychotherapy. The literature recognizes the difficulties associated with the treatment of the patients conditions, but does not suggest a fully established method of treatment. The treating physician proposes a relatively long period of continued treatment, and the Health Plan feels it should be essentially curtailed. The patients current regression, the nature of her psychopathology and her response to treatment since it began suggest that it would not be clinically wise to curtail her psychotherapy. However, the duration that her physician now advises is lengthy and possibly excessive. Three additional months of outpatient psychotherapy at a frequency not to exceed twice a week is medically indicated and appropriate. This should enable therapy to continue for the present time. It should also allow for treatment termination and/or treatment modification to be planned in an adequate and appropriate manner.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested a Medtronic MiniMed continuous glucose monitoring device for the treatment of his type I diabetes. Findings:  The physician reviewer found that the use of the proposed CGMS is appropriate in this case because despite the patients diligence in attempting to control his sugar with an insulin pump, he has thus far been unsuccessful. A New England Journal of Medicine article states there is beneficial effect from CGMS as evidenced in the study in patients with type I diabetes mellitus with the primary outcome being a change in the glycated hemoglobin at 26 weeks. The article concluded, Continuous glucose monitoring can be associated with improved glycemic control in adults with type 1 diabetes. Based on the clinical evidence provided, the patient is appropriate candidate for the CGMS device and is likely to benefit from its use.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested a gait analysis test for an evaluation of the enrollees recurrent painful toe walking. Findings:  Two physician reviewers found that gait analysis is a standard tool today to diagnose, plan therapy and treat patients with cerebral palsy. Other disorders such as rheumatoid arthritis and dementia have not been shown to be benefitted by it. Idiopathic toe walking is an unusual but not uncommon condition, often related to speech disorders and is a form of apraxia, improper development of coordinated muscle skills. This patient has undergone extensive physical therapy and casting, and had surgery. His symptoms here recurred, and the information provided by a thorough gait analysis can be crucial in planning further therapeutic interventions such as Botox injections, targeted physical therapy, orthotic design and application, and ever further surgery. Gait analysis will provide valuable information to assist with his care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has chronic migraine with heavy use of acute therapy, frequent emergency room visits, and high degree of disability. She has seen multiple neurologists and failed over 5 preventive therapies, including all of the FDA approved drugs for migraine prevention. The phase II Botox study (Mathew, et al.) included exactly this type of patient, and showed significant improvement in many of the secondary endpoints. The phase III studies are completed and a preliminary announcement indicated they met the primary endpoint of migraine reduction in chronic migraine. As this patient has already been given adequate trials of usual treatment, investigational treatment with an effective agent such as Botox is necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested Campral for the treatment of his alcohol dependency. Findings:  The physician reviewer found that the patients desire to pursue sobriety is relatively recent and he has not had any social or pharmacologic intervention to date, the evidence in favor of naltrexone outweighs that of Campral. There is no data to suggest that Campral is likely to be more effective than naltrexone as a first-line agent for alcohol addiction. It is medically reasonable and appropriate to require that the patient have a trial of naltrexone prior to coverage for Campral.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Avastin for the treatment of her metastatic lung cancer. Findings:  The physician reviewer found that Avastin has been found to be of some benefit when used in first-line chemotherapy with carboplatinum and taxol in patients with advanced non-small cell lung cancer. It has not been demonstrated to be of benefit when added to second and particularly third-line chemotherapy, as would be the situation in this case. Furthermore, its usefulness, even in first-line chemotherapy, has actually only been in patients with adenocarcinoma histology. This patient has squamous cell carcinoma. Many studies preclude the use of Avastin in patients with squamous cell histology, as discussed in the article by Sandler and colleagues. As such, there is insufficient evidence to support the use of Avastin in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested an additional continuous positive airway pressure (CPAP) machine for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient clearly needs a CPAP machine for sleep apnea based on the number of events he experiences during sleep as well as his body habitus. However, to reduce his overall morbidity and mortality, it is not medically necessary to provide an additional CPAP device for his convenience of transportation to work. No study has shown that providing additional durable medical equipment devices improves compliance. In addition, the cited studies above support lack of compliance even when patients are at home. Short-term compliance predicts long-term compliance. A recent study demonstrated only age and use of a sedative improved compliance. Since the patient cannot use a sedative while at work, compliance is not likely to be increased even with a second unit.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients symptoms were not sudden in onset, but had been present for one month. She was described as healthy-appearing and non-toxic. She was not experiencing chest pains or shortness of breath. She did not require any testing or treatment in the emergency department. In sum, this patients symptoms did not meet the criteria for an emergency medical condition. A prudent layperson with an average knowledge of medicine and nasal congestion, cough, body aches and headache would not reasonably expect the absence of emergency care to jeopardize their health. This patient could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested an Omnipod insulin pump for the treatment of his diabetes. Findings:  The physician reviewer found that the submitted records do not substantiate the medical necessity of an insulin pump or the Omnipod pump in particular. An insulin pump may be indicated if there is documented evidence that the patient is unable to maintain control despite frequent checks of his blood sugar (at least 4 times daily). While the records suggest that the patient is monitoring, a monitoring log documenting the frequency of the testing has not been provided. Thus, given the absence of data to support a specific need for an insulin pump, the medical necessity of an insulin pump has not been established. Furthermore, other than the fact that the Omnipod pump does not require a catheter which can be pulled or caught, no evidence has been provided that the Omnipod is superior to a standard insulin pump. As such, the Ominipod pump would not be necessary for this patient from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested Lyrica for the treatment of her neck and back pain. Findings:  The physician reviewer found that this patient has pain consistent with neuropathic pain due to radiculitis. She is also diagnosed with myositis (a pattern consistent with fibromyalgia). Lyrica reportedly gave good benefit for her global pain symptoms. She had already tried and failed Neurontin (which is a neuropathic pain medication). Lyrica is medically necessary as it has been approved for treatment of fibromyalgia which this patient has a pattern consistent with. In addition, the studies indicate Lyrica is recommended as a first-line treatment for neuropathic pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested Leukine for the treatment of his neutropenia associated with chemotherapy. Findings:  The physician reviewer found that the American Society of Clinical Oncology guidelines state that reduction in febrile neutropenia is an important clinical outcome that justifies the use of colony-stimulating factors, regardless of impact on other factors, when the risk of febrile neutropenia is approximately 20% and no other equally effective regimen that does not require colony-stimulating factors is available. These guidelines also state that primary prophylaxis is recommended for the prevention of febrile neutropenia in patients who are at high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. The National Comprehensive Cancer Network guidelines have taken a similar stand on the use of prophylactic growth factors. They recommend prophylactic growth factors with regimens with a moderate to high risk of neutropenia, or in cycles following an episode of febrile neutropenia. The incidence of neutropenia associated with the proposed regimen has not been established in clinical trials. However, based upon similar regimens, the intensity of neutropenia is moderate and would meet the guidelines for use of Leukine. As such, Leukine is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old male enrollee has requested ankle foot orthotics (type R-Wrap) for the treatment of the enrollees cerebral palsy, spastic quadriplegia. Findings:  Two physician reviewers found that R-Wrap ankle foot orthotics would be superior for treatment of this particular patient as traditional ankle foot orthotics do not maintain his feet in neutral position, and he is also having mid-foot breakdowns. This patient fits the criteria for this brace and has not had significant success with other traditional ankle foot orthotics. With the R-Wrap brace, he has potential to improve functional mobility with more comfort and less skin breakdowns.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her plantar fasciitis. Findings:  Three physician reviewers found that extracorporeal shock wave therapy has been employed in the treatment of plantar fasciitis, but the results have not been clearly defined.  There have been many reports of good results, but there are also many papers indicating a lack of definite evidence of clinical efficacy. This therapy remains investigational, and the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested inpatient acute detox services for the treatment of his polysubstance dependence and amphetamine abuse. Findings:  The physician reviewer found that while the patient was indeed beginning to improve this improvement was not fully established until the following day. The patient continued to require acute inpatient care. His symptoms of diaphoresis, anxiety, agitation and nausea were beginning to improve but remained sufficiently present to require acute inpatient care that day. Inpatient acute detox services were medically necessary and fully indicated from the time of admission through the initial date in question. On the following day, the patient was sufficiently improved and no longer required this level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested bilateral secondary mastopexy for the treatment of her congenital breast asymmetry. Findings:  The physician reviewer found that the clinical documentation provided shows that the extent of the patients asymmetry does not rise to the level that it constitutes an abnormal structure of the body; therefore, the proposed surgery is not considered reconstructive in nature. With regard to whether the surgery is indicated based on general concepts of medical necessity, there is no evidence that the patients condition results in a functional impairment. Furthermore, the submitted records and photographs do not demonstrate breast pathology that would cause significant pain or discomfort. As such, the proposed surgical intervention is not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Provigil for the treatment of his bipolar disorder. Findings:  The physician reviewer found that though there is literature support for the use of modafinil (Provigil) in a variety of mood disorders, including bipolar disorder, there is not adequate documentation of the exact course of this patients illness and treatment to support the patients use of Provigil. In a similar vein, there is no adequate documentation of the patients mental status exam at any juncture. Conventional treatments, such as combined Lithium and Lamictal, do not appear to have been tried. Alternately, if they have been tried, there is no documentation to this effect or indication of the patients response. All told, given the absence of a detailed history of the patients illness and prior treatment, Provigil cannot be substantiated as the preferred treatment for his most recent depressed episode.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested biliopancreatic diversion with duodenal switch (BPD-DS) surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient qualifies for bariatric surgery based on her comorbid conditions and severe obesity. The BPD-DS procedure has an advantage over Roux-en-Y gastric bypass (RYGB) primarily for individuals with a BMI greater than 50. The patients BMI is 42. The patient can expect an improvement and perhaps resolution of diabetes with either the PBD-DS or RYGB procedures. As such, there is not sufficient evidence that the BPD-DS is more appropriate in this patient population than RYGB.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested pelvic floor training with biofeedback for the treatment of his outlet dysfunction constipation. Findings:  The physician reviewer found that there is no effective therapy and treatment for constipation, other then biofeedback therapy. A review of the literature presented by the patient supports this position and provides adequate evidence that biofeedback results in positive outcomes in this patient population. Given the lack of treatment options available for the patients condition, the use of biofeedback therapy was medically reasonable and appropriate. The therapy received by the patient in this case was medically necessary to treat his pelvic floor dysfunction and should be covered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested a magnetic resonance spectroscopy (MRS) for an evaluation of his traumatic brain injury. Findings:  Three physician reviewers found that this patient had a serious brain injury nearly five years ago with significant physical recovery and residual mild cognitive changes. The literature shows that MRS may in the future give better insight into prognostic factors for recovery from acute traumatic brain injury. In this patients case, there is no information submitted to suggest that MRS would be beneficial in clarifying the diagnosis, that clinical decision-making would be altered by MRS findings or that MRS results would guide treatment decisions. Additionally, there is no evidence in the literature or the clinical record that MRS will provide meaningful prognostic information years after traumatic brain injury.