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

A 67-year-old female enrollee has requested stereotactic body radiation therapy for treatment of her metastatic pancreatic cancer with tumor recurrence around the celiac axis. Findings:  Three physician reviewers found that this patient has received multiple courses of chemotherapy post-surgically. Recently, she was treated with SIRT for her liver metastasis and a CT scan showed new and progressive disease in her liver and new disease in her celiac axis. The choice of radiation therapy used to treat this patients present tumor recurrence around her celiac axis, are likely to alert the patients prognosis. According to the submitted records, the indication for the SBRT requested is palliative treatment for the celiac axis mass. If palliative radiation therapy is required due to her symptoms of abdominal pain, this could be treated with conventional/standard radiation therapy. Based upon the scientific data available at this time, SBRT is not likely to result in a superior clinical outcome for this patient or provide significant benefit in terms of reduced toxicity, etc. as compared to standard radiation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested for radiofrequency ablation (RFA) for treatment of his kidney cancer.   Findings:  Two physician reviewers found that there is no evidence submitted which documents that this patient, who is otherwise healthy, has an increased risk for standard surgery above and beyond that which is normal for his age.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Lyrica for treatment of her peripheral neuropathy. Findings:  The physician reviewer found that this patients symptoms are highly suggestive of neuropathic pain, which could be secondary to the abnormalities in her thoracic spine. In addition, the pain described by the patient correlates well with the anatomical location of this abnormal finding. Lyrica (pregabalin) is a calcium-channel modulator which has been approved for the management of neuropathic pain due to diabetic neuropathy, post-herpetic neuralgia and fibromyalgia. It has been used off-label for many other neuropathic pain conditions including complex regional pain syndrome (type I and II) as well as post-laminectomy pain syndrome and spinal cord injury. A similar medication (Neurontin) was previously tried by this patient, but caused side effects requiring discontinuation of the medication. Based on this patients excellent response to her prior trial of Lyrica, its lack of side effects and its very low risk (as opposed to surgery or spinal cord stimulation trialing and implantation), the requested medication is medically necessary to treat this patients symptoms of peripheral neuropathy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Botox injections for treatment of her cervicalgia and headaches. Findings:  Two physician reviewers found that the records provided do not document chronic migraine, but rather chronic tension-type headache and cervicogenic headache. The records indicate mild, dull and diffuse headaches with rare moderate headaches, as well as long-standing chronic neck pain. The literature and recent phase III clinical trials demonstrate Botox has moderate efficacy in the treatment of chronic migraine (Lew and colleagues and Wheeler and colleagues). There have been no large blinded studies on Botox for chronic neck pain, but several small studies do not support significant efficacy or benefit that is superior to standard therapy. Several large studies on tension type headache also do not support better symptom improvement with Botox than with placebo injection. In summary, the records provided do not support a do not support a diagnosis for which Botox has shown to be efficacious (i.e., chronic migraine). Chronic tension type headache and chronic musculoskeletal neck pain are not proven indications for the use of Botox.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Real-Time Remote Heart Monitor for an evaluation of his arrhythmia. Findings:  Three physician reviewers found that remote event monitoring is becoming an accepted modality for use in the detection of cardiac arrhythmias. In this case, however, the use of the device was not indicated at the time it was performed. Based on the records provided, the patient had been free of symptoms for months, nuclear stress and echocardiogram studies failed to reveal significant pathology of any sort, and two Holter recordings provided no additional insight. While it might have been considered reasonable to pursue a remote event recorder at a time when the patient was more symptomatic, the most opportune time for detecting arrhythmia had passed. As such, the use of a Real-Time Remote Heart Monitor was not likely to have been a more effective method of evaluating this patient than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested a custom, functional knee anterior cruciate ligament (ACL) brace for treatment of his medical condition. Findings:  The physician reviewer found that this patient is status-post anterior cruciate ligament (ACL) reconstruction and has full knee range of motion and good stability on his post-operative knee. Bracing after an ACL injury has been extensively researched and the latest literature does not support the use of post-operative bracing after ACL reconstructive surgery. Although the patients work requires him to negotiate hazards and obstacles on his feet, the literature on prophylactic bracing to prevent the rate and/or severity of re-injury of an ACL tear (post-surgery) is inconclusive. Since this patient was doing satisfactorily with his rehabilitation program, and the current literature does not specifically support the contention that prophylactic bracing reduces the rate and/or severity of ACL re-injury, the medical necessity of a custom, functional brace is not supported.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of her multiple sclerosis. Findings:  The physician reviewer found that pregnancy is a relatively protective circumstance for individuals with multiple sclerosis, although the literature shows that relapses are more common during the postpartum period. The relapse rate in multiple sclerosis decreases during the nine months of pregnancy, and it rises significantly during the first trimester postpartum, affecting one-third of patients. Standard medications for disease modification in relapsing remitting multiple sclerosis are contraindicated during breastfeeding. The medical literature shows IVIG to be beneficial in managing relapses of relapsing remitting multiple sclerosis, and to be of adequate safety during breastfeeding. Preventive management of relapses is the cornerstone of treatment for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested a Neuromonics evaluation and Neuromonics tinnitus treatment, utilizing the Oasis device for treatment of his tinnitus. Findings:  Three physician reviewers found that there is very little literature to support that outcomes of treatment for tinnitus with the Neuromonics method are positive. The studies that have been published to date are primary by the same authors. There has not yet been adequate investigation into this devices medical efficacy, especially in the long-term. As such, there is not enough evidence in the scientific literature to support the conclusion that the proposed device is superior to standard treatment (such as tinnitus masking devices). The submitted records do not document a trial of tinnitus masking devices by this patient. In sum, the patient is likely to derive greater benefit from further attempts at standard therapy than from Neuromonics therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his neck pain.  Findings:  Three physician reviewers found that there are no long-term, large, scientific studies showing the safety and effectiveness of cervical artificial disc replacement to date. Only small studies including the study reported by Mummaneni and colleagues, have demonstrated results in the short-term (less than two years follow-up). Moreover, the Food and Drug Administration (FDA) has required a seven- and ten-year study of each of the approved cervical disc replacement devices and these studies are currently ongoing.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the right breast (CPT 77058) for an evaluation of her abnormal mammogram. Findings:  Three physician reviewers found that the Breast Imaging Reporting and Data System (BIRAD), developed by the American College of Radiology, provides a standardized classification for mammographic studies. This system demonstrates good correlation with the likelihood of breast malignancy. The BIRAD system informs physicians about key findings and identifies appropriate follow-up and management. Review of the submitted evidence demonstrates that the patient had an MRI exam which revealed an abnormality classified as BIRAD 3, which calls for short interval follow-up (six-months). This abnormality, foci of enhancement, was only seen on the MRI exam; as such, MRI is the only modality that is appropriate to use for follow-up. Since the patients last MRI occurred over six-months ago, a repeat MRI is indicated at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested total disc arthroplasty (artificial disc) for treatment of his back pain. Findings:  Three physician reviewers found that the scientific evidence demonstrates that there is a lack of large, scientific studies showing the long-term safety and efficacy of artificial disc replacement. While the FDA has approved artificial disc implants for marketing, the approval is contingent upon the performance of 5-year, 7-year and 10-year studies to determine the long-term safety and efficacy of these devices. At this time, these studies are still ongoing. Until longer-term results are available, the superiority of artificial disc replacement as compared to conventional modalities remains unproven in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Uroxatral for treatment of his urinary retention. Findings:  The physician reviewer found that the pharmacological approach to the treatment of patients with lower urinary symptoms consists of alpha-1 blockers or/and 5-alpha-reductase inhibitors. The prostate is functionally made up of glandular tissue and muscle tissue. The alpha-1 blockers relax the muscle fibers in the prostate. There are basically two types of these drugs, selective and non-selective blockers. The selective blockers have slightly less effect on muscle fibers seen outside the prostate. The selective blockers include Flomax and Uroxatral.  Clinical studies do not show a significant difference in these two selective drugs. Thus, the Health Plans alternative of Flomax is medically appropriate for this patient. No evidence has been provided that Flomax has been tried without adequate results or that the patient has a contraindication to Flomax. As such, Uroxatral is not clinically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested continued annual examination/evaluation with a retina specialist (the same specialist who performed the original surgery five years ago) for treatment of his detached retina. Findings:  The physician reviewer found that annual eye examinations are medically indicated for this patient. However, it is not medically necessary that the original surgeon performs these evaluations. The Health Plan has offered follow-up treatment with in-network providers. An in-network ophthalmologist should be appropriately qualified to perform a thorough dilated retinal examination. This is within the standard of care of board certified ophthalmologists. There is no evidence that this patients scleral buckle will be rejected. This would be a rare event, particularly after several years without problems. If there are future retinal issues, a referral back to the original retina specialist would be indicated. However, at this time, the patient can be appropriately followed with annual examination/evaluation performed by an in-network ophthalmologist.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested multi-chamber programmable lymphedema pump (E0652) for treatment of her lymphedema. Findings:  Two physician reviewers found that lymphedema management should be highly individualized and designed to meet the needs of the individual patient. This patient has failed conservative management techniques. The records indicate that she will not tolerate uniform pressures throughout the extremity.  In such instances, multi-chamber programmable lymphedema pumps are indicated so that different pressures can be set within each of the devices chambers. When truncal edema is present, programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program, as noted by Mayrovitz.  In this patients case, use of the multi-chamber programmable lymphedema pump will likely be the most efficacious treatment for her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a laparoscopic adjustable gastric band for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 43.7, this patient meets nationally accepted criteria for weight loss surgery. The Lap-band is a well-accepted bariatric surgery. The resultant weight loss that the patient is likely to achieve with the Lap-band procedure is likely to provide substantial benefit for her co-morbid conditions. The fact that the patient has not participated in a two-year medically managed weight loss program prior to surgery should not preclude her from being considered an appropriate surgical candidate. The patient has attempted diet and exercise without success. Further attempts with conservative methods are not likely to achieve adequate results for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his 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. The procedure is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show weight loss that is comparable to other restrictive procedures with an acceptable complication profile. Health outcomes related to improvement of weight-related co-morbid conditions have been shown to also be comparable to other restrictive procedures. In the case of this patient, he has several co-morbid conditions that are contraindications to LRYGBP. All told, laparoscopic sleeve gastrectomy is the most appropriate procedure in this particular setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe their child 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 experienced the onset of an earache and medication was administered at home. Upon presentation to the emergency department, the patient appeared to be in no distress, as documented by both the physician and triage nurse. Her mother denied that the patient was experiencing shortness of breath or vomiting. The same patient had been treated for an ear infection within the past three months. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. A prudent layperson in the parents circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize the patients health, particularly in light of the patients prior history of ear infection.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a custom knee brace and lightweight material for treatment of her torn anterior cruciate ligament. Findings:  The physician reviewer found that the requested brace is a functional brace that supports damaged ligaments. It is frequently used by individuals participating in sports after an injury. However, there is insufficient reliable evidence in the medical literature that supports the superior efficacy of this device in the postoperative period following ACL reconstruction in comparison to the use of a basic knee support such as a neoprene knee sleeve. Birmingham, et al. published the results of a clinical trial in 2008, concluding that, `A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.`  Subsequently, Andersson, et al. reviewed the literature and concluded that `the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction.` The specific features of the requested knee orthosis (i.e., a custom-fit, functional knee brace) are not medically necessary as there are no proven benefits of these features with respect to health or functional outcomes in the absence of anatomical abnormalities requiring custom fitting (e.g., extreme shortness, tallness, or obesity). No specific anatomical factors requiring custom fitting are documented in the present case. The requested device, therefore, is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested knee surgery (osteochondral allograft(s)) for treatment of his knee pain. Findings:  Two physician reviewers found that the patient leads an active lifestyle and has multi-focal full-thickness lesions involving the medial femoral condyle, lateral femoral condyle, and lateral tibial plateau of his left knee. He has chronic knee pain that interferes with his activities of daily living. In spite of multiple medical and surgical interventions, the patient continues to be persistently symptomatic with a diminished quality of life. At his relatively young age, total knee arthroplasty would ultimately commit him to multiple revisions in the future. Biological restoration would maximize his function and potentially be more durable than total knee arthroplasty. The use of osteochondral allografts is well-documented in the orthopedic literature with good success. Although microfracture is contraindicated in large lesions with multiple lesions in the same compartment of the knee, this is the exact circumstance for which osteochondral allograft may be the most beneficial. Osteochondral allografting is indicated as the preferred treatment for cartilage defects greater than 2 cm2 or lesions involving both sides of the joint.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested signal-averaged electrocardiography for an evaluation of her palpitations. Findings:  Three physician reviewers found that signal-averaged electrocardiography is a special electrocardiographic technique in which multiple electric signals from the heart are averaged to remove interference and reveal small variations in the QRS complex, usually the `late potentials.` These may represent a predisposition towards potentially dangerous ventricular tachyarrhythmias. There are well-established indications for signal-average electrocardiography (Epstein, et al.). In this case, the submitted documentation does not establish that indications for a signal-averaged electrocardiography were met. Based upon the records provided, a signal-averaged electrocardiography was not likely to confer added clinical value in evaluating this patients symptoms. The clinical information provided is insufficient to demonstrate the superior efficacy of signal-averaged electrocardiography in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific literature as well as the submitted clinical evidence demonstrates that the proposed duodenal switch procedure is the most appropriate surgical option for this patient and is medically necessary. As the medical literature demonstrates, each of the weight loss procedures currently available carries a risk of complications. These risks vary among procedures. However, in terms of outcome, the duodenal switch procedure offers significant advantage when compared to other bariatric procedures. A study by Buchwald and colleagues showed that the percentage of excess body weight loss (EBWL) averages 70% over the long-term with duodenal switch compared to an average EBWL of 50% with other procedures. Furthermore, this study also found that patients with diabetes experience better results with the duodenal switch than with other procedures. A study of long-term results of duodenal switch by Marceau and colleagues found, In the long-term, DS [duodenal switch] was very efficient in terms of cure rate for morbid obesity and its co-morbidities. In terms of risk/benefit, DS was very successful with an appropriate system of follow-up. Overall, the evidence available to date demonstrates that the duodenal switch procedure offers the best long-term success rate of all the bariatric procedures. It does not require an implantable foreign object (such as the Lap-band procedure) which may require further surgical care or adjustments. Furthermore, the incidence of nutritional deficiencies after duodenal switch can be minimized with careful follow-up.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for CyberKnife radiosurgery for treatment of his prostate cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed scientific data demonstrating a significant difference in complication events following traditional external beam radiation compared to CyberKnife therapy in this setting.