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

A 35-year-old female enrollee has requested laparoscopic lysis of adhesions and evaluation for possible endometriosis for the treatment of her medical condition. Findings:  The physician reviewer found that while a laparoscopy for the purpose of assessing this patients infertility is medically appropriate in this setting, at issue is whether the proposed procedure is medically necessary for treatment of a medical condition other than infertility. Review of the submitted evidence does not demonstrate sufficient symptoms or findings to justify a laparoscopy for any other indication.  References on evaluation of chronic pelvic pain and endometriosis generally discuss the presence of symptoms over time as well as other possible findings. As noted in the treatment notes from the patients reproductive endocrinologist, the patient does not have pelvic pain and had an unremarkable exam and ultrasound. Per American College of Obstetrics and Gynecology (ACOG) guidelines, chronic pelvic pain is generally defined as lasting for more than six months. Regarding endometriosis, again per ACOG guidelines, dysmenorrhea, chronic pelvic pain, dyspareunia, uterosacral ligament nodularity, and adnexal mass (either symptomatic or asymptomatic) are among the most well-recognized manifestations. It is true that endometriosis can be asymptomatic or cause subtle symptoms, but under those circumstances, the diagnosis is not consequential, except perhaps for infertility. The patients other co-existing issues (abnormal periods, ovulatory disorder) are not relevant to the decision to perform a laparoscopy and are not caused by endometriosis. Management of these issues would not be influenced by laparoscopic findings. Thus, based on the evidence provided, but for the patients problems conceiving, there is no indication for a laparoscopy in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients poor outcome is a consequence of the initial operative technique utilized in this case rather than patient non-compliance. The operative report indicates that a shorter Roux limb was created resulting in less malabsorption than the more effective 150 cm common channel technique. The study by Hess and colleagues confirms this finding and further states that the occurrence of the need for re-operation in patients with short limb LRYGBP is becoming more frequent, especially in the super obese patient. The records also appear to indicate that the patient did attempt diet, exercise and medications after her pregnancy with poor results. Additionally, it has been difficult for the patient to exercise given that she has also developed plantar fasciitis which cannot be treated with non-steroidal anti-inflammatory drugs (NSAIDS) due to the increased risk of ulcer formation or gastritis in patients who are status post LRYGBP. While re-operation is associated with significant risk, there is also a very high probability that without revisional surgery the patient will develop severe obesity-related co-morbidities with highly negative impact on her health, especially in light of her high BMI. The results of the Torgerson study clearly show that life expectancy in patients with a similar BMI is greatly reduced. Several studies support re-operation as a legitimate approach to correct a failed LYRGBP in selected patients. All told, surgical revision to duodenal switch is the best treatment option for this patient as it is likely to result in significant weight loss and thereby prevent the development of serious co-morbidities; improve her electrolytes, vitamin deficiencies and anemia, allow the patient to initiate NSAID therapy to relieve the symptomatology associated with her plantar fasciitis and thus start being able to exercise; and relieve her dumping syndrome, if present.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Sutent for the treatment of her metastatic thyroid cancer. Findings:  Two physician reviewers found that in patients with metastatic thyroid carcinoma who are refractory to radioactive iodine, there are no effective therapies. Small molecule tyrosine kinase inhibitors, such as Sutent, have demonstrated clinical responses with tolerable treatment. Based on these studies and the lack of other established treatment options, the National Comprehensive Cancer Network consensus panel noted that treatment with small molecule tyrosine kinase inhibitors should be considered in this patient population. Thus, Sutent is a medically reasonable and appropriate option in this setting, particularly in light of the limited treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a PET scan for an evaluation of her gait/mobility disorder. Findings:  Two physician reviewers found that the peer-reviewed literature showed little support for the use of PET scans in patients with known or suspected Parkinsons or related movement disorders. The use of PET scans in patients with movement disorders is limited to those patients who are participating in a clinical trial. At this time, there is a lack of randomized, well-controlled studies to support PET scans in patients with movement disorders. It has yet to be shown that the proposed study provides clinically useful information for evaluation and management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested psychiatric residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted medical documentation does not demonstrate medical necessity for placement in a 24-hour sub-acute residential setting. The patient was described as low risk for dangerous behavior, displayed no mood or thought disturbance, experienced no episodes of aggressive behavior and was motivated for treatment. Thus, the patient did not meet the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care criteria or the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for oppositional defiant disorder (ODD). The practice guidelines for the treatment of ODD recommends the least restrictive treatment setting whenever safely possible and identifies day treatment and/or intensive community based and family interventions as preferable alternatives to residential placement.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested Botox injections for the treatment of his intractable migraine headaches. Findings:  Three physician reviewers found that this patient has a severe secondary headache disorder and has been tried on all of the usual acute and preventive migraine medications without improvement. Botox has a unique mechanism of action and most likely works by blocking peripheral trigeminal nerve nociceptive input. While the vast majority of literature involves Botox in chronic migraine, Botox has also shown results in a variety of intractable headache and facial pain disorders including trigeminal neuralgia, occipital neuralgia and cluster headache. The records from the specialist suggest the patients headaches are related to intracranial pressure dynamics but multiple surgical procedures have failed to provide anything more than temporary relief. Given the intractable and severe nature of the headaches, the patients failure to respond to extensive trials of standard therapy, and clinical literature that suggests a variety of atypical headache disorders may respond to Botox, Botox is likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested minimally invasive, anterior approach, bilateral total hip arthroscopy using the HANA table for the treatment of his hip pain. Findings:  The physician reviewer found that the use of an anterior approach in this specific patient is likely to be beneficial, reducing the risk of dislocation and minimizing the surgical trauma to the tissues surrounding the hip joint. The approach chosen by the patients provider requires a meticulous and disciplined application of surgical technique. While it is possible to perform the planned procedure with a skilled assistant on a standard operating table, the use of the HANA table will provide easier access to the femoral shaft. The use of the anterior and anterolateral approaches allows for excellent visualization of the acetabulum, but requires special effort in visualizing and gaining access to the femoral shaft. By using special retractors as well as a specifically designed table, the difficulty created by the anterior approach can be overcome. The request for an anterior approach to bilateral total hip arthroscopy combined with the use of the HANA table is fully in the tradition of carefully developed surgical approaches and is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female has requested duodenal switch surgery for the treatment of her obesity. Findings:  The physician reviewer found that in the available scientific literature, the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. The Health Plan points to several alternative procedures (i.e., vertical sleeve gastrectomy, LRYGBP and gastric banding) which it contends are appropriate to address the patients presurgical history and potential postoperative concerns. However, no single alternative recommended by the Health Plan offers all of the advantages of the duodenal switch procedure. Furthermore, there is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications. All told, the duodenal switch procedure is medically appropriate and necessary for treatment of this patients obesity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested left total ankle arthroplasty for the treatment of her end stage post-traumatic arthritis. Findings:  Three physician reviewers found that the medical literature lacks long-term, controlled double-blind studies validating the safety and efficacy of this procedure. While preliminary studies suggest promise for total ankle arthroplasty, without peer-reviewed literature in support of the procedure, its efficacy remains unproven. SooHoo and colleagues state that, This study confirms that, compared with ankle fusion, ankle replacement is associated with a higher risk of complications but also potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion. Additional controlled trials are needed to clarify the appropriate indications for ankle arthrodesis and ankle replacement. Thus, there is currently insufficient evidence to support the conclusion that total ankle arthroplasty is likely to be more efficacious for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a urology consultation for the treatment of his possible urinary tract infection. Findings:  The physician reviewer found that an evaluation of a male with complaints of urinary frequency and suprapubic pain would in most cases be performed by a primary care physician; workup would include urinalysis, physical examination, and obtaining a prostate symptom score index and voiding dairy. In cases with moderate suprapubic pain, a CT scan could be ordered to rule out a urologic stone. According to Rosenberg and colleagues, this patients symptoms (assuming a negative urinalysis), would likely be treated with alpha one blockers, with or without a 5 alpha reductase inhibitor with re-evaluation in one to three months. All of services are within the scope of expertise of a primary care physician. Generally, if a patient is found to have a large residual amount of urine, a urologic stone, blood in the urine, or poor response to medical therapies with symptoms of prostate enlargement, a urologic consultation is indicated. Based on the documentation provided, this patient does not meet criteria for urologic consultation at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Beta irradiation for the treatment of her left eye pterygium. Findings:  The physician reviewer found that the patient is requesting Beta irradiation as primary treatment of her pterygium in her left eye. The patients treating provider, an ophthalmologist, recommended surgical excision with conjunctival autograft. This recommendation is the standard of care within the ophthalmology community for treatment of a primary pterygium in a patient that is not at significant risk for recurrence. Based on the information provided by the treating provider, this patient is not at high risk of recurrence as he indicated a 90% likelihood of success. In high risk patients, the standard of care is excision with conjunctival autograft in addition to intra-operative or post-operative mitomycin C. Beta irradiation is an adjuvant treatment for patients after surgical excision of a pterygium to reduce the risk of recurrence. However, the risk profile of Beta irradiation is greater than newer anti-metabolites such as mitomycin C and thus, Beta irradiation is no longer considered the standard of care, even for adjuvant treatment after pterygium excision.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested cervical disc replacement surgery for the treatment of her cervical radiculopathy. Findings:  Three physician reviewers found that there are as yet unresolved issues of long-term efficacy and long-term health outcomes for cervical disc replacement. FDA approval has been obtained contingent upon completion of a long-term study. The longest-term study published to date includes a two-year period of follow-up and demonstrates only non-inferiority when compared to more traditional cervical intervertebral disc arthrodesis, foraminotomy and discectomy. Furthermore, in the case of this patient, the patients provider noted in February 2009 that the specific levels responsible for the patients symptoms had not been adequately determined. They noted that the, Clinical scenario is too difficult to determine which level is a problem. The testing subsequent to this statement included EMG nerve conduction testing, which was reported to be normal and does not help in localization. The CT scan is consistent with the MRI findings but does not provide specificity as to level. All told, there is inadequate evidence demonstrating that cervical disc replacement is likely to be superior to standard therapies in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested participation in a clinical trial, Inamed Corporation Style 410 Silicone Filled Breast Implant Continued Access Reconstruction/Revision Expansion (CARE) Clinical Study for the treatment of the enrollee, who is status post bilateral mastectomy and reconstruction. Findings:  Two physician reviewers found that the provider notes asymmetry of the inframammary folds, lateral constriction and bending. These issues all point to capsular irregularities, not implant problems. A more projecting implant will not likely resolve these issues. This will involve removal of Alloderm remnants, reconstruction of inframammary folds, capsular excision and new implants. Potentially, the implants might need to be moved from retropectoral position to prepectoral, although their location is currently not clear. Current style implants are adequate. The medical literature does not demonstrate a more beneficial effect from the use of the requested implants over standard, currently available implants.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested use of a dynamic adjustable ankle extension/flexion device (Dynasplint) for the treatment of his ankle joint contracture/fasciitis. Findings:  Two physician reviewers found that the submitted documentation in this case indicates that a dynamic orthosis (Dynasplint) has been requested for the condition of plantar fasciitis. Limited clinical information is contained in the records submitted by the patients provider. Specific details regarding previously failed standard therapies are not documented. A review of the medical literature indicates that there have been very few published studies regarding the use of the Dynasplint device for plantar fasciitis. Those studies which have been performed are small and non-controlled and are only preliminary studies. Thus, the efficacy of the Dynasplint device for the treatment of plantar fasciitis remains unproven at this time. Furthermore, the submitted clinical evidence does not demonstrate that standard proven therapies have been exhausted in this particular case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Remicade 10mg/kg every 6 weeks for the treatment of her ulcerative colitis. Findings:  Three physician reviewers found that it is the standard of care to increase and adjust the dosage of medication when the initial dose stops working. While review of the scientific literature does not reveal any double-blind studies regarding the use of Remicade at a dose of 10 mg/kg every 6 weeks for treatment of ulcerative colitis, there does not appear to be any contraindication to the requested dosage and frequency. In fact, this patient did improve with the higher dose of Remicade administered. Further, the administration of the drug at a frequency of every 6 weeks appears appropriate given the breakthrough symptoms the patient has been experiencing toward the end of the 8-week course. At this stage, the only other option remaining would be surgical intervention, which is invasive and should be avoided if possible.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a back-up manual wheelchair for the treatment of her tetraplegia. Findings:  The physician reviewer found that this patients only mode of transportation is her power wheelchair, and when a breakdown occurs, as can reasonably be expected, this patient would not have any alternative form of transportation without a back-up manual wheelchair. Thus, the patient could be in a detrimental and hazardous situation with the risk of pressure sores if she were confined to bed during the breakdown of her power wheelchair. Additionally, the patient currently is transported via the familys van, although if that van ever needs maintenance or repair she would not be able to leave her home, whereas with the manual wheelchair her family could transfer her in a car. Therefore, a reclining manual backup wheelchair has been requested. In the past there was a period of time when the patient had a malfunction of her electric wheelchair, and she required a loaner reclining high-back wheelchair. The rationale provided by this patients treating physician, physical therapist and occupational therapist to support the medical necessity of a back-up manual wheelchair is appropriate and meets the standard of care. As noted by the patients providers, it is quite common over time for an electric wheelchair to malfunction or to need service. If this patients electric wheelchair was to malfunction, this would not be just a mere inconvenience to this patient, but would also create a risk of substantial complications of immobility if the patient had no option other than to stay in bed (skin breakdown, increased contractures, etc.). Easy and reliable access to a loaner wheelchair would be an alternative to purchasing a backup manual wheelchair for this patient. However, it is unlikely that a reclining high-back wheelchair would be available on a predictable basis if this patients power wheelchair were to unexpectedly require repair. Thus, the requested backup reclining high-back wheelchair is reasonable and not merely for the convenience of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain for an evaluation of her dizziness. Findings:  The physician reviewer found that this patient reported symptoms of dizziness and light-headedness (possibly positional). The differential diagnosis of dizziness is wide, including vertigo, presyncope, seizure, anxiety, stroke, anemia, and residual effect of head trauma. Appropriate evaluation would include a detailed history, measurement of vital signs, otologic examination, cardiac physical exam, neurologic exam, and consideration of provocative testing such as the Hallpike maneuver and forced hyperventilation. As a result of clinical assessments, further diagnostic testing may at times be indicated, including blood tests, EKG, EEG, and brain imaging. Isolated dizziness is unlikely to represent serious structural disease such as transient ischemic attack or brain tumor and as such, MRI and MRA are not helpful. Based upon the evidence provided, there were no signs or symptoms that would support the medical necessity of the MRI and MRA tests performed in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested Rituxan for the treatment of her acute cervical myelopathy. Findings:  The physician reviewer found that this patient suffered a devastating transverse myelitis that was treated very aggressively. Her evaluation did not show evidence of multiple sclerosis or neuromyelitis optica (NMO). Longitudinally extensive myelitis is a hallmark of NMO as well as systemic lupus erythematosus. However, in this case there is no mention of NMO antibody positivity, and no evidence of lupus. Nor does the patient have a history of NMO or recurrent myelitis. There are many articles concerning the use of Rituxan in patients with NMO. However, there is a paucity of literature on Rituxan in transverse myelitis. Given the patients stable status and absence of inflammation or enhancement on MRI coupled with the lack of supportive literature, retreatment with Rituxan is not medically necessary at this time. If the patient develops recurrent neurologic symptoms that suggest NMO, the request for Rituxan should be reconsidered.