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

A 55-year-old female enrollee has requested for Betaseron 0.3mg for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has relapsing remitting multiple sclerosis, and she has poor balance and tends to fall frequently, per the medical records. She was previously on Avonex, but this resulted in side effects. Betaseron is appropriate and indicated for the treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for inpatient services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services and the American Psychiatric Association (APA) guidelines, this patient received medically appropriate services at the least restrictive level of care possible throughout her treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested for a referral for surgical repair of the right fibulafor status post transmetatarsal amputation right foot. Findings:  The physician reviewer found that a fibula osteotomy is not likely to be beneficial in this particular setting. There is CT scan evidence of midtarsal comminuted fractures involving the navicular, cuneiform and cuboid bones. Additionally, the submitted documentation notes the development of an equinus contracture at the right foot. These findings will not be remedied by the proposed procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for chiropractic services for treatment of her neck and back pain. Findings:  The physician reviewer found that there is no indication as to what these activities are, nor any indication as to the patients frequency or progression of the home therapy. In addition, there is no evidence of objective findings (with relation to restoration of lost function and/or changes in range of motion, provocative assessments and/or palliative care) from which to assess whether additional chiropractic treatment is likely to be of benefit. Finally, throughout the patients treatment course, there was little if any change in her subjective complaints and/or relief of symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that this patient has right breast pain with a persistent area of palpable asymmetric fullness. She has undergone conventional imaging (mammogram and ultrasound) which showed no suspicious findings. A breast MRI is utilized to evaluate suspicious palpable abnormalities when conventional imaging studies are normal. The American Society of Breast Surgeons state that a breast MRI is medically appropriate, for the further evaluation of suspicious clinical findings or imaging results which remain indeterminate after complete mammographic and sonographic evaluations combined with a thorough physical examination. Enriquez and Listinsky advocate for a breast MRI in patients with, a compelling clinical presentation with negative or equivocal imaging results. Swayampakula and colleagues also recommend breast MRI for patients with inconclusive findings on physical examination, ultrasound and mammogram. It is well-documented in the peer-reviewed literature that conventional breast imaging does not detect all breast cancers.  A breast MRI used as an adjunct to conventional breast imaging can diagnose breast cancers that are mammographically occult.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that Turner and colleagues reported that the earlier and more intensive speech therapy that an autistic child receives, the better the prognosis for normalized speech in the autistic child. Paul and Sutherland emphasize that early intervention and intensity of speech therapy is essential for young autistic patients to develop meaningful speech. With regard to this particular patient, speech therapy is even more appropriate as he demonstrates normal or near normal intellect despite his speech delay and autistic features, and as such, is likely to derive significant benefit from early intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested  for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the FDA guidelines for GH therapy for idiopathic short stature, the use of GH is indicated for those individuals who meet the following criteria: are at least 2.25 standard deviations below the mean; current growth rates are unlikely to permit attainment of adult height in the normal range; epiphyses are not closed; and diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. This patients height is more than 2.25 standard deviations below the mean. Her current growth rates are unlikely to permit attainment of adult height in the normal range. Furthermore, her epiphyses are not closed. While it is not known if a karyotype has been performed to rule out Turners syndrome, the treatment for Turners syndrome is also GH therapy per the FDA 2003 guidelines for treatment of idiopathic short stature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a colonoscopy for an evaluation as she has a history of colon polyps. Findings:  The physician reviewer found that this patient has a substantially higher risk for colon cancer considering her family history, which raises the concern for lynch syndrome. According to Winawer and colleagues 2006 discussion of the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society guidelines, this consideration increases the intervals at which the patient should undergo follow-up colonoscopies. Her providers have been reasonably adamant that the patient also be followed more closely due to her personal history of a large cecal mass that developed three years after her previous colonoscopy. As the records do not specify the patients bowel preparation for her previous colonoscopy, this too elevates the possibility that synchronous polyps could have been missed. Additional scientific data from Lieberman in 2006 reports that an aggregate incidence of 0.3-0.9% of patients who had adenomas removed subsequently developed invasive colorectal cancer within three years after baseline colonoscopy during which all polyps were removed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested for residential treatment for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that she presented with serious manifestations, including purging, restricting, overexercising, amenorrhea, bradycardia, orthostasis, dizziness, elevated LFTs, episodes of self harm, and significantly stressful family dynamics.  While the patient had experienced some improvement, she was not appropriate for discharge from residential treatment level of care at that time. Continued treatment was needed to prepare the patient for a step-down in level of care. It was essential for the patient to participate in a therapeutic home pass to determine stability for discharge. The transition from the safety and containment of residential treatment to being an outpatient is difficult at best. The importance of a careful assessment of a patients ability to manage a pass out of the hospital, and scrupulous discharge planning cannot be overemphasized. The chances of a patient's enduring success are significantly bolstered when these critical junctures are given adequate time and attention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested neck surgery for the treatment of his cervical degenerative disc disease. Findings:  Three physician reviewers found that the available medical literature shows promise in total disc replacement at one level however the devices used in these procedures are still undergoing studies to determine their long-term overall safety and efficacy. Further, there is a paucity of evidence supporting replacements at more than one level. Murrey and colleagues reported that there are no large, scientific studies showing the long-term safety and effectiveness of the devices, only short-term (less than two-year follow-up) studies. Brown and Heller noted that the indications for ACDF are similar to those for disc replacement and limited to patients with documented cervical radiculopathy or myelopathy. This patient presents with chronic neck pain without evidence of radicular or myelopathic findings on examination. Thus, cervical disc replacement at two-levels and ACDF are not medically indicated for this patient without documented radiculopathy or myelopathy. Even if this patient were a disc replacement candidate, current guidelines only recommend one-level replacement. All told, total disc replacement remains experimental and investigational as the Food and Drug Administration (FDA) has required each of the devices to undergo post-marketing studies to fully establish the long-term safety and efficacy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for a breast reduction and abdominoplasty for treatment of her low back pain, rash and other symptomatology. Findings:  The physician reviewer found that the proposed abdominoplasty does not meet the requirements of reconstructive surgery as defined by California law. The submitted documentation does not demonstrate the patients abdominal pannus is an abnormal structure of the body caused by infection, trauma, tumor or disease. The excess tissue is not so great so as to be considered a structural abnormality.Breast reduction surgery can be effective in relieving symptoms related to large breasts such as back pain, neck pain, skin breakdown, etc. To delineate which patients are likely to experience improvement in symptoms with breast reduction surgery, the Schnur scale was developed. It is a well-accepted guideline for differentiating medically necessary breast reduction from cosmetic surgery. The Schnur scale relates the amount of breast tissue removed to the pre-operative body mass surface area of the patient. It accounts for differing body masses among each patient and is not solely based on weight and height. In general, the greater the volume removed, the more likely the procedure is medically necessary. In this case, there is no documentation of the amount of breast tissue that is planned to be removed.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer.  Findings:  Three physician reviewers found that this patient developed recurrent prostate cancer in prostate fossa after radical prostatectomy. After radical prostatectomy, the bowels drop into the pelvis and if high dose radiotherapy is used, the bowels may be exposed to doses above the level tolerated by the bowels. In order to avoid toxicity to the bowels and rectum, IMRT can deliver more conformal high dose to concave and convex targets and avoid excessive radiation therapy to critical organs at risk. Pinkawa and colleagues demonstrated that post-prostatectomy radiation therapy yields a lower dose to the bladder with improved non-target tissue and bladder volume sparing. Teh and colleagues found that the treatment related morbidity profile was favorable with IMRT, and this delivery method allowed dose escalation, leading to better tumor control. A study showed that acute and late rectal toxicities seem to be significantly reduced compared with what has been observed with conventional 3D-conformal radiation therapy techniques (Zelefsky and colleagues). Short-term PSA control rates appear to be comparable to those achieved with 3D-conformal radiation therapy at similar dose levels. Based on this favorable risk-to-benefit ratio, IMRT has become a well-accepted mode of conformal treatment delivery for localized prostate cancer. A study confirmed the safety of IMRT for clinically localized prostate cancer (Zelefsky and colleagues). The incidence of rectal bleeding at 8 years was less than 2%, and the authors concluded that excellent long-term tumor control outcomes were achieved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for lumbar spinal fusion surgery and a 3-day hospital admission for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that Resnick and colleagues conducted a comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, and concluded that, Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. The authors suggest the standard of care for lumbar spinal fusion is to be recommended as a potential surgical adjunct in patients with a herniated disc with evidence of pre-operative lumbar spinal deformity or instability, or in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. Applying these recommendations, this lumbar spinal fusion is not indicated for this patient at this time. While her discogram does demonstrate axial pain, the authors advise against spinal fusion as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested Lyrica for the treatment of his neuropathic pain. Findings:  The physician reviewer found that the use of Lyrica is commonplace as an adjunct to monotherapy with narcotic medication and is useful in many painful conditions. The traditional U.S. Food and Drug Administration (FDA) indications for Lyrica include painful neuropathy from diabetes and post-herpetic neuralgia, as well as fibromyalgia. As noted by OConnor and Dworkin, there are many clinical studies that have demonstrated the benefits of Lyrica for neuropathic pain, chronic pain and post-operative pain. In practice, Lyrica is used quite frequently for management of patients with severe chronic pain. With regard to this patient, there is documentation of several years of good results with Lyrica as part of a stable low-dose narcotic regimen that seems to be very effective. In addition, he has been intolerant of several other medications including gabapentin and thus was started on the Lyrica. As he experiences no side effects and good pain relief, there is adequate rationale to continue the requested medication. After reviewing the medical literature, applying the standard of care, and taking special consideration of all aspects of this patients medical history, Lyrica is medically indicated for the management of this patients chronic pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested CPT codes 64555, 64555-51 x 2, 77003-26, 95972 and 99144 for occipital and peripheral nerve stimulator trial for treatment of his pain. Findings:  Two physician reviewers found that the patient has received treatment with multiple modalities including suboccipital decompression. He has tried several medications and failed to achieve good results. Interventional blocks have been minimally and temporarily helpful, and his practitioner has noted that he would be a good candidate for peripheral and occipital nerve stimulation for the trigeminal and atypical facial pain and occipital neuralgia. These services have been shown to be effective in several case series.  Studies by Slavin, et al. and Jasper, et al. showed nerve stimulation had pronounced effect for individuals with severe headaches who have failed more traditional modalities.  These studies are small but show consistent efficacy. The patient at this point has limited treatment options. Other potential modalities include deep brain stimulation for the trigeminal or radiofrequency ablation of the Gasserian ganglion, but these are much more invasive and involve greater risk. In this patients case, given his young age, lack of significant viable alternatives and failure of so many conservative therapies, the requested services are medically appropriate. Although further study of nerve stimulation is needed to determine its long-term efficacy, new and emerging literature shows good results in selected, carefully screened patients who fail other more traditional approaches. As such, the requested occipital and peripheral nerve stimulator trial is likely to result in a better clinical outcome than the alternative treatments that remain for this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested an MRI for an evaluation of her hypersomnolence. Findings:  The physician reviewer found that the patient has reported symptoms of excessive daytime sleepiness. Obstructive sleep apnea has been diagnosed, as well as depression. The causes of daytime fatigue are diverse, including disturbed nighttime sleep from any cause, as well as depression and many other medical conditions. The medical literature does not support the notion that brain MRI is sensitive or useful in the diagnosis of daytime fatigue, in the absence of focal neurological signs or symptoms or signs or symptoms of central apnea on pneumocardiogram. Such signs and symptoms are not present in this case. Thus, there is no clinical indication for the proposed MRI.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested 10 treatments of proton beam therapy for treatment of his squamous cell carcinoma of the base of tongue.  Findings:  Two physician reviewers found that the patient has a history of significant radiation dosing to his cervical spinal cord. In light of this, as well as the current C3 vertebral body involvement, it is appropriate to consider this situation as being similar to a spine sarcoma. This patients case should therefore be treated in much the same way as a spine sarcoma. As indicated by DeLaney and colleagues, proton radiation is the standard of care for radiation treatment in patients with spine sarcomas. The authors also note that spine sarcomas are unlike other tumors in that they require doses well in excess of spinal cord tolerance, yet protons have been established to deliver the required doses effectively. Proton beam therapy is likely to provide this patient with a better outcome than Intensity Modulated Radiation Therapy or other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for varicose vein procedures for treatment of her varicose veins. Findings:  The physician reviewer found that this patient reports symptoms including aching, night cramps, and edema. A trial of conservative therapy has failed to improve her symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for direct voice rehabilitation for treatment of his spasmodic dysphonia.  Findings:  The physician reviewer found that the scientific data is replete with studies regarding the use of botulinum toxin (Botox) for this condition and it is well-accepted that this is the most commonly used treatment. In addition, there are published results demonstrating the positive outcomes in patients who have undergone surgical repair, although these studies involve small numbers of patients studied. All told, while there are limited options in this setting, there is greater support for the efficacy of Botox and surgical intervention than direct voice rehabilitation, which has not been the subject of peer-reviewed studies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for intensive outpatient program services for treatment of her eating disorder. Findings:  The physician reviewer found that this is the patients first course of treatment for her eating disorder, it is essential that she not be discharged from services or stepped down in services before it is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Botox injections for treatment of her intractable migraine headaches. Findings:  Three physician reviewers found that this patient has been diagnosed with intractable migraines. She has failed a variety of preventives in the past, and thus her condition can be considered refractory. The literature regarding Botox shows it to be well-tolerated, generally without systemic side effects, and with adverse effects that are generally mild to at most moderate. The most recent and largest studies show benefit in patients with chronic migraine, even with ongoing medication overuse. Thus, there is adequate evidence that Botox can be useful in a subset of migraine patients such as this patient. Botox is more likely than standard treatment to be of benefit to this patient, and should be covered for ongoing treatment of her chronic migraine.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a PET scan for an evaluation of her pancreatic ductal adenocarcinoma. Findings:  Two physician reviewers found that a PET scan is indicated in this patients case, as it may aid in determining the extent of disease. Additionally, a PET scan is appropriate when more standard imaging modalities are unable to conclusively provide required information. PET scans have been shown to have increased sensitivity in comparison to computed tomography (CT) studies and have been shown to change management in patients with invasive cancer. In this patients case, preoperative scans did not detect metastatic disease. A PET scan is likely to be the most efficacious method of evaluating this patients medical condition and is the next appropriate step for the care and management of this patient.