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

The parent of a 17-year-old male has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder and per the submitted documentation, his symptoms include hopelessness, suicidal ideation, poor concentration, anhedonia, and isolation.  The patients medical history does not reflect comorbid anxiety disorders or a history of substance abuse/dependence.  His prior medications have included Wellbutrin, Zoloft, Prozac, Lexapro, Cymbalta, Abilify and Adderall.  The superior efficacy of the requested services has not been established in this clinical situation. There is a lack of literature supporting the use of transcranial magnetic stimulation in the child and adolescent population.  The documentation noted that the patient experiences auditory hallucinations.  As per American Psychiatric Association guidelines, electroconvulsive therapy is superior over transcranial magnetic stimulation for patients with psychotic symptoms.  For patients whose symptoms have not responded to medications, electroconvulsive therapy remains the most effective form of therapy and is recommended with substantial clinical confidence.  American Psychiatric Association guidelines note that the treatment of refractory depression may include augmentation strategies, such as mood stabilizers, atypical antipsychotics, stimulants and thyroid replacement.  The clinical notes indicate that the patients medications have included lithium, Abilify and Adderall.  However, it has not been demonstrated that these medications were offered in the current episode of treatment, at therapeutic doses, for adequate time frames.  Therefore, the submitted documentation does not demonstrate that the current episode is refractory.  All told, transcranial magnetic stimulation is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male has requested nebulized Amphotericin B for treatment of his allergic bronchopulmonary aspergillosis (ABPA).  Findings:  Two physician reviewers found that the patient has been diagnosed with allergic bronchopulmonary aspergillosis (ABPA). The patient is also diagnosed with bronchiectasis with progressive cavitary degeneration of the lung, fungal mycetoma, arteriovenous malformation of the lung and recurrent hemoptysis. The patient has attempted trials of prednisone and voriconazole, which were of no benefit. Additionally this treatment is now contraindicated due to the presence of uncontrolled diabetes and liver failure. In this patients case, standard pharmacological treatments utilizing prednisone and voriconazole are now contraindicated given the patients diabetes. Standard therapy with embolization is a first-line therapy in this setting and is typically very effective at controlling hemoptysis. The proposed alternative with nebulized Amphotericin B has been suggested based on the higher tissue concentration with decreased toxicity and it has been noted to be successful as a prophylaxis in immunosuppressed patients with cystic fibrosis with allergic bronchial aspergillosis (Brinson, et al.). Bronchial arterial embolization and pharmacotherapy with nebulized Amphotericin B are not exclusive of each other. All told, it appears that a combination approach consisting of embolization along with nebulized Amphotericin B is likely to be more efficacious for this patient than standard pharmacological therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male has requested pro-disc cervical artificial disc replacement surgery for treatment of the his cervical radiculopathy.  Findings:  Three physician reviewers found that the patient has a nearly 2-year history of neck pain with some radiation into the left upper extremity in a C7 type distribution. The records indicate he has been treated with pain medications. His exam showed left triceps atrophy and 4 of 5 triceps strength with an absent triceps reflex. A magnetic resonance imaging (MRI) has shown C6-7 degenerative disc disease with severe foraminal narrowing on left. The patients provider noted options to include a posterior foraminotomy or artificial disc replacement (ADR). The provider recommended the ADR procedure. The use of ProDisc-C remains unproven as this device has not been proven to have long-term safety and effectiveness in properly designed randomized controlled clinical trials. There have been a number of published studies that have shown promising results with this procedure. However, these studies have either a small number of patients or only include short-term follow-up (Murrey, et al; Delamarter, et al). Further, the Food and Drug Administration (FDA) has required a post-approval study which is still ongoing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female has requested a positron emission tomography (PET) scan for evaluation of her small cell lung cancer.  Findings:  Two physician reviewers found that five years ago the patient was diagnosed with endometrial cancer and was treated with total abdominal hysterectomy.  At that time, she was found to also have a lung mass diagnosed as small cell lung cancer and was treated with radiation therapy and chemotherapy. At this time, she has no change in symptoms. She has diabetes mellitus and is taking Metformin. A positron emission tomography (PET) has been requested for three-month surveillance because her provider states that Metformin use requires 96 hours of withholding the drug to avoid contrast enhanced nephropathy with routine contrast enhanced computed tomography (CT) scanning.   The National Comprehensive Cancer Network (NCCN) guidelines for surveillance of small cell lung cancer specifically state that PET scans are not recommended. Similarly, the Centers for Medicare and Medicaid Services (CMS) does not advocate in favor of PET scanning as a surveillance modality for patients with small cell lung cancer. In addition, the argument that Metformin therapy needs to be withheld for 96 hours after iodinated contrast administration is not supported by the American College of Radiology (ACR) position paper on contrast usage in this clinical setting. The ACR recommends halting Metformin therapy the day of the contrast study and followed by 48 hours without the drug. Moreover, there have been no documented adverse effects on patients with diabetes with this regimen. For these reasons, the requested diagnostic procedure is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested coverage for a past magnetic resonance imaging (MRI) of the bone marrow for evaluation of his amyloidosis.  Findings:  Two physician reviewers found that the patient has a diagnosis of amyloidosis. He has documented gastrointestinal involvement, and has received treatment with Velcade, Cytoxan, and Decadron. He is being evaluated for treatment with high-dose chemotherapy followed by autologous stem cell transplant. As part of the work-up for this procedure, he underwent bone marrow evaluation by magnetic resonance imaging (MRI). In practice, bone marrow MRI is noted for its sensitivity in detecting extent of bone marrow involvement in plasma cell dyscrasias, and is more sensitive than plain x-rays in the detection of lytic lesions of bone. Despite this, it is not clear how data provided by MRI of the marrow is clinically applicable or how it would impact clinical decision making in this patient who is to undergo a stem cell transplant. The provider asserts that the MRI was indicated to fully evaluate the status of his bone marrow disorder. He further asserts that marrow MRIs are well-established tools for staging and evaluating marrow-based disease. In the National Comprehensive Cancer Network (NCCN) guidelines, MRI is recommended in the work-up of multiple myeloma when clinically indicated as in cases where a patients symptoms suggest the presence of a bone lesion, or plasmacytoma, and plain x-rays are non-revealing. However, routine evaluation of bone marrow by MRI is not recommended by the consensus guidelines. Given the absence of a compelling clinical justification for the utility of the diagnostic procedure at issue, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 20-year-old male has requested coverage for the past and current inpatient services provided for the dates under review and coverage for admission to a residential developmental disabilities and mental health issues (DDMI) program for treatment of the his autism and global cognitive delays.  Findings:  The physician reviewer found that although no assessment can predict future violence with significant accuracy, there are several known risk factors that increase risk for dangerousness. According to the American Psychiatric Association (APA) Textbook of Psychiatry, poorly educated young males with intellectual disabilities represent demographic risk factors associated with violence. Further, previous violent behavior is highly correlated with future violence. Clinically, this patient with Axis I and II disorders remains behaviorally unstable. Considering his current status, demographics and past history, the patient poses a risk to self or others in the community. At this time, he requires a comprehensive multidisciplinary treatment plan applied by specialized staff under 24-hour supervision to achieve the general goal of normalization via community integration.  The current acute hospital setting is suboptimal, but in the absence of an alternate residential facility, combined with the volatility and degree of risk to self or others, the current level of care is the most appropriate setting. The request for admission to a residential DDMI program upon discharge from the acute inpatient setting is medically reasonable and necessary given the patients clinical presentation and ongoing behavioral instability.  In conclusion, the patients stay was and is medically necessary to effectuate a safe discharge plan of care, and, admission to a residential DDMI program is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for diagnostic cardiac catheterization with coronary angiography and subsequent treatment for treatment of his medical condition. Findings:  The physician reviewer found that the likelihood of significant obstructive coronary disease is high, such that planning for possible percutaneous coronary intervention concomitant with a diagnostic coronary angiography is reasonable, appropriate and medically less risky compared to performing two separate procedures. Separate procedures may require two separate arterial access punctures which both carry an inherent increased risk; the alternative would be to utilize a shealth, which would be required to be maintained for several additional hours during transportation to a facility capable of performing percutaneous coronary intervention. Prolonged sheath placement would likely increase the rate of arterial access site complications such as infection or hematoma formation.  Also, if two separate procedures were required then additional catheter manipulation in the arterial system would likely result in an increased risk of catheter associated adverse events such as embolization. Therefore, it is medically reasonable, appropriate, less risky, and considered standard of care to expect elective cardiac catheterization to be performed in a facility that is also capable of performing percutaneous intervention in patients who have a high likelihood of needing such a procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female has requested lysis of epidural adhesions (epineurolysis) for treatment of her lumbar arachnoiditis.  Findings:  Two physician reviewers found that the patient has a history of two previous lumbar spine surgeries, and still reports chronic refractory low back and lumbar radicular pain. The patient has evidence of epidural scarring and arachnoiditis on exam and magnetic resonance imaging (MRI). There is also evidence of lumbar nerve root clumping at L3 and L4 levels, especially on the right side. She is being treated with narcotic pain medication, non-steroidal anti-inflammatory drugs (NSAIDs), physical modalities and other injections with marginal results. She is not a surgical candidate and has pain with everyday activities causing disability and a negative impact on her quality of life. Her pain physician is recommending lumbar percutaneous epidural lysis of adhesions with Racz catheter. In reviewing this case, the patient has a history of failed back surgery syndrome due to epidural scarring and arachnoiditis causing refractory radicular pain. The patient has reportedly failed traditional management including medications, physical therapy, and standard interventions, though her history of interventional management is not specifically noted. At this point, she is not a candidate for re-operation as the scarring may worsen. Further, the treatment options are limited to frequent steroid injections or spinal cord stimulation. The patient is a good candidate for lysis of adhesions and if successful for six months or more may be a good candidate for long-term management via injection technique. Patients with lumbar epidural adhesions have been treated with lysis of adhesions for many years using a standard protocol with or without hypertonic saline. The literature and systematic reviews do show strong short-term and moderate long-term evidence for efficacy with a very good safety profile. It is recommended at level 1C by the American Society of Interventional Pain Physicians (ASIPP) guidelines and can be safe and efficacious in these particular cases. This procedure has adequate long-term, evidence-based literature to support its use in patients with epidural scarring and failed back surgery complications. The injection should be approved in this case as it is likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male has requested electrical muscle treatment (WalkAide) for treatment of his right-sided weakness, spasticity and incoordination.  Findings:  The physician reviewer found that the patient suffered multiple injuries in a motorcycle accident.  The medical records noted a cervical spine injury.  As a result, the patient has spasticity of his leg and arm and right-sided hemiparesis, including a foot drop.  He has fallen secondary to his lower extremity dysfunction.  Given his gait impairment, the patients physician has recommended electrical muscle treatment (WalkAide).  Although a WalkAide is not indicated for all patients with a foot drop, there is medical literature supporting its use for a select population of patients.   The medical literature has demonstrated the safety and efficacy of this type of therapy for patients with chronic upper motor neuron disease.  Daly and colleagues showed that a neuromuscular stimulation device improved gait component execution and knee flexion coordination compared to controls who did not receive the stimulation device. Mesci and colleagues showed that spasticity decreased and dorsiflexion increased in a functional electrical stimulation group compared to controls during a single-blind randomized trial. In this particular case, the patient has foot drop and gait impairment secondary to his cervical spinal cord injury.  Given the provided literature and the fact that the patient had a suboptimal response to a brace and cane, the WalkAide is likely to be more beneficial compared to standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested selective internal radiation therapy (SIRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that the patient has a history of left breast infiltrating ductal carcinoma. At the time of her original diagnosis five years ago, she underwent mastectomy with chemotherapy. Her chemotherapy included agents Abraxane, Xeloda, and Navalbine.  Despite this treatment, the patient has developed extensive hepatic disease including multiple confluent metastatic foci causing enlargement of her liver. A computed tomography (CT) scan performed one year ago and subsequent positron emission tomography/computed tomography (PET/CT) both confirmed the presence of this extensive disease. The patient also reportedly has skeletal metastases but is currently experiencing her primary symptomatology from the bulky liver disease. The patient and her provider are seeking authorization and coverage for selective internal radiation therapy (SIRT) therapy in order to palliate the symptoms and preserve liver function. This patient has undergone conventional chemotherapeutic agents without control of the severe bulky metastatic liver disease as demonstrated on imaging studies. At this juncture, the goal of treatment is debulking of the liver disease which can both improve the patients symptoms and help preserve liver function. As demonstrated by Bangash and colleagues in the clinical studies on SIRT: Radioembolization with 90Y brachytherapy device may be a viable therapeutic option for the treatment of breast cancer liver metastases in patients who have progressed or failed on standard of care polychemotherapy. As SIRT for breast carcinoma has been shown to be efficacious and has demonstrated acceptable safety profile, SIRT is indicated for management of this patients medical condition as likely to be more beneficial than any available alternative therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male has requested Aciphex for treatment of his gastroesophageal reflux disease (GERD).   Findings:  The physician reviewer found that the patient has tried and failed several different proton pump inhibitor (PPI) medications, which are on the Health Plans list of preferred PPIs. Many patients respond better to one PPI than any others, as in this patients case. The patients cardiac conditions have been investigated, as well. Therefore, it appears that this patient has attempted to manage his heartburn with other conservative treatment modalities, prior to trying Aciphex. As this patient has not found relief of his symptoms with other PPIs and a trial of Aciphex has been beneficial in the treatment of his symptoms, it is appropriate that the patient be treated with Aciphex.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested an MRI for evaluation of her knee pain.  Findings:  The physician reviewer found that the peer-reviewed medical literature does not support MRI of the knee for this patient who presents with non-traumatic knee pain.  The American College of Radiology does not recommend MRI of the knee as an initial imaging study.  As noted by Miller, if imaging is required, an initial radiographic (x-ray) examination should be ordered.  Miller noted that MRI of the knee is only indicated for pain without mechanical symptoms if unexplained pain persists for three to six weeks. This patient presented with non-traumatic knee pain, and she has not had a trial of conservative care, such as NSAIDs, a home exercise program, or physical therapy.  Additionally, the medical records do not demonstrate that radiographs of the knee were performed.  The submitted documentation fails to establish the medical necessity of the requested diagnostic procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for all in one catheter for treatment of the enrollee, who is status post gunshot wound resulting in paraplegia. Findings:  The physician reviewer found that there is a lack of support in the medical literature demonstrating a benefit to the all in one catheter system for the prevention of infections.  While the current medical evidence supports the use of self-lubricating catheters, there is a paucity of support for the requested all in one catheter in this patients case.  All told, the requested all in one catheter is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested knee surgery (autologous chondrocyte implantation knee (27412), autologous cultured chondrocytes implant (J7330) and arthroscopy of knee with shaving of articular cartilage (29877) for treatment of his chondromalacia of patella.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case. Articular cartilage has poor intrinsic healing capacity, which has led to the development of many procedures in the attempt to obtain hyaline cartilage, but their efficacy has not been proven clinically. Cell-based therapies such as autologous chondrocyte implantation hold promise, but do not predictably result in hyaline cartilage formation. Prospective trials are needed to address these clinical questions.  There is a lack of high-quality studies that are properly randomized and controlled supporting the requested services in this patients case.  All told, the requested knee surgery is not medically necessary for the treatment of this patient.