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

A 60-year-old male enrollee has requested artificial disc replacement for the treatment of his cervical spondylitic radiculopathy. Findings:  Two physician reviewers found that the submitted journal article reported that the Prestige disc replacement appeared to be safe and effective in a study spanning about twenty-four months.  However, this should not be confused with a long term follow-up study determining safety and effectiveness. The FDA has provided preliminary approval for the implantation of these devices.  However, the FDA has also demanded a multiyear follow-up study to determine the long term safety and effectiveness of the device. On overview, the long term safety and effectiveness of this device has yet to be proven.  It has not been shown to be more beneficial than traditional anterior cervical discectomy with fusion in the treatment of this diagnosis, particularly in this age group. Cervical disc replacements are properly classified as investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested Provigil 200 mg, 90 tablets per month for the treatment of his obstructive sleep apnea (OSA). Findings:  The physician reviewer found that this patient had an AHI of 6.1 indicating mild OSA that would typically not require management with CPAP and an elevated Epworth Sleepiness Score. Provigil was prescribed, and his dosage was increased to 300 mg daily. The increase to 600 mg daily is not clinically indicated for mild OSA or explained in the record provided. Furthermore, this dosage is more than the maximum FDA approved dose of 400 mg daily. The packet insert notes that increasing the daily dose of Provigil above 400 mg does not increase efficacy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested ambulatory phlebectomy surgery for the treatment of her varicose veins. Findings:  Two physician reviewers found that this patient had tried compression therapy, but the symptoms persisted. Phlebectomy was performed, as there was no role for radiofrequency ablation or other saphenous treatment in this setting. Given the lack of alternatives, this was the appropriate approach.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested compression stockings for the treatment of her varicose veins. Findings:  The physician reviewer found that the patient in this case appeared to have asymptomatic varicose veins. The record submitted for review does not include documented complaints related to venous insufficiency.  The sclerotherapy does not appear to have been performed for symptom relief.  There is no evidence of reflux.  In this patients case, there is no clinical indication for the compression stockings.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 59-year-old male has requested Selective Internal Radiation Therapy (SIRT) for treatment of liver metastases from colon cancer.  Findings:  The physician reviewer found that this patient has had a partial hepatectomy and has exhausted chemotherapy choices. The radiofrequency approach was also attempted for hepatic tumor ablation. A stent was placed to relieve his biliary obstruction, and this was also unsuccessful. His options appear to have been nearly exhausted. The hepatic metastases are growing, and he now has an osseous metastasis in the right femur. His bilirubin and creatinine are increasing. A request has been made for SIRT. SIRT is not indicated in patients with advancing disease. It appears that this patient does not qualify for this therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female has requested a bilateral breast MRI for evaluation of the patient, who is status post breast cancer.  Findings:  The physician reviewer found that an MRI of the breasts provides the most accurate estimate of tumor size and is highly sensitive for multifocal disease in patients with breast cancer that is difficult to detect by conventional means. An MRI provides a resource to help screen patients for multifocal or recurrent disease. Several publications have confirmed that lobular carcinoma is difficult to diagnose. Authors have proposed the use of integrated diagnostic imaging, including mammogram, ultrasound and MRI. An MRI of the breasts is a reasonable tool to employ in the evaluation and management in a patient with lobular carcinoma.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female has requested a QCT bone density study for the evaluation of osteoporosis.  Findings:  The physician reviewer found that DEXA scans can be less accurate in patients who are obese or who have a very small stature. A QCT bone density study is a volumetric study, and the study is not dependent on the patients body habitus. A QCT bone density is not affected by degenerative changes or surrounding calcifications. As this patient has small stature and has not tolerated several medications for osteoporosis, it was medically necessary to accurately determine the extent of her osteoporosis to determine the appropriate therapy. The QCT bone density scan was appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested Aranesp for the treatment of her chemotherapy-related anemia and fatigue. Findings:  The physician reviewer found that as of 2007, the current guidelines from the American Society of Clinical Oncology and the American Society for Hematology support the use of erythropoietin factors to maintain or increase hemoglobin in patients receiving chemotherapy. The guidelines suggest an equivalence between Procrit and Aranesp, and do not require the use of one before the other. The guidelines also state that erythropoietin factors are indicated when hemoglobin is approaching, or has fallen below, 10g/dl, to increase hemoglobin and decrease transfusions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Humira for the treatment of his pityriasis rubra pilaris (PRP). Findings:  Two physician reviewers found that there is no medication approved by the FDA for treating PRP and there is no standard treatment for this condition. The patient is suffering with pain, discomfort, edema and congestive heart failure due to generalized erythroderma, which is a significant factor in his disease process. Cellulites and sepsis may also occur with severe PRP. Perhaps the most frequently used therapy is oral retinoids, which the patient is taking. There have been case reports describing beneficial results with anti-TNF drugs for PRP. This patients disease is severe, there is literature support for treatment with Humira, and the patient appears to be responding. Continued treatment with Humira is the best alternative at this juncture.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested epidural steroid injections and epidural lysis of adhesions for the treatment of his lumbar radiculopathy. Findings:  Two physician reviewers found that the information available for review indicates the patient had persistent symptoms with a poor response to conservative treatment. Epidural steroid injections are indicated for radicular pain, especially if medications and other modalities are ineffective. Although epidural lysis of adhesions is not considered a first-line therapy for this type of back symptoms, it was a reasonable therapeutic approach in this instance given the current medical literature and the refractory nature of the patients pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 89-year-old male enrollee has requested air ambulance transport for the treatment of him following a cerebral stroke. Findings:  The physician reviewer found that the standard of care in facilities outside of the US is not generally known. Within the United States, it would be the norm for a patient to be treated by a licensed physician, preferably one knowledge in neurovascular care, following a stroke. Because it is difficult to assess hospital and physician standards outside of the US, it is reasonable to transfer a critically ill patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested brand name Dilantin for the treatment of her seizures. Findings:  The physician reviewer found that Dilantin is now reformulated, and the pharmacokinetics are not identical to the old Dilantin (Dilantin Kapseal 100 mg) in terms of bioavailability. The Taro generic sustained release phenytoin does provide similar bioequivalence studies. Also, the patients treating neurologist believes the generic is as good as or better than the new Dilantin (Dilantin 100 mg extended oral capsules).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested biliopancreatic diversion/duodenal switch for treatment of morbid obesity.  Findings:  The physician reviewer found that the American Society for Bariatric Surgery endorses the requested procedure for the surgical treatment of morbid obesity.  The issues noted by the Health Plan regarding intractable diarrhea and malabsorption were from the earlier short-common-channel experience (less than 100 cm). Current data does support the need for vitamin supplementation. However, the reoperation rate with the duodenal switch procedure in experienced hands is low.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of his coronary arteries. Findings:  Three physician reviewers found that EBCT for CAC scoring is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset. It is not a medically acceptable replacement for conventional screening tests within the standard of care such as treadmill stress testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech and language deficits. Findings:  The physician reviewer found that the purpose of therapy for children with Aspergers Syndrome (AS) is to improve social functioning. The primary therapies for AS include social skills training, cognitive behavioral therapy, occupational therapy and/or physical therapy if there is poor motor coordination, medications if there are co-existing anxiety, depression or attention issues and specialized speech and language therapy to help children with difficulties in the pragmatics of speech. Instruction in the give-and-take of normal conversation along with parent training and support are common. This patient has been mainstreamed and attends a general education classroom. He has achieved all of the goals and objectives of his IEP with the school services provided. There is no evidence that the intensive in-home speech therapy, now in its third year, is clinically essential or is providing a health benefit beyond that achieved in the school setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Provigil for the treatment of her fatigue related to systemic lupus erythematosus (SLE) and fibromyalgia. Findings:  The physician reviewer found that the EE's symptoms are primarily related to her fibromyalgia. However, there may be other contributing factors. The patient is diagnosed with SLE; fatigue along with this diagnosis may indicate the illness itself is not under control. Provigil has specific FDA-approved indications, which do not include SLE or fibromyalgia. Safety and efficacy have not been established for those conditions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male has requested reimbursement treatment with oxaliplatin in combination with gemcitabine for the treatment of malignant mesothelioma.  Findings:  Three physician reviewers found that there is sufficient literature data to support the use of oxaliplatin and Gemzar in malignant mesothelioma, and to indicate that these drugs are more likely to be efficacious than any other possible chemotherapy drugs.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches.  Findings:  Two physician reviewers found that this patient has a history of refractory migraines with chronic daily headache. There are no FDA approved treatments for chronic migraine. She has tried and failed preventive medications, as well as SSRIs and biofeedback, and requires ongoing treatment with abortives. Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). Based upon the patients history and current condition, Botox should be authorized for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested Pegasys and ribavirin for the treatment of her hepatitis C. Findings:  The physician reviewer found that there is no consensus regarding the role of liver biopsy in the evaluation of patients with chronic hepatitis. Traditionally, liver biopsy has played a central role in the management of chronic hepatitis C, reflecting the pivotal place the liver holds as the most significant organ affected by this infection. Liver biopsy findings and staging can provide a firm basis from which to make a decision as to whether treatment is warranted immediately or if watchful waiting is an option. In patients with genotype-1, most clinicians would consider doing a liver biopsy to stage the disease, as often the severity of liver disease seen on biopsy is the key determinant for treatment options.  However, as set forth above, a liver biopsy is not essential and all patients with HCV infection should be considered eligible for combination therapy with pegylated interferon and ribavirin.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Botox scalene injections for the treatment of her cervical myofascial pain. Findings:  Three physician reviewers found that Botox is not approved for the treatment of myofascial pain syndrome. In addition, there is little to data to support the efficacy of Botox for myofascial. Given the patients previous benefit, another scalene block should be considered. There is no evidence that Botox would be as or more beneficial than another scalene block.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male has requested ongoing PET/CT scans for the evaluation of aggressive gastrointestinal stromal tumor.   Findings:  Two physician reviewers found that there is documentation of the unique utility of PET in the management of GIST with imatinib therapy(1-6), especially combined PET/CT. PET seems to be more sensitive to residual or recurrent disease than CT. PET/CT is superior to either technique separately. The operative term here is long term efficacy. Time is of the essence with this aggressive malignancy, and this patient needs PET now. The literature suggests no real alternative. PET should be approved for this patients rare, aggressive tumor.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested an MRI of the right breast for an evaluation of her breast lesion.   Findings:  Two physician reviewers found that a breast MRI is a useful adjunct to mammography and ultrasound to evaluate for multicentric breast cancer. This patient was found to have multiple areas of microcalcifications with architectural distortion highly suspicious for malignancy. In a young patient, it is clinically important to determine the extent of the disease.  Knowing the extent of the breast disease will assist the patient and her physicians in the proper treatment planning for the patients medical condition. Breast MRI has been proven to help determine the extent of the suspected breast cancer. The use of breast MRI also assists in determining the optimal location for biopsy (this patients initial biopsy was negative for breast cancer). The results of this patients breast MRI assisted in the determination of the extent of breast cancer. In my opinion, breast MRI is likely to be more beneficial for the enrollee than any available standard treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested for mental health residential treatment for treatment of her anxiety, depression and substance abuse. Findings:  The physician reviewer found that there appears to be no evidence demonstrating why the patient required residential treatment.It appears that part of the reason for his residential placement was predicated on his refusal to return home. Other placement options could have been considered and would have been available to the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested Electracorporeal Shockwave Treatment (ESWT) for the treatment of her plantar fasciitis. Findings:  Three physician reviewers found that ESWT is a non-invasive treatment for chronic proximal plantar fasciitis. It was FDA approved many years ago. Numerous studies have looked at the efficacy of ESWT. While there is not a definitive absolute efficacy rate, most studies show 60-80% effectiveness. Plantar fascia night splints and or intensive physical therapy have been shown to be 90% effective for treatment of plantar fasciitis. Endoscopic plantar fasciotomy also has a 90% effective rate, is minimally invasive, and has minimal risks and complications. In summation, ESWT is not likely to be more beneficial for treatment of the enrollees plantar fasciitis than other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested artificial disk replacement for the treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement is not yet considered a standard of care.  While there is FDA approval for the devices, they are considered investigational due to the lack of long term peer reviewed literature outlining their efficacy and safety. Continued research is required to address development of adjacent segment disease, implant debris, risk of dislodgement and other potential risks.  Disc replacement would, therefore, not be considered more beneficial than the traditional use of fusion.  Based on the lack of long term studies, use of an artificial disc replacement would not be considered medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested uvulopalatopharyngoplasty, tonsillectomy and partial glossectomy for the treatment of her obstructive sleep apnea syndrome. Findings:  The physician reviewer found that the parameters for polysomnographic criteria in establishing the presence of significant OSA and candidacy for use of CPAP or for surgical intervention are routinely stated to be AHI greater than or equal to 15 or AHI greater than or equal to 5 and less than or equal to 14 with documentation of daytime sleepiness, impaired cognition, mood disorder or insomnia, hypertension, presence of ischemic heart disease or history of a stroke.  Documentation of daytime sleepiness is generally done through the use of the Epworth scale questionnaire.  The patient had an Epworth score of one.  In standard practice, an Epworth score of less than 8 is considered normal.  The patient does not meet current standard of care criteria for medical necessity in terms of surgical intervention for OSA.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a second opinion consultation with an out-of-network oncologist/surgeon for an evaluation of her for possible lymphoma. Findings:  The physician reviewer found that with the information provided, there is no medical necessity for the out-of-network evaluation as resources are available within the network for ongoing care of the patient. This patient needs the left axillary lymph node biopsied by a surgical excision (as noted in the pathology report, if continued clinical concern exists, an excisional biopsy would be warranted due to a potentially false negative result). These services can be provided within the network, and therefore, the requested consultation is not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested a laparoscopic gastric reduction with duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient had multiple comorbidities that will likely be ameliorated or eliminated by bariatric surgery.  PBB/DS is one of the procedures endorsed by ASBS and is a component of the LABS trial currently funded by NIH.  This was an appropriate procedure for treatment of this patients obesity.  The patient has benefitted from this surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested a panniculectomy for treatment of an abdominal scar.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgery (ASPS) Position Paper Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients, when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature.   The patient does not have a large hanging pannus, and she does not have medical record documentation of intertrigo or other associated symptoms. She has a 3 cm scar that is said to be painful. Initial treatment of a painful scar consists of intralesional steroid injections and silicone patch pressure.  If the scar pain persists, a 3 cm scar revision would be the next step in treatment.  This patient does not meet the ASPS guidelines for a panniculectomy.  Removal of excess abdominal skin in the absence of significant symptoms is a cosmetic procedure.  Treatment of her painful scar is appropriate, but a panniculectomy is not medically necessary