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

A forty-nine year-old male with severe onychomycosis of the fingernails and toenails is requesting authorization for Lamisil.  The severity was characterized by pain, bleeding and extensive crumbling. The nails fell off and new nails started growing. Unfortunately, fungus infection returned in the new nails, with severe pain, bleeding and fragility and crumbling of the nails.Reviewers FindingsThe reviewing physician found that submitted clinical evidence shows that this patient has failed treatment with Lamisil and that continued treatment with Lamisil is not likely to be effective.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-one year-old female who sustained a gunshot wound to her neck is seeking reimbursement for the air ambulance transport.Reviewers Findings:The reviewing physician found that the patient required transfer to another facility where she could receive clinically appropriate and necessary treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a ten year-old female with chronic nasal congestion is requesting authorization of a septoplasty.  The patient has leftward deviation of the anterior portion of the nasal septum causing narrowing of the anterior portion of the left nasal cavity.  The patient has tried multiple allergy medications and topical steroid sprays without relief.Reviewers Findings:The reviewing physician found that the patient has tried and failed medical therapy, making the patient an appropriate candidate for surgical intervention. Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-nine year-old morbidly obese female with multiple comorbid conditions is requesting authorization to undergo gastric bypass with duodenal switch.  The patient has tried and failed multiple attempts at weight loss, and has obtained psychological clearance for weight loss surgery.  Reviewers Findings:The reviewing physician found that the patient is an appropriate candidate for surgical intervention.  And that duodenal switch is an accepted and necessary procedure for this patients medical condition.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-seven year-old female with breast cancer that metastasized to the spine is requesting reimbursement for a vertebroplasty.  The patient underwent a number of procedures followed by radiation therapy, and subsequently experienced disease progression in the spine.Reviewers FindingsOne physician reviewer found that despite the promising early results, the overall efficacy of vertebroplasty is still unproven in the management of metastatic vertebral compression fractures.  This reviewer found that the Health Plan denial should be upheld.The other two physician reviewers found that the patient was an appropriate candidate for the vertebroplasty. The procedure is not experimental or investigational and was clinically indicated in this case.  These reviewers found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-eight year-old female with chronic mouth pain is requesting authorization for a 10-week course of therapy recommended by the patients acupuncture provider.  The patient has had the mouth pain since the surgical removal of a tumor.Reviewers Findings:The reviewing physician found that in the clinical records of acupuncture therapy there is no reference to mouth pain with the exception of a note wherein the patient complained of mouth and jaw pain.  Also, the acupuncture providers notes do not indicate improvement or worsening of symptoms.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eighteen year-old female with a history of depression and multiple suicide attempts is requesting authorization of continued treatment at a psychiatric residential level of care.Reviewers Findings:  The reviewing physician found that the submitted information is unclear on how residential treatment differed in any way from what could have been offered via partial hospitalization.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A seventy-one year-old female with long-standing lumbar pain is requesting authorization for a kyphoplasty procedure.  The patient was seen by her surgeon for severe lower back pain and was noted to have a new L1 compression fracture, questionable nonunion and loosening of the fusion hardware.Reviewers FindingsOne of the reviewing physicians found that the patient does appear to have acute symptoms associated with the L1 vertebral fracture and she is an appropriate candidate for kyphoplasty.  This physician found that the Health Plan denial should be overturned.Two of the reviewing physicians found that it would be very difficult to determine how much pain she truly has from the compression fracture, and that the kyphoplasty procedure does not to appear to be indicated for this patient at this time.  Therefore, these reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a seventeen year-old female with previously Cannabis Abuse and ADHD are requesting authorization for inpatient drug rehabilitation services.Reviewers Findings:The reviewing physician found that the patient appeared to be suffering from a very significant Major Depression in addition to ADHD, and was treated properly for both during inpatient treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old male with coronary artery disease, post stents, is requesting a CT angiography.  The patient has non-exertional chest pain and arm tingling.Reviewers Findings:The reviewing physician found that a CT angiography is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-seven year-old male who is status post an intracranial hemorrhage is requesting continued skilled nursing facility services.  He has received two procedures and was transferred to a skilled nursing facility. Reviewers Findings:The reviewing physician found that the continued rehabilitation services are not medically appropriate at this time.  However, the patient should be reevaluated in 30 days as there may be improvement with a hemorrhagic stroke.  Therefore, the reviewing physician concluded that the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A thirty-six year-old male diagnosed with grade III anaplastic astrocytoma is requesting authorization for magnetic resonance spectroscopy (MRS).  The patient has also had radiation therapy and is receiving ongoing chemotherapy.  (MRS) has been utilized previously for this patient.  Reviewers Findings:The reviewing physicians found that anaplastic astrocytoma is a life-threatening disorder and that the request is medically indicated for a patient such as this one for optimal treatment. MRS is not considered experimental or investigational in this instance and is superior to other diagnostic modalities in its ability to discern the metabolic pattern of an active tumor.  Therefore, the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A sixteen year-old male with recurrent Ewings sarcoma is seeking authorization for off-label use of Celebrex. He was treated with combination chemotherapy, followed by a stem cell transplant, followed by local radiation therapy.  This resulted in stabilization of the tumor in his pelvic region. He was then started on vinblastine and celecoxib (Celebrex) to prevent tumor progress by suppressing angiogenesis of tumor vessels.Reviewers Findings:The three reviewing physicians found that this combined therapy has been adopted by the Childrens Oncology Group and is part of their protocol for Ewings sarcoma therapy and there is no alternative therapy to offer this patient at this time.  These reviewers found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A sixty-three year-old female with degenerative lumbar disc disease is requesting reimbursement for an electrical bone growth stimulator.  The patient underwent a number of spinal surgeries for fusion and decompression.Reviewers Findings:The three reviewing physicians found that a bone growth stimulator is indicated only for a high-risk fusion patient. With regard to this patient, the record makes no reference to risk factors other than hypertension and she underwent a single-level fusion.  Also, the clinical record does not suggest that the patient would realize any additional benefit with the use of the bone growth stimulator.  Therefore, the three reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fifty-two year old male with severe hip arthritis is requesting authorization of a hip resurfacing arthroplasty.  The patient has had chronic pain that is not alleviated by standard therapeutic interventions.Reviewers Findings:One of the physician reviewers found that hip resurfacing arthroplasty is an alternative to traditional total joint arthroplasty and is currently promoted to be indicated in younger, more active patients with osteoarthritis such as this patient. As such, hip resurfacing arthroplasty is a medically reasonable and appropriate treatment option in this case.  This reviewer found that the Health Plan denial should be overturned. Two of the physician reviewers found that the efficacy of the procedure in question remains unproven.  There are no long-term prospective studies that show hip resurfacing arthroplasty has clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  These two reviewers found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a seventeen year-old female with chest pain are requesting reimbursement and prospective authorization and coverage of Actiq.  Reviewers Findings:The reviewing physician found that the use of Actiq for the patients medical condition does not fall within the FDA approved parameters for this drug. Therefore, the reviewing physician found that the Health Plan denial should be overturned
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested authorization and coverage for the addition of a microprocessor-controlled knee-shin system, a replacement lithium battery and a battery charger to his lower extremity prosthesis. Reviewers' Findings:  Two of the three physician reviewers found that the requested microprocessor-controlled knee-shin system has not become the generally accepted prosthesis even for a patient who is high functioning. There has not been sufficient study of this prosthesis and it has not been proven to be functionally superior to a standard prosthesis. The microprocessor-controlled knee has not been shown to improve functional outcomes or to reduce disability as compared to a conventional prosthesis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-five year-old female who has been diagnosed as having post traumatic stress syndrome and attention-deficit hyperactivity disorder (ADHD) is requesting reimbursement and prospective authorization of Provigil.  Reviewers Findings:  The reviewing physician found that Provigil is still considered investigational for the treatment of ADHD and depression as there are concerns about its safety and side effects including rash, liver toxicity and cardiovascular symptoms.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-seven year old male with low back pain is requesting authorization for artificial disc replacement utilizing the Charite artificial disc.Reviewers' Findings:The three reviewing physicians found that the proposed artificial lumbar disc replacement is still an experimental procedure. There is no Class I, long-term outcome data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is still unknown and complications may be severe. The proposed artificial lumbar disc replacement is still an experimental procedure. There is no Class I, long-term outcome data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is still unknown and complications may be severe.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fourty year-old female with refractory Ewings sarcoma is requesting authorization for participation in a Phase I monoclonal antibody clinical trial. The patient underwent radiation therapy and then chemotherapy. She has recently been found to have progressive metastatic disease.Reviewers Findings:The three reviewers found that the requested treatment has not been shown to be safe and effective in the treatment of human sarcomas .  This is a very toxic regimen, with little anticipated benefit for the patient. Therefore, the reviewers concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a  sixteen year-old male with a history of two knee dislocations is requesting reimbursement for the cost of a cold therapy unit.  The patient underwent arthroscopic surgery and utilized a cold therapy unit postoperatively as prescribed by his orthopedic surgeon.Reviewers Findings:The reviewing physician found that a cold therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery, and the device is extremely helpful in relieving postoperative pain and swelling.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-five year-old male who has an asymmetric prostate with a nodule on the right lobe is requesting a referral for out-of-network brachytherapy services as he feels the wait for in-plan services would be too long.Reviewers Findings: The reviewing physician found that the patient is concerned that a delay in treatment will jeopardize his health. The Health Plan is following current, accepted standard of care and there is nothing in the record indicating that the physicians who have been involved in the care to date are not following national guidelines. Furthermore, the patient is not in the high risk category but rather in the low recurrence risk category based on NCCN guidelines.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-four year-old female with congestive heart failure and chronic obstructive pulmonary disease is requesting authorization of home oxygen therapy.  The patient was admitted to the hospital for chest pain and discharged with orders for home oxygen therapy.Reviewers Findings:The reviewing physician found that standard criteria have been established to determine when home oxygen therapy is clinically appropriate and this patient meets none of those criteria.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-five year-old female with an abnormal enhancement and a suspicious lesion within the breast is requesting a follow-up MRI.  The patient has had negative mammograms in the past and has dense breast tissue. MR imaging of the breasts showed areas of abnormal enhancement within both breasts. A subsequent MRI and right breast ultrasound showed a suspicious lesion within the right breast that was only visualized with MRI. The patient was scheduled for MR-guided biopsy, but the right breast lesion was not visualized on that MRI study. The biopsy was cancelled and a follow-up MRI of the breast was recommended.Reviewers FindingsThe reviewing physician found that the patient had a suspicious lesion identified within the right breast that was only visualized with MRI. At the time of the scheduled biopsy of the right breast, the suspicious lesion was not present. Whenever there is a suspicious breast lesion that is not visualized at the time of the biopsy, it is medically appropriate to closely follow the patient to ensure that the lesion is indeed no longer present.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested authorization for neuro/biofeedback therapy and speech/language/hearing therapy for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Reviewers' Findings:The three physician reviewers found that Neuro/biofeedback therapy is not an accepted method of treating ADHD within the psychiatric community. Treatment of ADHD with neuro/biofeedback along with speech/language/hearing therapy is considered investigational. There are no controlled studies supporting the efficacy of these treatments and their administration is not consistent with the standard of care for the treatment of ADHD.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested authorization for an MRI of the left breast for evaluation of possible spiculated density in the medial aspect of the left breast.Reviewers' Findings:Two of the three physician reviewers found that as noted by the society of breast surgeons, breast MRI is medically appropriate to further evaluate suspicious findings after a complete mammogram and ultrasound evaluation. The patient had a complete evaluation by mammography and ultrasound which remained indeterminate and therefore breast MRI was medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year-old male with a history of spinal muscular atrophy is requesting authorization for a Pro Bed.Reviewers Findings:  The reviewing physician found that the information provided is not sufficient to make a determination that this bed will safely meet the patients need or that it will be effective in repositioning the patient as needed during the night.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-five year-old male diagnosed with acute myelogenous leukemia (AML) is requesting one cycle of high dose chemotherapy and autologous stem cell transplantation. Cytogenetic analysis revealed inversion, which is a relatively favorable subtype of AML. The patient was induced into complete remission with chemotherapy.  Reviewers Findings:The reviewing physician found that autologous marrow (stem cell) transplant is superior to chemotherapy in preventing the relapse of AML and the use of high dose chemotherapy, and that autologous stem cell transplant for consolidation is likely to provide a better outcome than chemotherapy.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A Seventeen year-old female diagnosed as having bipolar affective disorder is requesting coverage of psychiatric residential care. The patient has had a number of inpatient admissions prior to the most recent psychiatric hospitalization.Reviewers Findings:The physician reviewer found that the submitted clinical records demonstrate that the patient has an extensive history of mental illness and is not ready to be transferred to a lower level of care.  The physician reviewer found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old female diagnosed with intraductal carcinoma of the left breast is requesting authorization for a single-stage mastectomy and breast reconstruction.  The patient has opted for mastectomy to treat the cancer and further selected a contralateral prophylactic mastectomy based on her increased risk of subsequent contralateral cancer. Reviewers Findings:The physician reviewer found that bilateral mastectomy involves a simple mastectomy for treatment and contralateral prophylactic mastectomy for risk reduction. The patient also requests immediate breast reconstruction. There is a potentially better surgical outcome with immediate reconstruction in comparison to delayed reconstruction.  Due to this information the reviewer found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male with metastatic thyroid cancer is requesting Cyberknife radiation therapy.  He has undergone the standard treatment modalities and has developed recurrent pelvic disease, which was evaluated by a specialist in orthopedic surgery/orthopedic oncology.Reviewers FindingsOne reviewer found that Cyberknife radiation therapy is appropriate for the needs of this patient. It can provide focused radiation to the tumor while sparing other pelvic structures.  This reviewer found that the Health Plan denial should be overturned.  The other two reviewers found that this is the first time radiation treatment will be utilized for the pelvic site. As such, the patient can be reasonably treated with conventional irradiation techniques.  These reviewers found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five year-old male diagnosed with an expressive/receptive language disorder is requesting authorization continued speech therapy.  Reviewers Findings:  The reviewing physician found that because of the lack of information provided, there is no evidence submitted demonstrating that continued therapy would benefit the patient or could be considered medically necessary.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty year-old male with extensive psoriasis involving the face, neck, chest, back, upper extremities, lower extremities and gluteal crease is requesting authorization for Enbrel.  The patients gastroenterologist affirms that the patients gastrointestinal condition would make it unlikely that he would be able to tolerate oral medications for this psoriasis. The patient is not aware of locally available UVA or UVB treatment.Reviewers Findings:The reviewing physician found that the patient has severe disease and Enbrel is medically appropriate unless it can be demonstrated that UVA or UVB treatment is readily available and would not be excessively burdensome for the patient to pursue.  Since UVA or UVB is not available the reviewing physician found that the Health Plan denial should be overturned.