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

A 60-year-old female enrollee has requested Xyrem for the treatment of insomnia.  Findings:  The physician reviewer found that Xyrem is gamma hydroxybutyrate or GHB. GHB has been an effective therapeutic intervention that not only has allowed the patient to sleep, but has decreased the polypharmacy. Furthermore, there is a treatment plan in place for behavioral modification in conjunction with the drug therapy, which provides for future weaning of the medication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male has requested proton beam radiation therapy for treatment of prostate cancer.  Findings:  The physician reviewer found that there is no convincing evidence that proton beam radiation therapy is superior to standard of care treatment in this setting such as surgery or others forms of external beam therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for Zometa for treatment of her osteoporosis. Findings:  The physician reviewer found that zometa is FDA approved for the treatment of bone complications from certain forms of cancer, Paget disease, hypercalcemia of malignancy and metastatic bone pain. Zometa is also used to treat osteoporosis in patients who cannot tolerate more standard therapies. This medication is associated with significant improvements in bone mineral density and bone metabolism markers. The safety of Zometa has been established in other applications and the record indicates that the patient has been effectively treated for two years without complications. As typical first-line therapies are not an option in this instance, continued treatment with Zometa is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for residential treatment services for treatment of her eating disorder. Findings:  The physician reviewer found that national guidelines published by the American Psychiatric Association suggest that a residential level of care may be necessary for someone who is less than 85% of her ideal body weight. The guidelines also suggest that group therapy, cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) may be useful in dealing with the underlying personality issues. Movement from a residential setting to a partial hospital setting should take into consideration patients motivation to recover, her preoccupation with ego-syntonic or -dystonic maladaptive thoughts, the need for structure to gain weight, the need for structure to prevent compulsive exercising and the presence of comorbid psychiatric conditions requiring intensive treatment. Optimal treatment for bulimia nervosa often includes the use of SSRI medications, and Prozac has been approved by the FDA for this indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested residential treatment services for treatment of substance abuse.Findings:  The physician reviewer found that the patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested right hip resurfacing arthroplasty for the treatment of her osteoarthritis. Findings:  Three physician reviewers found that total hip resurfacing arthroplasty is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy of the procedure. There is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip arthroplasty for this patient. In comparing surgical options, total hip replacement remains the gold standard for the treatment of severe hip joint disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested a Donjoy cold therapy unit for treatment following rotator cuff surgery.  Findings:  The physician reviewer found that the peer reviewed literature does not support the use of a cold therapy unit following rotator cuff surgery. Available data has not demonstrated that cryotherapy is an essential element of postoperative recovery or that the use of this equipment is more effective than the application of ice packs. Additionally, there is no long-term data showing that the use of a cold therapy unit results in better clinical outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested multiple outpatient therapy sessions for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates measurable improvement in the patients condition since she was admitted to inpatient treatment. The psychiatrists progress notes point to a steady improvement in the patients mood, perspective, and willingness to engage in treatment. Thereafter, all of the submitted documentation points to a similarly improved state, further supported by therapists notes, which regularly cite attended session, she appeared happy and emotional. Given the distinct absence of any significant symptoms by the point of the patients discharge from residential treatment, there is no documentation to support the need for the requested therapy sessions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Xifaxan for treatment of irritable bowel syndrome/bacterial overgrowth. Findings:  The physician reviewer found that Rifaximin is FDA approved for the treatment of travelers diarrhea and has been shown to be safe and effective. There is now reasonable evidence that this medication is also useful in the treatment of irritable bowel syndrome (and bacterial overgrowth). Although other antibiotics have also been found to be effective for this condition, they may have much more significant side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested a Pillar Palatal Restoration (Pillar) procedure for the treatment of his snoring. Findings:  The physician reviewer found that snoring is not considered to be a medical problem. Although snoring is a social nuisance and can be disruptive, there is no literature to support that it results in adverse health effects. Furthermore, although some outcome results have been published for this procedure, there are no long-term results based on studies performed in the United States. The Pillar procedure when used either in treatment of snoring or for treatment of mild obstructive sleep apnea remains of unproven efficacy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female has requested speech therapy for treatment of her autism.   Findings:  The physician reviewer found that review of the submitted clinical evidence does not demonstrate that the patient made significant progress in speech therapy during the period at issue. Furthermore, the goals outlined are generally considered educational in nature and are not typically treated in the medical system. Speech therapy for these issues is generally directed through an individualized education plan through the education system. There was no medical indication for the therapy at issue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 75-year-old male enrollee has requested for pulmonary vein ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that pulmonary vein ablation has become an accepted tool for the management of refractory, symptomatic atrial fibrillation. While long-term efficacy data is still evolving, clinical practice supports its use in symptomatic patients that have failed traditional medical therapy. Alternative treatments such as Rythmol, sotalol, flecainide and amiodarone and cardioversion have already been tried without success.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45 year-old male enrollee has requested artificial disc replacement surgery for the treatment of his degenerative disc disorder. Findings:  Three physician reviewers found that lumbar artificial disc replacement remains experimental for the treatment of degenerative disc disease. Although research is on-going, the long-term safety and efficacy of the procedure has not been established. The majority of the procedures may appear to be  successful in the short term, but long-term outcomes are unknown and complications may be severe. Artificial disc replacement has not been shown to be more effective than non-operative therapy or lumbar fusion in the long-term.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a l5-year-old male enrollee has requested prescription medication Lexapro for treatment of depression.  Findings:  The physician reviewer found that the pharmacy information concerning Celexa (citalopram) and Lexapro (escitalopram) suggests a similar pharmacological action with similar side effects. Both medications are SSRIs. Lexapro is the newer of the two drugs, and the Health Plan requires a trial of Celexa prior to authorization of Lexapro. A requirement such as this is not uncommon with a restricted formulary. Given that Lexapro was effective for this patient, it is very likely that Celexa will also be effective as the two medications are almost identical in their action and side effect profile. Lexapro is made from a different molecule than Celexa, but the switch from Lexapro to Celexa, adjusted for a difference in potency, should offer the same clinical benefit for the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male has requested CyberKnife radiosurgery for treatment of acoustic neuroma.  Findings:  The physician reviewer found that because CyberKnife is image-guided radiation therapy, the total radiation dose can be fractionated into three fractions, affording the patient additional protection from hearing loss. The overall tumor control achieved with CyberKnife is as good as with any other treatment modality. Gamma Knife is as effective as Cyberknife in tumor control, however the radiation dose must be delivered in one fraction and as a result, the complication rate is higher. There is greater potential for hearing loss with this technology as compared to CyberKnife. In a patient with total hearing loss, Gamma Knife would likely be the treatment of choice. However in this instance, the patient still has reasonably good hearing and CyberKnife offers a clear advantage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an MRI of the left knee for an evaluation of her knee injury. Findings:  The physician reviewer found that without a full assessment of her knee by a qualified specialist, it cannot be determined whether or not an MRI study is needed. The x-ray evaluation was essentially normal and there is no history of locking of the knee joint. The patient requires an examination by an orthopedic specialist who can determine the next appropriate diagnostic or treatment intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a cold therapy unit and external infusion pump for post-operative recovery. Findings:  The physician reviewer found that there is inadequate literature to support the use of a cold therapy unit following rotator cuff surgery. There is no available data demonstrating that cryotherapy is more effective than the application of ice packs. No long-term data exists showing that cold therapy units result in improved outcomes in this clinical setting. Furthermore, the use of an external infusion pump was not medically necessary based on the information provided. Standard pain management modalities would have been sufficient in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested the medication Levitra for the treatment of the enrollees erectile dysfunction (ED). Findings:  The physician reviewer found that although the specific cause of the patients ED has yet to be fully determined, both polyneuropathy and diabetes mellitus may lead to erectile dysfunction. The patient has been definitively diagnosed with polyneuropathy, and a diagnosis of diabetes is very likely given the current clinical evidence. He has had a good clinical response to Levitra, and the medication has been prescribed by his attending physician to treat his medical problem.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested Botox injections for the treatment of his spasmodic dysphonia. Findings:  The physician reviewer found that the enrolle had a prior Botox injection that was successful in improving his vocal function. Botox injections have been the standard of care in the treatment of spasmodic dysphonia for at least the past 10 years. Although Botox is not FDA approved for this use, it is listed as an off-label application. In addition, the Health Plans Drug Coverage Criteria lists spasmodic dysphonia/laryngeal spasm under its indications for the use of Botulinum toxin type A, stating that prior authorization is not required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Synvisc injections for the treatment of her osteoarthritis. Findings:  The physician reviewer found that the patient has severe joint disease in her right shoulder. Conservative treatment has not been effective and Synvisc injections were offered as a non-surgical treatment alternative. Although most commonly used to treat the knee, Synvisc has been utilized in other joints with positive results. This series of injections can reasonably be expected to decrease the patients pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (DS) for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 43.2 and multiple comorbid conditions, the patient met nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed  articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the DS as compared to other surgical procedures. Published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the DS. The patients assertion that the DS is the most effective surgical weight loss alternative is well supported in the literature and this option was a medically reasonable approach to surgical weight loss. Psychological, nutritional and cardiology evaluations indicated the patient was an appropriate candidate for the surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested medication Provigil for treatment of major depressive disorder.  Findings:  The physician reviewer found that there is significant clinical empirical evidence of the importance of Provigil in cases of major depressive disorder in conjunction with approved antidepressants, such as Lexapro and Wellbutrin.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested minimally invasive total knee arthroplasty for treatment of osteoarthritis of the right knee.  Findings:  Three physician reviewers found that minimally invasive total knee arthroplasty is still in the experimental phase. There is no Class I long-term data demonstrating an advantage to the minimally invasive approach over conventional total knee arthroplasty. The long-term safety profile is unknown and current data suggests an increase in early complications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested coronary, abdominal and peripheral CT angiography (CTA) for an evaluation of his potential CAD and peripheral vascular disease (PVD). Findings:  Two physician reviewers found that based upon the records provided for review, the patient has cardiac risk and atypical symptoms suggestive of ischemia in the setting of a normal variant EKG. Based on his age, risk factor profile and symptoms, there is a moderate pretest probability of coronary disease. In such circumstances, stress testing is considered the standard and accepted approach for further diagnostic evaluation. CTA does not provide a physiologic assessment or explain the relationship between the symptoms and any possible arterial stenosis that may be identified. Appropriateness guidelines for coronary CTA have been developed and endorsed by several national committees. These guidelines do not recommend the use of CTA in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female enrollee has requested an array CGH analysis for the treatment of the enrollees global developmental delay, hypotonia, macrocephaly, seizure disorder, hypermobility and mildly dysmorphic features. Findings:  Three physician reviewers found that this patient has undergone an extensive and thorough evaluation in an attempt to put a name/diagnosis on her collection of symptoms. The proposed array CGH test is not likely to be clinically useful in this setting. There are no significant studies demonstrating it is beneficial in cases such as this, and there is only anecdotal information regarding the possible usefulness of the test.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested speech therapy for the treatment of the enrollees speech deficits. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has benefited from speech therapy in the past and experienced regression after the therapy was discontinued. Based on the evidence provided, speech therapy should be resumed to prevent further relapse. The patient should receive speech therapy for a six-month period. The patients therapist should establish specific goals and evaluate progress toward those goals. At the end of the six-month period, the patient should be re-evaluated to determine if continued therapy is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested the medication Lyrica for the treatment of her fibromyalgia.   Findings:  The physician reviewer found that Lyrica is FDA approved for diabetic neuropathy and post herpetic neuralgia pain. It is not FDA approved for chronic fibromyalgia pain. Generally accepted off-label uses of Lyrica include primarily neuropathic type pain symptoms. The condition of fibromyalgia does not meet any of the aforementioned FDA or generally accepted off label uses of Lyrica.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested  once weekly occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is often a useful adjunct to interventions for autism spectrum disorders. In this case, although the patient has high functioning autism he is deficient in fine and gross motor skills and sensory processing. His deficiencies are likely to improve with the proposed course of once weekly occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female has requested a standing frame for the treatment of the enrollees epilepsy with severe developmental delay. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient is unable to use a folding wheeled walker. The requested standing frame is medically reasonable to assist in improving her standing endurance, reduce contracture and improve bone density. The use of a standing frame by this patient is clinically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested a microprocessor-controlled knee for his prosthesisn for treatment of his above the knee amputation.  Findings:  Two physician reviewers found that there is insufficient evidence to medically justify the use of a microprocessor-controlled knee over a standard prosthesis for this patient. Although the microprocessor-controlled knee is a useful device in certain amputees who are functioning at a high level, there is no evidence the patient fits within that subgroup of patients. In fact, it appears the replacement microprocessor-controlled knee is requested because of his diminished lung capacity. A standard prosthesis should provide sufficient stability and function to allow the patient to perform his activities of daily living.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested physical therapy (PT) for treatment of lower extremity pain.  Findings:  The physician reviewer found that the physical therapist provided comprehensive evaluations at regular and reasonable intervals. Functional deficits, short and long-term goals and expected outcomes were identified in each instance. Plans of care were reviewed and signed by the patients physician. The patients medical condition evolved over the course of his PT and services from a less skilled provider would have been inadequate. He was consistent with his treatment and showed improvement within a reasonable timeframe.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested The Vest Airway Clearance System (The Vest) for treatment of spinal muscular atrophy type I (SMA I).  Findings:  Two physician reviewers found that good pulmonary care, including chest physiotherapy, is important in maintaining the health and prolonging the life of patients with SMA. Respiratory complications are the primary cause of mortality with this disease. Although there are no controlled studies in the literature to support the use of The Vest in SMA patients, there is certainly anecdotal evidence of its usefulness. It is unlikely that there will ever be a well-designed, controlled study of The Vest in SMA patients because of the relative rarity of the illness and the problems associated with case matching. The usefulness of The Vest for the treatment of cystic fibrosis is well established. Extrapolation to other conditions requiring assisted respiratory clearance such as SMA is reasonable.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested pain management related services for the treatment of pain and muscle spasms. Findings: Three physician reviewers found that the literature pertaining to the use of Botox injections for management of chronic myofascial pain is not conclusive. There is no evidence the patient exhausted the conservative modalities available in this setting. Findings:  Three physician reviewers found that