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

A 62-year-old male enrollee has requested for computer-assisted surgical navigational procedure for treatment of his right hip during hip replacement surgery.  Findings:  Three physician reviewers found that navigation for total hip replacement has yet to be shown to be equivalent or superior to conventional methods, except in difficult cases where it can reduce outliers. there is no evidence that the use of computed-assisted navigation was likely to result in a superior clinical outcome in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested  for speech therapy for treatment of his delayed speech. Findings:  The physician reviewer found that Nelson and colleagues reports that speech and language development is a useful indicator of a childs overall development and cognitive ability and is related to school success. Additionally, they note that language-delayed children have also shown more behavior problems and impaired psychosocial adjustment.  From this detailed account, it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for continued stay at UCLA Neuropsychiatric Hospital for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient was noted to have specific medical issues (diabetes mellitus and herpes zoster). The patient had two other admissions during an approximately six-month period. She needed an additional period of acute hospital care before it was safe to place her in a less intensive level of care, such as a partial hospitalization program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested for weekly therapy sessions for treatment of the enrollees attention deficit/hyperactivity disorder and anxiety disorder, not otherwise specified. Findings:  The physician reviewer found that there is no recent psychiatric evaluation by a child and adolescent psychiatrist, and there is no apparent treatment plan.therapy, even though prior to the psychiatric reassessment, is indicated because there is compelling evidence in the material reviewed indicating that the patient is not improving with the sporadic treatment he is currently receiving. The patients need for higher level (weekly) therapeutic services has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for magnetic resonance angiography (MRA) of the head and neck for evaluation of her temporal lobe headaches.  Findings:  The physician reviewer found that there was no history to suggest aneurysm, arteriovenous malformation (AVM), dissection, or other abnormality that required MRA. The MRA studies were ordered without consideration of MRI findings, and a carotid Doppler test was not performed prior to the neck MRA. There are no documented findings that suggest a need for MRA of the head or neck, as MRA is not the standard of care for headache evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for skilled nursing facility (SNF) services for treatment of her fractured right ankle.  Findings:  The physician reviewer found that without continued daily skilled PT/OT, she may decline in strength and function by the time weight bearing as tolerated (WBAT) is allowed. Medicare guidelines allow continued daily skilled PT services when they are required to prevent or minimize deterioration.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for Fentora 800 mcg for treatment of his Guillain-Barre disease.  Findings:  The physician reviewer found that there are no studies in the literature that support the use of Fentora in neuropathic pain or in the patients specific syndrome, ascending polyneuropathy and Guillain-Barre disease. Other opiates as well as the anti-convulsants have been studied for their efficacy in Guillain-Barre syndrome. However, as concluded by Pandey and colleagues, buccal fentanyl (Fentora) has not been examined for this disease. Its efficacy for the treatment of the patients condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for Synvisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that it is reasonable for this patient to repeat these series of injections on a yearly basis, providing that there is documented improvement over this time interval. Given the patients young age, the importance of exhausting conservative modalities prior to undergoing any surgical treatment, and the patients previous benefit from the injections, she is a good candidate for repeat Synvisc injections and the request is both reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  for Yaz birth control medication for treatment of her menorrhagia.  Findings:  The physician reviewer found that oral contraceptives can be used for treatment of menstrual irregularities and menorrhagia. They have been shown to be useful in the treatment of acne. There are multiple preparations available that have been shown to be effective. There is no evidence that the patient has contraindications to other forms of oral contraceptives and there is no indication that alternative, Apri, would not be an adequate alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech production impairment. Findings:  The physician reviewer found that abnormalities in oral structures and anterior placement of the tongue with tongue thrust are functionally involved. It is highly likely that the same abnormalities in oral motor function that have resulted in articulation deficits are also the cause of his swallowing difficulties. Given his history of hypotonia and tactile defensiveness, it is possible that his oral motor dysfunction is due to a combination of structural and neurologic abnormalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for a bariatric surgery consultation for treatment of his obesity.  Findings:  The physician reviewer found that general practice guidelines indicate that patients with a BMI in excess of 40 are potential candidates for surgery if they strongly desire substantial weight loss because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation. In certain instances, less severely obese patients (with BMIs between 35 and 40) also may be considered for surgery. Included in this category are patients with high-risk co-morbid conditions such as life-threatening cardiopulmonary problems (i.e., severe sleep apnea, Pickwickian syndrome, and obesity-related cardiomyopathy), or severe diabetes mellitus. Other possible indications for patients with BMIs between 35 and 40 include obesity-induced physical problems interfering with lifestyle such as joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested  for Nutropin AQ injections for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that there is no evidence of growth hormone deficiency as the patient has not undergone growth hormone stimulation testing. In the absence of any evidence of growth hormone deficiency, the medical necessity of growth hormone therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested a DOPA positron emission tomography (PET) scan for the evaluation of his possible seizure activity. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) advocates for brain MRIs as the gold standard of brain tumor imaging. PET scans are also mentioned in the NCCN guidelines as a means to differentiate radiation necrosis from recurrent tumor. PET scans can also be used to locate a site for optimal biopsy. According to Wong and colleagues, FDG-PET is less sensitive than contrast enhanced MRI for detecting intracranial metastasis. Review of the peer-reviewed literature showed anecdotal use of DOPA PET scan in the evaluation of tumors of neuroendocrine origin. However, there is very little literature support for DOPA PET scan in the evaluation of patients with anaplastic astrocytoma who are experiencing seizure activity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested for a PET scan with CT attenuation (PET/CT scan) for evaluation of her atypical gastric cancer.  Findings:  Two physician reviewers found that PET/CT is likely to continue to be superior to any other imaging modality to detect early recurrent or metastatic disease in this case. There is adequate evidence of clinical utility to support the requested PET/CT scan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for Celebrex 200mg for treatment of her degenerative arthritis of both knees. Findings:  The physician reviewer found that the patient has had a trial of two NSAIDs without improvement in her pain. In addition, she has chronic gastric carditis, and has experienced significant gastrointestinal upset with Mobic, ibuprofen and Naproxen. The COX-2 inhibitor Celebrex is medically indicated since the patient has failed a trial of Mobic, ibuprofen and Naproxen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for a continuous glucose monitoring system for treatment of the enrollees type 1 diabetes mellitus. Findings:  The physician reviewer found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin-treated patients who are not in good control.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for OxyContin CR/SR 80mg, 270 per month for treatment of her peripheral neuropathy. Findings:  The physician reviewer found that the peer-reviewed studies support the use of opiates in non-cancer pain as long as the total dosage is below the equivalent of 1 gram of morphine per day. The requested amount of OxyContin is less than the 1 gram per day equivalent. Ballantyne and Mao report that opioids were shown to be effective in the treatment of neuropathic pain, provided an adequate dose can be reached that provides analgesia without side effects.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for psychoanalysis on an outpatient basis four times a week for treatment of the enrollees eating disorder and depression.  Findings:  The physician reviewer found that there is no evidence in the peer-reviewed literature that intensive psychoanalysis is more effective than weekly psychoanalysis for the treatment of OCD or eating disorder. That being said, given the length of time the patient had been in therapy four times per week, tapering the sessions over a period of several weeks was clinically warranted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 40-year-old male enrollee has requested continued inpatient acute rehabilitation for the treatment of his traumatic brain injury. Findings:  The physician reviewer found that this patient requires multidisciplinary/interdisciplinary team rehab with doctors, nurses, social workers, and physical, speech, and occupational therapists. Although this patient initially progressed slowly, he has made good progress in all areas (mobility, ADLs, cognition). He has not reached his maximal therapeutic benefit as of yet and therefore requires additional inpatient acute rehabilitation services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for a magnetoencephalography (MEG) for evaluation of her epilepsy.  Findings:  Three physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for use of a pneumatic compression device for treatment of her medical condition status-post bilateral meniscus tear.  Findings:  Three physician reviewers found that the literature indicates that cooling/compression devices have been used in postoperative knee surgery care. But, the studies do not prove that the use of compression devices improve or accelerate positive outcomes as compared to other treatments.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for human growth hormone (GH) therapy for treatment of the enrollees short stature.  Findings:  Two physician reviewers found that the FDA approval of GH therapy for children with idiopathic short stature indicates GH is appropriate for patients who are below the -2.25 standard deviation in predicted height. This patient does not meet this requirement as his predicted adult height exceeds the FDA cut-off. The use of Letrozole may promote some improvement in the prediction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for Provigil 100 mg (#60) for treatment of his treatment-resistant depression. Findings:  Three physician reviewers found that Modafinil is an FDA approved medication and it has shown promise in a variety of off-label indications in psychiatry including treatment-resistant depression as noted in the article by Minzenberg and Carter. This reference also notes that modafinil appears to be well-tolerated with a low rate of side effects and low liability for abuse. Another article by Vaishnavi and Gadde describes the benefit of modafinil for atypical depression in an open-label double-blind study. The authors found that modafinil significantly improved atypical depression symptoms during 12 weeks of open-label treatment and it was well-tolerated. A third reference in this same journal by Taneja and colleagues concludes that modafinil may have general mood-elevating effects and that these findings may have clinical implications for clinical practice, particularly for the adjunctive use of modafinil in the treatment of resistant depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-month-old male enrollee has requested for Similac Alimentum Formula for treatment of his milk/soy protein allergy. Findings:  The physician reviewer found that adverse reaction to cows milk protein is quite common in infants, with between 5% and 15% showing symptoms. The prevalence of cows milk protein allergy (CMPA) ranges from 2% to 7.5%. Symptoms of mild to moderate CMPA include urticaria, angioedema, regurgitation, vomiting and/or diarrhea, constipation, blood in the stool, persistent colic, atopic dermatitis, and respiratory problems. Severely allergic infants may present with failure to thrive, feeding refusal, protein-losing enteropathy, and large amounts of blood in the stool. A comprehensive history is crucial in making the diagnosis of CMPA, including family history, because the risk is increased in the presence of familial atopic diseases.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that multiple sclerosis (MS) is not considered a weight-related co-morbid condition, and in the absence of any significant weight-related co-morbidities, this patient would not meet criteria for weight loss surgery unless her BMI was 40 or greater.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees migraine headaches. Findings:  Three physician reviewers found that There is no documentation in the records provided that the patient has used Elavil, a calcium channel blocker, Topamax or a beta blocker in the past. Although Botox can be useful in select resistant cases of migraine, it is not a first-line therapy for this condition. There is no documentation in the records stating that the patient has failed other more well-established and standard headache prophylactic medications (such as Elavil, Topamax, calcium channel blockers or beta blockers); nor is there any documentation suggesting that the patient would not be able to take these medications. There is ample literature demonstrating the benefit of prophylactic medications for preventing migraine headaches. The article referenced above demonstrates standard practice parameters for migraine patients. It is not evident that this patient could not be adequately and better treated with more standard and proven therapies.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that there was no new injury or sudden change in her condition that prompted her emergency visit. Her pain does not appear to have been severe, as she declined pain medication in the emergency department.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 79-year-old male enrollee has requested for external counterpulsation (ECP) therapy for treatment of her angina. Findings:  Two physician reviewers found that the use of ECP in the treatment of heart failure shows promise in early trials, this therapy has not yet shown benefit in such patients. There are patients who present with crossover symptoms such as dyspnea, which may be an anginal equivalent in patients who are not amenable to revascularization procedures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy. Findings:  The physician reviewer found that this non-ambulatory patient will likely remain non-ambulatory and will require supportive wheelchairs throughout his lifetime. The  literature also shows that transportation load is non-variable and a constant, nearly daily need for children with cerebral palsy. The literature also notes that transportation safety depends on adequate restraints and support which would require an ultra-light wheelchair to have the supportive system recommended by the patients physical therapist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for a bilateral breast MRI performed for evaluation of her breast cancer. Findings:  The physician reviewer found that has a diagnosis of atypical ductal hyperplasia in the right breast and an MRI report raised the question of ductal carcinoma in situ, due to an abnormal area of enhancement next to a marking clip.  Since the subsequent excision was performed without MRI localization, it cannot be known if the suspicious area of enhancement was included in the surgical specimen.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for an electrical pelvic floor stimulation/biofeedback for treatment of his post-prostatectomy urinary incontinence.  Findings:  Three physician reviewers found that it was found that there are no randomized prospective clinical studies which demonstrate that electrical pelvic floor stimulation/biofeedback therapy will improve this patients condition. Furthermore, there is no data that the proposed therapy is superior to standard alternative therapies in this setting which include collagen injection therapy and artificial urinary sphincter.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for continued use of morphine for treatment of her multiple sclerosis and degenerative joint disease (DJD).  Findings:  The physician reviewer found that the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) states that, for a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had been suffering from hemorrhoids for a year according to his statement.He was not experiencing an acute hemorrhage from his hemorrhoid. The hemorrhoids had not suddenly become thrombosed or ulcerated. Since the patient had already been evaluated for his symptoms, had already been prescribed medication, and there was no acute change in his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for Ambien CR for treatment of her insomnia. Findings:  The physician reviewer found that Ambien CR is a controlled-release medication that can be more effective than Ambien or Ambien IR in a subset of patients due to its pharmacokinetic properties.