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

A 38-year-old female enrollee has requested for an artificial disc replacement procedure for treatment of her back pain. Findings:  Three physician reviewers found that the medical literature shows that total disc replacement procedures are associated with a high rate of re-operations.  The particular device at issue is also associated with substantial morbidity and even mortality.  The safety and efficacy of this procedure over standard ones is not yet established.  Also, in this case the patient has chronic pain, but her discogram results were equivocal at best and it is noted that her pain is on the opposite side from her disc bulge.  She is unlikely to obtain benefit from the proposed surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for multilevel artificial disc replacement surgery utilizing Prodisc for treatment of his back pain. Findings:  Three physician reviewers found that The discogram that was reportedly positive at all levels is an invalid and scientifically unsound study.  It cannot support a request for multilevel disc surgery.  Furthermore, there is insufficient scientific evidence supporting the long-term safety and efficacy of artificial disc replacement especially at multiple levels. The patient has other treatments available that are likely to be more beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for Botox injections for treatment of her back pain. Findings:  The physician reviewer found that although Botox is not the first line therapy for back spasms, there is certainly literature and science to support its use in select cases that are resistant to other more mainline therapies.  Given that this patient failed previous treatments, and is not a candidate for further surgical methods, and that he responded well to Botox in the past, it is certainly reasonable and medically appropriate to continue therapy with this agent.  Botox is the best available treatment for this patient and has provided relief where other available treatments have failed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a ten-month-old female enrollee has requested for a Dynamic Orthotic Cranioplasty (DOC) for treatment of the enrollees head shape.    Findings:  The physician reviewer found that the health outcomes of untreated plagiocephaly without synostosis are uncertain.  There are no randomized, controlled studies on the effects of this condition on neuropsychological function, development, the temporomandibular joint, or psychosocial concerns.  The natural history of this condition is not well documented.  Remarkably few adults have deformities of cranial symmetry or shape, suggesting that the abnormality is either self-correcting or effectively masked by a combination of increased cranial circumference and hair growth.  The available data do not support use of the DOC band.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a 14-year-old female enrollee has requested for Humatrope growth hormone for treatment of the enrollees short stature.    Findings:  The physician reviewer found that the patient does not meet the clinical definition for pathologic short stature.  Her height is in the 7th percentile, which is not the -2.25 standard deviations indicated for growth hormone use.  In addition, given her normal bone age, she is likely to have familial short stature. Furthermore, there are no lab abnormalities.  Also, there is no note of her Tanner stage, but with menarche at age 11, she is very likely Tanner V with closed epiphyses.  Closed epiphyses are a contraindication for use of growth hormone.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested for emergency services for treatment of his buttock abscess.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a large buttock abscess with 10/10 pain would reasonably expect the absence of emergency care to jeopardize their health. The patients pain level and the fact that the abscess required operative excisional debridement support the need for immediate care. Infected dermatological abscesses are normally incised and drained in the ED under local anesthesia and only go to the operating room if complex.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for Prestige ST artificial cervical disc surgery for treatment of her neck and shoulder pain and arm symptoms.   Findings:  The physician reviewer found that cervical discectomy and fusion, is considered the standard procedure in this country for symptomatic degenerative disc disease within the cervical spine.  Although artificial disc procedures seem promising, there is no long-term data to establish the clinical safety and efficacy of this procedure over the standard one at this time.  In the absence of long-term data, there is no evidence to support the requested procedure as medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for breast MRI for evaluation of her breast lesions.  Findings:  Two physician reviewers found that this patient has two small solid breast masses, one within the left breast and one within the right breast. These nodules have been visualized on both MRI and ultrasound. The MRI report suggests possible breast biopsy of these lesions and the ultrasound report describes them as benign (BIRADS 2 category  no further evaluation is needed at this time with follow up mammogram indicated in one year). Options for the patient at this time are biopsy of the masses under ultrasound guidance, follow-up bilateral breast ultrasound in six months or routine follow-up mammogram in one year. The patient does not want to undergo biopsy and her physician recommends a follow-up imaging study. The appropriate follow-up imaging study for this patient would be bilateral breast ultrasound as the two lesions noted on MRI can clearly be visualized with breast ultrasound. There is no medical need for breast MRI at this time. Breast MRI should be used as an adjunct to mammogram and ultrasound; not as a replacement. Breast MRI should also not replace breast biopsy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for a breast MRI performed for evaluation of her breasts. Findings:  The physician reviewer found that the use of breast MRI for screening purposes is limited to patients with known BRCA mutation or a family history of BRCA mutation or three or more first or second degree relatives (on same side of family) with known breast cancer. Based upon the information submitted, the patient has only a single first degree relative with a history of breast cancer and there is no documentation demonstrating a BRCA mutation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for the prescription medication Lyrica for treatment of his nerve pain. Findings:  The physician reviewer found that while Lyrica has use in refractory painful neuropathy, it should not be used before the more traditional first-line agents.  In this particular case, there is no evidence that the patient has failed a trial of Neurontin and there is no evidence that Neurontin is contraindicated for this patient. Unless there is evidence to the contrary, a trial of Neurontin should be considered prior to instituting treatment with Lyrica. However, if the patient fails a trial of Neurontin treatment with Lyrica should be considered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 42.3 and early comorbidities, the patient meets the National Institute of Healths medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, she has not yet obtained psychological clearance for the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for a gradient compression garment for treatment of her lymphedema.  Findings:  The physician reviewer found that as opposed to over the counter elastic stockings, gradient compression garments are considered an item of durable medical equipment. These garments are prescribed by a physician and the patient needs to be professionally measured for proper fit. The compression garments come in ready-to-wear and custom-fitted versions. In this instance, the patient has chronic pain associated with her condition and the nature of her employment precludes continuous elevation of the affected limb. The use of a gradient compression garment is clinically indicated. If the patient cannot wear an over-the-counter garment, then a custom-fitted garment is appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested for the medication Enbrel for treatment of his  psoriasis.    Findings:  The physician reviewer found that this patient has psoriasis that is becoming aggressive and spreading in a short period of time.  He has only 20% BSA involvement to date, but his disease is active and increasing in distribution. He has failed several topical therapies and UVB phototherapy.  The patient most recently failed an adequate course of Soriatane.  Methotrexate is not a good option for this relatively young patient due to its long-term risks of hepatotoxicity.  Also, cyclosporin has multiple side effects and patients frequently flare when the medication is discontinued.  As the patient failed a trial of Soriatane, the next appropriate therapy would be a biological therapy.  Enbrel is very effective and has a very safe side effect profile.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for residential treatment services for treatment of his alcohol dependence. Findings:  The physician reviewer found that the patient met the established criteria for admission to a residential treatment program. At that point, he required structured 24-hour care for stabilization. The patient needed to establish his long-term rehabilitation program and to make a commitment to sobriety. He had previously failed to follow through in the outpatient setting. This could have reasonably been accomplished in a 14-day residential program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for the prescription medication Viagra for treatment of his erectile dysfunction (ED).  Findings:  The physician reviewer found that Viagra is an accepted primary therapy for the treatment of ED and treatment is typically goal directed. Viagra and similar drugs have no impact on desire or sensation, so no patient that was not impaired would reasonably use or request such a drug. One-third of males in their 50s have some significant erectile dysfunction and Viagra has a good safety profile except for those taking nitrates. However, in this instance the documentation is not sufficient to establish a diagnosis of ED nor is the patients response to treatment with Cialis adequately documented.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 17-year-old female enrollee have requested for residential treatment services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that at the time of admission the patient was in need of 24-hour supervision because her eating had significantly decreased, she had stopped outpatient treatment and she was exercising several hours a day. The patient had primary amenorrhea, but her heart rate was normal at the time of admission. She was said to be mildly malnourished. Her blood chemistries and EKG showed no abnormalities. In the residential treatment facility, the patient was reasonably compliant but did refuse all medications. She was not psychotic, suicidal or homicidal and she was not medically unstable. Her provider, stated that the patient was doing well and had not recently engaged in any unhealthy behaviors. The patient was said to have an obsessive quality to her thinking and poor insight, but denied symptoms of obsessive compulsive disorder. Her mood was described as good and her anxiety was noted to be stable. The provider further indicated the patient was compliant and has no behaviors of concern. However, there was previously stated concerns that the patient could not maintain her improvements outside the structure of residential treatment. The patients weight was almost at her ideal body weight and there were no indications she needed intensive professional supervision on a 24-hour basis. By that point, the patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for a PET scan of the brain for evaluation of her neurological symptoms. Findings:  The physician reviewer found that current research indicates that PET findings of left hemispheric hypofunction have been associated with a myriad of neurological clinical entities. The PET findings are often nonspecific, and do not seem to affect therapeutic decision making. While further evaluation is needed in an effort to identify the source of the patients multiple medical concerns, PET scan is not likely to provide any meaningful help in directing her care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Rituxan (rituximab) therapy for treatment of her cryoglobulinemia.   Findings:  The physician reviewer found that mixed cryoglobulinemia is an immune complex mediated disease involving small to medium vessel vasculitis. It is associated with HCV in many instances. This disease can affect vital organs including the kidney, liver and heart. Early treatment often involves a combination of antiviral medication, interferon-alpha and ribavirin. Plasmapheresis, steroids or immunosuppression are utilized at later stages.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 14-year-old female enrollee have requested residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that The patient is a disturbed teenager with self-destructive potential. To recommend any form of treatment less than residential care would be dangerous and clinically inappropriate. She shows limited capacity to care for herself without around-the-clock professional supervision. In the short time she has been in residential care she has clearly been less destructive. The patient has attended almost all group and individual therapy sessions and is beginning to establish a therapeutic relationship with both therapists and staff. This would suggest she has the capacity to respond favorably to treatment and has a  restorative potential. In my experience, patients with her diagnoses can benefit from this type of intervention. Her progress is satisfactory and she is reasonably compliant given her level of pathology. Continued treatment at the residential level of care is clinically appropriate. A lesser level of care would not be safe or effective at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of a five-month-old male enrollee have requested Synagis for the treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  Two physician reviewers found that although there is an older sibling in the home attending preschool and the pediatrician ordered Synagis therapy for the patient, he does not meet criteria for RSV prophylaxis. There are no indications for treatment with Synagis, and it is not the standard within the pediatric community to do so.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of a five-month-old female enrollee have requested Synagis for the treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  Two physician reviewers found that although there is an older sibling in the home attending preschool and the pediatrician ordered Synagis therapy for the patient, she does not meet criteria for RSV prophylaxis. There are no indications for treatment with Synagis, and it is not the standard within the pediatric community to do so.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Avastin therapy for the treatment of his prostate cancer. Findings:  Three physician reviewers found that the patient has androgen-independent, apparently chemo-refractory prostate cancer, metastatic to the bones. Relevant scientific data does not establish the efficacy of Avastin in this setting. Research is ongoing, however the activity of Avastin for prostate cancer is not yet known. The record does not suggest the patient is enrolled in a clinical trial.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested high-dose chemotherapy with autologous hematopoietic stem cell transplant for the treatment of his autoimmune disease. Findings:  Three physician reviewers found that this patient has a severe, progressive autoimmune disease. He has tried and failed all standard therapies. Unmanaged, his condition will continue to worsen. There is literature support for autologous stem cell transplant as a more encouraging alternative for patients who are refractory to traditional treatments for autoimmune disease. There is no reasonable alternative at this stage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a PET/CT scan for an evaluation of her primitive neuroectodermal tumor (PNET). Findings:  Two physician reviewers found that primary uterine PNET is extremely rare. It is clear from a review of the literature there is no accepted standard for staging and follow-up of this cancer. It is not known if primary uterine PNET behaves like the bone tumor members of the Ewing sarcoma family or if the same guidelines should be applied. As such, there is no preferred standard imaging for this condition. PET/CT was utilized previously for this patient and consistent assessment of her disease status would require that PET/CT be utilized again to assess her response to chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Celebrex for the treatment of her osteoarthritis. Findings:  The physician reviewer found that when Coumadin therapy is used, the concomitant use of platelet-inhibiting agents should be avoided, as this clearly increases the risk of unwanted bleeding. All traditional NSAIDs have varying degrees of anti-platelet activity and should not be used in a patient who is anticoagulated with Coumadin. However, COX-2 selective inhibitors do not have anti-platelet effects. Standard practice would be to recommend Celebrex (the only available selective COX-2 inhibitor) for patients who must also take Coumadin. While it is true that serious bleeding events have been reported in patients taking Celebrex and Coumadin, this has typically been due to inadequate monitoring of the patients INR. It is known that Celebrex will displace Coumadin from serum proteins, freeing more active Coumadin and raising the patients INR. The patients Coumadin dose will usually need to be lowered to maintain the desired INR. When done correctly with appropriate monitoring, the concurrent use of Celebrex is considered the best way to provide non-steroidal anti-inflammatory effect in patients requiring Coumadin therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a CINE flow study of the brain and cervical spine for an evaluation of her type I Chiari malformation. Findings:  The physician reviewer found that no physician who has seen and examined the patient has requested or recommended a CINE MRI. It is highly unlikely that this patients borderline Chiari I malformation is responsible for her weakness, blindness, seizures, or other neurologic symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a breast MRI for an evaluation of her breast nodule.  Findings:  The physician reviewer found that The standard of care for a patient such as this, with a new palpable breast mass, is a diagnostic mammogram and breast ultrasound. At this time, the medically appropriate imaging study for this patient is a diagnostic mammogram and ultrasound. Breast MRI is usually used as an adjunct to mammography and ultrasound and is not performed in lieu of mammography/ultrasound. The use of breast MRI is reserved for a certain patient population including those patients with newly diagnosed breast cancer when there is concern of multifocal or bilateral disease; those patients with past surgery for breast cancer when there is concern of recurrence at the scar; and in screening patients with the BRCA gene mutation. This patient does not meet any of these criteria.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for emergency services for treatment of his pilonidal cyst. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with severe pain and an increased risk of infection would reasonably expect the absence of emergency care to jeopardize their health. The records indicate the patients pain was rated as 8/10 and he required significant doses of parenteral narcotics for pain control. He also has diabetes, a medical condition that places him at increased risk for severe infections such as necrotizing fasciitis
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for an MRI of the right knee for evaluation of her knee pain. Findings:  The physician reviewer found that the patient has advanced arthritis of her right knee with radiographs that demonstrate bi-compartmental degenerative changes. MRI would not provide any additional medical information that would change her treatment plan given this diagnosis. In addition, there has been no recent acute soft tissue injury documented in the record that would suggest the need for an MRI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for the medication Focalin XR for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that no information has been submitted demonstrating that either Adderal of Concerta is contraindicated for this patient. Adderal or Adderal XR or Concerta all have the potential to provide significant benefit for this patients condition.