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

A 33-year-old enrollee has requested for a laparoscopy for evaluation of his gender identity disorder. Findings:  The physician reviewer found that the persistent Mullerian duct syndrome (PMDS) is a rare form of inherited male pseudohermaphroditism characterized by the presence of Mullerian derivatives in otherwise normally masculinized XY males. The condition is due to a deficiency of anti-Mullerian hormone. Unless an elder brother has been diagnosed with the condition and there is appropriate suspicion raised, the persistence of uterus and tubes is discovered in a patient undergoing surgical repair of cryptorchidism or inguinal hernia. Two anatomical forms of PMDS have been described, and patients will only present with these findings on examination. The association of unilateral cryptorchidism, with one testis located in the abdomen and the other in a contralateral hernia, characterizes the most common form. One testis descends into the scrotum, and the ipsilateral uterus and fallopian tube either enter the inguinal canal, a condition known as hernia uteri inguinalis, or can be dragged into it by gentle traction, bringing the contralateral testis and fallopian tube in their wake. Often, no traction is necessary, because the contralateral testis is already in the hernia sac. Transverse testicular ectopia, as this condition is called, is extremely common in PMDS. More rarely, in a second clinical presentation, PMDS takes the form of bilateral cryptorchidism. The uterus is fixed in the pelvis, and both testes are embedded in the broad ligament in the abdomen. These clinical variants are not determined genetically and may occur within the same sibship.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for Flector patch (1.3%) for treatment of her costochondritis. Findings:  The physician reviewer found that there is no evidence that this patient has undergone an omeprazole trial or a COX-2 inhibitor trial. The use of the diclofenac (Flector) patch prior to the use of either of the two above mentioned interventions is not indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for occipital nerve stimulation implantation for treatment of her occipital neuralgia.   Findings:  Two physician reviewers found that the use of peripheral nerve stimulation for management of intractable pain has been discussed since 1977. In 1999, Weiner and Reed first described a technique for occipital nerve stimulation.  Since then, several articles published in peer-reviewed journals have suggested the efficacy of occipital nerve stimulation in the management of neuralgic pain (see Slavin, et al. and Kapural, et al.). These studies show evidence that clearly suggests the usefulness of occipital nerve stimulation in this condition. This patient has failed conservative treatment including multiple medications and epidural injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for a consultation with a neuro-otologist for treatment of her sudden hearing loss. Findings:  The physician reviewer found that there is no tumor, and that the cause for the sudden hearing loss was idiopathic or cause undetermined, though various possibilities have been entertained. The workup the patient has had to date has been medically appropriate and evaluation by a neuro-otologist will not result in any further insight into the cause of the hearing loss than what has already been ascertained.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 71-year-old female enrollee has requested for Hyalgan injections for treatment of her right knee osteoarthritis.. Findings:  The physician reviewer found that this patients knee has been injected with corticosteroids, and she has also been on anti-inflammatories.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a total ankle replacement for treatment of her post-operative and degenerative joint disease.   Findings:  Two physician reviewers found that Total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis has been the subject of a long running clinical debate that has yet to be answered. These implants are FDA approved and have been shown to provide pain relief and restore motion in a severely arthritic joint. All told, there is adequate evidence of the efficacy of total ankle arthroplasty to support its use in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for continued stay at a chemical dependency partial hospitalization program for treatment of her polysubstance abuse. Findings:  The physician reviewer found that Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) level of care utilization criteria and the American, Society of Addition Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders, dimensions to consider must include functional status, co-morbid conditions, recovery environment and stressors, treatment history, and engagement and readiness for change.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for replacement foot orthotics for treatment of her leg length discrepancy and bilateral bunions. Findings:  The physician reviewer found that dress orthotics provide less support than traditional orthotics. In this clinical setting, a lift may be placed both inside and outside the shoe to accommodate the shorter limb.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 21-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that prudent layperson standard defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had been suffering from hemorrhoids for a week. He was not experiencing an acute hemorrhage from his hemorrhoid.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for a positron emission tomography (PET) scan for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the National Oncologic PET Registry (NOPR) reports a 36.5% change in clinical management based upon PET imaging when all tumors are considered. In addition, the NOPR has petitioned the Centers for Medicare and Medicaid (CMS) for approval of PET imaging in all primary tumors as initial staging as well as for treatment monitoring. In the case of this patient, even though conventional imaging and CA-125 levels are unimpressive at the present time, she has documented previous widespread abdominal disease, and thus, is an appropriate candidate for restaging with PET prior to repeat surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for intravenous ceftriaxone (Rocephin) for treatment of her Lyme disease.   Findings:  Three physician reviewers found that the patient has no indication for the use of intravenous antibiotics. Furthermore, extended or repeat courses of antibiotics have not been shown in double-blind, placebo-controlled trials in peer-reviewed journals to be efficacious in the treatment of Lyme disease. All told, there is inadequate evidence to support the use of antibiotics in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for an osteotomy consultation to reduce nose width for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the most reasonable option is for the patients optometrist to attempt to fit the patient with a size 22 or 23 frame rather than to pursue surgical intervention, which is invasive and carries risk. The medical literature does not document any cases of rhinoplasty to facilitate eyeglass use.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for Botox injections for treatment of her migraine.   Findings:  Two physician reviewers found that the literature shows that Botox can be beneficial for individuals with chronic headache, including those with medication overuse.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-week-old male enrollee has requested Synagis therapy for Respiratory Syncytial Virus (RSV) prevention. Findings:  The physician reviewer found that although this patient does not meet all of the criteria as set forth in the AAP guidelines, he is at risk for significant morbidity and even mortality from RSV disease by virtue of his gestational age, gender, and birth weight, as demonstrated by the above studies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-week-old male enrollee has requested Synagis therapy for Respiratory Syncytial Virus (RSV) prevention. Findings:  The physician reviewer found that although this patient does not meet all of the criteria as set forth in the AAP guidelines, he is at risk for significant morbidity and even mortality from RSV disease by virtue of his gestational age, gender, and birth weight, as demonstrated by numerous studies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a panniculectomy for the treatment of her redundant skin status post gastric bypass. Findings:  The physician reviewer found that the submitted photographs document an overweight female with an abdominal pannus which does not extend over the inguinal ligament and does not cover the mons pubis. The evidence does not establish that the proposed procedure is reconstructive in nature. While the submitted photographs show some hanging abdominal skin, the amount of excess skin is not so great as to constitute an abnormal structure of the body. The patients condition is normal in that the excess skin is not visibly affected by disease or infection. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined in California law. Regarding the medical necessity of the proposed procedure, there is a lack of documentation of intertrigo, skin ulcerations and skin rashes. Only one of the many office notes mentions dermatitis (mild dermatitis skin fold abdominal wall). The rash was treated with miconazole 2% and there is no medical record documentation of recurrence. Furthermore, there is a lack of medical record documentation of functional loss of activities of daily living or attempts at conservative treatments with failure of those conservative treatments.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for emergency services for treatment of his abscess.  Findings:  The physician reviewer found that according to the prudent layperson standard, an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The wound was packed and antibiotics were prescribed. This patients condition was improving, not deteriorating. The patient did need to be reevaluated in several days for packing removal and to check that the wound was healing properly.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for pulsed radiofrequency ablation (RFA) for treatment of her meralgia paraesthetica.   Findings:  Three physician reviewers found that standard therapy for this condition is a lateral femoral cutaneous nerve block with local anesthetic and steroid (see Grossman, et al.). Peripheral pulsed radiofrequency ablation remains unproven for this condition. There are no published articles suggesting that peripheral pulsed radiofrequency ablation is efficacious in this setting. There are other standard therapies such as surgical decompression that are likely to result in a superior outcome (Grossman, et al.).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested gemcitabine (Gemzar) and Taxotere (docetaxel) chemotherapy for the treatment of her leiomyosarcoma. Findings:  The physician reviewer found that there is no convincing data to support the benefit of adjuvant chemotherapy in stage I uterine sarcoma. At this time, such therapy must be considered unproven, and therefore, not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for a Fragile X test. Findings:  The physician reviewer found that the appropriateness of routine screening must be guided by current evidence-based scientific society guidelines. The ACMGs current prenatal screening recommendations for Fragile X syndrome are quite clear. This patient meets none of the family or personal history criteria for recommending Fragile X screening. Furthermore, an incomplete history on her fathers side does not constitute an increased risk above the general population risk.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for bilateral breast magnetic resonance imaging (MRI) for evaluation of her unilateral nipple retraction.  Findings:  Three physician reviewers found that a diagnosis may be difficult to confirm not only clinically but also by imaging criteria as often mammography and ultrasound may be negative in this type of tumor. It is true that MRI of the breast is associated with a high degree of false positive results, but if this exam is negative it would virtually rule out neoplasm. Thus, while the standard imaging studies are negative, the physical findings plus the family history mandate further investigation, and breast MRI would be the procedure of choice in this particular individual.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested for a magnetoencephalography (MEG) and magnetic source imaging (MSI) for evaluation of the enrollees epilepsy prior to surgery.  Findings:  Three physician reviewers found that there are limited studies that allow proper localization of an epileptogenic focus. MEG has been shown in multiple studies to enhance the ability to determine the seizure focus through less invasive means.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for excision of a skin lesion for treatment of her benign cherry angioma.  Findings:  The physician reviewer found that Messenger and colleagues note that other lesions can mimic cherry hemangiomas and that treatment of these superficial lesions can be as simple as shave excision followed by electrodessication. Removal of a benign skin lesion may be medically necessary when the lesion has one or more of the following characteristics: bleeding, intense itching, and pain. Removal may be further medically indicated if the lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for an electrical bone growth stimulation device for treatment of his stress fractures in his right heel. . Findings:  Three physician reviewers found that the use of a bone growth stimulator in treatment of a stress fracture lacks peer-reviewed studies that prove it is effective in promoting bone growth. Therefore, the bone growth stimulator would not be more beneficial treatment for this diagnosis than the standard care usually employed. In this case, there is no evidence of delayed union or nonunion.  There is no documentation of a full thickness fracture on x-ray or CT scan. An MRI showed increased signal consistent with plantar fascial changes, and post surgical changes with a stress reaction at the level of the plantar fascial origin.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for a FIBROSpect II blood test for evaluation of his hepatitis C.  Findings:  Two physician reviewers found that in clinical trials, the FIBROSpect II has been shown to have a very good positive predictive value for the absence of significant fibrosis (F0-1) when the score is low, with many studies demonstrating the correlation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested for emergency services for treatment of his rash. Findings:  The physician reviewer found that there is no documentation that the patient was experiencing shortness of breath, difficulty swallowing, or any airway compromise.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for azithromycin 250mg, #30 for treatment of her Lyme disease. Findings:  The physician reviewer found that there is a lack of evidence supporting either recurrent pneumonias or Lyme disease.  Moreover, azithromycin would not be the drug of choice in either situation. In addition, the suggested dosing would be excessive. The Infectious Diseases Society of America recommendations for treatment of Lyme disease note that macrolides (the family that includes azithromycin) are not recommended as first-line therapy for treatment of early Lyme disease.  A search of the National Library of Medicine database does not reveal articles that support the use of this drug in Lyme disease. Similarly, there is little data about the use of this drug for chronic pneumonias.  Finally, this antibiotic has a very long half-life that allows five days dosing to yield therapeutic serum levels for approximately two weeks.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for artificial intervertebral disc replacement for treatment of her progressive degeneration of the L3-4 disc with stenosis. Findings:  Three physician reviewers found that short-term results are encouraging, long-term results of lumbar disc replacement are lacking. There are insufficient long-term, well-controlled studies showing lumbar disc replacement to be superior to lumbar fusion. In addition, the patient had a previous lumbar fusion and has multiple-level degenerative disease, which makes artificial disc replacement even less appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for the Liberty Pelvic Floor Stimulator for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that there is long-standing discussion regarding pelvic floor stimulation, biofeedback, magnetic stimulation and conservative therapy (e.g., Kegel exercises) for outcomes of treating pelvic floor symptoms. There is no good data, however, showing the role or place for these therapies and how they are to be used effectively. Bo and colleagues concluded that, Training of the pelvic floor muscles is superior to electrical stimulation and vaginal cones in the treatment of genuine stress incontinence. After a thorough review of the available peer-reviewed medical literature, I find it appropriate to conclude that the role of a pelvic floor stimulator in this setting has yet to be determined. As such, it has not been demonstrated that the disputed device was likely to be result in a better outcome for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 16-year-old male enrollee has requested for his treatment for Behavioral Assessment for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and reactive attachment disorder (RAD). Findings:  The physician reviewer found that there was a significant risk of deterioration at a lower level of care. As noted in the Child and Adolescent Level of Care Utilization System (CALOCUS), there are several dimensions to consider such as presence of significant co-morbid medical conditions, co-morbid psychiatric disorders and level of functional impairment. All told, the patient required the level of intensity provided at the Aspen Institute and was not appropriate for a lower level of care during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for inpatient chemical dependency treatment for treatment of her alcohol and cocaine dependencies.  Findings:  The physician reviewer found that the patient clearly needed treatment, services could have safely and effectively been provided at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested for Xolair for treatment of his asthma. Findings:  The physician reviewer found that a study found that patients with moderate to severe asthma who received Xolair reduced their steroid use. Given this patients previous failure of conventional combination therapy and strong contraindication to corticosteroid use due to his central serous chorioretinopathy, Xolair is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for Euflexxa injections for treatment of her right knee arthralgia secondary to osteoarthritis. Findings:  The physician reviewer found that the patient is unable to tolerate anti-inflammatory agents due to gastroesophageal disease. A cortisone injection provided no significant benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for 16 doses of Imitrex 6 mg per month for treatment of her migraine headaches.  Findings:  The physician reviewer found that studies of high frequency triptan use have not been performed, many observational studies support the concept of triptan rebound. Evidence suggests that use of triptans for more than three days a week will, over time, cause rebound headache. This is likely worsened by frequent narcotic analgesic use. Thus, the requested 16 injections of Imitrex a month is excessive and likely to cause rebound headache.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has for a continuous blood glucose monitoring system for treatment of the enrollees type I diabetes.  Findings:  The physician reviewer found that there is documented evidence of over 21 instances of blood glucose levels below 70 mg/dl with some readings as low as 28 mg/dl. The frequency and severity of these episodes require intervention. There is also growing evidence that her control may be improved with the use of the Paradigm Real-Time glucose sensor, as indicated in the referenced literature.