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

A 41-year-old female enrollee has requested for a bone growth stimulator (electric and ultrasonic) for treatment of her condition.   Findings:  Three physician reviewers found that this patient does not have a diagnosis of a non-union long-bone fracture, and therefore, there is no indication for a bone-growth stimulator.  The use of a bone-growth stimulator in this setting has not been shown to have clinical value. In the absence of scientific data to support its use in this setting, a bone-growth stimulator is not likely to result in superior benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for a consultation with a plastic surgeon for treatment of her breast ptosis and excess skin condition. Findings:  The physician reviewer found that the submitted records fail to document convincing and confirmatory evidence of a chronic functional problem that has failed to respond to reasonable attempts at conservative therapy.  Nor does the patient have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of problems with skin folds. Photographs documenting cellulitis, ulcerations or rashes have not been submitted.  In addition, the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy or have recurred and caused significant functional impairment despite initial response.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested thigh/lower body lift for the treatment of her excess skin condition. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the requested surgery is medically necessary for this patient. There is no evidence of a chronic functional problem that has failed to respond to conservative therapy. Furthermore, it does not appear the requested procedure is reconstructive in nature. The patient has generalized skin laxity consistent with her history of massive weight loss, which does not constitute an abnormal structure of the body. Additionally, the requested procedure would not improve function or create a normal appearance to the extent possible as the patient would still have obese thighs with cellulite and lipodystrophy. Finally, the requested surgery would offer no more than a minimal improvement in the appearance of the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested reimbursement for Chemical Dependency Residential Treatment Care (CDRTC) for the treatment of his condition. Findings:  The physician reviewer found that the patient is a chronic and persistent polysubstance abuser who uses and abuses whatever substances are available. Having experienced frequent early abuse of substances and failing outpatient care, this patient represents the classic case for which residential care is the last resort of choice. His particular traits mandated a structured setting to contain his impulsive drug use. The patient entered the RTC essentially out of control and he received appropriate care and supervision which was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an eight-year-old female enrollee have requested myofunctional/speech therapy for the treatment of the enrollees oral myofunctional deficit. Findings:  The physician reviewer found that the patient has swallowing and communication impairments as a result of a congenital abnormality.  The providers evaluation provides evidence that the patients swallowing and communication impairments are secondary to impaired neuro-motor control of her swallowing and speech production musculature. This congenital abnormality results in lingual muscle weakness and faulty motor placement of this structure for chew, transport, swallow, articulation, and at-rest posturing, as documented by the patients provider. Thus, myofunctional/speech therapy services are a medically indicated and necessary intervention for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested partial hospitalization services for the treatment of her eating disorder. Findings:  The physician reviewer found that the progress notes written at the time of the denial clearly show that the patient had poor impulse control concerning her over-exercising, drinking and compliance with medication.  She was not addressing the symptoms of her depression and was reluctant to start her medication.  During the weekend following the denial, she did lose weight.  Her active participation in a program that offered several modalities of treatment did contribute to her stabilization and ability to retain her weight gain, decrease excessive exercising and drinking.  The progress notes reflect the stabilization of the patient and her ability to move to a lesser level of care.  The patient needed the structure of the program to continue to improve with her eating disorder.  She regressed and then was able to stabilize and utilize medication appropriately.  Partial hospitalization services provided on the dates in question were medically necessary.  The patient was able to continue her improvement in treatment at the intensive outpatient level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested Humira injections for the treatment of her ulcerative colitis. Findings:  The physician reviewer found that there is only one open-label trial of 10 patients who received Humira for ulcerative colitis; 4 were reported to have received a benefit, but the extent of that benefit was unclear.  There is no consensus about the role of Humira in the treatment of ulcerative colitis.  It does not have a role in therapy as yet defined.  The treatment proposed here is akin to a clinical trial, rather than an innovative practice.  The benefit of such treatment as an experimental approach for this patient is entirely unclear.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the patient presented with signs and symptoms consistent with a variety of potentially serious diseases including sinusitis (especially given her past history of the diseases), meningitis, otitis media, and other infectious diseases.  It would be appropriate for a prudent layperson to seek immediate medical attention due to potential jeopardy to her daughters life and/or bodily organ functions.  Early cases of meningitis (a potentially life-threatening disease) often mimic general viral illnesses and present similarly to how the patient presented to the ED.  It was appropriate for the patients mother to bring her daughter in for an exam to rule out more serious disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested computed tomography angiography (CTA) for the evaluation of her chest pain. Findings:  Three physician reviewers found that the patient has known coronary artery disease, atypical chest discomfort and an adequate stress echocardiogram that revealed no evidence of provocable ischemia. In this circumstance, continued aggressive risk factor modification is the best approach. A coronary CTA, regardless of the results, would not prompt a treatment change in this setting. Appropriateness criteria for coronary CTA do not recommend performing the test in this circumstance of known coronary artery disease and a recent normal stress echocardiogram.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Sutent for the treatment of her condition. Findings:  The physician reviewer found that Sutent is an oral multi-targeted tyrosine kinase inhibitor. It has been approved for the treatment of metastatic renal carcinoma. A single phase II study in breast cancer has shown the drug to be modestly active. There are many other standard options for the treatment of breast cancer that would be appropriate for this patient. Sutent is not medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a breast MRI for an evaluation of the enrollees condition. Findings:  The physician reviewer found that the use of MRI in this setting is not shown to have distinct advantage over other routine mammographic imaging. The breast MRI was not medically indicated for evaluation of this patient. The Health Plans denial was appropriate and consistent with the current state of the art of medical imaging.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Actiq for the treatment of his condition. Findings:  The physician reviewer found that it is unclear if the prescribed medications are indeed helping the patients pain. Actiq has been used off-label for the management of non-malignant pain. Clear documentation is needed regarding the dose and frequency of the prescribed medication. Absent this information, the medical necessity of the requested medication cannot be established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of an 18-year-old male enrollee has requested residential treatment for the treatment of the enrollees chemical dependencies. Findings:  The physician reviewer found that while the patient does not appear to be actively suicidal, homicidal or psychotic, he is a seriously ill young man who has become therapeutically engaged at his current residential treatment facility. Disrupting his treatment and transferring him to another facility for less intensive treatment is not in the patients best medical interests at this time. Discharging this patient is likely to be disruptive to his course of treatment and is potentially dangerous.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Cymbalta for the treatment of his depression. Findings:  The physician reviewer found that the patient experienced a serious and long-standing depression. When the patient did not respond to Lexapro, the patients psychiatrist switched him to Cymbalta up to a relatively high dosage. The patient responded to this medication, and he is now able to perform various activities that he was unable to before. This particular patient has already been treated and is stable on Cymbalta. It is now medically unreasonable for this patient to stop the antidepressant that has resulted in the alleviation of his depression. To do so is to take a risk that the depression may resurface. Moreover, there is no guarantee that the approved generic versions will be as effective as Cymbalta.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient was suffering from an early flare up of a chronic condition. At the time of presentation to the emergency department, he was not suffering from significant pain, and he had no fever. According to the patient, he was being followed by several physicians for this condition. It seems reasonable that he could have contacted one or more of these physicians regarding the current flare up. As this patient was not suffering from severe pain, and there did not appear to be any threat to his life or bodily organ functions, a prudent layperson would not be expected to seek immediate emergency medical evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested bariatric surgery (Lap band or Roux-en-Y) without losing 10% of body weight for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has required Actos, leading to further weight gain. She has tried and failed conventional weight loss programs. The surgery is medically necessary and will significantly improve her insulin sensitivity. She will manifest moderate weight loss and improvement in comorbidities, which is the prime reason for the surgery.  The Health Plans denial is inappropriate. Bariatric surgery, specifically Roux-en-Y, is medically warranted for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested the use of a continuous passive motion (CPM) device for the treatment of her condition. Findings:  Two physician reviewers found that the evidence-based literature does not suggest that in standard shoulder surgery, including acromioplasty, distal clavicle resection and rotator cuff repair, use of a CPM device is more beneficial than traditional therapy, including early range of motion and early home exercises. Of note, this individual did not begin using the CPM within 72 hours and used it well beyond the traditional time frame where this is considered to be of value.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from acute right-sided abdominal pain due to gallstones and subsequent gallbladder inflammation (cholecystitis). She required a series of blood and ultrasound tests to make this diagnosis. Other diseases that are in the differential diagnosis of her presenting symptoms include gastritis, peptic ulcer disease, hepatitis, pancreatitis, urinary tract infection and/or stone among others. A prudent layperson would reasonably seek immediate medical attention due to the severity of pain as well as the potential jeopardy to other body organs.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested  for a repeat, postoperative PET scan.   Findings:  Two physician reviewers found that PET scans are useful to differentiate postoperative changes from recurrent/residual cancer in patients with a history of non-small cell carcinoma. The postoperative CTA of the chest did show a 2.4cm rounded density near the anastomosis. This rounded density may be postoperative in nature, although residual tumor is not excluded.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested the use of a Meniett device for the treatment of his Menieres disease. Findings:  Three physician reviewers found that though time may show this device to be an effective and consistent treatment for the condition, at this point it remains experimental for most patients, pending further studies. On the other hand, Menieres patients are sometimes disabled by their symptoms, which can lead to invasive surgical procedures with significant risks and side-effects as in this patients case. According to the note from his physician, this patient has experienced significant improvement in symptoms from this non-invasive device. For this reason, I recommend reimbursement for this device, as its surgical alternative (standard therapy) carries greater risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested Saizen for the treatment of his growth hormone deficiency. Findings:  The physician reviewer found that the patient is likely to have growth hormone deficiency. This may be due in part to the ongoing use of his medications. The patient has shown a brisk response to a trial of growth hormone therapy and is likely to continue to benefit from use of the therapy. In light of the patients likely growth hormone deficiency as well as the positive results he achieved with a trial of hormonal replacement therapy, the continued use of growth hormone is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old male enrollee have requested a CPM (continuous passive motion machine) and a cooling device (via an electronically-controlled circulating pump) for the treatment of the enrollees condition. Findings:  The physician reviewer found that the central issue to consider in this case is whether the CPM and cooling devices were medically necessary in the patients rehabilitation after knee surgery. The cooling device is considered a convenience item and was not truly needed. The patient could have used standard cold or ice packs in order to reduce pain and swelling.  In addition, the CPM is not a necessary device to restore range of motion after this type of surgery.   Traditional post-operative physical therapy or home exercise programs given by the physician would have provided the same benefits as the CPM machine such as increasing nutrition and joint range of motion, enhancing collage reformation, and reducing the possibility of adhesion formation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested a mandibular repositioning device and services for the treatment of his sleep apnea. Findings:  The physician reviewer found that CPAP is considered the gold standard for treatment of obstructive sleep apnea. However, CPAP only has a 50 to 70% compliance of patient use despite its effectiveness, indicating that a significant subset of patients cannot tolerate its use. For these patients, alternative therapies are available. One of these treatments is the use of an anterior mandibular positioning oral device for those patients where anterior positioning of the mandible eliminates the obstruction of the airway and thus reduces or eliminates apnea episodes. There are many studies in the literature which have demonstrated the safety and efficacy of these oral anterior mandibular positioning devices in 40 to 50 % of selected cases. Like CPAP many patients are not able to tolerate these devices due to TMJ joint pain, sore teeth, xerostomia, etc. However, for those individuals who are unable to tolerate CPAP it offers an alternative non-surgical treatment. Surgical treatments include nasal surgery, palatopharyngoplasty and othognathic surgery to move the mandible and/or maxilla forward depending on the site(s) of the airway obstruction.  However, all of these surgical treatments are associated with significant risks and adverse side-effects. The patient has signed an affidavit that he was unable to tolerate CPAP (which is patient-dependent and known to occur in 30 to 50% of patients treated with CPAP). The intra-oral mandibular anterior positioning device, is a medically acceptable alternative treatment. Therefore, the anterior mandibular positioning device was medically necessary in this case, and an acceptable alternative treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested SirSphere  yttrium-90 Radio-embolization (microsphere brachytherapy) for the treatment of his carcinoma. Findings:  Three physician reviewers found that this young male patient so far has exhausted the 20 cycles of chemotherapy which have worked favorably for him. Now, he needs a more definitive approach. A surgical approach would meet the requirement. However, the surgeons are being cautious (appropriately so) and want a SIR radioactive seed approach to help further decrease the volume of the tumor in the liver. They also want to then wait 4-6 months to allow time to help them in their evaluation of the patient, and his durability of tumor control. Only then will they consider surgical resection of the tumor in the liver. Based upon the evidence available to date, the best possible treatment option for this patient is to receive SIR-Sphere therapy at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested care for the treatment of her condition. Findings:  The physician reviewer found that the Health Plans denial of past and further care at the facility is correct and the request is not medically necessary. Based on the occupational therapy notes, the patient could and should able to do her (ADLs) activities of daily living at home without assistance. She is not requiring skilled nursing services that would warrant further inpatient care. In her case, the home physical therapy would be comparable to physical therapy services on an inpatient basis. Further inpatient care would be custodial and not medically necessary. She should be granted home physical therapy on an outpatient basis after removal of her non-weight bearing status and cast.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Zyvox 600mg for the treatment of his prostatitis. Findings:  The physician reviewer found that this patient is allergic to various medications. Contrary to the Health Plans allegation of no culture reports, the medical records submitted include a collected culture of prostate fluid which was found to contain methicillin-resistant staph which is a gram-positive organism. This culture is resistant to all but linezolid, nitrofurantoin, and tetracycline as well as IV vancomyin. The patients proper treatment was either IV vancomyin or oral linezoilid. The Health Plans denial should be reversed as this is exactly the situation where the use of this drug is medically necessary, appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested intensive outpatient therapy for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient had achieved a level of stability and symptomatic amelioration such that admission for intensive outpatient services failed to meet criteria of medical necessity. The patient was stable, able to function and not suicidal. By the date in question, the patients symptoms were substantially improved such that they did not interfere with the above listed capacities. The patient could have been safely treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Hyalgan injections to the right knee for the treatment of her condition. Findings:  The physician reviewer found that the requested Hyalgan injections for degenerative joint disease of the right knee do not appear to be medically necessary at this time.  There was a right knee examination documenting some tenderness and patellofemoral crepitus with x-ray describing patellofemoral degenerative changes.  While Hyalgan is used for the treatment of osteoarthritis in patients who have failed to respond adequately to conservative care (including anti-inflammatory medication and home therapy exercises), there is no documentation in the medical record that any conservative care was done for the right knee. In light of the lack of documentation of failure of conservative care, there is no specific medical indication for the requested series of Hyalgan injections for this patients right knee.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested a pancreas transplant for the treatment of his condition. Findings:  The physician reviewer found that the patient is an appropriate candidate for pancreas-kidney transplantation and there is sufficient evidence of the procedures efficacy to support its use in this setting. As such, the requested pancreas transplant is medically indicated for treatment of this patient.