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

A 50-year-old male is requesting for SPECT scan for the evaluation of his anxiety and depression. Findings:  Three physician reviewers found that SPECT is a neuroimaging technique that gives computer generated, 3D, in vivo images of the body using radiopharmaceuticals, gamma rays and a gamma camera. SPECT is used in the diagnosis and treatment of various medical conditions, such as cardiac studies that evaluate for myocardial infarction and ventricular arrhythmias. These particular studies concern perfusion and ischemia usually relating to stroke volume, ejection fraction, cardiac wall thickness and contractility.  Other common uses and accepted applications include bone scans and white blood cell scans to evaluate and treat lymphomas, tumors and other types of pathophysiologies involving white blood cells.  SPECT is used in brain scan imaging to assess glucose metabolism and brain damage from ischemic processes and to help evaluate dementia versus stroke. SPECT is not approved for use in the evaluation and/or treatment of anxiety and/or depression and there is no evidence to support its use for such evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Aranesp injections for the treatment of her unspecified anemia. Findings:  The physician reviewer found that the submitted documentation does not support the need for Aranesp for this patient.  She had a liver transplant. Although transplant medications may have caused the anemia, it is not known whether careful observation would have resolved the issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested growth hormone therapy for the treatment of his idiopathic growth hormone deficiency. Findings:  The physician reviewer found that The pituitary LH level was low, and testosterone level was high.  Lupron injections had been initiated. The patient has advanced bone age and likely premature epiphyseal closures. Growth in height had accelerated from four years of age according to the chart and was at the 90th percentile over recent years. The IGF-1 and IGFBP-3 levels preclude growth hormone deficiency. The differential diagnosis lies between testitoxicosis and idiopathic sexual precocity. There is a lack of literature support for growth hormone therapy in either case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested Ashkenazi Jewish Carrier Screening (Familial Dysautonomia, Niemann-Pick disease, Fanconi anemia, Bloom syndrome, Glycogen Storage disease and Maple Syrup Urine disease) for an evaluation of his carrier status. Findings:  The physician reviewer found that there was discussion among professional organizations about broadening of the ACOG guidelines.  There is typically a lag between the standard of care in the community and the issuance/publication of guidelines that reflect that standard of care. The testing recommended by the genetic counselor was for Tay-Sachs disease, Canavan disease, Familial Dysautonomia and Gaucher disease. Cystic fibrosis screening is now made available to individuals of all ethnic backgrounds. Based on the information above, the Health Plan should cover screening for Tay-Sachs disease, Canavan disease, cystic fibrosis, Familial Dysautonomia and Gaucher disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested lipoprotein-associated phospholipase A2 (Lp-PLA2) testing for an evaluation of his risk of cardiovascular disease. Findings:  Three physician reviewers found that the patient is a 40-year-old male who is requesting lipoprotein-associated phospholipase A2 (Lp-PLA2). Overall, there is no evidence that this test is helpful in changing clinical outcomes.  In addition, at the present time, there is limited literature to support its efficacy. Furthermore, the test at issue is not supported by the American College of Cardiology (ACC) Guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a lumbar discogram for an evaluation of her failed back syndrome. Findings:  The physician reviewer found that lumbar discography is a last resort, pain-provoking diagnostic test used to assess a patients candidacy for surgery for chronic low back pain that has failed extensive conservative care. This is because the outcome of this surgery is variable, and many studies demonstrate no better long-term outcome than extensive conservative care. Therefore, in any patient considering discography, an extensive diagnosis-specific, active physical rehabilitation program with pain control through NSAIDS and analgesics is the well-known standard of care prior to consideration for discography. This patient has not undergone adequate conservative treatment protocols since the hemi-laminectomy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested an emergency room visit for the treatment of her sinusitis. Findings:  The physician reviewer found that the enrollee had chronic pain with periodic exacerbations. Her pain was not responding to usual treatment and was reported as severe. The etiology of her pain was not diagnosed accurately or is multi-factorial. She was not responding to treatment and developed severe pain. Pain is the most common reason a person seeks medical advice. She had a flare of severe pain despite usual treatment. Health professionals and health care organizations and consumer advocate groups educate laypersons to respond to severe unexplained pain as an urgent matter.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested X-Stop implantation for the treatment of his lumbar spinal stenosis. Findings:  Three physician reviewers found that this 68-year-old male patient has a history of spinal stenosis with failed conservative treatment. Evaluation of the patients condition demonstrates canal stenosis at L4-5 with degenerative spondylothesis at that level. Although the patient meets many criteria for the X-Stop procedure, his MRI findings demonstrate he would be better served by standard neurosurgical decompression with or without fusion. Furthermore, while there is some data to support the risk and benefits of the X-Stop it has not been established as a more effective procedure than decompression with or without fusion.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for MRI studies of the cervical spine and brain and MRA studies of the neck and brain for evaluation of her symptoms of visual and auditory disturbances and cognitive and mobility impairments. Findings:  The physician reviewer found that MRI of the brain and MRA of the brain and cervical arteries are standard of care in a patient with transient ischemic attack (TIA) symptoms, especially given the prolonged and atypical nature of the symptoms. The MRI of the brain and MRA of the neck and brain were medically appropriate and necessary. The MRI of the cervical spine was not medically necessary and was not appropriate because the patients symptoms did not suggest radicular or myelopathic processes.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee requested for a Microgyn Pelvic Floor Stimulation Unit for treatment of his urinary incontinence.   Findings:  Three physician reviewers found that there is no accepted body of literature or scientific papers which have shown pelvic floor stimulation and devices to produce the same or better than time alone in restoring continence. The alternatives therapies currently accepted for treating male incontinence in the post-operative period are waiting for spontaneous resolution and artificial urinary sphincter and male sling procedure when that fails to occur. Many cases do persist as very minor leaks with stress maneuvers such as coughing, laughing, and sneezing. These are generally managed by a small absorptive pad. Anti-cholinergics with specific bladder selectivity are also used (and were used in this case).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested for the laparoscopic gastric banding procedure (Lap Band) for treatment of her morbid obesity. Findings:  The physician reviewer found that there is no scientific evidence that postponing weight loss surgery and requiring pre-operative diet plans predicts or improves outcome. From a technical point of view, a very short-term low calorie diet (1-2 weeks) reduces the size of the liver, thus making the operation technically easier. Given the patients BMI and comorbid conditions, the Lap Band procedure is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a spinal cord stimulator (SCS) for the treatment of her lower extremity pain. Findings:  The physician reviewer found that it is unclear if the decrease in beneficial effect from the spinal cord stimulator is due to battery depletion or persistent paresthesia coverage with no analgesia. The patient is being considered for a spinal cord stimulation trial for lower extremity pain seemingly based on the diagnosis of complex regional pain syndrome.  However, the information provided does not mention any details on the physical findings.  Moreover, the patient has significant psychological issues and she complains of whole body pain.  It is medically necessary to obtain a thorough psychological evaluation before considering this particular patient for a spinal cord stimulator trial to manage lower extremity pain.  Additionally, the patient may be due for a battery change.  The Synergy battery that was implanted is probably at the end-of-life.  Battery replacement is recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested Imitrex nasal spray and injections for the treatment of her migraine headaches. Findings:  The physician reviewer found that the patient uses Imitrex SQ about twice per month for severe migraines upon awakening.  She also uses Imitrex nasal spray for less severe headaches. This is medically appropriate and not excessive for Imitrex usage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for bilateral breast MRI for evaluation of her breast nodularity.  Findings:  Two physician reviewers found that breast MRI has been proven to be a useful adjunct to mammography. One of the difficulties in patients with prior lumpectomy for breast cancer is the evaluation of a palpable abnormality within the post-surgical breast. Physical exam and mammography are not always adequate to differentiate scar tissue from recurrent tumor. Breast MRI has been shown to be clinically useful in the evaluation of post-operative scar from tumor recurrence. This patients breast cancer has a high rate of recurrence and the complete evaluation of a palpable breast abnormality including MRI of the breast is medically appropriate. Mammography is not 100% in the detection of malignancy; breast MRI used as an adjunct to mammography in this patient will allow the patients physician to properly care for the patient. Breast MRI is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested sub-acute residential psychiatric services for the treatment of the enrollees major depressive disorder, attention deficit disorder and generalized anxiety disorder. Findings:  The physician reviewer found that though the patient apparently suffers from some degree of ADHD and dysphoria, the degree was not so flagrant as to have warranted months of residential treatment. Her medication adjustments could easily have been accomplished on an outpatient basis. Similarly, while the group therapies appear to have been of some use, these could have taken place on an outpatient basis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested a wireless capsule endoscopy for an evaluation of her abdominal pain.  Findings:  Two physician reviewers found that wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. Since the introduction of WCE, the indications for the procedure have expanded to include Crohn's disease, celiac disease, polyposis syndromes, monitoring of patients after small-bowel transplantation and monitoring for obscure gastrointestinal bleeding (OGIB). WCE has been particularly successful in finding the cause of OGIB and evaluating patients with inflammatory bowel diseases. WCE has been shown to improve the diagnosis of Crohns disease in a significant number of patients who would have otherwise remained undiagnosed. It offers the potential to directly visualize the entire mucosal surface of the small bowel, and it has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. WCE is less invasive than conventional endoscopy, and it does not require sedation or anesthesia. At the present time, WCE is approved for the evaluation of patients with OGIB, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease. It is also approved for patients with other small bowel diseases, such as small bowel tumors, family polyposis syndrome and arteriovenous malformation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of his diabetes. Findings:  The physician reviewer found that CGMS, used appropriately, on a periodic basis and under the auspices of an endocrinologist, is not experimental or investigative and may be medically necessary to periodically monitor a labile patient.Poor control with frequent hyperglycemia or recurrent episodes of severe hypoglycemia might require the use of a CGMS device to initiate changes in food intake or insulin in order to optimize blood sugar control.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Zofran for the treatment of her nausea and vomiting. Findings:  The physician reviewer found that the patient has had recurrent nausea and vomiting due to underlying comorbid conditions, and she has been tried on multiple antiemetics. These failed to control her symptoms of nausea and vomiting. Because she has responded to Zofran, it is medically appropriate to continue with this regimen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested a dual isotope stress test/stress echocardiogram for an evaluation of his medical condition. Findings:  The physician reviewer found that stress myocardial perfusion imaging provides reliable prognostic information. This particular patient had several cardiac risk factors and a high pre-test calcium score for which the dual isotope stress test/stress echocardiogram was clinically indicated.  The results of the nuclear stress were important to the patients clinical treatment plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for an oscillatory chest clearance system (Vest system) for treatment of her cystic fibrosis.   Findings:  The physician reviewer found that the Vest system was approved by the U.S. Food and Drug Administration in 1988.  It has been used widely for more than a decade. There are a number of studies looking at the quantity of sputum produced in response to manual chest percussion compared to other techniques of pulmonary toilet. Data regarding long-term use of high frequency chest wall oscillation in patients with cystic fibrosis demonstrates improved maintenance of lung function in children using chest wall oscillation compared to manual percussion. Whether this effect is due to enhanced compliance or superiority of the technique is immaterial, as the goal of pulmonary toilet is to maintain pulmonary health, and the outcome in this study is preservation of lung function as measured by pulmonary function testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested for serial casting, tenotomy and follow-up care using the Ponseti Method for treatment of the enrollees club foot. Findings:  The physician reviewer found that repair of congenital club foot should be initiated as soon as possible after birth. The Ponseti Method is a non-operative procedure requiring Achilles tenotomy followed by proper gentle manipulations and plantar casts. This technique avoids surgical reconstruction correction requiring multiple soft tissue release and wire fixation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for inpatient psychiatric hospital services for treatment of her psychosis, NOS. Findings:  The physician reviewer found that she was not at risk to self or others, and her behavior was not out of control. Thus, she could have been treated at a lesser level of care. A review of the treatment records shows that she was increasingly agitated and attempted to hit staff. A note suggests continuing psychosis of a significant degree. The patient continues to act in an aggressive and psychotic manner. She needs very close staff supervision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee has requested rhinoplasty for the treatment of the enrolle's nasal condition. Findings:  The physician reviewer found that the photographs submitted reveal a minimal bony dorsal hump and no collapse of the nasal tip. The bony dorsal hump did not constitute an abnormal structure, and its correction would not offer more than minimal improvement in appearance. The photographs do not support obstruction of nasal vestibules or otherwise document nasal malfunction. Thus, rhinoplasty would not improve nasal function.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested emergency services for the treatment of her back pain.  Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe the lack of immediate medical attention would endanger her health. This patients symptoms had been present for two weeks. They were not sudden in onset. The patient also had prior history of similar back pain, making it unlikely that a prudent layperson would believe an emergency existed. This patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested home health physical therapy (PT) for the treatment of her gait instability and poor balance. Findings:  The physician reviewer found that it is not clear as to why this patient was unable to be managed in an outpatient program. Based on the nurse evaluation the patient is mostly independent with activities of daily living and can ambulate with a cane or walker at minimum distances. There is no evidence that the patient is homebound.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for detoxification and drug rehabilitation services for treatment of her opiate and benzodiazepine dependence. Findings:  The physician reviewer found that the patient did get lab work up, physical examination and typical residential type treatments, as per the progress notes. There is mention of a recovery program. The patient is noted as being anxious and depressed. The patient has chronic pain, which is a risk factor for relapse. She noted feeling nervous, dysphoric and reported fleeting suicidal thoughts. Additionally, although the patient showed motivation for recovery, it was early in the recovery process.  She was at high-risk for relapse without the structure of the treatment provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a two-year-old male enrollee has requested for his speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that he is below the age when public education would provide any assistance. It is generally accepted in the medical community that early intervention is optimal for children with developmental delay in language or other areas of development. Speech therapy should be covered for this patient until he is three years of age.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is a lack of scientific data that supports pre-operative weight loss. Additionally, there is no scientific data that shows long-term or short-term benefit for non-surgical weight loss trials. This patient should be allowed to have weight loss surgery without delay for treatment of her conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for Lyrica 75mg for treatment of her degenerative disease of the lumbar spine. Findings:  The physician reviewer found that there is a lack of articles in the literature that support the use of Lyrica for pain associated with this patients condition. Its use here would be off-label and unproven.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  Three physician reviewers found that according to a well-respected general pediatrics textbook, there is compelling evidence that intensive behavioral therapy, beginning before three years of age and targeted toward speech and language development, is successful in improving both language capacity and later social functioning. The authors also note that controlled studies of early intensive 1:1 behavioral training (ABA) have resulted in significant cognitive and behavioral gains. Multiple studies comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality have shown that the behavioral treatment groups exhibited greater increases in IQ and adaptive functioning, and fewer aberrant behaviors and social problems, than did the eclectic groups. Behavioral therapy is considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy. Many consider the advances made in the treatment of children with autism spectrum disorders to be attributable to early intervention with ABA techniques. ABA therapies have been utilized and studied for decades, and the data indicates positive results with consistent implementation of this method. ABA is considered standard of care, particularly in early intervention programs, by many experts in the field.