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

A 48-year-old male enrollee has requested for Pegasys for treatment of his hepatitis C virus. Findings:  The physician reviewer found that widespread interest in maintenance therapy has been fueled by the published randomized trial of maintenance therapy with interferon in which patients after six months of virologic nonresponse to interferon received either 24 additional months of interferon or no treatment. The patients who received treatment had significantly lower Hepatic Activity Indices (HAI). At present, there are three large randomized controlled trials of maintenance therapy in patients with HCV infection who failed to achieve sustained virologic response following previous therapy with conventional treatment. The Hepatitis C Antiviral Long-term Treatment Against Cirrhosis (HALT-C) trial, sponsored by the National Institutes of Health, is the largest and best recognized of these studies. These trials are evaluating the efficacy of maintenance therapy in prior non-responders to interferon-containing regimens, and many experts feel that it is very reasonable to offer maintenance therapy with reduced dose of interferon with the intent to prevent further progression of fibrosis in this subset of patients who already have advanced fibrosis/cirrhosis. Such a strategy can prevent these patients from developing complications such as decompensated cirrhosis and hepatocellular carcinoma. There is scientific data documenting the antifibrotic effects of interferon. In a recent study, reversal of fibrosis was observed in 75 of 153 patients (49%) treated with interferon who had baseline cirrhosis. Based on the evidence available to date, it is appropriate to consider the use of low dose maintenance pegylated interferon, which may reduce the risk of histological progression and decompensation in patients with advance fibrosis and cirrhosis as well as the risk of complications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female has requested a bariatric surgery consultation for evaluation of morbid obesity.  Findings:  The physician reviewer found that according to the American Society for Bariatric Surgery consensus statement, candidates for bariatric surgery should not be required to complete formal non-operative obesity treatment as a pre-condition for having bariatric surgery if they can document credible weight reduction attempts. Furthermore, the criteria for eligibility for bariatric surgery from the National Institutes of Health and the Society of American Gastrointestinal and Endoscopic Surgeons do not require physician-supervised obesity treatment prior to weight loss surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male has requested Avastin for treatment of metastatic melanoma.  Findings:  Two physician reviewers found that the use of Avastin in metastatic melanoma is currently being studied as a single agent, and in combination with other agents in several early phase two studies. Thus, the use of Avastin for metastatic melanoma is experimental/investigational in nature. The FDA has not approved Avastin for treatment of the patients condition. There is no compendium listing for Avastin for metastatic melanoma. Furthermore, there have been no randomized control trials evaluating the efficacy of Avastin alone in this setting. Finally, Avastin is not accepted by major medical bodies as being appropriate treatment for this indication.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Avastin, paclitaxel and carboplatin for the treatment of his malignant melanoma.  Findings:  Two physician reviewers found that an abstract presented at the American Society of Clinical Oncology conference this year involved the use of carboplatin, paclitaxel and bevacizumab in 20 patients with metastatic melanoma. There was one partial response among all of the study participants. Although moderate effectiveness had been demonstrated with carboplatin and paclitaxel in the treatment of metastatic melanoma, there is no data indicating the addition of Avastin is useful. Thus, the proposed therapy offers no proven clinical advantage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested long-term acute care for treatment of multiple medical problems.  Findings:  The physician reviewer found that the patient does not have hospital level of care needs. He does not need advanced monitoring, advanced whirlpool, daily physician rounds, or therapy that is not routinely provided in a SNF. His wound care is a daily dressing change. This type of care is also provided at home and does not warrant an acute level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for treatment of speech and language deficits.  Findings:  The physician reviewer found that childhood apraxia of speech is a controversial issue and the peer reviewed literature does not wholly support apraxia as an individual diagnosis with specific clinical criteria. Language delays that are unrelated to a medical diagnosis are generally considered developmental, and are best addressed by the school system. While speech therapy may be appropriate to treat the patients speech deficits, the therapy is not medically indicated in this instance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female is requesting physical therapy for the treatment of her cervical sprain. Findings:  The physician reviewer found that post laminectomy pain syndrome typically requires prolonged physical therapy treatments. Physical therapy is an established treatment option in the literature. Post laminectomy cervical strain often requires multiple sessions of physical therapy. The submitted clinical information demonstrates that this patient ultimately responded to physical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that to the extent that there was not a dramatic shift in the patients status or treatment plan during the requested period, there is inadequate evidence that the patient was in need of residential treatment for this two-day period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested annual screening breast MRI for evaluation of potential breast disorder.  Findings:  The physician reviewer found that the utility of breast MRI for screening purposes is limited to those patients with known BRCA mutations. This patient has no history of breast cancer, no first line relative with a history of breast cancer and no known or reasonably presumed BRCA mutation. Breast MRI has not yet been proven to be more advantageous than standard imaging (mammography and breast ultrasound) in patients with dense breast tissue only.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requests for a repeat DEXA scan for evaluation of her osteopenia.  Findings:  The physician reviewer found that a follow-up DEXA scan is not indicated within one year of the initial test unless specific conditions are met. As such, a repeat DEXA scan is not necessarily at this time. A follow-up DEXA scan two years after the initial test would be appropriate to monitor the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested the medication Crestor (rosuvastatin) for the treatment of her dyslipidemia.  Findings:  The physician reviewer found that although both Zocor and Lipitor are non-hydrophilic and Pravachol and Crestor are hydrophilic, the incidence of adverse effects including fatigue and myalgias is similar in each of the four drugs. There is little evidence that switching from a non-hydrophilic to a hydrophilic agent is likely to reduce the risk of adverse effects if one has already had such a response. At high doses, Crestor will lower triglycerides by 23 to 28%, increase HDL by 8 to 16% and lower LDL by 34%. At similarly high doses, Pravachol will lower triglycerides by 24%, increase HDL by 12% and lower LDL by 34%. Although the patient may experience adverse side effects with Lipitor, a clinical trial of this drug is reasonable before prescribing Crestor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male has requested the medication Imitrex (26 doses per 90 days) for the treatment of his migraine headaches. Findings:  The physician reviewer found that based on the submitted medical records it does not indicate that the patient is on preventive medications despite the significant frequency of his headaches. This patient would be better served by using preventive medication. Furthermore, Imitrex has been implicated in causing rebound/medication overuse headache, which would is likely to be an issue with the proposed frequency of treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 10-year-old male enrollee has requested (Saizen) growth hormone therapy for treatment of idiopathic short stature (ISS).  Findings:  The physician reviewer found that growth hormone stimulation testing was performed with only one normal growth hormone finding; all other findings were low. This raises the possibility of a growth hormone deficiency. The marked discrepancy between the mid-parental height prediction and the estimated adult height places the patient in the short stature category.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested coronary CT angiography (CTA) for an evaluation of her potential coronary artery disease (CAD). Findings:  Three physician reviewers found that based on the information and history presented there is no indication for CTA at the present time. Limitations in the visualization of the coronary arteries are not uncommon and there remains an overall inability to translate the diagnostic performance of CTA to expected effects on management and health outcomes. The test is not a substitute for cardiac catheterization or nuclear SPECT imaging and the current role CTA is best defined in terms of coronary anatomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested sclerotherapy for treatment of varicose veins.  Findings:  The physician reviewer found that this patient has no complications of these veins, no varicosities, no superficial venous incompetence, and no stigmata of chronic venous insufficiency. As such, there is no medical justification for the proposed treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a panniculectomy/abdominoplasty for treatment of excess abdominal skin.  Findings:  The physician reviewer found that the submitted clinic notes do not contain findings of intertrigo supporting the patients complaints. No accompanying office notes were submitted to document any patient complaints, or more importantly, what treatment was offered to ameliorate the symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for homeopathic treatment for treatment of his skin condition.  Findings:  The physician reviewer found that the peer-reviewed journals do not include any studies that would validate this form of therapy, only some personal testimonials. The homeopath the patient wishes to see is not licensed to practice medicine according to published literature. Furthermore, a multidisciplinary approach is more likely to uncover factors contributing to the patients ongoing dysesthesias, which may include alcohol dependence, an underlying affective disorder and persistent disability thinking.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested gastric bypass bariatric surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 47.4 and multiple comorbid conditions that would likely be ameliorated or eliminated by bariatric surgery. With regard to the Health Roads program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of her type I diabetes mellitus. Findings:  Three physician reviewers found that although there are no substantial studies to demonstrate the utility of continuous glucose monitoring in preventing severe hypoglycemia, the results of Garg and others suggests that the warning system would have been helpful during the patients hypoglycemic episodes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested acupuncture for treatment of fibromyalgia.  Findings:  The physician reviewer found that there were no objective or subjective findings/factors discernible in the notes provided. The evidence submitted does not provide objective documentation that the patient has benefited from previous acupuncture treatments or is likely to benefit from additional acupuncture at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of an 11 year-old male enrollee has requested IVIG for treatment of pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS).  Findings:  Two physician reviewers found that the symptomatology described in the available information does not fit all the diagnostic criteria for PANDAS. There is no evidence presented that this patients disorder is linked to a previous or current streptoccal infection. Furthermore, IVIG is still considered investigational for treatment of PANDAS. At the present time, the National Institute of Mental Health recommends this therapy only as part of a research protocol.  Side effects are also a concern with IVIG.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested a custom ACL brace for the treatment of the enrollees anterior cruciate ligament tear. Findings:  The physician reviewer found that a custom anterior cruciate ligament brace was not medically necessary for treatment of the patients medical condition. There is no documentation that this patients condition or body habitus required a custom-made brace. Furthermore, an appropriate alternative was offered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a chemical peel for the treatment of her actinic keratosis. Findings:  Three physician reviewers found that the submitted information does not demonstrate that a chemical peel is clinically indicated or necessary in this case. There is no mention of a contraindication to cryotherapy or fluorouracil cream, which is standard of care in this clinical setting. As such, there is insufficient evidence demonstrating that a chemical peel is appropriate or warranted for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Leukine for treatment of Crohns disease.  Findings:  The physician reviewer found that Leukine is designated for the treatment of neutropenia. Due to neutropenia the patient cannot be treated with either immunosuppressive agents such as 6-MP, Imuran or Remicade. As such, it is prudent and appropriate to use Leukine in this setting, which allows for treatment of the patients Crohns disease and neutropenia with a single agent.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Alimta (with carboplatin) for treatment of pleural mesothelioma.  Findings:  Three physician reviewers found that there has been ample documentation in the literature of the usefulness of Alimta when given in combination with carboplatin in the treatment of malignant mesothelioma. Indeed, many oncologists use this carboplatin/ Alimta combination as first-line therapy. The proposed treatment regimen is no longer considered investigational as the medical benefit has been clearly established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested for the medication Lyrica for treatment of her idiopathic sensory neuropathy.   Findings:  The physician reviewer found that lyrica is currently FDA approved and has demonstrated efficacy and safety in the peer-reviewed literature for neuropathic pain due to diabetes and post herpetic neuralgia, but not for idiopathic sensory neuropathies. There is no evidence to indicate the patient has undergone trials of other neuropathic medications that have been utilized for longer periods of time and have a history of efficacy and safety for idiopathic sensory neuropathic pain/sensations.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested the prescription medication Provigil for the treatment of her depression and daytime somnolence. Findings:  The physician reviewer found that providing a supplemental medication to relieve these symptoms is appropriate. Ritalin and Dexedrine were limited in their efficacy and were not well tolerated. In contrast, the patient responded well to Provigil without the nervousness she experienced with the other stimulants. Provigil is known to be a useful adjunct in the treatment of depression within the psychiatric community, and continued treatment with this medication is clearly indicated in this instance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested the medications pegylated interferon and ribavirin for the treatment of his hepatitis C. Findings:  Two physician reviewers found that optimal management of a patient with hepatitis C who fails therapy is unknown.  Two studies address the use of alpha-2b interferon in the treatment of patients who failed therapy with standard interferon and ribavirin. In these studies, overall response for re-treatment was 16% (Jackson, et. al.) and 23% (Taliani, et. al.). In the recent Mayo Clinic Study (Cheruvattath, et. al.), 10% of the patients retreated with pegylated interferon and ribavirin had a sustained virological response. All told, there is sufficient evidence to support the treatment of this patient with pegylated interferon alpha and ribavirin.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested prescription medication Provigil for treatment of bipolar disorder and daytime somnolence.  Findings:  The physician reviewer found that the records do not include documentation of the dosages of any of the medications she was prescribed. Although there is ample documentation of her subjective assessment of her response to Provigil, there is no particular documentation of the patients mental status examination in this regard. Without basic data on drug dosages and an objective assessment of her clinical response to Provigil, the benefit derived from this medication cannot be ascertained.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for a full body MRI for evaluation of her medical condition. Findings:  The physician reviewer found that MRI imaging is usually performed on a certain body part or region (i.e., abdomen, pelvis, spine, knee, shoulder, brain or neck) when there is clinical concern of an underlying mass or internal derangement or to further evaluate an abnormality noted on another imaging study. Multiple imaging studies have shown no suspicious abnormalities. There is no medical evidence to support MRI imaging of the whole body.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female has requested coverage for a parathyroid nuclear study for evaluation of her hyperparathyroidism. Findings:  The physician reviewer found that the appropriate therapeutic approach in this case appears to be a parathyroidectomy. If a single adenoma can be demonstrated preoperatively, surgery can be performed by a minimally invasive procedure. As such, it is medically appropriate to perform a parathyroid nuclear study in this setting. The proposed study is within the standard of care and should be authorized
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested an abdominoplasty/ panniculectomy for treatment of her condition. Findings:  The physician reviewer found that there is a lack of documentation of uncontrolled intertigo that has not been responsive to conservative management over a period of time.  There are no medical records demonstrating the presence of a ventral hernia documented on imaging. There is a lack of documentation that the patients weight loss is the cause of the panniculus.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested participation in a Phase III stem cell transplantation trial at the University of Arkansas for treatment of multiple myeloma.  Findings:  The physician reviewer found that Autologous peripheral stem cell transplant is considered a standard treatment approach to myeloma that has progressed after induction therapy. This approach is endorsed by NCCN guidelines. There is no other therapy available in this setting that is likely to be superior to the proposed clinical trial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested sacroiliac injections for the treatment of her back pain. Findings:  Three physician reviewers found that the injections at issue are not generally accepted treatment for the patients condition. There is inadequate data to show that the injections result in superior clinical outcomes. Additional studies are needed to demonstrate the efficacy of these injections.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that she appeared engaged in treatment, but her controls were tenuously held and she clearly required continued residential treatment. The patient was not prepared for a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested a continuous glucose monitoring system for the treatment of the enrollees type I diabetes mellitus. Findings:  Three physician reviewers found that the proposed continuous glucose monitoring system is a medically appropriate adjunct to the patients diabetic control. The alarm system will permit her to have lower blood glucose excursions during the night, while the detailed glucose measurements provided by the device will allow for better incremental insulin interventions throughout the day. The use of the requested device is medically reasonable in this setting and should be authorized.