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

A 41-year-old female has requested Botox injections for treatment of headaches.  Findings:  Three physician reviewers found that Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). However, Botox is only indicated after standard therapies such as beta-blockers or tricyclics have been tried and failed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a cardiac CT angiography for evaluation of her coronary arteries. Findings:  Three physician reviewers found that the American College of Cardiology (ACC) has published guidelines regarding the appropriate use of cardiac CT angiography. This patient falls in the asymptomatic group.  Per Table 2 of the ACC guidelines, Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) cardiac CTA is inappropriate for low and moderate risk patients such as this patient. A high LDL is not as yet an appropriate indication for cardiac CT angiography.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for Xolair for treatment of her recurrent chronic sinusitis. Findings:  The physician reviewer found that there is no record of wheezing, coughing, shortness of breath, etc. Pulmonary function testing yielded normal results with no reversibility. Xolair is considered medically necessary for the diagnosis of allergic asthma. It is not indicated for the treatment of sinusitis and allergies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for knee arthroscopy for treatment of her knee pain. Findings:  The physician reviewer found that there is no evidence of meniscal tear as the cause of her pain. With a diagnosis of arthritis, and no evidence of a tear, arthroplasty would not be indicated. Numerous studies have shown minimal benefit in treating arthritic knees with arthroscopic debridement, chondroplasty, etc. with little long-term improvement noted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for Tysabri for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the FDA has approved Tysabri as monotherapy for the treatment of patients with relapsing forms of multiple sclerosis to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations. It is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, alternate multiple sclerosis therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Tarceva for treatment of her metastatic ependymoma. Findings:  Two physician reviewers found that National Comprehensive Cancer Network guidelines for the treatment for recurrent ependymoma recommend etoposide, temozolomide, nitrosurea and platinum based regimens or participation in a clinical trial. Other sources make similar treatment recommendations. The clinical literature included for review provides information regarding clinical trials of Tarceva for glioblastoma multiforme. Recurrent ependymoma is a different type of brain tumor. There are no published peer reviewed studies demonstrating the efficacy of Tarceva for the treatment of recurrent ependymoma. While Tarceva may have some minimal activity in high grade gliomas, clinical investigation is still in the early stages.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 81-year-old female enrollee has requested an MRI of the breast for an evaluation of her breast pain. Findings:  The physician reviewer found that there are several indications for an MRI of the breast which include evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. The high-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. The symptom of soreness/pain is not an indication for an MRI of the breast. Furthermore, the patients history of breast cancer is quite remote (31 years ago). The patient can be appropriately evaluated with a mammogram, if one has not been performed recently, ultrasound of the breast and correlation with any physical findings. MRI of her left breast is not medically necessary based upon the evidence provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for the medication Namenda for treatment of his obsessive-compulsive disorder. Findings:  Two physician reviewers found that the drug is still being studied and multiple issues have not yet been determined. For instance, the clinical efficacy of this medication for OCD has not been established. There is inadequate data from which to conclude the drug is efficacious for the treatment of this condition. Another issue is that the patient is on multiple medications (including Remicade) for his medical conditions with a potential for drug-to-drug interactions.The use of Namenda for the treatment of OCD is not supported by the literature at this time. Additional data including the published results of the above-mentioned study are necessary prior to approving this medication for conditions other than dementia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male has requested Lyrica for treatment of severe pain.  Findings:  The physician reviewer found that pain management practitioners have found Lyrica very effective especially in managing chronic neuropathic pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 75-year-old female enrollee has requested for octreotide for treatment of her nausea. Findings:  Three physician reviewers found that octreotide has been used in the treatment of nausea and vomiting following chemotherapy. However, there is no data in the peer-reviewed journals on the safety and efficacy of octreotide in the management of nausea in patients with either gastroparesis, GERD or CREST syndrome. As such, there is insufficient evidence supporting the use of octreotide for patients such as this patient. There are other medications/modalities available for the management of her symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested reimbursement for physical therapy (PT) for treatment of his before and after right knee surgery. Findings:  The physician reviewer found that The patient had surgery for right ACL reconstruction and right MCL repair. He resumed PT postoperatively. His right knee range of motion (ROM) had decreased to 0 to 60 degrees, he was unable to do household chores and car transfers were difficult. It was medically appropriate to resume therapy at that time. The patients ROM was 0 to 95 degrees, he could perform car transfers and was able to ambulate without an assistive device (although he still had pain). His right knee ROM was 112 degrees in flexion, strength was 4/5, he had minimal pain with gait and was full-weight bearing on the right lower extremity.  The patient appears to have followed a prescribed exercise plan, which could have been done in a home program. The record also indicates he was no longer using his cane to assist with ambulation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested  for the medication Somatropin for treatment of her hypopituitarism.   Findings:  The physician reviewer found that the QOL-AGHDA questionnaire was not initially submitted, it was subsequently provided and contained 16 Yes responses before therapy with only 4 Yes responses remaining after therapy was initiated. Thus, the criterion of an absolute change of 7 points on the QOL-AGHDA questionnaire has been met in this case. As such, there is adequate evidence the patient has benefited from Somatropin.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a total abdominal hysterectomy and bilateral salpingoophorectomy for the treatment of her medical condition. Findings:  The physician reviewer found that this patient had heavy vaginal bleeding, anemia and she had a 16-week size uterus. Her symptoms recurred despite treatment with progesterone and NSAIDs. Her exam was consistent with fibroids and adenomyosis. Hysterectomy was medically necessary due to a markedly enlarged uterus and heavy bleeding. The pathology retrospectively confirms the need for hysterectomy (markedly enlarged uterus with fibroids, polyps, and adenomyosis). The patients post-operative care was routine and was also medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested the  prescription medication Subutex (8 mg tablets / 90 per month) for the  treatment of his back pain. Findings:  The physician reviewer found that chronic pain management is often met with significant difficulties due to its complicated and multifactorial etiology. Although Subutex has recently been approved for the treatment of opiate addiction, buprenorphine has been used for the treatment of pain for many years. The drug is a partial agonist with a high affinity for the  receptors, making it very useful in the treatment of opiate addiction. Additionally, there are several studies in which a transdermal system was used to deliver buprenorphine in the management of chronic pain. The article cited above from the American Journal of Therapeutics deals with the use of sublingual buprenorphine in patients with chronic pain that were poorly controlled with long-term opiate analgesic therapy. 86% of these patients experienced adequate analgesia without significant side effects. Subutex (buprenorphine) has been effective for this patient at the requested dosage. Given the complexities of chronic pain management, it not clinically appropriate to withdraw or significantly change a therapy that has already been shown to be successful.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for a five-day-a-week, eight-hour-a-day intensive outpatient program (IOP for treatment of her eating disorder. Findings:  The physician reviewer found that the patients condition is severe and she regressed to a life threatening state prior to entering the residential program. The more intensive local IOP (five days a week, eight hours per day) is comparable to the  intensity of care provided in a partial hospital program. The patients history and the family dynamics strongly suggest that she needs this level of care and frequency of encounters. Family participation is also essential to successful treatment at the requested level of care. A family session involving the twin sister, mother and father (and any other family members) should occur at least one time per week for the duration of the IOP. If the family is not willing to participate in this requirement, the potential benefit of the IOP cannot be fully realized. The familys on-going commitment to weekly therapy is a reasonable prerequisite to initial authorization and continuing authorization for treatment in the non-Plan, five-day-a-week, eight-hour-a-day IOP.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male has requested provocative lumbar discogram, microdecompressive lumbar discectomy and interspineous process decompression (X-Stop implantation  2 levels) for treatment of back pain.  Findings:  Three physician reviewers found that discogram and microdiscectomy were not medically indicated for treatment of this condition. There was no role for use of a discogram, as discograms are generally performed as part of a work-up for fusion surgery, which was not under consideration for this patient. Additionally, there is insufficient evidence from well-designed studies supporting the safety, efficacy and long-term results of percutaneous microdiscectomy procedures. The X Stop procedure has not been shown to be more effective than a simple laminectomy, which is the gold standard for treatment of degenerative spinal stenosis. More outcomes data is needed in regard to the durability of the X-Stop procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested prescription medication Celebrex for treatment of back pain.  Findings:  The physician reviewer found that Celebrex has provided good analgesia for this patient in the past, at a relative low dose. All things considered, it is not clinically reasonable to require the failure of two additional non-steroidals when Celebrex is very likely to provide significant symptom relief.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a CT scan of the abdomen and pelvis for an evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scans are a commonly used diagnostic test to evaluate the abdomen and pelvis. Indications for CT scan include pain or suspected masses. The patient was adequately evaluated prior to the study. CT scan of the abdomen and pelvis was an appropriate diagnostic examination for further evaluation of the patients symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested coronary CT angiography (CTA) for an evaluation her potential coronary artery disease (CAD). Findings:  Two physician reviewers found that this patient has significant cardiac risk, symptoms of atypical chest discomfort and an equivocal stress test result. Under these circumstances, additional testing is reasonable and could include either invasive coronary angiography or noninvasive coronary CTA. Since the likelihood of coronary intervention is low based on primarily favorable stress test parameters, CTA was appropriate. In addition, the patient had at least an intermediate pretest probability of coronary ischemia and had an equivocal stress test result. The Appropriateness Criteria for coronary CTA support its use given these factors.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  for speech therapy for speech therapy. Findings:  The physician reviewer found that the patient has learning, language and motor problems for which no specific medical diagnosis has been determined. There is no indication the patients speech and language delays were the result of a specific injury, illness, or other medical condition. While speech therapy appears appropriate to treat the patients developmental speech and language delays, this type of intervention is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested for transdermal fentanyl patches for treatment of his neck and shoulder pain.  Findings:  The physician reviewer found that the issue to be addressed is the use of transdermal fentanyl versus long acting morphine preparations for management of the patients chronic pain. The half-life of fentanyl is much shorter than that of morphine. It is the transdermal delivery system that extends the duration of the analgesia. The transdermal fentanyl patch provides 72 hours of pain relief versus eight hours with oral sustained-released morphine. The transdermal approach is particularly effective for chronic daily pain. There is no evidence that the potential side effects of transdermal fentanyl would place the patient at greater risk than the potential side effects of long-acting oral morphine. Morphine and fentanyl, at equipotent doses, share the same profile of risks and side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested continued speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that autism is a disorder of socialization, communication and behavior. The etiology in most cases is unknown. There are no medical treatments that are known to cure autism. Most therapies are generally psychoeducational and are directed toward specific behaviors. Because the loss of speech and other behavioral issues are related to communication and social issues associated with autism, there is no medical indication for speech therapy for patients such as this patient. In cases such as this, speech therapy can typically be appropriately provided through means other than private therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested electro-acupuncture for the treatment of her neurodegenerative condition. Findings:  The physician reviewer found that the acupuncture treatment notes do not indicate any significant improvement in the patients symptoms. Her neurologist referred her to another acupuncturist who specializes in MS, but the patient apparently wanted to continue the electro-acupuncture treatments. The most recent progress note indicates that patient is `still getting headaches` and had soreness in the head, neck and low back areas and sensitivity in the shoulders and upper back. Correspondence from the patients neurologist, stated the patient 'reported having acupuncture and other treatments with an acupuncturist but did not think it was helping her.' Although acupuncture can be beneficial in reducing headaches and musculo-skeletal symptoms, this patient has been treated by two acupuncturists without  even moderate improvement in symptoms per the medical record submitted. It is not clear why the electro-acupuncture treatments were continued and on-going therapy of this nature is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy for the treatment of the enrollees articulation disorder and dysarthria. Findings:  The physician reviewer found that developmental delays including speech are common following prematurity, especially for those born at 25 weeks gestational age. The etiology of the language delay in prematurity is unclear. Individualized speech therapy is not generally considered clinically or medically indicated in this group of patients. The submitted documentation demonstrates that this patients deficits are educational in nature and do not warrant individualized private speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested speech therapy services for treatment of autism.  Findings:  The physician reviewer found that current medical literature fails to establish the efficacy of speech therapy in the treatment of autism. Because the loss of speech and other behavioral issues are related to communication and social issues associated with autism, there is no medical indication for speech therapy for patients such as this patient. Speech therapy can typically be appropriately provided through means other than private therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for an X-Stop procedure for treatment of his degenerative disc disease. Findings:  Two physician reviewers found that there is not enough long-term outcome data to establish the safety and efficacy of the X-Stop procedure. There is some concern about this device over time and more outcome data is needed about this procedure before it can be recommended. Standard lumbar decompression and fusion is the standard of care for treatment of this patients condition and was more appropriate for this patient than the X-Stop procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy initiated at a young age can result in marked improvement in children with major speech problems and impairments similar to those of this patient. Intensive therapy is necessary to allow the patient to acquire normal social interaction and communication skills. Individual therapy at an early age is medically appropriate and indicated based on the severity of this patients deficits. Speech therapy once a week for 10 weeks should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for physical therapy (PT) for treatment of her cervical pain. Findings:  The physician reviewer found that a TENS unit and electrical stimulation are not typically utilized for the treatment of cervical degenerative disc disease. These passive modalities are not the standard for first-line treatment of degenerative disc disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female has requested a duodenal switch bariatric procedure for treatment of morbid obesity.  Findings:  The physician reviewer found that the evidence shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for a PET scan for evaluation of his splenic lesions. Findings:  The physician reviewer found that positron emission tomography (PET) scans are a noninvasive imaging method to assess the level of metabolic activity and perfusion in various organ systems of the body. PET scans have proven clinical utility in the evaluation and management of several cancers. However, the current clinical scenario does not meet the Medicare criteria or the Health Plans criteria for coverage of a PET scan since the patient does not have a histological diagnosis of cancer. The other scenarios for which PET scan is covered for oncologic screening, such as a solitary pulmonary nodule, are not present in this case. The utility of PET scans in differentiating non-cancer etiologies such as infection, inflammation or rheumatologic/autoimmune conditions from malignancy in patients with multi-system involvement has not been well characterized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested  for laser hemorrhoidectomy for treatment of his hemorrhoids. Findings:  Two physician reviewers found that the treatment of choice for advanced hemorrhoids, refractory to topical treatment, is surgical hemorrhoidectomy or band ligation. Other modalities such as radiofrequency ablation and laser hemorrhoidectomy are also being evaluated. There are some small studies available in the peer-reviewed journals that have demonstrated good results with laser hemorrhoidectomy. However, there are no large clinical trials comparing the safety and efficacy of laser hemorrhoidectomy with conventional surgical hemorrhoidectomy. At the present time, laser hemorrhoidectomy is not considered the standard of care.