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

A 47-year-old male enrollee has requested multi-level disc replacement surgery with Pro Disc-C for the treatment of his cervical stenosis. Findings:  Three physician reviewers found that multi-level artificial disc replacement remains an unproven procedure. Currently, artificial disc replacement has been approved only for single-level. Given the lack of documentation of the success and completion rates of multi-level disc replacement, and the absence of long-term prospective studies, multi-level disc replacement cannot be recommended. Standard surgical interventions would have been more appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested Lyrica 75mg for the treatment of her left gluteal bursa pain. Findings:  The physician reviewer found that Lyrica is often used off-label for a variety of conditions, including radiculopathy or radiculitis. Lyrica has been shown to decrease neuronal hypersensitivity by binding to the alpha 2 delta subunit of the voltage-gated calcium channel, thus decreasing excitatory neurotransmitter release among neurons. Gabapentin is a medication similar to Lyrica in that it has an analogous mechanism of action and is used in many of the same conditions. Many patients report comparable benefit with Gabapentin. However, some patients note better outcomes on Lyrica versus Gabapentin, perhaps related to better compliance on twice daily dosing of Lyrica versus three times daily dosing of Gabapentin. Lyrica has a linear pharmacokinetic profile in that there is a direct linear relationship between higher doses and clinical effect. Gabapentin has a plateau effect, as higher doses may not have a directly linear increase in therapeutic effect. This patient is noting benefit with Lyrica without limiting side effects. It is rather possible that the patient would have similar efficacy from Gabapentin. It is medically appropriate for the patient to have a trial of Gabapentin, and is it medically appropriate for the Health Plan to provide coverage for Lyrica only if there is an inferior response or adverse side effect.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a thirteen-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has ongoing communication dysfunction. Continuity of her care by a developmental pediatrician has been documented since the age of four. Apparently, consistent recommendation of speech therapy has occurred since that time. The patient was extensively reassessed by qualified speech therapists with recommendation of hourly speech therapy sessions with specific goals of improvement within six months. The clinical situation is that of continuity of care documented from the age of four in a child with a congenital communication disorder. Documentation of medical necessity is abundant in the available reports. Speech therapy was and is medically indicated for treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented for emergency medical care due to abdominal pain, rectal protrusion and inability to move his bowels for several days.  The differential diagnosis for these symptoms includes bowel obstruction, fecal impaction, diverticulosis, rectocele, and other potentially serious disorders.  A prudent layperson suffering from these acute symptoms and significant pain would appropriately seek immediate medical attention out of fear of jeopardy to his health and possible injury to bodily organ function.  Without immediate medical evaluation, diagnostic work-up and specific therapy, the patients condition would not likely improve.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eleven-year-old male enrollee has requested Genotropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients height at the time of application was between the 3rd and 10th percentiles. The workup showed normal growth hormone-dependent IGF-1 and IGFBP-3 levels, while an MRI of the brain showed a normal pituitary. A bone age was 1.5 years delayed. The physicians predicted adult height was 167cm. The patients diagnosis appears to be one of constitutionally delayed adolescence, with a predicted adult height above the limit of the FDA 2003 guidelines for idiopathic short stature. Thus, growth hormone therapy in this instance is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested intense pulse light therapy for the treatment of her acne. Findings:  Two physician reviewers found that this patient has had cystic scarring acne vulgaris for over twenty years. She has been treated with every medical therapy that is currently available, including Accutane and hormonal therapy. She has required many injections of intralesional steroids to reduce the inflammation of cysts and to prevent scarring. The latter treatments may very likely lead to atrophic scarring if repeated multiple times in the same locations. She has finally achieved good results with intense pulse light therapy for acne. Numerous studies have been published that demonstrate the effectiveness of photodynamic therapy in the treatment of acne vulgaris. Lesion counts are reduced significantly with this therapy. Although it has not been shown to be wholly effective as monotherapy, photodynamic therapy is recommended in combination with topical therapy in patients who do not respond to standard acne treatments or who cannot take systemic retinoids.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a thirteen-year-old male enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that since the enrollee has had serious illnesses in the past, the mother was worried that this current illness might be serious and potentially life-threatening.  The differential diagnosis for the patients presenting signs and symptoms include several potentially serious disorders that needed to be ruled out, including strep throat, epiglottitis, pneumonia, exacerbation of asthma, and others.  A prudent layperson would appropriately take his or her child for immediate medical evaluation given the severity of fever and associated symptoms that the patient was suffering from.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested a right knee brace for the treatment of the enrollees condition. Findings:  The physician reviewer found that the requested ACL brace for the right knee does not appear reasonable on a prophylactic basis for the patient.  There is no proven scientific benefit for prophylaxis against injury for patients at the high school level. The use of prophylactic bracing even at a more competitive level remains controversial. The brace would be completely unrelated to the patients prior patellar stabilization surgery. No bracing should be required at this stage postoperatively. For these reasons the brace cannot be justified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of an 18-year-old female enrollee has requested a sub-acute residential eating disorder program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that though the patient has suffered from something of an eating disorder and dysphoria, her symptoms appeared to be relatively middling, as compared to someone typically deemed in need of something as intensive as residential treatment.  No doubt there are struggles at hand for her, but given how relatively low-level they are, it is unclear why her treatment could not have been approached on an outpatient basis (be it Intensive Outpatient Treatment per se or Partial Hospitalization).  As shown in the note submitted, there is no conveyance of anything particularly striking that would fall outside of the bounds of conventional outpatient care.  In addition, none of the subsequent chart notes convey anything striking.  Therefore, I find that there is no medical indication for residential treatment beyond the date in question and recommend upholding the Health Plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eleven-year-old male enrollee has requested an evaluation for auditory processing disorder for the evaluation of the enrollees condition. Findings:  The physician reviewer found that the nature of the problem, auditory processing, is included as a condition than can interfere with the ability to function in school. The school is required to assess a child after the parent has requested an individualized education program. The assessment would include a speech and language assessment that is part of the schools contracted services to evaluate any potential learning disability. Since the child has a superior IQ and is functioning well in school, there may be reluctance on the part of the school to complete their evaluation. The information furnished in this packet is sufficient for the parent to use as part of the request to receive a speech and language assessment. The primary care physician can refer the patient for an audiology assessment if there is any question regarding diminished hearing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a CT scan of the heart for an evaluation of her atypical chest pain and labile hypertension. Findings:  The physician reviewer found that CT angiography (CTA) and electron beam computerized tomography (EBCT) are not accepted screening or confirmatory tests for the diagnosis of coronary artery disease in this patient subset and are not medically acceptable replacements for other conventional screening tests within the standard of care, such as treadmill stress testing. CTA is also not a medically acceptable substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CT scan of the heart in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental application of this technology. The Health Plans denial is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition. Findings:  The physician reviewer found that the CPM device is used routinely postoperatively following knee replacement surgery. It has been used extensively for more than twenty years. The equipment is used for one to two weeks postoperatively, and it is sometimes used for knee procedures other than total knee replacement. The CPM device was medically indicated and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a CT angiography for an evaluation of her cardiac condition. Findings:  Three physician reviewers found that there are guidelines published from the American College of Cardiology (ACC) regarding the appropriate use of cardiac CTA. In this case, the patient has had prior testing which was abnormal. Her prior stress echocardiogram was described as abnormal rather than equivocal. She does not meet the guidelines for cardiac CTA. In this case, her prior testing was abnormal and the next clinical step would be a clinical decision to treat her atypical chest pain or even silent coronary artery disease with aggressive medical intervention, or a decision to proceed with diagnostic cardiac catheterizations towards revascularization. The ACC guidelines do not, as yet, recommend cardiac CTA as an intermediate step prior to cardiac catheterization after abnormal stress testing. The ACC guidelines recommend CTA as appropriate after equivocal prior stress testing in symptomatic patients with chest pain, rather than CTA as an intermediate step to confirm prior abnormal stress testing.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested angioplasty and/or stent replacement for the treatment of her increased intracranial pressure. Findings:  Three physician reviewers found that this patient has been treated conservatively with Diamox without improvement. There is no other treatment other than the requested procedures. She is having visual symptoms, and the requested procedures are medically appropriate and warranted for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested Botox injections for the treatment of her recurrent headaches. Findings:  Three physician reviewers found that Botox therapy has been presented in the medical literature as an alternative treatment for managing migraine headaches. This treatment remains fairly controversial, and articles suggesting its efficacy as well as its lack of effect have been published in several peer-reviewed medical journals. This is an option that should be considered if more conventional treatments fail to provide adequate migraine prophylaxis. In this patients case, there is not enough evidence to justify the use of Botox since the medical records fail to provide documentation on prior treatments, including duration or migraine disability assessment questionnaire scores. Additionally, in the note that was submitted it further suggests that additional Botox treatments are not indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested continued PET scans and lab work for an evaluation of her lung cancer. Findings:  The physician reviewer found that the treatments provided are unproven methods of cancer therapy. This includes anti-neoplaston and other therapies. The efficacy of the therapies provided has not been substantiated to the satisfaction of the oncologic community. The requested diagnostic services, including PET scans and lab work, are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested a continuous passive motion (CPM) machine and cold polar therapy for the treatment of his knee condition. Findings:  The physician reviewer found that there is not sufficient literature to support the use of cold polar therapy. Cold polar therapy remains experimental at this time as more outcomes data that is peer-reviewed and demonstrates efficacy over standard heat or ice pack treatment is needed. Conflicting studies with relatively short-term follow-up exist in the literature. Based on the available literature, cold polar therapy and CPM are not medically necessary for this patient who had routine knee arthroscopy and anterior cruciate ligament reconstruction. Specifically, there is no class 1 data to demonstrate that cold therapy and CPM are better than intermittent ice pack use or even nothing at all with respect to improving mid-term and long-term functional outcomes. Furthermore, no class 1 study exists to demonstrate improved functional outcomes to justify cold therapy and CPM use after anterior cruciate ligament surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Lyrica for the treatment of her chronic pain. Findings:  The physician reviewer found that the patient has failed a trial of an FDA approved or medically accepted medication for neuropathic pain, and she has found relief with an anticonvulsant, Lyrica. The use of an anticonvulsant is appropriate and medically necessary as specified by Clinical Practice Guidelines for reflex sympathetic dystrophy/complex regional pain syndrome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees articulation and language deficit secondary to verbal apraxia. Findings:  The physician reviewer found that verbal apraxia is a congenital disorder due to failure of speech development in the Broccas area of the temporal lobe of the dominant [usually the left] cerebral hemisphere of the brain. It is a treatable disorder, with anticipated improvement in articulation and expressive speech. This patients speech improved from no linguistic skills to a vocabulary of 40-50 words and 2 word phases during 5 months of speech therapy. He has progressed from language of a less than one-year-old child to the level of a two-year-old child following 27 speech therapy sessions. Thus, as a congenital disorder that is treatable, it is designated as a treatment of medical necessity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested maxillary Lefort 1 reconstructive surgery, which includes mandibular osteotomy and genioplasty for the treatment of her dental facial deformity. Findings:  The physician reviewer found that the patient has a history of an inability to effectively masticate foods and given that she has an anterior open bite (lack of contact between maxillary and mandibular incisors and canines), the patient meets generally accepted criteria for orthognathic surgery. In fact, it appears that the patient meets the Health Plans own criteria for the procedure. In any event, the proposed surgery is medically warranted and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested a discogram (both physician fee and hospital charge) for an evaluation of his chronic low back pain. Findings:  The physician reviewer found that the patient had a previous discography which demonstrated concordant pain at all levels.  It is not clear through these medical records, the benefit which would be gained by repeating a discogram, which previously was inconclusive in substantiating a specific level of involvement.  An MRI also demonstrates multilevel degenerative disc disease.  One would question the need for discography in light of this MRI finding and in light of the fact that this is a postsurgical spine.  Based on the medical records, discography is not medically indicated and necessary. It should be noted that conservative measures have not been clearly documented in the medical records, but those should be exhausted before undergoing diagnostic intervention such as an MRI.  It is not clear that these have been done recently.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Increlex for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the projected adult height according to the Greulich and Pyle Hand Atlas approximates the height at 5 foot, 6.8 inches.  It thus appears likely that the patient has a constitutional delay in his adolescence and is destined to achieve a normal adult height without treatment.  The diagnosis of IGF-1 deficiency seems unlikely since the IGF-1 level would be normal when matched to the pubertal stage, and GH levels were not elevated.  The increased growth from IGF-1 therapy in such an instance is interesting, but does not in and of itself make the case for IGF-1 therapy as a medical necessity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an active cooling device with additional pneumatic compression for the treatment of her postoperative knee care. Findings:  Three physician reviewers found that the patient had an arthroscopy for degenerative changes that would be expected to be followed by postoperative pain and swelling.  These postoperative issues are generally and appropriately treated with rest, elevation and an ice pack.  Cold therapy is standard care following injury or surgery but does not require special equipment.  There is a lack of medical literature that would support that mechanical devices are more efficacious than appropriate use of an ice pack in terms of overall recovery.  While these devices are convenient, they are not considered as medically indicated based on a lack of supportive peer-reviewed literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a full-body PET scan for an evaluation of her thoracic spine lesion. Findings:  Three physician reviewers found that the request for a PET scan in this patient should be denied. If a destructive lesion was suspected, a radionuclide bone scan with SPECT would have been the procedure of choice. If this exam proved negative, a malignant process would be highly unlikely particularly in light of no known primary malignancy. Also, no attempt was made to evaluate the T8 level on a CT of the chest. Such evaluation could have shed some light on the potential possibilities at this level. PET scans are not utilized routinely as a means with which to evaluate incidental findings on imaging studies absent a history of malignancy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested an increase in quantity of Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that the present endocrinologist argues that the patient is unable to control his morning fasting blood sugars with Byetta in its present formulation. The FDA has approved a daily dose of 20mcg given twice daily. She has found a novel way to extend the action of Byetta to the next morning by utilizing a continuous overnight infusion via an insulin pump. Utilizing an insulin pump to change the pharmacokinetics of the presently available preparation of Byetta is a novel, but not off-label, use of administering the medication. Assuming that the patient continues to take all three glucose lowering agents, he should be allowed to obtain at least two Byetta pens per month until the long-acting preparation of Byetta becomes commercially available. This will allow him to maintain excellent control without resorting to insulin in the short run.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 26-year-old male enrollee have requested inpatient rehabilitation therapy (including physical therapy, occupational therapy and speech therapy) for the treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that the patient currently is not cognitively appropriate for an admission to the Sharp Rehabilitation Facility. The patient is not responsive to pain, is unable to track objects and inconsistently responds to commands. The patient and his family should be given optimal training for home care. The patient should be given reconsideration for admission to the Sharp Rehab Facility if he shows sufficient cognitive improvement.