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

A 46-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her tibial plateau fracture. Findings:  Two physician reviewers found that this type of fracture is generally treated with a brace and restricted weight-bearing activity for six to eight weeks. It is important to move the knee joint during this time. The use of a CPM machine to achieve range of motion is not unreasonable or inappropriate and it certainly is not experimental. Patient compliance is high with this device, and it was likely to be more effective than the standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee has requested for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that there is no evidence presented in the documentation supporting a medical need for speech therapy. There was no supportive documentation from the pediatrician indicating an assessment of a medical condition related to an on-going articulation disorder. After only a few speech therapy sessions the sound production problems had been alleviated. This suggests a self-correcting skill delay that has no medical basis and would have resolved through normal progression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested  for speech therapy for treatment of the enrollees articulation disorder and word-finding deficits.  Findings:  The physician reviewer found that there is no evidence presented in the documentation supporting a medical need for speech therapy. No aspects of the perinatal history or the achievement of early developmental milestones, speech or otherwise, were noted as contributing to the patients speech pathology. There is no supportive documentation from the pediatrician indicating an assessment of medical conditions related to speech deficits nor is there a neurological or developmental assessment. There is no clinical evidence of swallowing or oral/motor dysfunction. The etiology of the patients speech disorder is not clear nor is it apparent whether or not it is related to a more global developmental issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested  for deep brain stimulation surgery for treatment of her Parkinsons disease. Findings:  The physician reviewer found that this patient clearly has Parkinsons disease and demonstrates the cardinal symptoms of bradykinesia, rigidity, rest tremor and postural instability. With regard to rigidity, there is a known On-Off phenomenon that commonly occurs, and patients will not demonstrate rigidity when they are On.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for a screening colonoscopy for evaluation of her colon. Findings:  The physician reviewer found that the  updated guidelines for colorectal cancer screen recommend that people with one first-degree relative with colon cancer or adenomatous polyps diagnosed at less than 60 years of age or two first-degree relatives diagnosed with colorectal cancer at any age, should have a screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosis in their family, whichever comes first. Colonoscopy should be repeated every five years. People with one first-degree relative with colon cancer or adenomatous polyps diagnosed at greater than 60 years of age or two or more second-degree relatives with colorectal cancer should be screened as average risk persons, but beginning at the age of 40 years. The guidelines for colorectal polyp surveillance indicate that after a complete clearing colonoscopy done at the time of the polypectomy, a repeat colonoscopy should be performed in three years for patients at high risk for developing advanced adenomas. After a negative follow-up colonoscopy, subsequent surveillance intervals may be increased to five years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for Synvisc injections for treatment of his osteoarthritis. Findings:  The physician reviewer found that this patient has attempted and failed several NSAIDs. In addition, he is unable to tolerate additional treatment with NSAIDs because of stomach irritation and bleeding issues. The patient has also failed cortisone injections and arthroscopic debridement.  He would like to put off knee replacement as long as possible because of his young age.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested  for the medication Cialis for treatment of his erectile dysfunction.   Findings:  The physician reviewer found that the etiology of erectile dysfunction in younger patients can be difficult to ascertain. Often type 5-phosphodiesterase (PDE-5) inhibitors like Cialis are used empirically. Some patients will respond to this therapy. This patient appears to have responded positively to Cialis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for an MRI study of the thoracic and lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that there is no documentation of a trial of adequate conservative measures including physical therapy and NSAIDS. Further attempts at standard therapy should be initiated prior to consideration of imaging studies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for BRCA1 and BRCA2 Genetic Analysis for evaluation of her risk of an inherited cancer syndrome. Findings:  Three physician reviewers found that BRCA testing is an accepted methodology to look for a particular set of gene mutations that significantly increase the risk of breast and ovarian cancer, as well as several other cancer types. It is often used when a woman develops breast cancer at a relatively young age, and particularly when there are other members of the family with cancer. Although there have been attempts to develop strict guidelines as to when the BRCA analysis should be performed, oncologists will generally recommend it when there is at least a reasonable chance of positivity for a given individual.A positive BRCA1 or BRCA2 Genetic Analysis has very real clinical significance. Often it is recommended that the ovaries be removed near or at the age of menopause. Examination of the breasts will usually include routine MRI in addition to mammogram. In the appropriate patient, BRCA testing is essential.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for participation in clinical trial CC06451 entitled A Phase I/II Study of Fixed-Dose Rate of Gemcitabine Plus Bevacizumab for Postoperative Adjuvant Treatment of Patients with Resected Pancreatic Cancer for treatment of his pancreatic cancer. Findings:  The physician reviewer found that Gemcitabine has been found to be effective as a single agent in the adjuvant treatment of pancreatic cancer. However in the treatment of metastatic pancreatic cancer, adding bevacizumab to gemcitabine was not found to be better then gemcitabine alone. While the proposed clinical trial is an interesting study, at this time there is insufficient data to suggest that adding bevacizumab to gemcitabine will improve the adjuvant treatment of pancreatic cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for IVIG therapy for treatment of her polymyositis.  Findings:  The physician reviewer found that this patient had steroids, Imuran and Cellcept, yet she still had symptoms attributable to polymyositis. Although one can argue that the symptoms may be due to a history of sacral trauma, Hashimotos thyroiditis or diabetic neuropathy (history of elevated HgbA1C), the elevation of transaminase and CPK point more toward polymyositis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested for a Meniett device for treatment of his Menieres disease. Findings:  Two physician reviewers found that review of the medical literature reveals multiple articles supporting the use of the Meniett device in the treatment of Menieres disease. Although the Meniett device is a more recent development in the treatment of Menieres disease, its success rate and low adverse effect/risk rate are impressive. To date, there continue to be many otolaryngologists who question the efficacy of surgical endolymphatic procedures. In addition, the invasiveness of vestibular nerve and labyrinthine surgeries limits the patient population in which they may be useful. The Peterson review strongly indicates that the Meniett device as a second-line treatment for Menieres disease may become standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for a CT angiography for evaluation of his chest pain. Findings:  Three physician reviewers found that angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. In this case, although the patient already had a nuclear stress test, other diagnostic options exist such as stress echo. The relevant literature regarding CT angiography includes a consensus statement by the American Heart Associate indicating that the test is not ready for widespread use at the time.  Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, and the need to use contrast, potentially nephrotoxic dye, as well as the radiation exposure. The clinical trials have been small, and overall the study is best considered investigational. The data available at this time does not provide sufficient information to permit a conclusion on the effect of CT angiography on health outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested for participation in a clinical trial entitled A Phase I Open-label Dose Finding Study Evaluating the Safety and Pharmacokinetics of AMG 479 in Subjects with Advanced Solid Tumors for treatment of his desmoplastic small round blue-cell tumor.  Findings:  The physician reviewer found that AMG 479 is an investigational drug currently undergoing Phase I trials. Such trials essentially focus on dosage and toxicity and offer little discernable benefit to the patients being treated. Thus far the only published data on this drug (including 2007 ASCO) relate to such Phase I trials. There is no meaningful data about its efficacy. AMG 479 is of no proven clinical benefit in this or any type of cancer, as yet.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for Lyrica for treatment of his peripheral neuropathy. Findings:  The physician reviewer found that while Lyrica is specifically approved for painful diabetic neuropathy, it is also useful for a number of different painful neuropathies. Furthermore, the patient has tried and failed other available medications. Treatment with Lyrica is appropriate, safe and effective for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for a Meniett device for Menieres disease for treatment of his Menieres disease. Findings:  Two physician reviewers found that the nature of Meniere's disease, with a highly variable clinical presentation, lack of pattern or often a provoking reason for the attacks makes management difficult. The pathology is understood as an increase in pressure in the fluids of the inner ear, but the cause of that pressure increase is not known. Over the years various treatments, medical and surgical have come and gone. Most of them boast small studies with limited results suggesting a breakthrough, but many have subsequently been abandoned as more data is gathered. An interesting feature of many of these studies is a significant improvement in symptoms in placebo groups, regardless of the treatment studied.The Meniett device invokes a theory that by increasing air pressure in the middle ear, fluid in the inner ear will be displaced and Menieres symptoms will reduce. Early studies often (though not always) show some benefit in the treated groups in reduction of dizziness, but objective criteria such as the hearing loss that accompanies Menieres disease remains unimproved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for the medication Arimidex for treatment of the enrollees short stature. Findings:  The physician reviewer found that the literature cited in the endocrinologists letter raises no concern over possible side effects and supports a high probability that this treatment will be effective for the patient. Additionally, at the Annual Meeting of the Endocrine Society in Toronto, Canada. The presenters spoke favorably about the use of aromatase inhibitors to promote an increase in adult height in otherwise normal but short boys and in boys with constitutional growth delay. All told, there is sufficient evidence of the benefit of Arimidex to warrants its use in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested  for Viagra for treatment of his erectile dysfunction (ED). Findings:  The physician reviewer found that there is also some evidence that Viagra may be helpful with psychogenic impotence. In any event, treatment with an oral PDE-5 inhibiting medication, Viagra, was initiated several years ago. This medication has apparently been an effective treatment for the patients ED. Regardless of the source of erectile dysfunction, Viagra is considered a first-line therapy. There are no contraindications to the medication based upon the information provided and the patient should continue to receive Viagra for appropriate management of his ED.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested  for gastric bypass surgery for treatment of his 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 39.7 and severe co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% preoperative weight loss, 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. Delaying surgery until the patient loses 27 ponds is not consistent with national criteria. According to the 2004 ASBS Consensus Conference, bariatric surgery candidates should not be required to have completed formal non-operative obesity therapy as a pre-condition for the operation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for Erbituxfor treatment of his metastatic duodenal adenocarcinoma. Findings:  Two physician reviewers found that the patient has appropriately been treated by analogy with colon cancer. He has been responsive to each of his prior therapies, which is likely to be a better predictor of benefit from CPT11 and Erbitux than any literature or extrapolation from related tumor types.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested  for the medication Zyrtec for treatment of his asthma. Findings:  The physician reviewer found that there is no documentation provided necessitating the approval of Zyrtec at this time. The patient requires a trial of nasal spray prior to prescribing Zyrtec.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested  for Avastin for treatment of his non-small cell lung cancer. Findings:  Three physician reviewers found that Avastin is one of a new class of drugs that inhibits in some way the vascular endothelial growth factor (VEGF). It has been approved for use with chemotherapy in metastatic colon cancer. Avastin has also been approved for use as primary therapy with carboplatin and Taxol in metastatic, non-squamous non-small cell lung carcinoma based on one large study.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a three-year-old male enrollee has requested continued partial hospitalization services for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted clinical evidence does not establish the medical necessity of continued partial hospitalization services. The patient has clearly made significant clinical gains in the partial hospital program. These gains are sufficient to allow him to return to a less restrictive mode of therapy. As such, the patient can be appropriately treated at a less restrictive level of care and no longer requires partial hospitalization services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for an endoscopic resection via retrosigmoid approach for treatment of her acoustic neuroma. Findings:  Two physician reviewers found that there is no available peer-reviewed literature supporting the superiority of the endoscopic retrosigmoid approach to acoustic neuroma resection. Recurrence rates of the minimal exposure technique are not addressed in the literature. Furthermore, there is no documentation that the endoscopic retrosigmoid approach to acoustic neuroma resection is likely to result in a better clinical outcome than other procedures. Nor is it within the standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested  for the medication Fentora for treatment of the enrollees low back pain.    Findings:  The physician reviewer found that the medication Fentora is FDA approved for breakthrough pain in patients with cancer. The patients painful condition is not the result of cancer. In addition, there are other treatment alternatives that have not been fully explored. Treatment with Fentora is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested substance abuse residential treatment services for treatment of his alcohol dependence.  Findings:  The physician reviewer found that although the patients family history is significant for alcohol dependence, his personal patterns of abuse are unclear. It does not appear that a structured outpatient program was attempted prior to admission. The admission examination does not suggest symptoms of physical withdrawal or any other particular distress that would require 24-hour supervision. The patient could have been appropriately treated at an outpatient level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for an abdominoplasty, panniculectomy and suction assisted lipectomy for treatment of her excess skin condition Findings:  The physician reviewer found that there is a lack of photographic evidence of intertrigo, rashes, or hyperpigmentation of the lower abdominal areas. Furthermore, the submitted medical records do not support a six-month or longer history of diagnosis of intertrigo, dermatitis or skin necrosis problems with treatment and failure of conservative therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested  for Avastin therapy for treatment of her glioblastoma multiforme. Findings:  The physician reviewer found that Avastin is one of a newer class of drugs, which interferes with the development of the blood supply feeding tumor cells. It has been FDA approved for use, along with chemotherapy, in metastatic lung and colon cancers. There is some preliminary, pre-clinical data suggesting that Avastin might also be useful in the treatment of brain tumors. There have been a few studies combining it with irinotecan, mostly to determine toxicity and feasibility. There is no convincing data as yet to demonstrate that Avastin alone, or with chemotherapy, has a significant impact in terms of either tumor responsiveness or survival benefit for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for a brain PET scan for evaluation of his for possible dementia. Findings:  Two physician reviewers found that fronto-temporal dementia most typically presents with an early change in social and personal conduct, and less commonly with progressive language change. Neither of these presentations is documented in this case. Treatable causes of dementia are usually screened with imaging including CT or MRI. The latter is not appropriate in this patient due to his pacemaker. No report of a CT scan is noted in the records. A brain CT scan, if not already performed, could be helpful to screen for structural causes of dementia such as a frontal mass, multiple infarcts or neoplasm. Based on the records provided, there is no evidence to suggest that fronto-temporal dementia is a realistic clinical consideration in this case
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for Botox injections for treatment of his temporomandibular joint (TMJ) disorder.  Findings:  Three physician reviewers found that there is sufficient literature to support the use of Botox in this clinical setting. The patient has tried multiple other regimens without sustained benefit. He has already tried Botox therapy with excellent results. Botox injections are medically appropriate for this patient and should be continued.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested a capsule endoscopy for the evaluation of anemia.  Findings:  The physician reviewer found that it is the standard of care to evaluate the small bowel in this setting. Capsule endoscopy is more sensitive than the standard small bowel series and can better identify minor lesions in the small bowel.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested prescription medication Provigil for the treatment of spastic paraparesis.  Findings:  The physician reviewer found that many of the more standard therapies have been ineffective. Provigil is known to be safe and effective for other neurological conditions such as multiple sclerosis, and has resulted in functional improvement for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested neuro/biofeedback for the treatment of the enrollees attention-deficit hyperactivity disorder (ADHD). Findings:  Three physician reviewers found that neuro/biofeedback is not generally considered an appropriate treatment for ADHD within the psychiatric community. At best, it remains an investigational approach and should only be considered when all available standard and accepted therapies have clearly been shown to fail. That is not the case in this instance according to the record. In fact, it does not appear that any of the established treatments for ADHD were attempted.