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

The mother of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees speech and language deficits. Findings:  The physician reviewer found that based on the medical documentation provided, there is no history of trauma or illness that can be associated with the symptoms of speech apraxia. The speech delays are deemed developmental and therefore speech therapy is not medically indicated. Therapy for the treatment of speech apraxia would typically be considered educational and would fall under the auspices of the school system through an Individualized Education Plan (IEP).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested intravenous immunoglobulin therapy (IVIG) for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that the patient has relapsing remitting MS. Although there is some evidence from small European studies that IVIG may reduce relapses, there is no evidence demonstrating IVIG is effective in reducing long-term disability. The American Academy of Neurology Practice Guidelines on therapy for MS indicate IVIG is of little benefit in slowing disease progression. IVIG is usually recommended for those patients who fail or are unable to tolerate standard therapy. Based on the evidence provided, this patient has never used interferon, Tysabri, monthly intravenous steroids, Novantrone or other immunosuppressives that are FDA approved or have good clinical data to support their use.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The father of a 17-year-old female enrollee has requested Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that the patient has refractory chronic daily headache. She has failed or been intolerant of more than three preventive agents. It is also likely that the patient has medication overuse headaches related to her daily use of Dilaudid. It is important that she taper off the Dilaudid as it will only lead to worsening headaches over time. Botox is very likely to be effective in treating the patients headache disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female, with a prior history of major depression, has requested authorization for acute inpatient psychiatric services.Reviewers Findings:The reviewing physician found that given the patients prior history of major depression, she was clearly at increased risk of relapse following the birth of her son. The dosages of her psychotropic medications prior to admission were quite high, but provided no benefit. Her inpatient course was appropriately managed, without an undue length of stay, and with clearly documented improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male, with idiopathic short stature, has requested authorization for growth hormone therapy.Reviewers Findings:The reviewing physician found that the information provided demonstrates the patient has benefited from the use of growth hormone therapy in the past and is likely to continue to experience positive results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female, with complex regional pain syndrome (CRPS), has requested authorization for the prescription medication Lyrica. Reviewers Findings:The reviewing physician found that the safety of Lyrica has been sufficiently tested in other clinical applications and the medication was found to be safe in the prescribed dosage range. Treatment with Lyrica has been beneficial for this patient and without untoward side effects.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female, who presented to her physician for evaluation of pain and numbness of both feet, has requested authorization for pulsed radiofrequency.Reviewers Findings:All three reviewing physicians found that there is insufficient evidence supporting the long-term efficacy of pulsed radiofrequency in good quality, scientific peer-reviewed literature. In addition, there is insufficient current peer-reviewed literature demonstrating the safety of pulsed radiofrequency to recommend it for use at this time. There is no data to suggest that pulsed radiofrequency has greater efficacy than standard treatment such as orthotics, medications and injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male, with a history of Parkinsons disease, has requested authorization and coverage for a power-operated vehicle (POV).Reviewers Findings:The reviewing physician found that the patients mobility-related deficits (decreased balance and retropulsion) can be corrected by using a walker and/or a manual wheelchair. Mobility-related activities of daily living can also be completed with a walker/manual wheelchair without increased risk of morbidity from a fall.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-year-old female, who has an eating disorder, has requested reimbursement for partial hospitalization program (PHP) services and on-going authorization and coverage for PHP services.Reviewer's Findings:The reviewing physician found that the patient had been in intensive outpatient treatment and this level of care was not sufficient. The letters written by her psychiatrist and her therapist assert a need for continued PHP treatment based on their evaluation and the documentation in the record. The intensity of her symptoms, including distorted body image, depressed mood and food restriction, puts her at substantial risk of relapse.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The son of a deceased 85-year-old female, who was admitted to a skilled nursing facility (SNF) after a prolonged hospitalization, has requested authorization for skilled nursing facility services.Physician's Findings:The reviewing physician found that the patient was appropriately discharged from skilled services as she had no skilled nursing or rehabilitation needs  no injections, no wounds, and no complexity requiring daily skilled observation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested a PET scan for evaluation of his mental status. Findings:  Three physician reviewers found that the patient likely has a neurodegenerative dementing illness. The differential diagnosis includes Alzheimers disease, frontotemporal dementia and Lewy body disease. PET scanning is recognized by many as useful in evaluation of frontotemporal dementia. Peer-reviewed literature clearly supports the utility of PET imaging in the identification of dementing illness, especially in younger patients with atypical presentations. As frontotemporal dementia may have a hereditary component and a different clinical course than Alzheimers, it is important to diagnose early for optimal treatment. PET scanning is the best tool to assist in this diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin, sulfonylureas, or thiazolidinediones, alone or in combination, but have not achieved adequate control. This patients blood glucose is under excellent control. She was apparently begun on Byetta to help her lose additional weight which is not the intended purpose of the medication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested carotid angioplasty with stent placement for treatment of his carotid artery stenosis.  Findings:  Two physician reviewers found that given the clear indication for carotid revascularization and the patients increased risk for conventional endarterectomy surgery due to multiple comorbidities, remote CABG, and moderate provokable ischemia on stress testing, it is reasonable to consider alternative revascularization procedures. This procedure is less invasive and is strongly recommended by the treating physician. It is reasonable and appropriate under these circumstances of higher operative risk to proceed with angioplasty and carotid stenting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested speech therapy services for treatment of the enrollees verbal apraxia. Findings:  The physician reviewer found that the patient has received speech therapy and has made measurable and significant progress. Notes from this therapy indicate a need for close monitoring, evaluation and modification every 12 months. Considering the severity of this patients speech and language deficits, speech therapy sessions have been, and continue to be, medically necessary and essential. The patients quality of life, education, growth and development will depend on her participation in a speech therapy program. Periodic assessments and reevaluations should be conducted, and will dictate the type and frequency of future therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested a bilateral reduction mammoplasty for treatment of the enrollees macromastia. Findings:  The physician reviewer found that the patient has breast hypertrophy and her complaints of shoulder, neck and back pain are typical for symptomatic macromastia. The photographs confirm obvious macromastia. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic relief. Non-operative treatments are unlikely to improve the patients pain; surgery offers the only real chance for improvement. Although the patient is 17-years-old, the literature supports the beneficial role of breast reduction for adolescents. In relevant studies, almost all teenagers with symptomatic macromastia experienced symptomatic improvement, and reoperation rates are extremely low. The patients age should not be a contraindication for surgery as she is quite incapacitated by her current condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested psychiatric residential treatment services for treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical documentation is not adequate to support the contention that the patient warranted residential treatment. It is clear that by the point of admission the patient was rather variable in the extent of her binging and purging, was quite motivated for treatment, and was both tolerating previously prescribed Lexapro as well as devoid of depression. Therefore, there does not appear to have been a medical indication for intensive treatment services along the lines of residential care. The patient was likely to benefit just as much from a less intense level of treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested a wireless capsule endoscopy for evaluation of his possible lymphoma. Findings:  The physician reviewer found that the patient has mesenteric and retroperitoneal lymphadenopathy and the possibility of lymphoma (low grade). There is no evidence of occult gastrointestinal (GI) blood loss, and his hemoglobin and hematocrit are normal. As there are no signs of GI bleeding, wireless capsule endoscopy is not medically indicated for evaluation of the small bowel.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that although pragmatic in nature, the goals documented in this case by the patients speech therapist are not related to community function and appear educationally based. Furthermore, the goals have not changed substantially over time. Based on the documentation provided, the patients speech therapy does not appear to have been coordinated with a behavioral program working toward social communication. All told, there is insufficient evidence supporting the medical necessity of past or future speech therapy in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested electroconvulsive therapy (ECT for treatment of his depression. Findings:  The physician reviewer found that there are many unanswered questions regarding the interplay between the patients depression and his borderline personality disorder. Questions have also been raised about the efficacy of psychotropic medications versus the possibility of noncompliance. Regardless of these concerns, the primary consideration in determining the need for ECT is the extent of the patients depression at the point of admission. The clinical record indicates the patient was severely depressed with a full array of neurovegetative symptoms. Despite the unanswered questions, there is no question as to the validity of the patients depression. ECT is an appropriate course of treatment for severe depression and failed pharmacotherapy is not a prerequisite to prescribing ECT.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested an out-of-network consultation, Botox injections and MR neurography for treatment of her pudendal nerve entrapment. Findings:  The physician reviewer found that in determining medical necessity for the out-of-network consultation, consideration must be given to the fact that the patient had to wait six months for an appointment with the in-network pain specialist, during which time she was in significant pain. This constituted an unreasonably long delay and, as such, the consultation at issue was medically necessary. Furthermore, the use of magnetic resonance is an appropriate tool in the diagnosis of sacral plexi. The American Academy of Radiology endorses its use as highly appropriate for this indication in their practice guidelines. Therefore, the use of MR neurography was clinically indicated and medically necessary for proper evaluation of the patient.With regard to the Botox injections at issue, although trigger point injections have been used successfully to treat pudendal neuropathies, the efficacy of Botox in this clinical setting remains unproven. Thus, given the absence of significant trials demonstrating the benefit of Botox for patients such as this patient, its use in this case was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a yearly DEXA scan for evaluation of his hemiplegia and osteoporosis. Findings:  The physician reviewer found that the clinical evidence demonstrates the patient is on bisphosphonate, calcium and vitamin D therapy for presumed regional disuse osteoporosis. The Health Plans policy of approving scans every two years is reasonable in this clinical setting. There is no evidence that DEXA screening more often than every two years will show a significant change in bone mineral density. As such, there is no clinical indication for performing a DEXA scan on an annual basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested the medication Lyrica for treatment of his lower extremity pain and Parkinsons disease. Findings:  The physician reviewer found that the use of Lyrica is FDA approved for neuropathic pain from diabetes and post-herpetic neuralgia, but not for back and radicular leg pain from degenerative disc disease of the lumbar spine.  It is not uncommon for a physician to use a medication off label in a somewhat similar situation as the medication was initially designed for and often times, FDA drugs are approved for a specific diagnosis and then the indication for use widens over time. Given the patients excellent response to Lyrica (to the point that he was able to cancel his planned surgery) continued use of the medication is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested a CPAP machine for treatment of his excessive daytime somnolence. Findings:  The physician reviewer found that based on subjective complaints and polysomnographic findings, this patient may be suffering from upper airway resistance syndrome (UARS). UARS is a condition in which patients complain about excessive daytime sleepiness and they may snore and wake frequently during the night. UARS patients may not have the breathing abnormalities that characterize OSA and they may not show a reduction in oxygen saturation as seen in patients with OSA according to Exar and Collop. Treatment of UARS includes CPAP, surgery, and oral appliances. In the case of this patient, the CPAP device should be considered medically indicated to improve his daytime somnolence and snoring.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a power-operated vehicle (POV) for her mobility. Findings:  The physician reviewer found that there is no description of the patients actual motor strength in terms of a 0-5 point scale submitted, nor is there documentation of the patients actual walking distance, her ability to ambulate in the home, or of any specific inability to perform activities of daily living within the home. There is no objective clinical evidence demonstrating that the patient cannot functionally ambulate within her home.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient initially lost weight after undergoing a Lap-band procedure in 2004, but then gained some of the weight back. She is seeking authorization for removal of the Lap-band and revision to a vertical sleeve gastrectomy. The patients weight regain appears to be secondary to non-compliance. There is no evidence of Lap-band slippage or prolapse. Furthermore, based on a BMI of 35 and minimal comorbidities, the patient does not meet medical necessity criteria for surgical intervention. The risks of further surgical intervention outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested acute inpatient substance abuse rehabilitation services for treatment of his behavioral health problems. Findings:  The physician reviewer found that the patient did not meet established criteria for admission to an acute inpatient substance abuse rehabilitation program. He was not suicidal, psychotic, homicidal or suffering from serious withdrawal symptoms at the time of admission or during his inpatient stay. He did not require 24-hour monitoring for behaviors considered to be life-threatening or a danger to self/others or for monitoring of medication effects. The patient could have been managed and treated at a less intense, less acute, level of care on an outpatient basis. A partial hospitalization program or an intensive outpatient treatment program in addition to community-based resources such as a 12-step program would have been medically appropriate in lieu of the acute inpatient hospitalization.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his bipolar disorder and polysubstance dependence. Findings:  The physician reviewer found that the patient was quite encumbered by his mood symptoms and his medication management was complex. It appears the patient's anxiety and agitation only settled somewhat towards the very end of the inpatient period. All things considered, the patient clearly warranted all the inpatient treatment he received.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain. Findings:  The physician reviewer found that the patient has been diagnosed with cervical dystonia and is being treated appropriately. Lyrica is not indicated for the pain associated with cervical dystonia. This residual pain is likely to respond to any of a number of interventions including more aggressive Botox therapy, muscle relaxants, Gabapentin or Amitriptyline. The use of Lyrica for this patient would not be considered the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a power-operated vehicle (POV for her mobility. Findings:  The physician reviewer found that the durable medical equipment evaluation indicates the patient was observed over several sessions and she was able to propel a manual wheelchair in the home. She was able to navigate on carpeted surfaces and had sufficient mobility for mobility-related activities of daily living. The therapist did not indicate the need for a POV and recommended a light-weight hemi-height wheelchair for the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested an intensive outpatient desensitization program for treatment of the her obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that with a clinical scenario such as this one, an IOP utilizing exposure and desensitization therapies is the cornerstone of treatment for OCD.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested a magnetoencephalography (MEG for evaluation of the enrollees brain tumor. Findings:  Two physician reviewers found that MEG is utilized at tertiary epilepsy and neurosurgical centers. The procedure is useful in specific brain tumor surgery when tumors are in eloquent areas and there is a need to pre-operatively identify the central sulcus and Brocas area. MEG has been demonstrated to have superior capacity to adequately localize the margins of tumor in epileptogenic zones of brain tissue, allowing for more accurate surgical resection. MEG in this clinical setting is not considered investigational and was likely to be superior to any other method of pre-surgical evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested pelvic therapies (pudendal nerve blocks, trigger point injections and physical therapy) provided by a non-plan pelvic pain specialist and a physical therapist for treatment of her pudendal neuralgia. Findings:  The physician reviewer found that there is little controversy as to the benefits of pudendal nerve blocks and physical therapy in the treatment of pelvic neuralgias. The Health Plans contention that there is a lack of scientific evidence is without merit. The literature does support these pelvic therapies and no reasonable alternate treatment was made available to the patient. The providers notes document when and how the patients symptoms started, as well as what circumstances exacerbate or fail to exacerbate the pain. The character of the pain is adequately described along with  associated conditions and past medical/surgical history. It is clear from the record the patient has benefited from these pelvic therapies, and continued treatment is medically appropriate.