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

A 50-year-old female enrollee has requested right knee replacement surgery for the treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that there is no question that this patient has fairly severe arthritis of her right knee and she has had multiple prior knee surgeries. However, the records demonstrate that three individual orthopedists have recommended that the patient not proceed with knee replacement because of an unfavorable risk/benefit ratio. Knee replacement surgery requires a reliable patient who can clearly show that he or she would carry out the rehabilitation program appropriately. The submitted records demonstrate that the patient has had compliance issues with her treatment regimens to date. Therefore, it is highly unlikely that she would be able to meet the demands of a post-operative rehabilitation program at this time. Thus, I agree with the patients orthopedists that the risk/benefit ratio for the requested surgery is extremely unfavorable, and as such, knee replacement surgery is not clinically indicated or necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested an Abbott FreeStyle Navigator continuous blood glucose monitor for the treatment of his diabetes mellitus. Findings:  The physician reviewer found that this patient has uncontrolled diabetes mellitus type 1 due to his Aspergers syndrome which inhibits his ability to remind himself to check his blood glucose and therefore administer insulin. A CGMS has been recommended to assist the patient in achieving better control. Given the patients elevated HbA1c, complications are likely to occur without the use of a CGMS. The patient is an appropriate candidate for a CGMS and is likely to benefit from its use.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for brachytherapy for treatment of her breast cancer.  Findings:  Two physician reviewers found that in the current National Comprehensive Cancer Network (NCCN) practice guidelines for breast cancer, within the section of ductal carcinoma in situ (DCIS), primary treatment recommends lumpectomy without lymph node surgery plus whole breast radiation therapy. There is Category 1 data to support this treatment. Within the radiation therapy section, it states that the breast should receive a dose of 45-50 Gy in 1.8-2.0 Gy per fraction or 42.5 Gy at 2.66 Gy per fraction.  Furthermore, the section on partial breast irradiation (PBI) states that, PBI should be performed only as a part of a prospective trial. PBI should be reserved for patients with low risk of recurrence.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for an orthopedic specialist consultation for treatment of her carpal tunnel syndrome. Findings:  The physician reviewer found that patient has tried splinting and injections, and she still has ongoing discomfort from carpal tunnel syndrome. Further non-operative care is not likely to be of benefit. A referral to an orthopedic specialist will provide a more detailed evaluation and allow for patient education regarding the conservative and operative treatments of this condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested occupational therapy for the treatment of the enrollees hypertonia secondary to prematurity. Findings:  The physician reviewer found that this patient suffers from multiple delays that affect her ability to function in an age-appropriate manner, most likely due to her history of prematurity. She has balance difficulties, gross and fine motor deficits, and sensory processing deficits. Persistence of these deficits can lead to difficulties navigating the educational system, interacting with peers, and ultimately, entering the work force and functioning in society. With its focus on developing motor planning skills, teaching self-help skills, and developing fine and gross motor skills, OT is well-suited to affect positive change in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested air ambulance services for the treatment of his head trauma. Findings:  The physician reviewer found that the Health Plan does not agree that the air ambulance services the patient received were medically necessary. Specifically, the Health Plan states that air ambulance services are covered in exceptional circumstances. The patients condition must be such that immediate and rapid ambulance services could not have been provided by land ambulance or the time needed to transport the patient by land poses an immediate threat to his health. These circumstances could include the point of pick up not being accessible by ground ambulance, great distances, limited time frames, or other obstacles involved in getting the patient to the nearest hospital with appropriate facilities. In this case, the patient had sustained head trauma but no one witnessed the actual injury. It is unclear whether he fainted or had a seizure. He certainly needed continued observation in a hospital as well as a CT scan of the head at a minimum. At the time he was transferred, however, the patient was stable. He was awake and alert and not on life support. He had no open head injury, neurologic abnormality, or lateralizing signs. The patient was transported 760 miles to another facility. No documentation was provided that shows that the patient could not have received appropriate services at a closer facility accessible by ground ambulance. The submitted documentation does not demonstrate that this patient had an exceptional circumstance that required immediate and rapid ambulance transport that could not have been provided by land ambulance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested an increase in Enbrel dosage to 75 mg/ml per week for the treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that the clinical trials of etanercept showed that a dose of 100 mg/ml weekly was not more efficacious than 50 mg/ml weekly in the treatment of rheumatoid arthritis as discussed by Johnson and colleagues. There does not appear to be any support in the literature for a dose of 75 mg/ml weekly. Thus, there is insufficient evidence to justify increasing the dose of Enbrel above the manufacturers recommended dose. Alternative treatments such as a steroid taper could be considered and would be consistent with the standard of care in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a power operated wheelchair for her impaired mobility secondary to rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for a power wheelchair in this case. Specifically, this patient is unable to ambulate despite use of an assistive device and she is also unable to self-propel a manual wheelchair. She requires a power wheelchair to perform in home mobility-related activities of daily living. It has been documented that she is able to operate a power wheelchair. Further, her home environment can accommodate a power wheelchair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested long-term speech therapy for the treatment of the enrollees autism and attention deficit-hyperactivity disorder. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. While school services are essential, they are based on educational needs, and are not sufficient for children with the severity of deficits as seen in this patient. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the patient in this case had been vomiting for several days. She had been evaluated the same day by her primary care provider. Her condition had not suddenly changed prior to her arrival in the Emergency Department. The medical records indicate that the patient appeared well. During the three hours she was observed, no emesis was noted. The patients symptoms were not acute in onset and were not such that a prudent layperson would have sought immediate medical attention for the patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that there is no evidence that this patient's presentation was urgent due to the infectious nature of the disease. A scabies infestation was not proven, and even if proven, is not a medical emergency. The patients request for coverage of this medical visit should be denied, as a prudent layperson would be able to identify the somewhat long-term nature of the problem and realize that treatment could wait for evaluation until the clinic hours of his regular physician. This patients symptoms do not meet the prudent laypersons criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Xifaxan for the treatment of his Crohns disease. Findings:  The physician reviewer found that the use of Xifaxan is not medically necessary in the treatment of Crohns disease. The use of this medication is typically in a setting of Travelers diarrhea, hepatic encephalopathy or bacterial overgrowth in small intestine. Its use in Crohns disease is limited and not FDA approved. A search of the medical literature revealed little data regarding the efficacy of Xifaxan in this context. A study by Prantera, et al. looked at this issue, but the difference between the treatment group and placebo was not statistically significant. There is inadequate evidence-based support for the use of Xifaxan in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a phase I clinical trial of high dose immunoablation followed by autologous stem cell transplantation (NU FDA CIDP.AUTO 2003) for the treatment of her chronic inflammatory demyelinating polyneuropathy. Findings:  Three physician reviewers found that although immunoablation followed by stem cell transplantation shows promise as a potential therapy for chronic inflammatory demyelinating polyneuropathy, there currently is not adequate literature to support its use over more standard and tested therapies for this condition. No large scale controlled trial has been performed with a population with this condition. The efficacy and safety has not been determined in a large size, or even moderate size, population with chronic inflammatory demyelinating polyneuropathy.  Furthermore, this patient has not tried more standard and proven therapies for this condition, such as plasma exchange or other immunosuppressive agents such as mycophenolate mofetil and rituximab.  The use of the requested stem cell transplantation in place of these therapies could cost the patient potential benefit at the risk of severe side effects. At this time, stem cell transplantation remains promising. However, until the safety and efficacy can be proven, its use should not supplant more traditional and tested therapies.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested for hospital services and follow-up office visits.  Findings:  The physician reviewer found that Kawasaki disease (KD) is an idiopathic vasculitis defined by a constellation of clinical signs supported by certain laboratory data. The principal cause of death is myocardial infarction caused by thrombosis of coronary artery aneurysm or thrombosed coronary arteries. The treatment for KD is intravenous immunoglobulin given within 10 days of the onset of symptoms. This is supplemented with the use of aspirin or other anti-inflammatory medications. Patients require evaluation with an electrocardiogram as well as an echocardiogram. Prompt diagnosis and treatment can prevent coronary artery aneurysm in 95% of patients. Kawasaki disease is a medical emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for inpatient skilled nursing facility (SNF) services for treatment of her medical condition status post craniotomy.  Findings:  The physician reviewer found that the patient was safe for transfer and ambulation and safe cognitively by the last authorized date of service. She did need help with bathing and dressing but due to her independence with mobility, continued care and rehabilitation could have been provided at a less intensive level of care than skilled nursing care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for continuing outpatient mental health treatment with an out-of-network provider for treatment of her generalized anxiety, depression and posttraumatic stress disorder. Findings:  The physician reviewer found that this length of additional therapy is medically necessary to prepare the patient for a safe transition to an in-network provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested  for speech and language therapy, occupational therapy with sensory integration therapy and social skills group therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that Zachor and colleagues, early intervention can help the patient acquire skills for his daily living and decrease his dependence on others. Further delay with therapy will prolong the goals for acquisition of skills and may cause regression. Utilizing this patients interests in a global approach is medically indicated, as he is already in therapy and is showing some positive signs. Providing skills for this patient to take care of self help needs, communication and social well-being will enable him to fare better in his adult years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for Lyrica for treatment of her small fiber neuropathy. Findings:  The physician reviewer found that the clinical literature supports the benefit of Lyrica not only for diabetic peripheral neuropathic pain, but for other painful neuropathies. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy, as well as the patients prior beneficial experience with Lyrica.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the breast for evaluation of a suspicious spot on her left breast.  Findings:  Three physician reviewers found that there is no evidence to support an MRI in this particular setting. No documentation of a mammogram performed more recently has been provided. there is no clinical evidence that would suggest that a breast MRI is indicated, as it is not a first-line diagnostic tool.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested for a bariatric surgery consultation for treatment of his obesity and obstructive sleep apnea.  Findings:  The physician reviewer found that there is no scientific evidence that demonstrates any benefit to psychological evaluations and clearances pre-operatively. Since weight loss surgeries are major operative interventions, the patient will undergo the appropriate medical workup and obtain the necessary clearances prior to the surgery. He should be allowed to pursue the only definitive treatment for his morbid obesity by obtaining a bariatric surgery consultation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested  for applied behavioral analysis (ABA) therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that ABA therapy is an established treatment modality widely accepted in the practicing community and by centers specializing in this disorder. Foxx described ABA therapy as a state of the art treatment modality for this medical disorder. The article noted that ABA therapy utilizes methods derived from scientifically established principles of behavior and that intensive treatment is needed, usually between 20 to 40 hours per week. Myers and colleagues noted that the effectiveness of ABA therapy has been well-documented through several decades of research using single subject methodology. The National Institutes of Health also acknowledges that ABA therapy has become widely accepted as an effective treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that autism spectrum disorder is a medical condition of unknown origin. Myers and colleagues supported speech therapy for the treatment of autistic children. Occupational therapy is cited as being recommended but not proven due to methodological difficulties in proving its value. Schaaf and Miller indicate that occupational therapy utilizing sensory integration can be successful in improving function in autistic children. Most authorities recommend extensive occupational and speech therapy for autistic children. Two hours per week of speech therapy and two hours per week of occupational therapy are medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that autism remains a complex neurological disorder whose etiology remains unknown, and it often involves profound communication problems. Myers and colleagues noted that speech therapy can be medically effective for children with autism. The same report indicates that occupational therapy is valuable for children with autism, but mentions that it is of unproven benefit due to methodological difficulties in establishing control groups in this population. Schaaf and Miller note the value of sensory integration by occupational therapists in this population. Most authorities recommend extensive occupational and speech therapy for autistic children. All told, the scientific evidence supports speech therapy and occupational therapy for patients such as this patient. Two hours per week of speech therapy and two hours per week of occupational therapy are medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 78-year-old female enrollee has requested for hernia surgery for treatment of her hernia. Findings:  The physician reviewer found that bowel resection is a high risk procedure. Many patients with large herniae can be followed if their anatomy is such that the contents do not obstruct or strangulate. The patients age, weight and multiple comorbidities all support a nonoperative approach, unless symptoms worsen and increase in frequency. Based upon the information, surgical intervention is not medically indicated or appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for intensity-modulated radiation therapy (IMRT) for treatment of his prostate cancer.  Findings:  The physician reviewer found that IMRT plus brachytherapy is a reasonable approach in the treatment of localized prostate cancer. Dosimetrically, it may be preferable to brachytherapy alone or IMRT alone. Nevertheless, IMRT is not medically necessary when combining external beam radiation with brachytherapy. There are innumerable studies to support conventional external beam radiation treatment in conjunction with brachytherapy, but there appears to be no studies that compare the dosimetry or clinical outcome with conventional radiation plus brachytherapy versus IMRT plus brachytherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is evidence that shows a far better outcome with management of the co-morbidity of diabetes with weight loss surgical procedures (metabolic surgery) than any of the medical regimens available for the treatment of diabetes. (Sjostrom, et al.) Further attempts at non-surgical weight loss are not likely to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 54-year-old male enrollee has requested for continued acute inpatient rehabilitation for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient does not meet all the Medicare criteria for continued acute inpatient rehabilitation as: he does not require 24-hour close medical supervision by physician, he does not require 24-hour rehab nursing and he does not require intensive rehabilitation as his participation was limited due to agitation and decreased ability to follow commands.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for robotic surgery for treatment of her ovarian mass. Findings:  Three physician reviewers found that the laparoscopic approach is not recommended due to the inability to adequately assess for spread, or to debulk possible tumor implants.  If this is in fact a fibroid or a benign ovarian mass, at this time the use of the robotic approach is also not the standard of care. The additional size and number of ports used for the robotic approach compared to standard laparoscopy could actually increase her risk of pain and scarring. Thus, the robotic approach is not uniformly appropriate for most gynecologic abdominal procedures.