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

An eighteen year-old male diagnosed with oppositional cannabis abuse, alcohol abuse and dysthymia is requesting authorization reimbursement for residential treatment services.  The patient was admitted to a residential level of care and remained at this level of care for a number of months.  Reviewers Findings:The reviewing physician found that there is no documentation of risk taking behaviors during the period at issue. There is nothing in the records provided to demonstrate that the patient required a 24-hour treatment setting or that he could not have been safely treated at a less acute level of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-three year-old female with profound anorexia and bulimia is requesting authorization for residential treatment services.  The patient had failed partial hospitalization level of care and then entered residential treatment.Reviewers FindingsThe reviewing physician found that the submitted clinical information demonstrated the patient was too sick to be cared for in a partial hospitalization program and could not return home to an unsupervised situation.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-one year-old female with hyperhidrosis of the axilla is seeking reimbursement for the Botox treatments.  The patient had not responded to Drysol, but has had effective treatment with Botox.Reviewers Findings:The reviewing physician found that the evidence provided does not demonstrate that Botox injections were clinically indicated for treatment of this patients condition.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old female with multi-level lumbar disc disease is requesting authorization of an X-Stop decompression procedure.  Reviewers Findings:The reviewing physician found that this patient has multi-level disc disease, which would be a contraindication to the use of the X-Stop device.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year-old female with a history of recurrent major depression and opioid abuse is requesting authorization for enrollment in partial hospitalization program.Reviewers Findings:The reviewing physician found that there are no grounds to support the medical necessity of partial hospitalization program services.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-seven year-old female who was diagnosed with ovarian cancer is requesting authorization for PET/CT scans.  Reviewers Findings:  The reviewing physician found that National Oncologic PET Registry lists ovarian cancer as an indication for PET scan for the purposes of diagnosis, staging, restaging, and monitoring.  Also, the sensitivity and specificity for PET and CT combined is higher than CT alone.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-three year-old male with a hypodense mass in the body of the pancreas and two small low densities in the liver is requesting reimbursement for a PET scan.  Reviewers Findings:  The reviewing physician found that National Oncologic PET Registry lists the diagnosis, staging, restaging and monitoring of pancreatic cancer as valid indications for PET scan.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty year-old male who had coronary stents placed to the mid circumflex, RCA and RPDA coronary arteries is requesting authorization for a 64-slice CT angiography.Reviewers Findings:  The reviewing physician found that the CT angiography in an asymptomatic patient for evaluation for in-stent restenosis and coronary anatomy after PCI is considered an inappropriate indication for CT angiography per the American College of Cardiology guidelines.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested authorization and coverage for the medication Celebrex for treatment of left shoulder pain. Reviewer's Findings:  The physician reviewer found Celebrex is a second generation NSAID that is generally not clinically indicated absent the failure of the more commonly prescribed NSAIDs taken in combination with a proton pump inhibitor. Such a trial would be reasonable for this patient before the long-term use of Celebrex is initiated. It does not appear that has occurred, therefore the use of Celebrex cannot be recommended.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old female with speech production delay are requesting authorization for previous and future speech therapy.  There is no medical information demonstrating a clinical rationale for the patients delay has been provided.Reviewers Findings:  The reviewing physician found that there is no evidence that speech therapy for a three-year-old with a speech delay without an associated medical diagnosis is medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

SummaryThe patient is a 54-year-old female with stage IV breast cancer.  She is requesting authorization for treatment with Sutent. The Health Plan denied her request citing the experimental nature of the therapy in this clinical setting.  The three physicians reviewing the case all found that the Health Plan denial should be upheld.Analysis and FindingsClinical Facts:  The patient has a history of advanced breast cancer initially diagnosed in 1993. As per the record, her treatment has included the following chemotherapeutic regimens: FAC, HD SCT/etoposide, tamoxifen, Femara, Aromasin, Herceptin, Taxotere, lapatinib, Navelbine/Herceptin, Herceptin/Gemzar/Xeloda, Alimata/Herceptin, Doxil, Gemzar/Oxaliplatin and several clinical trials. Complicating the clinical picture are diagnoses of brain metastases and hypertension and treatment with Temodar.Reviewers Findings:The three reviewers indicated that although Sutent is an up and coming drug in the management of several types of malignancies including breast, it remains experimental.  And there is only one small phase II study that may show benefit in patients with a heavily pre-treated history. The manufacturer reports that seizures have been observed in subjects with radiological evidence of brain metastases. In fact, all of the angiogenesis inhibitors are known to carry an increased risk of tumor hemorrhage and this complication is potentially devastating in the context of brain metastases. Additionally, liver function is often adversely affected. Any preliminary data that may support the efficacy of this therapy is not sufficient to offset the lack of data supporting the safety of the proposed treatment with Sutent.  Therefore, the three reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-nine year-old male with posterior right knee pain is requesting authorization of an MRI of the right knee.  An examination note documented the request for a right knee MRI. However, there was no description of physical findings and there was no documentation of failed conservative treatment.Reviewers Findings:The reviewing physician found that the record submitted for review contained no documentation of a complete physical examination or of a diagnosis.  Nor does it appear that an ultrasound was performed.  Without this information an MRI of the right knee is not medically indicated.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-six year-old male was diagnosed with lymphadenitis is requesting authorization of a PET scan.  A CT of the neck was performed which showed a few lymph nodes up to 9mm in size and prominent parotid glands bilaterally.Reviewers Findings:The reviewing physician found that there is little difference between a separately obtained CT scan and PET scan or a combined PET/CT scan and neither a standalone PET or a PET/CT are indicated at this time.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Sixty-year old female who has been diagnosed with asthma is requesting authorization for Xolair.  The patient has a history of cough and chest congestion. She has been diagnosed with asthma with FEV1 of 65% predicted (with IgE 128kU/L). She is allergic to trees, weeds, dust mites, grass, and molds. She is currently on immunotherapy, montelukast, fluticasone/salmeterol, desloratidine, triamcinolone nasal spray, and albuterol. She has required oral steroid rescue and emergency department visits. She is currently poorly controlled using albuterol four times a week.Reviewers Findings:The reviewing physician found that the patient meets criteria for authorization of Xolair. The patient is more than 12-years-old and has an IgE greater than 30 (128kU/L) and most likely has FEV1 reversibility of greater or equal to 12% as her variability over time ranges between 65% to 85%. Furthermore, as the patient appears to be a refractory asthmatic who is not well controlled and continually using albuterol, there may not be any reversibility. Moreover, given the nature of severe asthmatics, requiring a severe asthmatic to demonstrate reversibility at one time point in time is not a valid exclusion criterion.  Therefore, the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 60-year-old male with cancer of the pancreas.  He is requesting authorization to be treated with Gemzar and Tarceva.  The Health Plan denied authorization on the basis that Tarceva is not medically necessary.  The physician who reviewed the case concluded that the requested medication is medically necessary for treatment of the patients condition and the Health Plan denial should be overturned.Analysis and FindingsClinical Facts:  The patient was diagnosed with cancer of the pancreas in March 2005. At that time he underwent a Whipple procedure and was then treated with pre-radiation Gemzar, followed by radiation therapy along with infusion 5-FU. He then was well until he was diagnosed with recurrent and inoperable cancer in October 2006. It has been recommended that the patient be treated with Gemzar and Tarceva.Reviewers Findings The reviewer determined that the combination of Gemzar and Tarceva had a median survival of 6.37 months with 24% survival at one year, and the addition of Tarceva in this case is likely to be more beneficial than Gemzar alone.  The physician reviewer found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

SummaryThe patient is a 34-year-old woman with chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy.  The Health Plan has denied authorization for Botox indicating it is not medically necessary.  The physician reviewer concluded that the Health Plan denial should be upheld.  Analysis and FindingsClinical Facts:  The patient has chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy. The patient has consistently refused usual migraine preventive therapy. MRIs of the brain and neck were unremarkable. An EMG reported cervical muscle spasm consistent with dystonia.  Reviewers Findings:The reviewer found that although Botox is beneficial for some patients with intractable migraines, it is not appropriate as a first or second line therapy for this condition. Additionally, while Botox is FDA approved and clinically indicated for cervical dystonia, the presence of cervical spasm alone is not sufficient to support a diagnosis of cervical dystonia. The patients history and neurologic examination do not support a diagnosis of cervical dystonia. Furthermore, EMG testing cannot establish or confirm a diagnosis of cervical dystonia. All told, the patient has not exhausted conventional therapies for treatment of her headaches and neck pain and is not an appropriate candidate for Botox at this time.  Therefore, the reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 43 year old female who has Ewings sarcoma of the left pelvis treated with chemotherapy and radiation therapy.  Since that time the patient has been followed with PET, CT and MRI scans.  She is requesting coverage for another PET scan.  The Health Plan indicates the requested PET scan is investigational in this context and therefore, not a covered benefit.  Two of the three reviewing physicians concluded that the denial for the PET scan should be overturned.  The third physician concluded that the denial for the PET scan should be upheld.  Analysis and FindingsClinical Facts:  The patient has Ewings sarcoma of the hip/pelvis and was diagnosed in 2002.  The patient underwent chemotherapy and radiation therapy. Since that time the patient has been followed with PET, CT and MRI scans.  A PET scan in March 2006 was compared to a prior PET/CT scan (November 2005) and showed uptake at T9 with the scan otherwise negative. MRI of the thoracic spine (April 2006) was normal.  A CT scan (March 2006) showed no evidence of recurrent disease.Reviewers Findings:One Review indicated that the patient has no suspected recurrent or metastatic disease, follow-up imaging with more conventional modalities (i.e., CT and/or MRI) is adequate to monitor this patients condition.  And, for monitoring patients in remission, PET imaging has not yet been proven to be superior to conventional imaging.  The reviewer has determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition and the Health Plan denial should be upheld.The other two physicians determined that the sensitivity of PET for the presence of Ewings sarcoma and/or metastases is up to 96%, with the PET scan being superior to bone scintigraphy in detection of bone metastases.  And, the use of a PET scan for detection and metabolic characterization of Ewings sarcoma is an appropriate medical practice. Its use in localizing tumor and characterizing tumor response to therapy is well accepted and represents the current state of the good practice of Oncology and Nuclear Medicine.  Therefore, these reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Fifty-four year-old male is requesting authorization to proceed with the osteochondral autologous transfer system (OATS) procedure.  The patient has undergone three surgeries to his right knee. The most recent was an arthroscopic subtotal medial meniscectomy in July 2005. An MRI from May 2006 showed advanced osteoarthritic changes, a five millimeter osteochondral defect involving the medial femoral condyle surface and severe chondromalacia of the medial compartment. The patient was referred for a second opinion regarding a possible total knee arthroplasty. He was seen in July 2006 and the orthopedist noted a slight effusion, tenderness to palpation over the medial aspect of the right knee and no limp. X-rays of the right knee from October 2006 showed moderate to severe degenerative changes, joint effusion and a right medial femoral condyle osteochondral defect.Reviewers Findings:The reviewing physician concluded that the patient is not a good candidate for the requested procedure because of the diffuse nature of the arthritic changes in his knee. OATS procedures are typically utilized in young patients with focal osteochondral lesions and normal surrounding cartilage.  The patients diffuse arthritic changes and severe chondromalacia would make him a poor candidate for the procedure. There are other viable, non-operative measures still available to this patient.  Therefore, the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Forty-three year-old female with Mediastinal lymphadenopathy is requesting PET Scan for further evaluation.  The patient had CT scans of the chest and abdomen for left upper quadrant pain in March 2006. Mediastinal lymphadenopathy was identified. The patient is presently asymptomatic except for occasional night sweats. There is a past history of hypothyroidism, prediabetes and adrenal insufficiency.Reviewers Findings:Neither a positive nor a negative PET scan would add to the evaluation of the patients adenopathy. Adenopathy without a specific etiology is not an approved indication for PET scan under the guidelines of the Centers for Medicare and Medicaid Services.  If a specific diagnosis is needed, then biopsy should be considered with mediastinoscopy. Follow up CT scans can also show the stability of the adenopathy.  Therefore, the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-eight year-old female with chronic headaches diagnosed as migraines and chronic cervical pain is requesting for continued authorization of Botox therapy.Reviewers Findings:Two of the reviewing physicians found that Botox therapy would be beneficial for treatment of the patients medical condition.  The Third physician found that Botox therapy is not likely to be more beneficial for treatment of the patients medical condition.  The physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-four year-old male who underwent an audiometric evaluation is requesting authorization for a follow up evaluation of his hearing.Reviewers Findings:  The reviewing physician found that it is reasonable for the patient to undergo follow-up audiometric testing to compare with the previous results.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee is requesting authorization for an Oncotype DX tumor assay for evaluation of breast cancer.Reviewers' Findings:  The three reviewing physicians found there is good literature support for the assay's reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very important as it is particularly in this group of breast cancer patients that it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients, and Medicare has approved its use.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one year-old male who was born with Pierre Robin sequence and diagnosed with Stricklers syndrome is requesting authorization for ongoing pediatric ophthalmologic care with the out-of-network ophthalmologist.  Reviewers Findings:  The reviewing physician found that the submitted clinical evidence indicates the patients condition is stable to the point that care can be transferred to another pediatric ophthalmologist.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a seven year-old female with short stature are requesting authorization for growth hormone therapy.Reviewers Findings:The reviewing physician found that the patient does not appear to have GH deficiency, nor is there evidence of intra-uterine growth retardation with failure to catch up.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a fourteen year-old male who had gynecomastia has requested reimbursement for bilateral mastectomy.Reviewers Findings:The reviewing physician found that the procedure at issue was not medically necessary for treatment of the patients medical condition and that there were other methods to treat the condition.  The physician concluded that the health plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-one year-old female who is addicted to heroin is requesting reimbursement for chemical dependency day-treatment (partial hospitalization).  Reviewers Findings:The reviewing physician found that detoxification alone would have been inadequate in terms of longitudinal treatment. Referral of the patient to day treatment post-detoxification was entirely reasonable, as well as in line with standards of care for serious addictions.  The physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 56 year old male with lymphocytic leukemia (CLL) which was refractory to alkylators, Fludara and Rituxan.  He is asking for reimbursement for two cycles of the OFAR chemotherapy.  The Health Plan denied his request, indicating the oxaliplatin included in this chemotherapy regimen was not medically necessary.The reviewer concluded that that the chemotherapy was medically necessary and that the Health Plan denial should be overturned.Analysis and FindingsClinical Facts:  The patient has CLL which was refractory to alkylators, Fludara and Rituxan.  He was treated with a regimen of oxaliplatin, fludarabine, cytarabine and rituximab (OFAR). The patient had an excellent response, optimizing his candidacy for allogenic transplant.Reviewers Findings:The reviewer indicated that the literature submitted by the patients providers is sufficient evidence of the potential benefit of the OFAR chemotherapy regimen in the treatment of refractory CLL. The reviewer also stated that the patient will clearly benefited from the protocol which included the disputed oxaliplatin chemotherapy.  This reviewer concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male with a serious psychiatric problem are requesting authorization of continued partial hospitalization.Reviewers Findings:  The reviewing physician found that the program the patient is currently attending is medically appropriate and clinically indicated based on the information provided.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-seven year-old obese female with significant comorbidities is requesting authorization for laparoscopic adjustable gastric banding.  Reviewers Findings:The reviewing physician found that Lap-Band is as effective as other weight loss procedures and presents the least surgical risk.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-four year-old male with diagnosed Bipolar Disorder is requesting authorization for residential treatment services.  Reviewers Findings:  The reviewing physician found that the extent of the patients illness warranted inpatient treatment.  The reviewing physician found that the Health Plan denial should be overturned.