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

A 58-year-old female enrollee has requested reimbursement and out of network surveillance studies (laboratory and imaging) per the Phase II Clinical Trial of Interferon Alpha-based Adjuvant Chemoradiotherapy for her pancreatic cancer.  Findings:  The physician reviewer found that it is unlikely that she had an adequate EUS evaluation of the specific area along the lateral border of the SMA. As such, it is possible that there are both regional and distant recurrences and the reading by the Health Plan was not incorrect. The Health Plan indicates a willingness to perform ongoing surveillance studies in-Plan and to communicate these results to the trial site at the out of network medical center.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested acute inpatient psychiatric treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there may well be a manipulative element to his behavior, but this does not obviate the need for much more intensive services than the patient himself would have allowed for on an outpatient basis. A week of inpatient evaluation and treatment was needed to ascertain what was transpiring with the patient and his family, and to have a better sense of therapeutic direction.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested pudendal nerve block for her endometriosis. Findings: The physician reviewer found that review of the relevant scientific literature reveals no valid studies to support the use of pudendal block for the treatment of chronic pain from endometriosis. The patients stage IV endometriosis was appropriately treated surgically, and as a result she should be expected to have significant chronic pain relief. Furthermore, there is no evidence the pudendal block was necessary to give immediate relief from postoperative pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested a PET scan for an evaluation of her thyroid cancer. Findings:  The physician reviewer found that a review of the literature indicates the sensitivity of PET in well-differentiated thyroid cancer (which includes papillary) was between 47% and 100%; true-positive FDG-PET findings correlated with increasing thyroglobulin levels. In one study, PET was found to be superior to thyroglobulin levels in identifying cervical lymph node metastases. In another study, the results of PET changed the clinical management in 44% of the patients. There is sufficient evidence in the literature to establish the efficacy of PET for thyroid cancer; its use in this instance is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for thermal breast imaging for evaluation of her breasts. Findings:  Three physician reviewers found that a review of the National Comprehensive Cancer Network guidelines and a literature search reveal there is no support for the use of thermal breast imaging as a screening tool for breast cancer. Although there is radiation exposure from mammograms, the benefits of this modality in terms of mortality outweigh the risks as noted in the above reference. Thermal breast imaging cannot be recommended for breast cancer screening at the present time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for acupuncture for treatment of her chronic pain syndrome. Findings:  The physician reviewer found that the patient is currently on disability, can no longer drive a car, lives at home with her mother and needs some assistance with activities of daily living. Based on review of the submitted records, it does not appear that the patient has had any significant improvement in her symptoms/complaints with any of the prescribed therapies/modalities/medications including acupuncture.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for Avastin for treatment of his breast cancer. Findings:  Two physician reviewers found that the use of bevacizumab in combination with paclitaxel has been shown to improve progression-free survival in a randomized phase III cooperative group study of the Eastern Cooperative Oncology Group. Both paclitaxel and docetaxel are taxanes and have known efficacy in breast cancer treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of 16-year-old female enrollee has requested for psychiatric residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that though the patient suffers from Bulimia, it is not quite clear from the notes included just how often she was actively restricting her calories or binging. In addition, the patient was clearly preoccupied with her own appearance and sexuality and was quite given to angry acting out when limits were set with her at home. To this extent, some of her claim of wanting to weigh as little as 90 pounds appears to be anger-fueled bravado and not genuinely reflective of the extent of her eating disorder per se.  In conjunction with some of the previously cited notes, one might conclude that she demonstrates a fair amount of Histrionic and Narcissistic pathology. That said, it has not been established that the optimal approach for the patient was or is residential treatment. In fact, one can make a cogent argument for the patient being held more firmly to outpatient treatment so as not to reinforce this sort of acting out. Family therapy could have been integrated into intensive outpatient therapy, and could have been more successful in the long run, having to occur in the home environment, which seems to trigger so much for the patient. As for her medications, these could have been equally efficacious if administered via intensive outpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for minimally invasive left total knee arthroplasty for treatment of his osteoarthritis. Findings:  The physician reviewer found that there are no long-term and well-controlled studies demonstrating a clear benefit with minimally invasive knee replacement. The gold standard is total knee replacement and there are numerous ways to perform the replacement once the skin is incised, all of which are considered the standard of care. While the smaller incision may appear to be advantageous, there is more risk of suboptimal positioning of the knee implant and no significant difference in recovery. The long term durability of this technique has yet to be established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for cognitive rehabilitation therapy for treatment of the enrollees brain injury. Findings:  The physician reviewer found that review of the submitted therapy evaluation and daily progress notes reveals that the objectives as written in the evaluation are not measurable. There is no mention of the frequency of therapy or short- or long-term goals. Nor is there evidence of significant functional gains. Furthermore, there is no literature to support the benefit of cognitive rehabilitation therapy four years following traumatic brain injury.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for an MRI for evaluation of her herniated disk. Findings:  The physician reviewer found that based on the clinical information provided, an MRI is not clinically indicated for this patient at this time. An MRI is not necessary to make a change in the patients treatment course at this juncture. The next appropriate step in this case is a consultation with an orthopedist to discuss whether diagnostic studies are needed and, if so, which particular imaging modality would be most useful.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Tysabri infusions for treatment of her multiple sclerosis. Findings:  The physician reviewer found that review of the scientific literature reveals that Tysabri has shown better efficacy than interferons in indirect comparisons. Per FDA prescribing information, Tysabri is indicated as monotherapy for the treatment of patients with relapsing forms of MS to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations.. Per TOUCH program guidelines, it is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, alternate multiple sclerosis therapies. No recommendation is made that it be given only if a patient has failed two prior disease modifying MS therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees polysubstance abuse and depression. Findings:  The physician reviewer found that the patient did not meet the ASAM criteria for admission to a residential treatment center. The patient had no biomedical conditions and there was no need to protect the patient or provide a 24-hour structured environment. The patient had adequate social functioning and was able to manage his activities of daily living. The patient could have participated at a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested a magnetoencephalography (MEG) for evaluation of her seizure disorder. Findings:  Three physician reviewers found that compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of patients with epilepsy, especially those with a negative PET scan. Accurate lateralization of her epiletiform events is crucial for this patient and MEG is the most appropriate study to accomplish this.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested an MRI.  Findings:  The physician reviewer found that a working diagnosis can be established based on medical history, physical examination and plane x-rays or panoramic tomogram (panorex). Standard treatment would consist of analgesics, anti-inflammatory medications, a dental occlusal orthotic splint and physical therapy. If this combination of therapies fails, then surgical intervention would most likely be considered. It is at the time of the pre-surgical evaluation that an MRI would be medically appropriate. MRI was not indicated at the time it was performed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested repeat Synvisc injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the patient has documented degenerative changes and the initial series of Synvisc resulted in improvement. There is no contraindication for repeat Synvisc injections based on the evidence provided. The patient is likely to benefit from another series of Synvisc injections at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for the prescription medication Provigil for treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that a review of the literature supports the premise that behavioral interventions and/or other stimulant or non-stimulant medications may be more beneficial for this patient than Provigil. Provigil is indicated for the treatment of adults with excessive daytime sleepiness, fatigue related to multiple sclerosis, obstructive sleep apnea and shift/work disorder. It is not indicated for the treatment of ADD in the child or adult population.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for subcutaneous hormone pellet implantation for treatment of her low estrogen level. Findings:  Three physician reviewers found that replantable estrogen pellets remain unproven at this time. There are alternative patches with different adhesives and chemical formations that do not appear to have been tried in this case. Additionally, there are multiple oral agents that can be used. Furthermore, the patients measured estradiol levels post patch and pellet implantation are 150 to 200% of the upper limits of normal. These are not physiological levels and may have serious potential negative consequences, i.e., VTE, CVD, dyslipidemia, etc. There is no substantive data on the efficacy or safety of the pellets compared to standard dermal and oral therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for Lyrica 75 mg and a spinal cord stimulator trial implant for treatment of his reflex sympathetic dystrophy. Findings:  The physician reviewer found that Lyrica is medically appropriate for patients with reflex sympathetic dystrophy that is refractory to standard medications. Thus, the use of Lyrica is medically justified as the next appropriate step to help manage the patients pain. However, there is insufficient evidence at this time supporting the efficacy of a spinal cord stimulator trial implant in this clinical setting. No significant trials have been performed, and there is only anecdotal information regarding the possible efficacy of a spinal cord stimulator implant in this group of patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for nasal surgery (septoplasty and turbinectomy) and uvulopalatopharyngoplasty (UPPP) for treatment of her nasal obstruction and/or obstructive sleep apnea.  Findings:  The physician reviewer found that UPPP is indicated for patients with significant sleep apnea who have failed CPAP. Significant sleep apnea is defined as a respiratory disturbance index over 15 or a lower index with daytime somnolence and an Epworth sleepiness score greater than 10. Although the original consultation report did not document a trial of CPAP or excessive daytime sleepiness, the subsequent letter from the provider stated that the Epworth score was over 10 and that CPAP had been tried and failed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother or a five-year-old male enrollee has requested for partial hospitalization program (PHP) services for treatment of the enrollees attention deficit/hyperactivity (ADHD) and anxiety disorders. Findings:  The physician reviewer found that clearly this is a seriously troubled child in need of intensive psychiatric care. He was unable to function in a pre-school program despite many months of outpatient care and a variety of psychotropic medications. His initial response to the PHP was good. A diagnosis and treatment plan is clearly a part of the clinical record provided for review. The fact that he had improved in no way indicates that the child had integrated the behavioral controls provided to him in the treatment setting. His rapid regression and subsequent need for readmission are not surprising.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for Avastin for treatment of her non-small cell lung cancer. Findings:  Three physician reviewers found that Avastin is one of a new class of drugs that inhibit tumor angiogenesis. It has been approved when used with chemotherapy in several types of cancer. There is one study in non-small cell lung carcinoma demonstrating a two-month improvement in median survival when Avastin is combined with carboplatinum-taxol chemotherapy for metastatic disease. However, at this time there is no data demonstrating any advantage to the use of Avastin when it is combined with any other drugs including Alimta. Nor is there any evidence that continued use of Avastin will be effective at this point.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for the Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that the Oncotype DX tumor assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score. This score quite accurately predicts the risk of recurrence of the cancer within ten years, if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay is valid only in node-negative, estrogen-receptor-positive cancers. It is particularly difficult to make recommendations about adding adjuvant chemotherapy in this group of breast cancer patients, and Oncotype DX testing has become very important. The assay has been rapidly adopted by many oncologists as part of their standard evaluation and Medicare has approved its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for Raptiva for treatment of her psoriasis.  Findings:  The physician reviewer found that it is indisputable that Raptiva is an effective treatment for many patients with psoriasis who are resistant to standard therapies. The safety profile of Raptiva in patients with a negative TB skin test is much more favorable than methotrexate, cyclosporine or Soriatane. The providers letter lists a number of appropriate references to support this conclusion. A case study presented to the American Academy of Dermatology demonstrated Raptiva was particularly effective in treatment-resistant hand and foot psoriasis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for Botox injections for treatment of her chronic headaches. Findings:  Two physician reviewers found that the medical literature does not demonstrate conclusively that Botox is helpful in managing chronic daily headache or episodic type of migraine headache. At this point, there is not sufficient evidence establishing that Botox is expected to provide superior treatment results compared to available standard treatment. There are other preventive medications available for this patients headaches.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for a kyphoplasty for treatment of his vertebral fractures. Findings:  Two physician reviewers found that use of kyphoplasty remains an unproven technique for the management of pathological vertebral compression fractures. Despite promising early results, the overall efficacy of kyphoplasty remains unproven. The proposed procedure remains experimental/investigational procedure in the management of multiple metastatic vertebral compression fractures, and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested  for substance abuse intensive outpatient (IOP) services for treatment of the enrollees drug and alcohol addiction and depression. Findings:  The physician reviewer found that there is no documentation that the patient was receiving services at a minimum of three days per week and at least three hours per day, even when he initially began participating in the IOP program. Furthermore, the submitted records consist primarily of weekly notes concerning individual and family therapy. There is not sufficient evidence in the clinical records provided to establish that the patient was in need of IOP services or actually benefited from participation in the program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer. Findings:  Three physician reviewers found that Avastin is a monoclonal antibody that targets vascular endothelial growth factors and presumably treats cancer by inhibiting tumor vascularity. It has been approved for use in several types of cancer, when given with chemotherapy.In breast cancer there is a randomized trial comparing the efficacy of Taxol with and without Avastin as first line chemotherapy for metastatic breast cancer. Indeed this study demonstrated a better response rate as well as a longer time to cancer progression with the combination. As mentioned, this was a first-line study and did not involve patients such as this patient who have been heavily pretreated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested for surgery for treatment of his Moyamoya disease. Findings:  The physician reviewer found that the physician specializes in neurovascular procedures including the surgical treatment of aneurysms and AVS, as well as extracranial to intracranial bypass surgery and microvascular decompression. No evidence has been provided that the physician recommended by the Health Plan is not qualified to evaluate and treat patients with Moyamoya disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested for a perinatologist/high-risk obstetrician prior to her becoming pregnant. Findings:  The physician reviewer found that this patient has multiple medical problems including insulin dependent diabetes, hypothyroidism and hypercholesterolemia. It is important to have excellent glycemic control prior to conception because the risk of birth defects is increased in a diabetic with poor glycemic control before conception. It is also important to have excellent thyroid control around conception in the first trimester.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested for a Nucleus Freedom Speech Processor for treatment of her bilateral hearing loss. Findings:  The physician reviewer found that the patients current ESPrit 3G processor is functioning well and there has been no change in the patients physical condition requiring a change in processor. Although there is an improvement in the patients performance with the Freedom processor, the changes are relatively small, and do not result in a dramatic difference in the patients functional status.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Actiq for treatment of her buttock and lower extremity pain. Findings:  The physician reviewer found that Actiq is currently approved by the FDA for the management of opioid recalcitrant, cancer related, breakthrough pain. The medication has not been approved for the management of chronic post-operative abdominal pain with adhesions. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a replacement prosthesis with a microprocessor-controlled knee for treatment of his knee amputation. Findings:  Two physician reviewers found that there is insufficient peer-reviewed evidence to medically justify the use of a microprocessor-controlled knee over a standard prosthesis. A standard prosthesis will provided sufficient stability and function to allow the patient to perform his activities of daily living. The transition from a microprocessor-controlled knee to a standard above the knee prosthesis is not likely to result in a loss of functionality.