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

A 23-year-old female enrollee has requested for services from a pediatric cardiologist who specializes in caring for patients with adult congenital heart disease/polysplenia and who is also an electrophysiologist for treatment of her congenital heart disease. Findings:  The physician reviewer found that Centers of excellence are comprised of pediatric cardiologists, pediatric cardiology surgeons, adult cardiologists with specific training and experience in congenital heart disease, electrophysiologists with specific training and experience in adult congenital heart disease, and associated nursing, counseling, and social service professionals who are all integrated to optimally provide comprehensive care for this population of patients with unique needs.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for an allogeneic hematopoietic stem cell transplant for treatment of his systemic sclerosis (scleroderma).  Findings:  Three physician reviewers found that While the relevant literature suggests a risk of mortality of 15-20% within 1-2 years of transplant, the prognosis for this disease is generally quite poor. Further, there are reports that stem cell transplant has resulted in resolution of disease in several patients. There is considerable optimism within the rheumatology/immunology community based on anecdotal reports of patients who have experienced considerable improvement with this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for the Pillar procedure for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that there is no documentation of length of CPAP trial or why the patient was intolerant of the device. The Pillar implant has been approved by the FDA for marketing as a device to improve mild to moderate obstructive sleep apnea. Steward and colleagues noted that palatal implants for mild to moderate sleep apnea demonstrate efficacy over placebo for some outcome measures, but overall effectiveness remains limited. In a one-year follow-up study of 26 patients, Nordgard and colleagues showed reduction of apnea/hypopnea index in 80 percent of patients. The available data is not sufficient to establish that the Pillar procedure results in a superior clinical outcome despite some endorsement by national academies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested and coverage for Taclonex for treatment of his psoriasis. Findings:  The physician reviewer found that this patient has responded well to Taclonex in the past. Months later, he experienced recurrent symptoms necessitating Kenalog IM. He was subsequently prescribed a very potent steroid (clobetasol) with Dovonex cream. He experienced some improvement. Taclonex is medically appropriate and indicated in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old female enrollee has requested for Xifaxan for treatment of her small intestinal bacterial overgrowth. Findings:  The physician reviewer found that results of clinical trials demonstrate that the reduction or elimination of SIBO with antibiotics can alleviate IBS symptoms. The systemic antibiotic neomycin has been evaluated in two clinical studies by Pimentel and colleagues. The non-absorbed oral antibiotic rifaximin is the most thoroughly studied antibiotic for the treatment of IBS. The efficacy of rifaximin in the treatment of IBS was evaluated in a randomized, double-blind, placebo-controlled, parallel-group study of 87 patients who met Rome I criteria for IBS, and it was found to be beneficial in terms of substantial improvement of global symptoms. Long-term therapeutic benefits of rifaximin were also observed in two studies that assessed the effects of rifaximin on other functional gastrointestinal symptoms. However, long-term prospective studies are needed comparing various antibiotics including quinolones, metronidazole, neomycin, tetracycline and rifaximin in the patients with SIBO before any conclusions can be drawn about the superiority of rifaximin over other antibiotics.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for use of a continuous passive motion (CPM) device for treatment of her left knee status post total knee arthroplasty.  Findings:  The physician reviewer found that a review of peer-reviewed Level 1 and Level 2 studies in current medical literature does not support the use of continuous passive motion (CPM) device in the home following total knee arthroplasty. There is no significant increase in range of motion in the long-term from the use of a CPM machine following total knee replacement surgery. The references cited above are consistent with this determination. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested  for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6 percent of children have speech and language difficulties. The authors of this meta-analysis noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested for a myoelectric prosthetic device for treatment of his post traumatic non-dominant right shoulder disarticulation amputation. Findings:  The physician reviewer found that it would be difficult for the patient to use a body-powered prosthetic device in large part due to a limited ability to actively retract and protract his shoulder.  The patients shoulder and scapular pathology make it difficult to actively retract and protract his shoulder. These movements are essential in proper use of a body-controlled prosthesis.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for emergency services for treatment of her sudden onset of dizziness and nausea. Findings:  The physician reviewer found that a prudent layperson with an average knowledge of medicine who was experiencing dizziness and nausea would not expect the absence of immediate emergency care to jeopardize her health. The patients condition could have been safely evaluated and treated in an urgent care or private office setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for use of a continuous passive motion (CPM) device for treatment of her post left total knee arthroplasty. Findings:  The physician reviewer found that there is a subgroup of patients who need help achieving motion after total knee replacement. If the patient required use of the CPM device for the right side, it is clinically reasonable that she would need it for the left side to prevent arthrofibrosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that multilingualism may affect the way in which a child learns each language in that the early expression of a language is very likely to vary somewhat from that seen in children in a monolingual environment. This difference in language is not a deficit. Syntactic systems may remain undifferentiated for a time. A variety of speech and language standardized tests are available for Spanish speakers. It is important to remember that children who are bilingual cannot have a communication disorder in one language alone, their deficit would be present in both languages.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for Byetta 5 mg  for treatment of his type II diabetes.  Findings:  The physician reviewer found that his diabetes mellitus type II was inadequately controlled with Metformin alone (A1C of 6.9%, with goal of less than 6.5% per American Association of Clinical Endocrinologists (ACCE) guidelines). Additionally, all other medications would cause further weight gain which would be counterproductive for an obese man.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for a continuous glucose monitoring system and related supplies for treatment of her diabetes.  Findings:  The physician reviewer found that the equipment at issue was and is medically necessary for treatment of the patients medical condition because the patient is using this for pre-conceptive planning to maximize her control and minimize the risk of the fetus developing congenital/structural anomalies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for a chest CT angiography for evaluation of her coronary artery disease. Findings:  Three physician reviewers found that chest CT angiography would be unlikely to reveal a normal coronary anatomy free of disease. The standard medical treatment of this patient would be to either maximize her medical treatment for angina or coronary artery disease or proceed with cardiac catheterization towards a revascularization strategy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for bariatric surgery revision for treatment of her medical condition status post bariatric surgery.  Findings:  The physician reviewer found that in the literature, revisional surgery is associated with two to four-times the incidence of anastomotic leak, two-times the incidence of wound infection and other major morbidity. Revisional surgery has also been associated with increased mortality, this is because the operations are often complicated by the presence of adhesions (particularly to the liver), patients may still be morbidly obese, and tissue perfusion may not be optimal. Each of these factors can inevitably affect anastomotic healing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Xifaxan 200mg (20 count) for treatment of her diverticulitis and diarrhea. Findings:  The physician reviewer found that the only condition Xifaxan would improve would be bacterial overgrowth, which has not been documented in this case. Xifaxan has not been shown to prevent attacks of diverticulitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for Ambien CR 12.5.mg (60 tablets per month) for treatment of her insomnia.  Findings:  The physician reviewer found that insomnia may persist despite treatment of underlying factors that were thought to bring on the insomnia; that is, insomnia may require treatment despite successful alleviation of underlying or causative factors. Patients can be divided into two groups: those needing help falling asleep, and those needing help maintaining sleep. While a behavior approach which directs attention to sleep hygiene has a number of advantages, many patients require medication for successful outcomes. Underlying medical conditions need attention when medications are prescribed; examples include: pregnancy, chronic kidney and liver disease (which may affect drug clearance). Patients with a history of drug misuse and abuse also present challenges as many sedatives are habit forming. Patients already taking psychotropic medications also present extra treatment challenges due to drug to drug interactions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested for artificial cervical disc replacement for treatment of his ruptured disc.   Findings:  Two physician reviewers found that There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. TDR has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up.No truly blinded studies have been done to establish efficacy; the results available are short-term at best. Until this is a proven therapy, it cannot be considered to be equivalent or better than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested for physical therapy for treatment of the enrollees developmental coordination disorder. Findings:  The physician reviewer found that the physical therapy evaluation does not contain the level of detail required to establish the need for additional therapy. The evidence provided does not demonstrate the extent of the patients functional deficits or that he is likely to benefit from additional physical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for occupational therapy (sensory integration therapy) for treatment of the enrollees developmental coordination disorder. Findings:  Two physician reviewers found that the requested therapy has the potential to ameliorate pre-existing damage to the developing brain.  While most underlying etiologies that give rise to developmental delay are due to a static insult to the central nervous system, they must be viewed as superimposed on the continuum of the developing nervous system, which still has considerable plasticity to respond to insults.  Thus, the notion that occupational therapy has no indication for a chronic condition such as developmental delay is incorrect, since therapy, like other sensorimotor training, can condition and change the developing nervous system, taking advantage of brain plasticity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Subutex for the treatment of her major depressive disorder. Findings:  The physician reviewer found that the patient has been prescribed a great variety of medications for her treatment. It is not entirely clear if each of these has been used at its fullest dose for an adequate duration of time. She indicates Subutex (buprenorphine) is the only drug that has been effective. Subutex is used to manage patients with opiate dependence. It is not an entirely safe and appropriate treatment, or adjunctive treatment, for depression. I therefore concur with the Health Plan. I believe the conditions the Health Plan sets forth for the use of this drug are entirely appropriate. Based upon the evidence provided, Subutex is not medically indicated in this particular case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested physical therapy and physiotherapy for the treatment of his pelvic pain syndrome and prostatitis.  Findings:  The physician reviewer found that while the relevant medical literature does demonstrate some response to the therapies at issue, a placebo effect likely plays a role. Therefore, further studies are needed before the efficacy of these modalities can be sufficiently established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested immunosupport therapy for the treatment of his metastatic testicular cancer. Findings:  The physician reviewer found that the immunosupport therapy program offered consists of a combination of high-dose intravenous nutritional supplementation, the use of hyperbaric oxygen chamber, far-infrared sauna, acupuncture, and various oral supplements coupled with lifestyle modification. There is no scientific evidence that any of the treatment modalities included in this immunosupport program are of significant benefit in the treatment of cancer, or in boosting the immune system. No peer-reviewed studies have been published demonstrating that these interventions are efficacious in this setting. In the absence of such data, the clinical value of the disputed services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a breast MRI for an evaluation of her breast discharge. Findings:  The physician reviewer found that a breast MRI can be a useful adjunct to standard breast imaging studies in select patient populations. Breast MRI is used as a screening tool in patients with known BRCA mutation and used as a diagnostic tool in patients with a recent diagnosis of breast cancer. This patient does not have known BRCA mutation and does not have a recent diagnosis of breast cancer. The standard of care in the evaluation of bloody nipple discharge includes diagnostic mammogram, ductography and, at times, breast ultrasound. There is no documentation of a ductogram or attempted ductography, which is the procedure of choice for bloody nipple discharge. Azavedo notes that magnetic resonance galactography remains under investigation and is not the method of choice in evaluating this condition. At this time, the use of breast MRI in the evaluation of bloody nipple discharge has not yet proven to be clinically effective. Therefore, breast MRI was not medically indicated for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a Positron Emission Tomography (PET) scan for an evaluation of her ovarian cancer. Findings:  Two physician reviewers found that although PET scan has been proven useful for the detection of tumor recurrence, in this case, the CT scan showed findings indicative of the diagnosis so that PET scanning was not necessary to document metastatic liver disease. Thus, although the customary practice of an oncologic work-up for tumor staging typically includes PET scans, the ordinary follow-up CT in this case provided enough information to make the diagnosis of metastatic disease within the liver without the benefit of information derived from the PET scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested a cold therapy unit for the treatment of her torn rotator cuff. Findings:  The physician reviewer found that the medical literature does not demonstrate significant differences in temperature of joints, overall pain control, or in the overall temperatures provided by the use of a cryotherapy cuff versus simple ice and elastic wrap. There is also no difference demonstrated in the literature in regards to functional abilities of patients after the use of those different cold therapy treatments. Active cooling devices are not shown to provide significant differences in temperature provided versus ice packs. A cold therapy unit is thus best viewed as a convenience item and not a medical necessity in this case. The medical record does not document a trial and failure or contraindication to standard ice packs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that although there is increasing interest in sleeve gastrectomy it is not yet considered a standard primary treatment for morbid obesity or complications of clinically severe obesity. Vertical sleeve gastrectomy (VSG) is currently being studied in long-term follow up position papers, but at this time it has not been established as superior to other weight loss procedures. A prior nephrectomy would not preclude a patient from alternative laparoscopic bariatric procedures given that the right nephrectomy is usually performed through a retroperitoneal dissection.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech disorder. Findings:  The physician reviewer found that this patient is a young preschool-aged child with neuro-oral-muscular dis-coordination resulting in a severe stuttering disorder. Some theorists consider stuttering to be the result of subtle neuron-physical dysfunctions resulting in disruption of the precision needed to produce speech. Stuttering, or speech dysfluency may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder. For this latter group, if therapy is started early, the prognosis is favorable. It is important for clinicians to know when to refer for therapy. In general, referral is indicated if the child is over four-years-old, has been stuttering for more than three months, shows consistent stuttering and demonstrates tension or struggle behavior when stuttering (Lawrence and Barclay). Therapy is considered to be more effective if started before the age of five years (Ward). In the case of this patient, given the underlying neuro-oral-muscular dis-coordination and severity of his symptoms, his chances of spontaneous recovery are small. Aggressive speech therapy offers him the best chance of full recovery. Speech therapy was therefore appropriate and medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a functional electrical stimulator (WalkAide) for the treatment of her multiple sclerosis. Findings:  Two physician reviewers found that a multicenter trial of a neuromuscular electrical stimulation foot drop brace has demonstrated increased speed and good patient satisfaction, possibly as a result of decreased use of energy for ambulation thereby resulting in decreased fatigue, which is very common with MS.  Thus, the literature demonstrates that the proposed device is likely to be more efficacious for this patient and should be approved.