Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for an F-DOPA PET scan of the brain for evaluation of his parkinsonism. Findings:  Three physician reviewers found that the routine use of the PET scan with respect to neurological conditions is limited to localization of seizure foci in patients prior to surgical intervention. The use of PET scan (including F-DOPA) for other neurological conditions is generally still in the context of clinical trials or other investigational studies. A review of the peer reviewed literature affirms that the diagnosis of Parkinsons disease is currently based on clinical assessment; imaging studies are not routinely utilized to confirm the diagnosis
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for Amevive for treatment of her psoriasis. Findings:  Two physician reviewers found that phototherapy and systemic therapies are effective ways to treat psoriasis. A trial of the older systemic therapies and/or phototherapy is medically reasonable prior to the initiation of treatment with Amevive. Should the more established therapies prove ineffective, then the issue of coverage for Amevive should be re-addressed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for a radiofrequency ablation (RFA) hysterectomy alternative (HALT) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that an increasing number of women have demanded a uterine-sparing treatment to manage symptomatic fibroids. There are several small studies and pilot studies that suggest RFA is a technically feasible treatment for the relief of symptomatic fibroids.  However, there are no large multi-center, double-blinded trials in peer reviewed scientific literature regarding this therapy.  In addition, there is no long-term data about its safety and efficacy.  Furthermore, there are other available standard treatments such as uterine artery embolization with proven efficacy and safety.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has for occupational therapy, speech therapy and ABA therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that as the patient clearly meets the criteria of autism, a plan of therapy has to be based on the best medical practice and interventions.  Due to the nature of this neurological illness, with an unknown etiology, virtually all studies are relatively small and lack a gold standard of treatment.  Specialists recommend immediate, intensive intervention at the age of recognition. Per a recent review article in Pediatrics, occupational therapy (10 hours per week), speech therapy (twice per week) and ABA therapy (20 hours per week) are within the recommendations of this in-depth review.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested emergency services for the treatment of her urinary tract symptoms. Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention to result in placing the members health in serious jeopardy. This patients symptoms had commenced gradually over three days. She reported pain with urination, but did not require pain control in the emergency department nor prescription pain medication. Since her symptoms were not acute in onset and her pain was not severe, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male enrollee have requested for speech therapy for treatment of his articulation disorder. Findings:  The physician reviewer found that this patient did suffer an injury the results of which could require speech therapy, this patients condition is not at such a level that individual speech therapy is medically necessary. The speech therapy assessments do not demonstrate a significant speech disorder requiring individual speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a positron emission tomography (PET) scan with computed tomography (CT) attenuation for an evaluation of her swollen lymph nodes. Findings:  Three physician reviewers found that in this case, a PET/CT is not clinically indicated at this time.  From an imaging standpoint, it would be best to first establish a diagnosis.  Chills and fevers might raise the possibility of an infectious/inflammatory etiology, or lymphoma, rather than recurrent myoblastoma, especially after so many years.  Along with appropriate medical work-up, CT of the neck, chest, pelvis, and abdomen would be logical and may point to another area that could be biopsied.  Once a diagnosis is established, then PET/CT could be considered for staging, if indicated.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested for emergency services for treatment of his fever. Findings:  The physician reviewer found that it is very concerning when a toddler with a history of URI symptoms develops new-onset fever/vomiting/diarrhea. This constellation of symptoms could represent a new illness (urinary tract infection, gastroenteritis) or a complication of the original illness (otitis media, pneumonia). A parent cannot be expected to differentiate between these two possibilities. In addition, tachycardia without fever, combined with decreased urine output, are concerning for significant dehydration. Parents are generally instructed by their pediatricians to bring a child to immediate medical attention when they are not drinking and they are not urinating normally. In summary, it was appropriate for the parent, a prudent layperson, to seek immediate medical attention for this small child at the closest ER.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested skilled nursing facility (SNF) services for the treatment of her compression fracture. Findings:  The physician reviewer found that the level of function achieved with PT and OT indicates the enrollee no longer required inpatient rehabilitation. Her rehabilitation needs could be addressed at a lower level of care. She had no daily skilled nursing needs.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for emergency services for treatment of her upper respiratory symptoms.  Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the members health in serious jeopardy. Medical records in this case document that the patients symptoms had gradually commenced over five days. Her physical exam was significant only for nasal edema. She was not having any pain and was not in any respiratory distress. Since this patients symptoms were not acute in onset, and she was not experiencing any chest pains or severe symptoms, they do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested for individual cognitive behavioral therapy (CBT) for treatment of his obsessive-compulsive disorder (OCD). Findings:  The physician reviewer found that the records submitted for review do not demonstrate that individual CBT at the recommended intensity was or is available.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested for residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that the patient did indeed respond positively to residential care and achieved her goal weight.While her medications continued to require adjustment, this did not require 24-hour supervised care. The patient did not have more than a single behavior that impaired recovery by this time and her progress was such that she could have safely and effectively transitioned to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested the prescription medication Rozerem for the treatment of her insomnia. Findings:  The physician reviewer found that Rozerem has a unique mechanism of action, different than that of the numerous other agents tried in this patients case. Retrying any of the other agents is not medically indicated, even if they have not been tried in the previous 180 days. Because the patient has failed therapy with other hypnotics, the patient has reported benefit with the use of Rozerem and there is no evidence to suggest a need to attempt trials of additional hypnotics.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested for emergency services for treatment of his headache. Findings:  The physician reviewer found that The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and the gradual onset of headache symptoms over four days, would not reasonably expect the absence of emergency care to jeopardize their health. Although the patient was experiencing pain, his pain was not acute in onset.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee has requested for a pneumatic compression cooling therapy unit for treatment of the enrollees postoperative shoulder condition. Findings:  Three physician reviewers found that there is no indication in the medical records that the pneumatic compression cold therapy unit was required for postoperative healing of this patients right shoulder.  Additionally, data confirming the efficacy of pneumatic compression cold therapy over traditional treatment is lacking.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested  for acute inpatient psychiatric for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the degree of improvement was not sufficient for discharge. The patient had not maintained this improvement for a reasonable period of time nor had he internalized his behavioral gains. He continued to need inpatient hospital staff supervision around the clock.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for emergency services for treatment of the enrollees gastrointestinal symptoms. Findings:  The physician reviewer found that The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with symptoms of nausea/vomiting/cramping would reasonably expect the absence of emergency care to jeopardize the patients health. Although the family was apparently very concerned about toxic mold exposure, these symptoms can represent other more common and serious illnesses in children, such as gastrointestinal bleeding, infection, inflammatory bowel disease, kidney stones, urinary tract infection, appendicitis, or bowel obstruction. In addition, poor oral intake accompanied by vomiting can easily result in dehydration and progression of dehydration can have serious consequences.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for partial hospitalization program (PHP) for treatment of her bulimia, depression and alcohol abuse. Findings:  The physician reviewer found that although the patient unquestionably suffers from Bulimia Nervosa and obsesses about her body image, her binging and purging as well as obsessing had diminished.  Given her compliance, improvement and regular attendance to treatment throughout, both in terms of the various therapies as well as the medication she was prescribed, it is not clear why transition to Outpatient Treatment couldnt have been considered by this point.  Based upon review of all the information submitted there is no evidence to document the necessity of Partial Hospitalization.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for growth hormone therapy for treatment of his short stature. Findings:  The physician reviewer found that Arimidex and growth hormone therapy was initiated in April 2007, and the initial three months growth response rose from a subnormal 2.4 cm per year to 12 cm per year. This supported a putative diagnosis of partial growth hormone deficiency or lack of physiological growth hormone secretion. No MRI of the brain appears to have been done, despite a history of chronic headaches.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested for emergency services for treatment of her eye pain.  Findings:  The physician reviewer found that the patients pain as a 10 on a scale of 1 to 10. Although his symptoms had been present for 4 days, they had progressed over the past day. His vision was slightly decreased and blurry. Infectious complications of contract lens use range from bacterial conjunctivitis to keratoconjunctivitis to corneal ulcer. Pseudomonas accounts for 75% of corneal ulcers related to contact lens use and causes permanent visual loss. Although this patient was diagnosed with conjunctivitis, his symptoms were worrisome for a corneal ulcer. Any delay in differentiating among these contact lens related infections and antibiotic treatment could cause permanent visual impairment. Based upon this information it is reasonable that a prudent layperson would believe lack of immediate medical attention could result in serious impairment or dysfunction of his bodily functions if he experienced severe eye pain associated with diminished visual acuity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested Zomig for the treatment of her migraine headache. Findings:  The physician reviewer found that this patient has chronic migraine (e.g., greater than 15 migraine days/month). The use of 24 Zomig a month is not medically necessary and is likely to worsen her condition. A prescription of 15 Zomig 5 mg/month is medically indicated and reasonable based upon the information provided. Furthermore, there are a variety of medications, especially in combination that are potentially of benefit for a patient in this situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for a bath chair, an automotive positioning device and a portable ramp for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the patient is unable to be properly supported in a typical car seat.  A bath chair is medically necessary to ensure safety when bathing. This is not a convenience item, as this would not be needed for a child with no medical problems.  A portable ramp is medically necessary since the child does need to be able to enter his home to maintain health and hygiene.  A four-year-old would not normally require a ramp to enter the home, nor would parents typically have to carry a 4-year-old up steps.  An automotive positioning device is medically necessary for safe car transport since the off-the-shelf car seat will not properly position the child.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The spouse of a 54-year-old male enrollee has requested for positron emission tomography (PET) scan of the brain for evaluation of the enrollees cognitive problems. Findings:  Two physician reviewers found that a PET scan would not change medical management for this patient. In addition, imaging and exam findings were not clearly suggestive of frontotemporal dementia for this patient. There is a lack of evidence supporting the need or usefulness of a PET scan for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested for inpatient psychiatric services for treatment of his depressive disorder and anxiety disorder. Findings:  The physician reviewer found that all physicians who have worked with the patient have attempted to help with a wide assortment of medications, but with paltry success.  This ought to have led to a diagnostic question some time ago as to whether the patients struggles are truly ameliorative with any course of medication, much less something more intensive, such as inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-month-old female patient has requested a cranial remolding or banding helmet for the treatment of the enrollees head shape. Findings:  The physician reviewer found that plagiocephaly can lead to abnormalities of the orbit, temporal bone, and jaw.  Cranial remodeling/banding helmet therapy is not effective at later ages and is only appropriate when there is no synostosis.  It is a reconstructive process that is part of the appropriate management of plagiocephaly and it is not cosmetic.  The information submitted demonstrates that the patient is an appropriate candidate for cranial remodeling/banding therapy and that such therapy will prevent the occurrence of potential abnormalities related to the patients plagiocephaly.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for bilateral custom knee braces supplied for treatment of his knee condition. Findings:  The physician reviewer found that the bilateral custom knee braces were obtained to be used prophylactically during motorcycle riding and other physical activities. They were not medically necessary for treatment of the acute right knee sprain. There is no medical evidence demonstrating there was a medical need for the knee braces.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for the prescription medication Tazorac for treatment of her skin condition. Findings:  The physician reviewer found that Tazorac is not considered standard treatment for vitiligo.  There is no evidence in the medical records submitted establishing why this off-label intervention is being utilized over standard treatments.  In addition, there is no evidence demonstrating that the patient has attempted and failed available standard treatments or that standard treatments are contraindicated. As such, the medical records do not support use of this medication for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for radiofrequency ablation (RFA) for treatment of her renal mass. Findings:  Two physician reviewers found that radiofrequency ablation involves the local application of radiofrequency thermal energy to a tumor.  A high frequency alternating current moves from the tip of an electrode into the surrounding tissue, resulting in heating and tissue necrosis around the electrode.  Increasing data support the safety and efficacy of radiofrequency ablation for small renal tumors.  Although results are encouraging, studies on this treatment are deficient and provide only short follow-up. There are no randomized controlled comparisons to surgical resection and no comparison of complication rates. Due to these factors, the advantage of radiofrequency ablation over existing treatments for renal cell carcinoma is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins. Findings:  The physician reviewer found that there is no evidence of a duplex scan or a recent trial of conservative treatment attempts.  Sclerotherapy cannot be recommended without evidence of failed conservative treatments and a duplex scan demonstrating the medical need for treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for Lexapro for treatment of her generalized anxiety disorder. Findings:  The physician reviewer found that Lexapro treatment and has responded positively.A review of the package insert for Paxil (paroxetine) does not indicate that weight gain is a frequent problem. Accordingly, there is no clinical reason to recommend an exception.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested for Botox injections for treatment of his hyperhidrosis. Findings:  The physician reviewer found that Botox is the newest therapy that does provide significant improvement of symptoms in many patients.  The above list of references supports the effectiveness of Botox in management of palmar hyperhidrosis.  Palmar hyperhidrosis can be debilitating as it interferes with a persons ability to use their hands for routine activities as well as for job-related activities.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested for emergency services for treatment of her thumb abscess.  Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms commenced gradually over at least three days. She was not experiencing severe pain, nor did she require any medication in the emergency department. She had already been evaluated for her thumb lesion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a colonoscopy for an evaluation of her colorectal condition. Findings:  The physician reviewer found that according to the American Gastroenterological Association Guidelines related to colorectal cancer screening and surveillance, patients with a first-degree relative (parent, sibling, or child) with colon cancer or adenomatous polyps diagnosed prior to 60 years, or two first-degree relatives diagnosed with colorectal cancer at any age, should be advised to have screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosed person in the family, whichever comes first, with repeat exams every five years.  Patients with a first-degree relative with colon cancer or adenomatous polyps diagnosed prior to or at age 60 years or two second-degree relatives with colorectal cancer should be advised to be screened as average-risk persons, but beginning at age 40 years.