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

A 31-year-old male enrollee has requested Lidocaine injections for the treatment of his temporomandibular joint dysfunction/jaw pain. Findings:  The physician reviewer found that there are many physical medicine methods that are recommended for the treatment of myofascial pain. Conservative therapy is generally the first-line treatment and includes use of splints and physical therapy. First-line therapies were not effective for this patient. In select patients, lidocaine injections may be beneficial. The submitted records document that lidocaine was in fact helpful to this patient. Coverage for lidocaine injections is appropriate and necessary for this patients temporomandibular joint pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested an increase in Humira for the treatment of his rheumatoid arthritis. Findings:  The physician reviewer found that this patient continues to have active and inadequately controlled rheumatoid arthritis as described by his rheumatologist, and he has already failed Enbrel in standard as well as increased dosage. He had an initially good response to biweekly Humira, but then lost benefit. This is a fairly common circumstance in rheumatologic practice, for although the original trials and approval for the use of Humira in rheumatoid arthritis involved biweekly dosing, it is clear that a substantial number of patients require 40mg weekly dosing for adequate benefit. A number of studies have shown that the concomitant use of methotrexate with Humira or other TNF inhibitors leads to better responses than does the use of either agent alone.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested Lexapro for the treatment of the enrollees depression. Findings:  The physician reviewer found that a practicing physician is licensed to prescribe these drugs to children. The Health Plans mandate for a trial of paroxetine or venlafaxine is not medically reasonable. Both of these formulary medications have been particularly problematic for use in children and adolescents. Paroxetine has been found to have limited to no effectiveness in this age group, and it has been associated with suicidality. Additionally, the incidence of suicidality found in research studies of venlafaxine was particularly high when compared with other antidepressants. Suicidality (thoughts and actions related to suicide) is a particular concern when treating depressed teens. Recommending paroxetine or venlafaxine to patients under age eighteen may be inappropriate. The patient is responding to Lexapro, and this medication is medically indicated for her treatment. It is in this patients best clinical interests to remain on Lexapro.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested physical therapy sessions for the treatment of the enrollees fibromyalgia (back pain). Findings:  The physician reviewer found that This patient was prescribed additional PT sessions for her additional complaint of back pain, but by the end of 15 sessions when no significant progress was noted and there was enough time to establish a home exercise program, her skilled PT could have been safely discontinued. The PT delivered on the dates in question were maintenance in nature and should not be covered as it was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Flector 1.3% patches for the treatment of her chronic back pain. Findings:  The physician reviewer found that there was no documentation provided necessitating use of the Flector Patch for the treatment of the patients chronic back pain. The medication is specifically indicated for acute pain due to minor strains, sprains, and contusions. There is no indication in the literature for its use in the treatment of chronic pain. The patient has lumbosacral spondylosis without myelopathy and bursitis. There are other treatment options (tricyclic antidepressants, anticonvulsants, muscle relaxants, and low dose narcotics) available for the treatment of chronic back pain. The patient might benefit from a formal pain management evaluation to determine the best course of treatment for her chronic back pain condition. Furthermore, the patient does not have an intrinsic swallowing defect for which she cannot take oral medication. Thus, the submitted evidence does not establish that Flector 1.3% is medically necessary for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested emergency services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient presented with right lower quadrant pain and symptoms of sufficient severity that a prudent layperson would reasonably seek immediate medical attention for fear of jeopardy to her life and/or bodily organ functions. The differential diagnosis of her presenting symptoms included appendicitis, abdominal abscess, cellulitis, abdominal herniation and other serious disorders.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested Prevacid for the treatment of her GERD. Findings:  The physician reviewer found that pharmocologic therapy for GERD continues to focus on optimizing acid suppression. Proton Pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continues to be the standard of therapy. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen. In this case, the patient should be given a trial of Protonix (single and double dose for eight weeks each), Aciphex (single and double dose for eight weeks), and Omeprazole (single and double dose for eight weeks) on the formulary. If she fails to respond to these trials, only then should she be approved for Prevacid.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested Remicade injections for the treatment of his Sarcoidosis. Findings:  The physician reviewer found that there are no FDA-approved treatments for Sarcoidosis despite a long history of using immunosuppressive treatment. Remicade has recently been demonstrated to be effective in the treatment of severe Sarcoidosis that has failed traditional non-FDA approved treatments. Since there are no FDA-approved treatments and the patient continues to have severe Sarcoidosis threatening his organ function, Remicade is medically necessary and must be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 1-year-old female enrollee have requested a Dynamic Orthotic Cranioplasty for the treatment of the enrollees condition. Findings:  The physician reviewer found that the deformity (as per neurosurgeon) had become fused, hence the patient needed therapeutic intervention to prevent deformity of her face and skull throughout her life. Using a non-surgical intervention was ideal (i.e., DOC band) with less risk to the patients life. The Health Plan has suggested head positioning and exercises. These would not work in a patient who does not lie still constantly. That would have been more appropriate for a child with developmental delays. Moreover, the patient had torticollis which definitely makes it more difficult for her to lie on the opposite side. The successful completion of DOC band confirms the appropriate method of therapy was used in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested Keppra for the treatment of his condition. Findings:  The physician reviewer found that the patient has well-controlled epilepsy. A change in medication is not medically indicated given the excellent control for four years on Lamictal. Depakote or Zonegran are reasonable alternatives to Keppra. The requested medication is not medically warranted for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that despite the therapy addressing the patients fine motor deficits, the findings emphasize the realm of sensory integration and its dysfunction. The therapists interventions focused on sensory integration therapies rather than several other mainstream therapies for ASD. Sensory Integration Disorder (SID) originated in the OT literature and is specific for that discipline. However, there is limited data to support the efficacy of sensory therapy for the treatment of ASD. There is no empirical data to support sensory integration treatment and it should not be viewed as a primary intervention strategy in children with ASD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested behavior modification therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the medical literature confirms the success of ABA, both after several years of therapy and after long-term follow-up. In this instance, therapy is being supervised by qualified and licensed psychologists and social workers. The utilization of trainees in the medical arts has a long tradition of encouraging and depending on unlicensed personnel. Medical students and interns are supervised, but practice unlicensed medicine. Post-graduate psychologists and family therapists all need to spend three years of supervised clinical practice to be able to sit for the licensing examination. Thus, supervised therapy by a licensed therapist is licensed therapy by proxy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested Extracorporeal Shock Wave Therapy (ESWT) for the treatment of his left foot chronic plantar fasciitis and calcaneal spur. Findings:  Two physician reviewers found that the literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established and there is a lack of information regarding the durability of the treatment effect or any long-term adverse effects of ESWT. In addition, there have been some conflicting results among the randomized controlled studies.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from a severe headache associated with nausea, vomiting, visual changes, slurred speech and other symptoms for which a prudent layperson would reasonably seek immediate medical attention due to fear for jeopardy to her health and bodily function.  The differential diagnosis of the patients presenting symptoms includes migraine headache (and variants), cerebral-vascular accident, intra-cerebral bleeding and other potentially serious disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for a minimally invasive laser procedure for treatment of her low back pain with right lower extremity pain.   Findings:  Three physician reviewers found that laser surgery remains experimental for the treatment of low back pain. There is not sufficient evidence in the scientific literature to show that the procedure is effective in the long-term.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for total disc arthroplasty with a Prestige Cervical Disc for treatment of his herniated cervical disc.   Findings:  Two physician reviewers found that cervical artificial disc replacement remains experimental for the treatment of cervical spondylosis and cervical disc herniation. More outcomes data is needed in the mid and long-term to establish the safety and efficacy of this device. Complications in the mid and long-term are not clear at this time. Artificial disc surgery is not appropriate and not likely to be more effective than cervical fusion in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested for an osteochondral autograft transplantation (right arthroscopy and meniscectomy) for treatment of his right medial femoral condyle lesion.   Findings:  Three physician reviewers found that the procedure performed is not experimental or investigational. It is used in cases such as this for coverage of an area of cartilaginous defect. This patient, as outlined by the treating surgeon, was an appropriate candidate for the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for Applied Behavorial Analysis (ABA) therapy for treatment of the enrollees autism.   Findings:  Three physician reviewers found that ABA is an extensive one on one behavioral altering program that requires a skilled therapist working with the child 20-40 hour per week. Significant controlled studies have documented ABAs long-term effects on improving language, learning skills and socialization in autistic children. ABA is considered the gold standard of treatment of autistic children. No other therapy is likely to be more efficacious for this patient than ABA therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for radiofrequency tissue shrinkage of the soft palate, base of tongue and floor of the mouth for treatment of his symptomatic obstructive sleep apnea.   Findings:  Two physician reviewers found that the relevant medical literature currently does not include any evidence-based outcome studies demonstrating that radiofrequency of the tongue base, soft palate and floor of the mouth is better than medical devices and nasal CPAP. Furthermore, based on the limited descriptions in the medical documentation, the need for surgical intervention with radiofrequency ablation has not been established in this case. An adequate trial of alternative devices is likely to be more successful for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from significant pain and that she was concerned that she might have a contagious infectious disease such as strep throat.  Due to her discomfort and fear of jeopardy to her health and the health of her infant, it is reasonable that a prudent layperson would seek immediate medical attention in that situation.  The differential diagnosis of the patients presenting symptoms include strep throat, pneumonia, bronchitis, sinusitis, otitis media, and other potentially serious infections which could have required specific therapy such as antibiotics and respiratory medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a thirteen-year-old female enrollee has requested residential treatment services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient clearly needed a variety of therapies, but her particular need for residential care was not justified or specified. The services she needed could have been provided at a lesser level of care such as partial hospitalization program or intensive outpatient program. There was limited psychiatrist contact, and many of her therapies are of questionable utility (neurofeedback, biofeedback, EMDR and nutritional supplementation). I am also seriously concerned with the concept of keeping a child in residential care for more than two years, especially when the care was not in very close proximity to her home. The value of telephone therapy in situations like this is limited. Residential services were not medically indicated for the entire period in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested Protopic 0.1% for the treatment of the enrollees condition. Findings:  The physician reviewer found that the submitted evidence does not establish that Protopic 0.1% is medically necessary. Based on the evidence provided, it is unclear whether Protopic ointment 0.03% has been used on the patient and if so, for how long. If Protopic ointment 0.03% has been used for three months or more with little to no improvement, then Protopic ointment 0.1% would be medically necessary. If Protopic ointment 0.03% has not been used, or used for less than three months, then the patient should undergo a three-month trial of Protopic ointment 0.03%. If the patients treating provider documents little to no improvement, the treatment should be switched to 0.1%.  However, because there is no evidence in the medical record that there has been a trial and failure of Protopic ointment 0.03% for at least three months, there is no medical necessity for a trial of Protopic ointment 0.1% at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested Forteo 750mcg injectable for the treatment of her osteoporosis. Findings:  The physician reviewer found that the patients provider feels that osteoporosis would impair healing of the proposed fusion surgery and that Forteo would improve it. However, there is no information as to how long the patient would have to take Forteo before it would be appropriate to proceed with the fusion (i.e., three months, one year, or two years?). There are other methods that would suggest response to treatment within three months such as measurement of urinary N-telopeptide. All told, the submitted evidence does not support the use of Forteo in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 13-year-old female enrollee have requested speech therapy for the treatment of the enrollees tongue thrust. Findings:  The physician reviewer found that although there is some literature supporting the use of myofunctional/speech therapy to correct dentition, there is little to no evidence-based literature. In addition, it does not appear that this patient has any speech disorder. Therefore, it does seem that this problem is in fact behavioral in nature. In the absence of any studies showing the medical necessity of speech therapy for this clinical situation, the requested therapy cannot be supported.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested a Meniett device for the treatment of his bilateral Menieres disease. Findings:  Three physician reviewers found that there is enough literature and support for the use of this device in the medical community as a second line of treatment for active Menieres disease that it should be no longer deemed investigational.  Alternative treatments such as intra-tympanic gentamicin injection, endolymphatic shunt surgery or labyrinthectomy are invasive, do not have a greater success rate, and carry a much greater risk, especially to a patient with hearing left only in one ear.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a rapid lysis procedure for the treatment of his blood clot. Findings:  The physician reviewer found that treatment with heparin and Coumadin are the standard of care for this circumstance.  There is no evidence that the requested procedure is necessary for the patient or that it is more clinically appropriate than treatment with heparin and Coumadin.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy, occupational therapy, physical therapy and applied behavioral analysis (ABA) for the treatment of the enrollees pervasive developmental disorder/autism. Findings:  The physician reviewer found that this patient has been diagnosed with autism based on evaluations by two child neurologists. The second child neurologist prescribed speech, physical and occupational therapy weekly programs. The patient was evaluated by qualified speech, physical and occupational therapists who recommended active therapeutic approaches. Applied behavioral analysis is not an experimental program, and the peer-reviewed literature has documented its effectiveness. The various therapies have been proposed as part of a comprehensive treatment plan for this patient and are medically appropriate for the treatment of autism. The requested therapy is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested spinal fluid immunoassay for an evaluation of his condition. Findings:  Three physician reviewers found that it has not established that the patient has cognitive impairment. Measurement of cerebrospinal fluid tau and other proteins for diagnostic purposes is still investigational and not applicable to patients who are anxious about the possibility of having Alzheimers disease. The requested testing is not medically warranted for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested robotic prostatectomy with urethropexy for the treatment of his prostate cancer. Findings:  Two physician reviewers found that radical prostatectomy is appropriate therapy for localized prostate cancer in a healthy male with no contraindications. It is the gold standard in terms of cancer outcomes and cure. The complications which can occur with this surgery include erectile dysfunction, urinary incontinence and intraoperative blood loss. The addition of robotic assistance has increased the facility, speed and safety of this operation. There are now multiple centers with extensive experience doing robotic prostatectomy, and the frequency with which it is performed has exploded in the last few years. In 2008, more than one half of the 100,000 radical prostatectomies that will be done will be done laparoscopically with robotic assistance. The outcomes for cancer cure and continence appear to be equal to the open procedure. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it to be superior. This procedure is not experimental and is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 15-year-old female enrollee has requested Xolair for the treatment of the enrollees allergies. Findings:  The physician reviewer found that this patient has been followed for a diagnosis of severe allergic asthma that appears poorly controlled despite optimal medical treatment. The patient has adhered to treatment plans, and her condition has failed to respond adequately. The patients quality of life is severely impaired by her condition. There is concern regarding the episodes of life-threatening anaphylaxis, and it is noted that the patient has been prescribed an Epipen for emergencies. In light of the above, treating this patient with Xolair for her severe allergic asthma condition is appropriate and medically necessary.