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

A 37-year-old female enrollee has requested an magnetic resonance imaging (MRI) of her lower back for an evaluation of her back pain. Findings:  The physician reviewer found that some patients have continued or worsening back pain even with conservative therapy.  Such is the case with this patient.  She has worsening back pain with leg pain in spite of NSAIDs, pain medications, and physical therapy.  She has also had cortisone injections but her symptoms continue.  At this time, MRI of the lumbar spine is medically appropriate to evaluate for disc herniation or spinal stenosis as a cause of her symptoms.  MRI is the exam of choice to evaluate the lumbar spine, and this study will assist in directing the patients future treatment properly
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of her medical condition. Findings:  Three physician reviewers found that the patient does not currently have a breast cancer diagnosis, nor does she have ovarian cancer in her family history.  There is no clinical benefit for the requested diagnostic testing at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for physical therapy services, including electrical and passive modalities for treatment of his left shoulder rotator cuff tear. Findings:  The physician reviewer found that therapy is usually performed for four to six weeks which graduates into a home program.  However, to be approved, it should also include an exercise program for stretching and strengthening.  There must be active treatment rather than solely passive modalities. It appears that this individual did have an exercise program. Therapy would be appropriate for four to six weeks, three times weekly, with a diagnosis of impingement syndrome. Electrical stimulation, if part of an active treatment program, would be appropriate.  Modalities may include, but are not limited to, cryotherapy, hydrotherapy, electrical stimulation and thermotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for the prescription drug Differin 1% cream for treatment of her rosacea.  Findings:  The physician reviewer found that every standard textbook of dermatology recognizes topical retinoids as accepted treatment for acne rosacea. It is part of the standard of practice, according to the American Academy of Dermatology.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for an emergency room for treatment of the enrollees cough, runny nose, fever, decreased appetite and constipation. Findings:  The physician reviewer found that these signs and symptoms are suggestive of a potentially life-threatening infection, including pneumonia, bronchitis, bacteremia and/or sepsis. Although he did not appear to be in distress, his vital signs were indicative of dehydration. Tachycardia is especially concerning in the presence of anorexia and vomiting. An elevation of respiratory rate is a sign of respiratory distress (possibly due to pneumonia or other pulmonary infection).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for continued Nutropin growth hormone therapy for treatment of the enrollees stated short stature/growth failure. Findings:  The physician reviewer found that the recorded height nears 54. Growth hormone deficiency and celiac disease has been excluded. The mid-parental height was above the 25th percentile. The projected adult height at 13 years 4 months was below the 3rd percentile, and he had a subnormal rate of growth. He was placed on growth hormone therapy and has had an excellent response. The patients excellent growth response indicates the benefits of continuing growth hormone therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for a multi-chamber programmable lymphedema pump for treatment of her medical condition. Findings:  The physician reviewer found that the requested equipment is clinically indicated and the most appropriate equipment for treatment of the patients condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for emergency ambulance for treatment of his abdominal pain, nausea and vomiting. Findings:  The physician reviewer found that it appears that this patient relied on emergency medical services as a convenient means of transportation to the emergency department for what was a non-necessary visit to the emergency department. His complaints clearly do not meet the definition of an emergency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested the prescription drug Lyrica for the treatment of his shingles. Findings:  The physician reviewer found that Lyrica has an FDA approved indication for this disease. The patient has achieved acceptable pain relief on this level of medication. The Health Plan refuses to cover this medication since a trial of gabapentin was not performed first. Since the patient is now pain free, it is unreasonable to ask the patient to re-experience the pain of postherpetic neuralgia in a trial of the first line drug gabapentin. Both drugs are acceptable first line treatment. Additionally, the dosage prescribed is in the range of those used in randomized, placebo-controlled trials and is appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested bilateral breast MRI studies for an evaluation her breasts, due to the fact that she has a previous history of breast cancer. Findings:  Three physician reviewers found that this patient does not fall into the group of patients requiring breast MRI exams for routine surveillance. First, the breast tissue has been described on mammographic reports as heterogeneously dense. This type of parenchyma permits a useful evaluation by radiologists for initial or recurrent tumor, as opposed to the extremely dense parenchyma. In the latter case, mammography is of quite limited value. In patients with heterogeneously dense tissue, mammography is quite useful.  If there is any clinical or mammographic change suspicious of tumor recurrence, a follow-up ultrasound and possibly an MRI would be the procedure of choice. This is not the case at this point.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested emergency room services for the treatment of his headaches and neck pain. Findings:  The physician reviewer found that on exam, the patient was found to be in moderate distress, had bilateral frontal sinus pain, tearing of both eyes and sinus pressure. He was noted to be immunosupressed due to treatment with interferon. An immunocompromised state may predispose the patient to more severe illnesses and disorders. In these cases, patients must be worked up more aggressively than immuno-competent patients who present with the same symptoms. Lab testing was significant for elevation of liver function tests, thrombocytopenia (low platelets), and a low potassium. The patients condition was noted to improve.The symptoms of severe headache and neck muscle tightness in an immunocompromised patient are consistent with potentially life-threatening conditions, including meningitis, subarachnoid hemorrhage and other cerebral disorders. It is reasonable for a prudent layperson to access emergency medical care for such symptoms. The patients symptoms did met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested BRCA1 and BRCA2 gene testing for an evaluation of the enrollees medical condition. Findings:  The physician reviewer found that there are no other appropriate services offered by the Health Plan in lieu of the testing. Further, the patients clinical circumstances meet the criteria for coverage of the BRCA testing as set forth in the Health Plans own criteria. The Health Plans criteria are consistent with national practice standards and guidelines for the use of BRCA testing, as published by the National Comprehensive Cancer Network, and the U.S. Preventative Services Task Force. Patients with a history of breast cancer and a strong family history of breast cancer who are found to have a deleterious mutation in BRCA 1 or BRCA 2 genes may consider elective bilateral oophorectomy to reduce their risk of development of ovarian cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested the prescription drug Starlix for the treatment of her diabetes. Findings:  The physician reviewer found that this patient has diabetes, which was diet-controlled until recently. Progression of diabetes is consistent with elevated postprandial glucose levels and loss of early postprandial insulin response. The patient developed hypoglycemia with sulfonylurea. A glinide is a good choice for treatment of this patient. According to the patients Health Plan, Prandin is the preferred non-formulary medication, and Starlix may only be approved if the patient fails or has a reaction to Prandin. In this case, it is medically appropriate that Starlix should precede Prandin, as Starlix is less potent. Starlix may be safer in this patient, who is at risk for hypoglycemia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested the prescription drug Skelaxin for the treatment of her musculoskeletal condition. Findings:  The physician reviewer found that the Health Plan has recommended the patient attempt trials of two formulary alternative muscle relaxants prior to authorization of Skelaxin. This is a reasonable position. There is no clinical evidence demonstrating that the patient must take Skelaxin or that the muscle relaxants recommended by the Health Plan are contraindicated. Based upon the information provided, it is likely that the patient will benefit from the muscle relaxants recommended by the Health Plan. If the patient fails reasonable trials of two of the recommended muscle relaxants the Health Plan should authorize Skelaxin. However, there is currently no medical justification for authorizing Skelaxin.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested the BioniCare Electrical Stimulator for the treatment of his knee and low back pain.  Findings:  Three physician reviewers found that although the BioniCare device has been approved by the Food and Drug Administration, and there are some anecdotal reports that the use of pulsed electricity has been helpful on some occasions for knee pain, there is a lack of peer-reviewed literature which proves that this device is effective at providing long-term pain relief or improving the functionality of patients with osteoarthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for a liver CT scan for evaluation of her liver lesions. Findings:  The physician reviewer found that the patient remains asymptomatic and her laboratory studies are also unremarkable. Based upon the patients history and the fact that she is currently asymptomatic, there is no medical indication or need for a repeat CT scan at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for Synvisc therapy for treatment of his osteoarthritis of the ankle.   Findings:  Three physician reviewers found that Synvisc injections have been approved for use in the knee, but there has been no documented approval for the use of Synvisc in the shoulder, elbow, hip, or ankle.  There is no documentation that viscosupplementation, such as Synvisc, is appropriate for post-traumatic arthritis of the ankle.  Although this patient has had treatment in the past, and it has been deemed to be helpful, it would not be medically appropriate to approve the viscosupplementation with Synvisc due to the fact that it has not been proven to be appropriate care for ankle arthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for the prescription drug Lovaza for treatment of his mixed hyperlipidemia. Findings:  The physician reviewer found that Lovaza is generally used for treatment of primary hypertriglyceridemia, which is not the primary abnormal lipid in this patient. If treatment of hypertriglyceridemia is desirable, in addition to treatment of LDL cholesterol, the other medications recommended are more clinically appropriate in this type of therapy than Lovaza. The information presented does not demonstrate that Lovaza is indicated or clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested the prescription drug Lipitor for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that this patient had previous treatment success with Lipitor, and he was placed on Vytorin without adequate response. The patients recent trials demonstrate Vytorins lack of clinical effectiveness. Vytorin is not indicated for this patient. Furthermore, because of the patients current tolerance to Lipitor, there is a good likelihood that other medications would not be effective.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested for an emergency room visit for treatment of her sore throat. Findings:  The physician reviewer found that 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. This patients symptoms had commenced gradually over five days and were not acute in onset. She did report pain, but she did not require pain control in the emergency department. There is adequate documentation that the patient was able to tolerate oral intake and was not in any respiratory distress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested a fourth lumbar epidural injection for the treatment of his lower extremity radiculopathy and low back pain. Findings:  The physician reviewer found that the patient has obtained relief of pain with epidural injections and has had a series of three injections in the past. There is no contraindication for a fourth injection, or for the patient to have another series of three injections. This is especially true, if the injections are his only means of relief. He has attempted physical therapy, chiropractic care and massage with no relief. Further epidural injections would be considered appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested a PET/CT scan for an evaluation of his multiple myeloma. Findings:  Two physician reviewers found that the patient is a 44-year-old male who has been diagnosed with multiple myeloma.  The treating physician is requesting a PET/CT for follow-up. Per National Comprehensive Cancer Network Guidelines (NCCN), recommended tests for this patient include quantitative immunoglobulin, CBC and differential, BUN, creatinine, calcium, bone survey annually and bone marrow biopsy as clinically indicated. Additional tests to consider include a PET/CT scan. The documentation in this patients case fails to provide a clinical rationale for this study. In the absence of information from the treating oncologist supporting the long-term efficacy of a PET/CT scan for monitoring multiple myeloma in this patients case, the Health Plans denial is reasonable.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his prostate cancer. Findings:  Three physician reviewers found that this patient has clinically localized curable prostate cancer. He was given various treatment options. CyberKnife radiosurgery has been used at several institutions for curative treatment. There is a lack of long-term data showing superiority of CyberKnife radiosurgery over other established treatment.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested an emergency room visit for the treatment of his fever and sore throat. Findings:  The physician reviewer found that the patient is a 23-year-old male who presented to the emergency department complaining of sore throat, fever and abdominal pain that had spontaneously resolved. He had no significant past medical history. It does not appear as though he made any effort to contact his primary care doctor or visit an urgent care center. His exam was benign, other than for pharyngeal erythema and bilateral exudates. He was diagnosed with acute pharyngitis, prescribed antibiotics and discharged for outpatient follow-up. This patient could have contacted his primary care physician or an urgent care facility instead of going to the emergency department. His condition clearly was not life-threatening, and the typical layperson would realize this.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an eleven-year-old female enrollee has for a continuous blood glucose monitoring system for treatment of her Type I diabetes.   Findings:  Three physician reviewers found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin treated patients not in good control.  Recent reports of monitoring up to six months have shown improvement in hemoglobin A1c levels.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for an emergency room for treatment of her abdominal pain. Findings:  The physician reviewer found that 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. This patients symptoms were not acute in onset and had been present for one week. Her pain was not severe, but rated a 2 on a scale of 1 to 10. The patient did not require any medications in the emergency department.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested the surgical implantation of a diaphragmatic pacing device for the treatment of his amyotrophic lateral sclerosis (ALS). Findings:  Three physician reviewers found that the provider has requested that the patient participate in a clinical trial.  The requested diaphragmatic pacing device is experimental and investigational and does not meet national Medicare criteria for medical necessity. There is no documentation to show the requested participation in the clinical trial for diaphragmatic pacing is safe and effective or superior to no treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested Humatrope growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that that the patient most likely has a constitutionally delayed adolescence with a height prediction approximating his mid-parental height.  For these reasons there is no clinical justification to treat this patient with growth hormone therapy. The patient does not meet accepted criteria for treatment with growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee has requested for intravenous (IV) Rocephin for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the Lyme Western blots do not indicate active infection. Her symptoms are not specific for Lyme, and multiple courses of antibiotics have not improved her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions. Findings:  The physician reviewer found that this patient meets nationally accepted criteria for authorization of bariatric surgery. This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension. The 2004 Bariatric Surgery Consensus Conference statement supports prompt bariatric surgery in this circumstance.  There is documentation that full reversal of diabetes is severely diminished when surgery is delayed.  Further, surgery will improve the patients life expectancy.  Additionally, and quite significantly, non-operative approaches have nearly 100% failure rate in class III obese patients, such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested the prescription drug Viagra for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that Viagra is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal-directed. The patient is the one who actually makes the diagnosis of erectile dysfunction, and the patient is the only one who can report successful treatment. It is appropriate to treat complaints of erectile dysfunction empirically with Viagra. The medications high safety profile in all except those taking nitrates has been established and justifies empiric use. Since erectile dysfunction is self-reported, the history of erectile dysfunction is the prime indication of its use.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Leukine therapy for the treatment of her melanoma. Findings:  Three physician reviewers found that the patient is a 54-year-old female who has now been diagnosed with Stage III melanoma. Her nodal disease has been resected, and adjuvant Leukine therapy (GM-CSF) has been recommended. There is very little data to support the use of GM-CSF in the adjuvant treatment of melanoma. A single arm study suggested improved outcomes compared to historical experience. No randomized comparative data is available to support this recommendation.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The representative of a now deceased female enrollee has requested reimbursement for medical services for treatment of the enrollees sudden hepatic failure, breast cancer with multiple metastases and electrolyte imbalance. Findings:  The physician reviewer found that the patient was seeking possible alternative treatment, but she deteriorated quickly and received standard emergency care just prior to her death.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested for a nerve block for treatment of her post-operative pain. Findings:  The physician reviewer found that regional anesthesia (nerve block) is standard of care for shoulder surgery, and it has been for the past several years. It provides excellent post-operative analgesia, minimizes the need for narcotics post-operatively and decreases the need for excessive anesthesia during the operation.