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

A 52-year-old male enrollee has requested a genioplasty procedure for the treatment of his Class II malocclusion with an anterior open bite. Findings:  The physician reviewer found that the patient has a maxillofacial skeletal deformity, specifically mandibular hypoplasia. These types of deformities may be apparent at birth or may manifest during subsequent growth and development creating functional, degenerative, cosmetic and/or psychological problems. Given the degree of this patients deformity, his mandibular hypoplasia/microgenia did constitute an abnormal body structure which was caused by a congenital and/or developmental abnormality. The advancement genioplasty was performed to create a normal appearance to the extent possible and improved the function of the mentalis muscle and lower lip. It did offer more than a minimal improvement in the patients appearance. The surgery was medically reasonable and appropriate.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested an emergency room visit for the treatment of her ear pain. Findings:  The physician reviewer found that the symptoms of ear pain, redness, swelling of the ear and face, fever and chills could be indicative of several potentially life-threatening emergencies, including perichondritis, malignant otitis, mastoiditis, and facial cellulitis. It is critical to evaluate patients who might have such infections as soon as possible, as a delay in diagnosis and treatment can lead to an ominous outcome. It is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for a liver transplant for treatment of his hepatocellular carcinoma. Findings:  The physician reviewer found that the medical records document this noncompliance with liver transplant requirements.   Although his diagnosis of liver cancer should give him priority in receiving a donor liver, his active drug use and noncompliance should exclude him from listing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for speech and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that these therapies are well established, with significant peer-reviewed literature to establish both medical necessity and improvement in language and motor skills in children with autism. Early intervention by these therapies, before the age of two and no later than the age of four, is recommended by studies of autistic children.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for the prescription drug Subutex 8mg BID for treatment of his degenerative disc disease. Findings:  The physician reviewer found that the literature supporting this approach consists of one case series and some review articles which do not report any evidence-based results. Subutex was approved by the FDA for detoxification of patients from opiates. While the patient has failed trials of several opiates, there are still several other opiates that are on the formulary that have not been tried.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for repeated Hyalgan injections for treatment of his osteoarthritis of the knees. Findings:  The physician reviewer found that this patient had prolonged benefit from the prior Hyalgan injections. Because she is again symptomatic, the requested therapy is appropriate for treatment of the enrollees condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a polar care unit for the treatment of her post-surgical pain and swelling. Findings:  The physician reviewer found that the polar care unit was not medically necessary for the treatment of this patient during the postoperative period. The literature does not demonstrate any significant benefit of cryotherapy or pneumatic cooling devices over standard intermittent ice pack cold treatment. Also, improved outcomes in the mid-term and long-term have not been clearly shown in the literature. The equipment was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested for skilled nursing care  for treatment of his Fanconi Syndrome and osteomalacia with multiple skeletal fractures. Findings:  The physician reviewer found that the occupational therapy records also show progress towards minimal assistance. The patient had not reached his potential, and he had not reached a plateau.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for continuous CEA testing for evaluation of her metastatic breast cancer.   Findings:  Three physician reviewers found that CEA marker has been useful in predicting response. Although CA15.3 is often used in breast cancer, it is not useful in this clinical setting. The CEA is a very useful marker in this patient. The traditional CA15.3 is not useful in monitoring this patients response to therapy. The requested CEA testing is likely to be beneficial for monitoring of this patient, and it is likely to be more efficacious than alternative testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for robotic-assisted laparoscopic radical prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that there is no superiority of survival with the requested procedure. Robotic-assisted laparoscopic radical prostatectomy is not likely to be more efficacious than standard techniques.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested laparoscopic adjustable gastric band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has a BMI of 35 and multiple obesity related comorbidities that will be ameliorated or eliminated by bariatric surgery. Although her comorbidities have been medically controlled, they are progressing and require increasing numbers and classes of drugs. Her hemoglobin A1C is rising and is now 6.5. The patients lipid profile remains worrisome. She has had excellent therapy from Scripps Clinic which has optimized her health and provided support for non-operative weight control. Despite this, comorbidities have progressed. She fulfills criteria for bariatric surgery. The requested procedure is an appropriate and medically indicated procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested panniculectomy revision surgery for the treatment of her excessive abdominal skin and scarring. Findings:  The physician reviewer found that the patients excess skin is not an abnormal structure. She has skin redundancy that is consistent with her obesity. She has normal skin that is simply redundant.  The requested surgery will improve appearance but will not improve function.  The improvement in appearance will be relatively mild, as the patients deformity is not severe.  Her mild skin excess and midline abdominal scar are not significantly disfiguring, and her abdomen is easily covered by clothing. The requested procedure is not medically indicated because it will not correct a significant deformity and will not improve function. The patients concerns are cosmetic, and the planned operation is a cosmetic procedure with the only purpose to improve appearance.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested for sensory integration therapy for treatment of the enrollees autism spectrum disorder.   Findings:  Two physician reviewers found that there are minimal statistically significant peer-reviewed studies that show consistent and sustainable effect and benefit from sensory integration therapy. Better-controlled studies are necessary before sensory integration therapy can be considered a proven effective therapy for the treatment of autism. Without further investigation and research, sensory integration therapy remains an investigational therapy of unproven benefit. It is not considered a standard or primary intervention for the treatment of autism.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for lumbar artificial disc replacement for treatment of his lower back pain. Findings:  Three physician reviewers found that artificial disc replacement presents a novel surgical approach to the treatment of degenerative disc related low back pain, interbody fusion remains the standard of care surgical procedure for this condition. At this time, there is insufficient peer-reviewed evidence that artificial disc replacement has an equal or superior long term efficacy and safety profile to traditional interbody fusion surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested for floortime therapy for treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that floortime therapy is a framework that includes working with a child at his or her developmental level through a variety of therapies to improve individual differences in sensory-motor, language, and social functioning, and supporting family and other learning relationships. It is meant to tailor caregivers and decisions interaction to one childs unique functional profile. While floortime seems to have promise, there are no independent, peer-reviewed published studies of floortimes effectiveness for children with autism. Therefore, there is no data to support floortime as a proven and effective therapy for the treatment of autism spectrum disorder. In addition, there are other proven therapies available to this patient. Because of this lack of evidence supporting the effectiveness of floortime therapy and the fact that there are other proven therapies available.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for a double balloon enteroscopy for evaluation of her gastrointestinal bleeding.   Findings:  Three physician reviewers found that capsule endoscopy did show some small bowel ulcerations.  With double balloon enteroscopy, one is able to evaluate the ulcerations and cauterize them if necessary to treat the bleeding issue. Double balloon enteroscopy is medically appropriate for evaluation of this patient. It is likely to be more efficacious than alternative therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 27-year-old male enrollee has requested for cognitive rehabilitation therapy for treatment of the enrollees acquired brain injury.   Findings:  Two physician reviewers found that a review of the literature indicates that cognitive/behavioral rehabilitation can be effective in improving function. However, there is no evidence that inpatient rehabilitation is superior to in home rehabilitation. Therefore, cognitive rehabilitation is recommended, but it does not have to be in a hospital or residential-based setting. It could be in home, day treatment or on an outpatient basis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of an 18-year-old female enrollee have requested magnetoencephalography (MEG) and magnetic source imaging (MSI) for an evaluation of the enrollees focal epilepsy. Findings:  Two physician reviewers found that these tests remain investigational for evaluation of the patients condition. The patient has undergone a number of standard diagnostic procedures, which indicate that the seizure focus stems from the left frontal lobe. A large number of standard anti-epileptic drugs have not been effective and have produced intolerable and unwanted side effects. The patient is now a candidate for surgical resection of the lesion that is responsible for the seizures. A reliable and accepted technique for successful surgical ablation of the epileptic focus is the use of intraoperative corticography. The requested tests show promise as eventually becoming standard tests. However, further study is necessary to establish their reliability and efficacy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of an eight-year-old male enrollee has requested speech therapy for the treatment of her pervasive developmental disorder. Findings:  The physician reviewer found that this patient has been diagnosed with autism and a speech disorder.  Both of these are medically recognized and carry diagnostic codes.  As such, his medical problems are recognized and coded by the medical community.  Furthermore, the patients IQ falls into the very low normal range which would project him as capable of being educated.  Moreover, the patients speech therapy report indicates continued and steady improvement with his speech.  Each of these factors demonstrates that speech therapy is a medically appropriate intervention for this patient with a likelihood that it will improve his condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A parent of a 17-year-old female enrollee has requested neuro-rehabilitative services for the treatment of the enrollees traumatic brain injury (TBI). Findings:  The physician reviewer found that the patient is independent with gait transfers, dressing, hygiene and basic self care. The patient has received extensive physical, occupational, and speech therapy and numerous other therapies and counseling. The information provided demonstrates further therapy at such levels is not medically necessary. Furthermore, the information submitted demonstrates the patient can receive appropriate care through a less intensive program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for a continuous glucose monitoring system and associated insulin pump for treatment of his diabetes. Findings:  Two physician reviewers found that there is evidence that this device improves net health outcomes in someone such as this patient who is having severe hypoglycemic reactions and needs to avoid low blood sugars. The literature also supports CGMs as improving HgA1c levels over time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Botox therapy for the treatment of her TMJ-related tension headaches. Findings:  Two physician reviewers found that the enrollee has attempted a number of medications without sustained benefit and has recently achieved a significant reduction in symptoms with Botox therapy. She is now seeking authorization for further Botox therapy. Records demonstrate this patient has had success with Botox where other therapy has failed. It is likely she will again receive benefit from further Botox therapy. Furthermore, there is data to support Botox therapy for this patients headaches.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for a Positron Emission Tomography (PET) study for evaluation of her ovarian cancer.   Findings:  Three physician reviewers found that a review of the literature indicates that PET scan is an appropriate diagnostic test for evaluation of patients with ovarian cancer. The number of patients in the studies ranged from 8 to 132. In some of the studies, the patients had rising CA-125. All the articles supported the use of PET or PET/CT to identify and help characterize recurrent ovarian cancer.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for a radiofrequency annuloplasty and disc decompression for treatment of his back pain. Findings:  Three physician reviewers found that the procedure in issue here is unproven in the scientific medical literature as an effective long-term treatment for lumbar radiculopathy and there is no evidence it provides greater benefit than other standard procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-year-old male enrollee has requested for laboratory tests for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that there are no prospective studies in the peer-reviewed literature to demonstrate the utility and efficacy of a celiac sprue panel as a screening test to diagnose Celiac disease. The clinical presentation of celiac disease may be characterized by chronic abdominal pain, but there are no large studies available in the literature showing the actual incidence or prevalence of celiac sprue in patients with abdominal pain. One community-based control study found no association between recurrent abdominal pain and the prevalence of anti-endomysial antibody. A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for anti-endomysial antibody. The frequency of anti-endomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a Mini-Med Insulin Pump for the treatment of her Type I diabetes. Findings:  The physician reviewer found that a prescription for the Mini-Med Insulin Pump has not been submitted, and the records submitted fail to establish the medical indication for this requested equipment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The guardian of a 15-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of the enrollees stated Prader-Willi syndrome. Findings:  The physician reviewer found that a methylation genetics test for Prader-Willi syndrome should be performed in order to verify the diagnosis. In the absence of such evidence, the case for growth hormone therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested acupuncture services for the treatment of her headaches. Findings:  The physician reviewer found that the patient has had a less than favorable response to traditional medicine.  Acupuncture is a viable treatment alternative for her medical condition.  It is used to treat not only postsurgical pain and nausea associated with pregnancy or chemotherapy, but also more usual problems such as muscle pain, headaches, addiction and asthma.  Acupuncture should be considered in this case, as traditional medicine has seemingly been of little or no help, and there is no other specified alternate treatment.  Furthermore, records submitted indicate it has already provided the patient with significant relief.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested an emergency room visit for the treatment of her throat discomfort, swallowing difficulties and cough. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with are consistent with several potentially life-threatening emergent medical conditions and disease processes, including epiglottitis and peritonsillar abscess. Both of these diseases can result in airway compromise which can be fatal. It is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The spouse of a 40-year-old female enrollee has requested for intravenous (IV) Rocephin infusions and home health nursing visits for treatment of her Lyme disease. Findings:  Two physician reviewers found that there is no documentation in the literature advocating the use of intermittent IV antibiotic therapy for the treatment of chronic Lyme disease.  To date, the use of chronic antibiotic therapy for the treatment of a post-Lyme syndrome remains unproven.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested an emergency room visit for the treatment of her head and neck pain. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with appear to be of a chronic and intermittent nature. She reported having similar headaches many times in the past and did not report any worsening symptoms. There is no evidence of a life-threatening cause of her headache, such as meningitis or subarachnoid hemorrhage. It is not reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested a reduction mammoplasty for the treatment of her bilateral gigantomastia. Findings:  The physician reviewer found that the concept supported in the medical literature is that patients who present with the typical symptoms of macromastia and who have a confirmatory exam benefit greatly from breast reduction surgery. As noted by Kerrigan, weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms were unlikely to improve unless she had a breast reduction.  The peer-reviewed literature strongly supports the concept that this patients breast reduction was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for speech therapy for treatment of his speech disorder subsequent to head trauma. Findings:  The physician reviewer found that complex concussions involve cognitive impairment, such as poor attention or concentration, memory dysfunction, irritability, anxiety, depressed mood, sleep disturbance, persistent low-grade headache, lightheadedness, and sensitivity to light or sound. The term post-concussive syndrome/disorder has been used to describe these prolonged symptoms and cognitive impairment. This patient has a history of multiple episodes of blunt head trauma, at least two of which were associated with LOC.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a seven-year-old male enrollee has requested myofunctional therapy for treatment of the enrollees oral condition. Findings:  The physician reviewer found that there is no documentation of oral, facial, or tongue dysfunction in this patient, other than reports by the orofacial myologist.  The specialty of orofacial myology has some recognition among speech pathologists and dentists, but it is not a recognized medical specialty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 21-year-old female enrollee has requested for services for depressive disorder, bipolar disorder and borderline personality disorder.  Findings:  The physician reviewer found that there is no evidence to support the need of the services at issue.