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

A 35-year-old female has requested authorization the Minimed Paradigm Real Time continuing glucose monitoring system for treatment of diabetes.  Findings:  Three physician reviewers found that since their inception several years ago, continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypo and hyperglycemia in insulin treated patients who are not in good control. Recent reports indicate that continuous glucose monitoring for up to three months results in improvement in A1c levels as well as in detecting unexpected hypo and hyperglycemia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Rituxan for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that rituxan is an unproven drug for the treatment of PPMS. At this time, there are no reported clinical studies of Rituxan and PPMS. Nor is there any evidence that Rituxan is effective for the treatment of PPMS. Although there is an ongoing study of Rituxan in this setting, no information regarding the drugs efficacy is yet available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a deceased 64-year-old male enrollee has requested for skilled nursing facility (SNF) services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient was in worse condition in terms of PT and OT performance. He regressed from contact guard assist with PT to minimum assist of two and from moderate assist with OT to maximum assist. However, the patient was found to have a stage III decubitus, which required daily skilled nursing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old female enrollee has requested the medication Provigil for the treatment of the enrollees excessive daytime sleepiness. Findings:  The physician reviewer found that provigil is known to be effective in reversing excessive daytime sedation caused by various psychoactive medications. This agent is often used off-label for this purpose. Excessive daytime sleepiness is an iatrogenic effect of many psychoactive and antipsychotic medications, and can be a disabling part of a patients illness. In this particular case, the patient has a complex variety of clinical symptoms and medications. Provigil is clinically indicated to counteract her daytime sedation and optimize her therapeutic regimen. It has clearly been effective for this patient and the treatment should be maintained.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that the adverse effects reported for both Neurontin and Lyrica are essentially the same. Actually, there are more adverse effects in the greater than 10% category associated with Lyrica than with Neurontin. Arthralgia, lethargy, fatigue, muscle spasm, myalgias, vomiting, confusion, weight gain and flu-like syndromes are among the adverse effects noted in clinical trials of Lyrica. Arnold and others found Neurontin to be helpful for the pain of fibromyalgia and generally well tolerated. A trial of Neurontin before taking Lyrica is clinically reasonable and consistent with the community standard of care. However, should Neurontin prove to be ineffective or not well tolerated, authorization of Lyrica should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for acute inpatient psychiatric services for treatment of her depression. Findings:  The physician reviewer found that according to the record, she reported feeling suicidal with a plan to her school counselor and refused to contract for safely upon admission. The enrollee also had an acute psychiatric admission approximately one month earlier. Her admitting diagnoses included major depression, post-traumatic stress disorder and parent-child relational problems and she was taking Lexapro for depression. The enrollees treatment plan included individual therapy, group therapy and family therapy. There is a reported history of severe family conflict and a remote history of physical abuse and there was reluctance on the part of the enrollee to return home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for the Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that Oncotype DX is a 21-gene assay that has proven to be a reliable and valid predictor of the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. This test is widely accepted by the oncology community for patients such as this patient and considered by some to be standard of care. Ordinarily, the result of the test is a pivotal factor in making a recommendation about adjuvant chemotherapy. Specifically, for those cancers that fall into the low risk category, it is generally held that chemotherapy is not worthwhile. In this instance the patient received chemotherapy, suggesting the test may not have been utilized in clinical decision-making.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested for the prescription medication Mepron for treatment of his babesiosis. Findings:  The physician reviewer found that babesia infection cannot be diagnosed clinically because the symptoms are non-specific. Absent a blood smear, positive serological study or a PCR, the diagnosis cannot be made. Due to the absence of evidence supporting this diagnosis, treatment with Mepron is not clinically appropriate. Evidence of past infection is not a valid basis for treatment, as 50-60% of patients infected with Babesia recover without therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 42-year-old female enrollee has requested continued acute inpatient rehabilitation services for the enrollees rehabilitation following a stroke. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the technology used as part of the patients rehabilitation as well as expertise in its use have been an essential component of her progress. The technology used in this case is not usual and customary in subacute rehabilitation. The acute inpatient rehabilitation services the patient has been receiving are a vital part of her rehabilitation and should be continued.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has for magnetic resonance imaging (MRI) of the brain for evaluation of the enrollees pineal cyst. Findings:  The physician reviewer found that migraines in children are rarer than in adults. When a child develops persistent headaches, it is imperative that severe etiologies be ruled out. Given that this patient has a documented pineal cyst, serial imaging studies are warranted to rule out pineoblastoma or apoplexy. Either of these scenarios would significantly change the patients medical management. Additionally, after an extended period of unexplained headaches, MRI may help to identify a cause unrelated to the patients pineal cyst.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for artificial disc replacement surgery for treatment of  her degenerative disc disease. Findings:  Two physician reviewers found that artificial disc replacement is a novel surgical option for the management of discogenic lower back pain. To date, there is no long-term data supporting the benefits of this procedure over more conventional surgical interventions such as fusion. It has not become standard of care for management of degenerative disc-related pain. Long-term safety and efficacy studies are lacking in the peer-reviewed literature along with head-to-head comparison between total disc replacement and interbody fusion surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A representative of a 50-year-old female enrollee has requested for a motorized scooter for her mobility. Findings:  The physician reviewer found that there is no documentation that the patient would be unable to propel a manual wheelchair. As other assistive options exist, a motorized scooter is not required.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for lumbar laminectomy and spinal fusion at L4-5 with decompression of the left L5 nerve root for treatment of her back pain.       Findings:  The physician reviewer found that fusion at L4-5 is unlikely to be successful given the multiple levels of DDD. Laminectomy will not help the patients back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Supartz injections for treatment of her right knee pain.    Findings:  The physician reviewer found that she appears to have tried and failed NSAIDs in the past, but has not tried other conservative measures, such as cortisone injections. As there are other treatments available that are likely to be efficacious for this patient, Supartz is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested for psychiatric residential treatment for treatment of the enrollees medical condition.      Findings:  The physician reviewer found that A review of the medical records shows that the patient did not meet medical necessity criteria for continued residential treatment. The submitted documentation indicates that the patient was stable, did not have any imminent safety risk, and did not have medical or emotional complications that required a residential level of care. The patient showed substantial progress in her symptoms and behavior and was functioning close to her baseline. Thus, she could have been effectively treated at a lower level of care during the period in question.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested for a wireless capsule endoscopy for evaluation of his abdominal pain. Findings:  Three physician reviewers found that chronic abdominal pain is a common complaint. In many cases, even an extensive workup does not reveal the cause of the pain. WCE is a new method for visualization of the entire small bowel. There are no randomized controlled trials in peer-reviewed journals pertaining to WCE for abdominal pain. In one study by Bardan, et. al., 20 patients with chronic abdominal pain of 6-96 months' duration were enrolled in the study. They had had an extensive diagnostic workup, which was negative. WCE was performed in all patients. Imaging of the small intestine was excellent and the colon was reached in 16 patients. In 14 patients the study was completely normal; in six patients the procedure revealed findings that were considered to be clinically insignificant. All patients tolerated the capsule well and had no adverse effects. WCE did not seem to have any significant clinical value in the evaluation of patients with obscure chronic abdominal pain. In another study by Tatar, et. al., WCE was most effective in evaluation of patients with anemia (61%) and diarrhea (36%), and least effective in patients with abdominal pain (17%).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for the medication Zometa for treatment of his osteoarthritis and osteoporosis.   Findings:  The physician reviewer found that there is recent relevant peer-reviewed scientific literature proving the efficacy of Zometa for this type of patient, and specifically for the stated indication. As such, the use of Zometa was medically appropriate in this case and should be continued.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested for DIR/Floortime therapy for treatment of the enrollees autism. Findings:  Three physician reviewers found that review of the relevant medical evidence reveals no peer-reviewed studies demonstrating that DIR/Floortime therapy is efficacious for the treatment of autism. There are no definitive studies proving the therapy at issue results in an improved clinical outcome. Without further study and research, it is not possible to predict whether the proposed therapy will benefit this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male is requesting partial hospitalization services for the treatment of chemical dependency.  Findings:  The physician reviewer found that during the specified date he needed the structure, supervision and psychological intervention provided in a partial hospital program. The submitted evidence demonstrates the patient did require partial hospital treatment through the specified date.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested X-Stop implantation for the treatment of her spinal stenosis. Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is the superior treatment option. Laminectomy is the gold standard for patients such as this patient. No study has demonstrated that X-Stop is more than or as effective as laminectomy, particularly with a two-level procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for wedge resection or bisection of the ovaries (CPT 58920) for treatment of her polycystic ovaries. Findings:  The physician reviewer found that ovarian wedge resection or bisection of the ovaries is performed in the treatment of infertility, not for dysfunctional uterine bleeding. The submitted documentation does not include any documentation regarding the patients infertility from the time of her office visit in August 2004 until the date of surgery. If there is objective clinical evidence regarding the patients fertility issues, the patients request for reimbursement should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a 15-year-old male enrollee has requested for psychiatric residential treatment services for treatment of the enrollees behavioral health problems.            Findings:  The physician reviewer found that his impairment is significant and long-standing. He recently failed in another treatment program due to his aberrant behaviors, which could be accepted as the equivalent to failure of intensive outpatient and partial hospital program services. The patient meets the criteria for a residential level of care. He clearly has a pattern of impairment of psychosocial functioning due to his psychiatric illness. He has a clinical need for 24-hour structure, supervision and active treatment.  Furthermore, it is likely that his condition will deteriorate without residential care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested a C-leg microprocessor controlled knee and related items for the treatment of above-the-knee amputation.  Findings:  Two physician reviewers found that the C-leg has not statistically demonstrated improved performance when compared to a conventional mechanical prosthesis. Furthermore, there is no statistically significant evidence to indicate that the C-leg will in fact prevent falls to a greater extent than a conventional leg or that it will result in increased activity levels for amputees as compared to the mechanical prosthesis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested the Oncotype DX tumor assay for the evaluation of breast cancer.  Findings:  The physician reviewer found that the Oncotype diagnostic assays greatest utility is in indicating whether an individual patient falls into the low-risk category, or the high-risk category. Many authorities in breast cancer have accepted the validity of this testing and the applicability of the results in patients with low recurrence and high recurrence scores, which constitutes approximately 70% of all results. Based on this data, use of the Oncotype diagnostic assay is reasonable to risk-stratify a patient with node-negative, estrogen receptor-positive breast cancer, as in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for a follow-up visit and perinatology (detailed fetal anatomy) ultrasound for evaluation of her high-risk pregnancy. Findings:  The physician reviewer found that uterine fibroids can lead to pregnancy complications including IVGR, abortion and pre-term labor. Perinatology ultrasound is sometimes necessary in cases such as this to monitor fetal growth, fibroid growth, and sometimes other parameters. A follow-up visit and third trimester perinatal ultrasound is clinically indicated for this patient due to sizable uterine fibroids.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for a blepharoplasty for treatment of her eyelid ptosis. Findings:  The physician reviewer found that based on the patients significant visual field defect and the submitted photographic evidence, she satisfied medical necessity criteria for functional blepharoplasty.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested  for biofeedback therapy for treatment of the enrollees constipation. Findings:  Two physician reviewers found that paraoxical external anal sphincter contraction during attempted defecation (anismus) is thought to be an important contributor to chronic fecal retention and encopresis in children. Biofeedback training can be used to teach children to abolish this abnormal contraction. Multiple randomized trials have been performed in medical treatment resistant and treatment dependent encopretic children and none of these trials have shown any benefit of biofeedback therapy over enhanced toilet training in children with encopresis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested authorization and coverage for additional Botox therapy for treatment of chronic daily headaches/migraines.  Findings:  Three physician reviewers found that although Botox therapy is routinely used for chronic, medically refractory, migraine, such use generally occurs after the failure of three to four medications from different classes of prophylactic drugs. The record does not provide details of previous medication trials or the patients response (i.e. beta blockers, calcium channel blockers, anticonvulsants). There are also no details regarding the patients response to previous Botox therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for single-level artificial disc replacement surgery for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement surgery remains experimental for the treatment of lumbar degenerative disc disease. More long-term outcome studies are needed to establish the safety and efficacy of this treatment. Lumbar fusion is the gold standard for surgical treatment. No long-term outcome studies exist to demonstrate that artificial disc surgery is more effective in the long-term than single-level fusion.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested  for Synvisc injections for treatment of her ankle pain. Findings:  Three physician reviewers found that synvisc injections have not been approved for joints other than the knee. There is insufficient evidence in the medical literature supporting the use of Synvisc or any other form of viscosupplementation for the ankle. Based upon the evidence available to date, the patient is likely to achieve better results with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested reimbursement for single proton emission computed tomography (SPECT) for evaluation of psychiatric conditions.  Findings:  Three physician reviewers found that current literature does not support the use of SPECT in the diagnosis and treatment of major depression, anxiety or agoraphobia. There are no multi-centered, researched-based, studies showing the usefulness of SPECT for this application. SPECT is still considered an investigational and experimental diagnostic procedure according to the latest literature and community standards of psychiatric practice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested for Synvisc injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the record submitted does not include this treatment or the patients clinical response to the corticosteroid injections. Standard of care requires that the efficacy of the steroid injections be assessed by her provider. If it is determined that the patient failed to respond to this intervention, then it is appropriate to consider Synvisc injections.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for consultation  for treatment of her inflammatory breast cancer (IBC).  Findings:  The physician reviewer found that inflammatory breast cancer is a rare type of breast cancer, representing only 2% to 3% of all breast cancers diagnosed annually in the United States. The literature also indicates that it is a fast-growing breast cancer and can be misdiagnosed, as was apparently the case with this patient. The literature also states that starting treatment as soon as possible is important.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 38-year-old male enrollee has requested for inpatient psychiatric treatment services for treatment of the enrollees paranoid schizophrenia and major depressive disorder. Findings:  The physician reviewer found that a review of the inpatient progress notes clearly indicates the patients illness was quite severe. Moving forward with conservatorship was appropriate given this severity along with the absence of insight and frequent medication noncompliance. A vital part of his inpatient treatment plan was to ensure that conservatorship and subsequent placement were obtained, allowing for a safe discharge. In addition, progress notes thoroughly document the acuity of the patients condition and the extent of his delusions and his paranoia up until his transfer.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male has requested rituximab for treatment of Wegeners granulomatosis.  Findings:  Two physician reviewers found that review of the medical literature reveals many reports of uncontrolled use of rituximab with benefit for WG in patients who have failed cyclophosphamide. The use of rituximab for the treatment of WG is now standard practice in rheumatology given the life-threatening nature of this illness.