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

A 45-year-old female has requested gastric bypass surgery without first completing the Medical Groups six-month supervised dietary counseling  program for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling  program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested growth hormone (GH) therapy for the treatment of her GH deficiency. Findings:  The physician reviewer found that the patient has a history of IGF-1 levels in the low normal range and underwent pituitary surgery for a presumed ACTH-producing pituitary tumor. One of two GH stimulation tests supports the patients diagnosis of GH deficiency. Furthermore, the patient has developed diabetes insipidus, which indicates an antidiuretic hormone (ADH) deficiency. In sum, this patient is an appropriate candidate for GH therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of her coronary arteries. Findings:  Three physician reviewers found that EBCT for CAC scoring is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset. It is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested labiaplasty for the treatment of her hyperplastic labia.  Findings:  The physician reviewer found that there were no records submitted identifying the course of the patients labial excess, particularly when it developed and efforts toward symptom management. There does not appear to be a degree of functional impairment sufficient to justify surgical intervention. It is also not entirely clear whether the patients pain with exercise can be fully attributed to enlarged labia. A literature search over the past 10 years revealed only two peer-reviewed articles on labiaplasty, neither of which discusses the medical necessity of the procedure. As no medical basis for this surgery has been established in the peer-reviewed literature, the procedure should reside in the realm of cosmetic surgery until there is valid evidence to the contrary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested image-guided radiation therapy (IGRT) with intensity-modulated radiation therapy (IMRT) for the treatment of his prostate cancer. Findings:  The physician reviewer found that the patient has high-risk cancer of the prostate with a rising PSA and rectal and lymph node involvement. Although IGRT may be superior in principle to IMRT, the patients medical status must also be considered. His cancer is no longer confined to the prostate and systemic therapy is needed with radiation used for palliation. IGRT with IMRT is not medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Actiq 200mcg lozenges for the treatment of her Behcets syndrome. Findings:  The physician reviewer found that the patients diagnosis of Behcets syndrome is not at issue. She has had a complicated and difficult course with various problems related to her illness itself, as well as to medications used in treatment. The patient has pain of multiple sources, and has already received many different pain medications, including Duragesic patches. She now has pain related to bone infarcts and/or early osteonecrosis of her knees and hips. The knee and hip pain at issue can be expected to improve/resolve if due to bone infarction. The pain will otherwise likely worsen if due to true osteonecrosis, which would most likely lead to orthopedic intervention. Actiq is approved only for breakthrough cancer pain, and this patients presentation does not justify off-label use of this medication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested the medication Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has fibromyalgia, which has failed to respond to various standard medication trials including antidepressants and Neurontin. Neither Neurontin nor any antidepressant has specific FDA approval for treatment of fibromyalgia, though standard practice usually includes trials of these agents. However, among these agents, any choice is arbitrary. Based on the evidence provided, this patient has already failed trials of Neurontin and antidepressants (Zoloft, Wellbutrin, and Trazadone) and has shown a beneficial response to a trial of Lyrica, which is the only agent approved by the Food and Drug Administration for treatment of fibromyalgia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 72-year-old male has requested an X-Stop procedure for treatment of back pain.  Findings:  Two physician reviewers found that there is no class I data demonstrating that X-Stop is more or equally effective as other available treatments. Simple laminectomy decompression is the gold standard in this setting. There is no literature establishing that the X-Stop procedure is superior to laminectomy surgery. To date, the long-term safety and efficacy of X-Stop remains unproven.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested Botox injections for treatment of migraine headaches.  Findings:  Three physician reviewers found that Botox can be beneficial in some patients with migraine and chronic headache; however, it does not have literature support as a first-line agent. Although this patient has tried a few abortive therapies, her use of standard prophylactic agents is not documented. Anticonvulsants, beta-blockers, calcium channel blockers and tricyclic antidepressants have all been shown to be effective therapies for migraine. It does not appear that the patient has been given an adequate trial of these medications. If she fails to respond to the standard prophylactic medications, then Botox therapy might be appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested the medication Byetta for the treatment of diabetes.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that while the patient was taking Byetta her medical conditions improved. All of these changes have been found to decrease the risk of both micro and macrovascular complications including blindness, renal failure and acute myocardial infarction. Given the failure of other therapies, it is medically appropriate for the patient to continue on Byetta for better diabetic control.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested reimbursement for residential treatment services for treatment of chemical dependency.  Findings:  The physician reviewer found that the patient had no acute signs of withdrawal when she was admitted to the residential treatment facility and there were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. Although she had a significant history of polysubstance abuse/dependence, there is no evidence she required on-going residential treatment. The patient could have been appropriately treated at a lower level of care such as chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested compression stockings for treatment of varicose veins. Findings:  The physician reviewer found that the patients medical records do not reflect swelling, abnormal pulses, varicosities, stasis ulcers, or other circulatory abnormalities. Rather, the records generally document normal extremities. As such, compression stockings are not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a medication regimen of Rocephin for the treatment of her Lyme disease. Findings:  The physician reviewer found that the patient may have late stage Lyme disease. As such, treatment with IV Rocephin was appropriate, but not in the dose or for the period indicated. Treatment regimens of doses higher than two gm per day or regimens longer than 30 days are not supported by the literature. There are no scientific, peer-reviewed studies that demonstrate the efficacy of extended antibiotic therapy. A treatment regimen of IV Rocephin not to exceed 2 gm per day for 30 days was medically necessary for this patient. Any use of Rocephin in excess of this was not clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the submitted clinical evidence does not provide any objective documentation that the patient has improved with physical therapy. There are subjective reports that she feels better, but no discussion of any goals either being set or achieved. There is no mention of improvement in functional activities. It is not likely that continued physical therapy will result in objective benefit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested artificial disc replacement for the treatment of her cervical stenosis. Findings:  Two physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. There is no clinical indication demonstrating the artificial disc replacement was the best treatment option for this patient. The literature demonstrates anterior cervical discectomy and fusion has an excellent track record of long-term outcomes in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested pre-conception consultation with an endocrinologist for the treatment of her hypothyroidism. Findings:  The physician reviewer found that this patient has been diagnosed with hypothyroidism and recurrent miscarriage. Hypothyroidism is a recognized cause of recurrent miscarriage and monitoring of thyroid function including TSH and free T4 levels is required. This is standard of care and should be managed by a medical endocrinologist. It appears that the Health Plans policy would also support the requested pre-conception endocrinology consultation. It is clearly the most appropriate level of service considering the potential benefits and harms to the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested the UCSF Weight Loss Clinics physician supervised Very Low Calorie Diet program for the treatment of his obesity.  Findings:  The physician reviewer found that this patient is at high risk for diabetes mellitus and also has risk factors for cardiovascular disease. The existing comorbidities point to an urgent need for weight loss. However, it is not clear from the record provided what formal treatment he has undergone in recent years. Consultation with a registered dietician is the usual first-line approach for weight loss in patients such as this one. The Diabetes Prevention Program study demonstrated the benefits of lifestyle interventions for inducing weight loss and preventing the onset of type 2 diabetes in high-risk patients. Furthermore, the benefits of very low calorie diets are not clear. Although popular several years ago, they are now rarely used to treat obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a diagnostic bilateral breast MRI for her breast cancer monitoring. Findings:  The physician reviewer found that breast MRI is a valuable tool used in addition to mammography and ultrasound. However, the clinical efficacy of breast MRI is limited to select patients. These include those with known breast cancer to evaluate for extent of disease, those patients with lymph node positive breast cancer and normal mammograms, and for screening high risk patients (i.e., those with BRCA mutation).  This patient has no personal history of breast cancer, her mothers breast cancer occurred post-menopause, and there is no history of BRCA mutation.  There is consequently no medical evidence to support breast MRI for screening purposes.  As this patient has had prophylactic mastectomies for non-cancerous breast disease, the chance of developing breast cancer is reduced because she no longer has breast tissue. Mammography would be appropriate for breast cancer screening in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee is a 46-year-old female who is requesting retreatment with Rituxan infusion therapy for the treatment of her rheumatoid arthritis. Findings:  Two physician reviewers found that while studies in peer-reviewed journals have documented the efficacy of retreatment of Rituxan after six months for rheumatoid arthritis, there is no specified schedule for repeat Rituxan infusions; the need for retreatment depends on the individual patient presentation. In this case, the records fail to document that the patient is having a flare of rheumatoid arthritis. Her only symptom is morning stiffness and the severity of the stiffness is not documented. As such, it has not been demonstrated that retreatment with Rituxan is warranted in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested residential treatment services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient is a seriously ill woman with a multitude of psychiatric issues. Her progress in the RTF was not rapid, but she was improving somewhat. Her medications were being adjusted as needed and they appeared to be of benefit. Relatively continuous monitoring of the patients behavior seems to have been indicated during the period at issue. The patient also experienced side effects from her anti-psychotic treatment compromising its utility. She was still significantly ill with a need for treatment at the RTF level of care and this need extended. The fact that she was re-admitted shortly after discharge seems to strengthen this point.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested myofascial release therapy for treatment of myofascial pain.  Findings:  The physician reviewer found that the technique of myofascial release is usually instructed to patients for self application. It is used in conjunction with a therapy program and is not generally used as a sole modality because strengthening is required. Most physical therapists are quite familiar with the technique and its use and can instruct patients accordingly. Upon review of the submitted records in this case, there is no evidence of a plan of care with goals and a timeframe to achieve the goals.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested a clear lens extraction with placement of a posterior chamber intraocular lens implant for treatment of ocular problems.  Findings:  The physician reviewer found that based on a review of the submitted clinical evidence, the patient has few options to improve her vision. The clear lens extraction with intraocular lens placement is the most appropriate treatment for her pathological ocular condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female has requested Herceptin 450mg every three weeks for treatment of metastatic breast cancer.  Findings:  The physician reviewer found that the continuation or re-starting of Herceptin in patients with a past history of treatment with Herceptin remains controversial. Several studies have examined this question, but data remains limited at this time. In this setting, many oncologists would initiate a combination of Xeloda with Tykerb (an oral drug that bears similarity to Herceptin in mode of action), but this patient was unable to tolerate this regimen. Prevailing opinion in the oncologic community would then be to add Herceptin to the patients new chemotherapy regimen. Thus, the continued use of Herceptin in this patient is within the community standard of care and is clinically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested a referral to an intensive eating disorder program such as the Mandometer Clinic for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that the treatment provided at the Mandometer Clinic does not fall within generally accepted standards of medical practice and is not likely to be effective for this patient. Given the severity of the patients condition, she requires a higher level of care, specifically, inpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female has requested the medication Provigil for treatment of idiopathic hypersomnolence.  Findings:  The physician reviewer found that there is insufficient evidence that the patient has idiopathic hypersomnia. A study by Richardson, et. al. reported that normal individuals usually demonstrate a mean sleep latency of greater than 10 minutes and pathologic daytime sleepiness is defined as a mean sleep latency of less than five minutes. The findings do not support a diagnosis of idiopathic hypersomnia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for an MRI-guided focused ultrasound ablation for treatment of her uterine fibroids. Findings:  Three physician reviewers found that focused ultrasound has been reported for the treatment of multiple medical diagnoses including liver, prostate and breast neoplasms. Ultrasound waves are guided by means of an MRI scanner, travel through the abdominal wall and converge at the site of the lesion. Thermoablation occurs only at the site of the convergence. Temperature feedback is achieved continuously during the therapy. The FDA approved the use of this modality in the treatment of uterine fibroids following the completion of a multicenter trial, published in January, 2006. This is the only known published trial with a follow-up of clinical outcomes. 176 women were entered, and 109 treated, indicating a large exclusion. Uterine volumes, symptom severity scores and quality of life scores were performed. A mean of slightly greater than one fibroid was treated per subject. Given the strict limits on the size of the ablation, less than 10% of the uterine volumes were treated. The authors concluded that the treatment held promise for a noninvasive method of fibroid treatment, but cautioned that a randomized clinical trial was necessary to confirm whether this is an effective treatment options for fibroids. The efficacy and safety of the proposed treatment has been placed into serious question by peer review. Although the study was well done in its limited context, it is curious the FDA would approve this modality given the small patient numbers reported, the short follow-up and poor shrinkage response of the lesions. The authors themselves admit the significant limitation of the study and that more and larger studies are required to alleviate these concerns and to adequately establish this treatment as within the standard of care. In addition, there are still no adequate peer-reviewed studies directly comparing the safety and efficacy of MRI-guided focused ultrasound ablation with standard interventions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Taxotere (docetaxel) and irinotecan for the treatment of her pancreatic cancer. Findings:  Two physician reviewers found that there is no clear-cut choice for second-line chemotherapy in the treatment of metastatic pancreatic cancer. All such treatments must be considered investigational due to a lack of controlled data indicating a clear impact on survival. However, there have been at least two recent reports suggesting some real clinical benefit with the combination of irinotecan with Taxotere. These studies coupled with the patients clinical response, suggest irinotecan with Taxotere is the most advantageous treatment option at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 14-year-old female have requested growth hormone therapy for treatment of short stature.  Findings:  The physician reviewer found that there is no medical documentation to support the necessity of growth hormone therapy in this case. In fact, administration of growth hormone at the patients current bone age maturation can be detrimental.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for an X-Stop procedure for treatment of her back pain. Findings:  Two physician reviewers found that there is no class I data demonstrating that X-Stop is more effective or equally effective as other available treatments. It is unclear whether this patients condition is appropriate for consideration of the X-Stop. Based upon available evidence it is unlikely the patient will derive long-term benefit from the X-Stop procedure. There are on-going studies and upon conclusion of these studies there may be sufficient evidence demonstrating the effectiveness of X-stop; however, at this time the long-term safety and efficacy of X-Stop remains unknown.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female has requested Actonel 35mg twice weekly for treatment of Pagets disease.  Findings:  The physician reviewer found that Actonel is an appropriate agent for Paget's disease. However, the standard regimen for Actonel treatment of Pagets disease is 30mg every day (not weekly or twice weekly). The patient should continue on daily Actonel 30mg for six months with monitoring of AP levels (in the absence of clinical symptoms). If this regimen fails, it would then be appropriate to switch to a parenteral agent.