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

A 62-year-old female enrollee has requested for a pneumatic compressor system for treatment of her condition status post massive rotator cuff repair surgery.   Findings:  Three physician reviewers found that there is no peer-reviewed medical literature with long-term clinical trials that proved an electronically controlled thermal unit is more effective and superior to the traditional use of ice packs for cold application to control pain and swelling.  Thus, there is no indication that the device at issue is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.    Findings:  The physician reviewer found that the use of Botox has been shown to be effective in a number of studies as a headache preventive.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for ultrasound-assisted liposuction for breast gynecomastia for treatment of the enrollees bilateral gynecomastia.    Findings:  The physician reviewer found that there are no abnormalities found on physical exam including hepatic, renal, or thyroid        function and no documentation of evaluation of abnormalities of any serum profiles.  There are no biopsies, and no tissue diagnoses of gynecomastia. . There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. No loss of functioning member is documented in the record.  The surgery was not performed to improve function or create a normal appearance to the extent possible.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for Aciphex 20mg for treatment of her gastroesophageal reflux disease (GERD).    Findings:  The physician reviewer found that proton pump inhibitors (PPIs) continue to be the backbone of therapy to fight acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant or differences in their effects with regards to clinical or endoscopic end points or side effects profile.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 10-year-old male enrollee have requested  for inpatient neuropsychiatric hospital stay for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that the differential diagnosis for this patient includes Bipolar Disorder or a primary Psychotic Disorder on the order of Schizophrenia. Certainly, the manner of treatment which proved at least somewhat effective could well span either diagnostic consideration.  However, to the extent that the patient was quite impaired (and his home environment unstable), some manner of extended time in an inpatient setting to ensure the patients improvement was imperative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested vertebral corpectomies (posterior and anterior) for the treatment of his degenerative disease of the lumbar spine and post laminectomy syndrome. Findings:  The physician reviewer found that this patient did not need the corpectomies (taking the whole vertebral body) listed by the CPT codes billed based on the imaging studies provided. The imaging studies indicate that the patients spinal cord and nerve root compression was only at the disc level. It was not behind the vertebral bodies. A corpectomy (removal of the vertebral body) is only needed if the imaging studies show compression behind the vertebral body. That was not the case here. Discectomy-only surgery was the most appropriate surgery in this patients case. The billed CPT codes for the anterior and posterior corpectomies should be denied as they were not medically necessary to treat this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for the use of AlloDerm in breast reconstruction surgery post-mastectomy for treatment of her post-mastectomy condition.   Findings:  Three physician reviewers found that prosthetic breast reconstruction with implant or expander is a current standard in immediate breast reconstruction post-mastectomy. A key issue with this surgical technique is attaining adequate pectoralis major muscle coverage of the implant/expander such that the prosthesis is held in place within the mastectomy pocket. Muscle loss during mastectomy and the poor quality of the remaining muscle could preclude extending the muscle over the prosthesis and securing it at the lower breast pole. Current options to supplement the muscle deficiency include the transfer of autologous tissue from the latissimus dorsi, the elevation of the external oblique muscle together with its rectus abdominus fascia for implant coverage, or the elevation of the serratus anterior muscle for lateral implant coverage. All of these options introduce further morbidity and, in the case of the latissimus tissue, has the added disadvantage of donor site complications.  The strength and flexibility of AlloDerm, as well as its ability to resist infection and rejection and to rapidly regenerate into viable tissue without scarring and fibrosis, makes it an ideal tissue substitute to supplement the muscle deficit at the lower breast pole. As a tissue replacement at the lower breast pole, AlloDerm helps to define the shape and contour of the reconstructed breast and better defines the inframammary pole.   A study by Spear of 100 patients undergoing implant expander coverage with AlloDerm has shown no incidence of hematoma, seroma, infection, or implant exposure as well as a decreased incidence of capsular contracture.  At least eight other studies show that AlloDerm can prevent rippling, symmastia, implant malposition, and bottoming-out, all common problems with expander based breast reconstruction.  AlloDerm is incorporated into the surrounding tissue and late re-operative biopsies show that over time AlloDerm takes on the histologic characteristics of fascia.  Based on the medical literature, the use of AlloDerm for breast reconstruction is appropriate and represents appropriate care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for an open-wedge tibial valgus osteotomy with internal fixation allograft bone grafting with an osteochondral allograft OATS procedure for the left knee for treatment of her left knee osteoarthritis.   Findings:  Three physician reviewers found that the requested OATS with allograft is experimental for the treatment of knee degenerative joint disease. This procedure combined with osteotomy lacks long-term outcomes follow-up. More outcomes data is needed to establish the safety and efficacy of this procedure in this type of case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for residential treatment for treatment of her anorexia nervosa.    Findings:  The physician reviewer found that the key issue is her chronic resistance to outpatient treatment, and the efforts of primary care physician and other specialists trying to help her. Her ED was chronic, persistent and severe. Her motivation for outpatient treatment was poor, and I believe that she would have declined further if residential treatment and partial hospitalization programs had not been available to her. She did well and required the DBT approach, combined with the structure and supervision of 24 hour care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for 21 hours of neuropsychological testing for evaluation of the enrollees Aspergers Syndrome. Findings:  The physician reviewer found that three days of evaluation and testing to develop appropriate recommendations for this patient are far in excess of what a practical assessment would require. The additional testing is only likely to confirm the patients known deficits. The psychologist is not doing a case study for a clinical thesis, but is requested to diagnosis the less than obvious in order to improve the patients ability to cope in the classroom and develop social skills.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested  for a Magnetoencephalograpy (MEG) for evaluation of the enrollees seizures.   Findings:  Two physician reviewers found that the medical experience with MEG is increasing and there is a substantial amount of literature about the usefulness and advantages of MEG over traditional methods of preoperative evaluation for neurosurgical treatment of intractable seizures. Many institutions depend on MEG for these type of evaluations and believe that it is rapidly becoming the standard.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested for referral and treatment by a neurologist who specializes in treating patients with multiple sclerosis (MS) for evaluation and  treatment of his MS.    Findings:  The physician reviewer found that patients with MS should be under the care of a neurologist, preferably one who is familiar with the disease and comfortable with caring for MS patients.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested for vertebral axial decompression therapy for treatment of her lumbar pain and disc herniation at L4-L5.   Findings:  Three physician reviewers found that decompressive spinal therapy is no more effective in improving pain and decreasing disability than other standard treatments of lower back pain with or without sciatica. Although there may be anecdotal reports of decompressive therapy providing relief, this is not supported by the scientific studies available. It is also not clear as to whether the patient has tried all other standard treatments (e.g., physical therapy or other non-surgical treatments).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 56-year-old male enrollee has requested for continued care at a skilled nursing facility (SNF) for treatment of his cerebral vascular accident (CVA).    Findings:  The physician reviewer found that there is no expectation that continued daily skilled rehabilitation services will significantly alter the patients functional status. He continues with a dense hemiparesis and has made excellent functional progress. However, without more neurological recovery he is not expected to experience additional functional recovery with skilled rehabilitation. The literature is very clear  skilled rehabilitation does not increase neurological recovery. Additionally, the level of function the patient has reached places him at a level that no longer requires inpatient services. His needs for assistance could be met at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested for a PET scan for evaluation of his Ewings sarcoma. Findings:  Three physician reviewers found that according to the National Cancer Institute, PET scans in patients with metastatic Ewings sarcoma have a relevant impact on therapy planning. The conventional studies (bone scan and CT studies) did not show the patients recent recurrent pelvic tumor. To properly re-stage this patient, a PET scan is medically appropriate and indicated, as conventional imaging has not been able to properly ascertain this patients disease state.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for an MRI of the brain and sinuses for evaluation of his facial and sinus pain. Findings:  The physician reviewer found that CT of the sinuses is accepted as useful in diagnosing sinusitis, in conjunction with relevant clinical and laboratory findings. No clinical differential diagnosis is recorded. A thorough exam should be performed of the head and neck area, as well as an appropriate neurologic exam.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested for Botox injections for treatment of her migraine headache.   Findings:  Two physician reviewers found that the patient has a diagnosis of migraine, although the frequency and severity are not documented and the effect of prior preventives is not documented. The effect of prior Botox treatment has not been documented by the physician. Although Botox has been shown to be beneficial for preventive management of chronic migraine, the records submitted do not demonstrate that the patient has chronic migraine with failure to respond or intolerable side effects to appropriate conventional preventives. If such records do exist and substantiate a refractory pattern, Botox should be approved for headache prevention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for total abdominal hysterectomy and anterior repair for treatment her condition. Findings:  The physician reviewer found that anterior vaginal prolapse (cystocele) may be repaired with traditional midline anterior colporrhaphy as is planned in this case, with or without the addition of mesh or graft material, or by paravaginal repair, which can be accomplished vaginally or retropubically by open or laparoscopic access.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested for a wearable cardioverter-defibrillator for treatment of her wide complex tachycardia.   Findings:  Two physician reviewers found that without electrophysiology guidance, it would be impossible to definitively assess a medication that would be able to suppress this symptomatic arrhythmia, and repeat cardioversion may be necessary. Therefore, a reasonably clinically acceptable alternative would in fact be a Life Vest for detection and electrical treatment of a recurrent dysrhythmia. A Life Vest for this patient was medically indicated and continues to be appropriate for the time it takes to complete a cardiac MRI and electrophysiology study to determine the etiology of her tachycardia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for Provigil for treatment of her shift-work sleep disorder.    Findings:  The physician reviewer found that shift-work sleep disorder is a well-known indication for treatment with Provigil
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for gastric bypass/lap band surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the criteria for the procedures include: a BMI of 40 or greater than 35 with co-morbidities. In this situation although her BMI has fluctuated in and out of the necessary range, there are no co-morbid conditions. She does claim unsuccessful attempts at weight loss but there is no documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a functional neuromuscular stimulator for treatment of his foot drop.   Findings:  Two physician reviewers found that the current medical literature and the current standards of care do not support the need for the requested device in this clinical situation. There is inadequate evidence the Bioness device is likely to be superior to a standard ankle-foot orthotic in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for Botox injections for treatment of her headache.   Findings:  Two physician reviewers found that there is no indication about previous use of beta blockers, Depakote or antidepressants. While Botox has been shown to be effective in chronic migraine, it is not clear that this patient currently meets the criteria for this diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for out-of-network inpatient chemical dependency program treatment for treatment of his opioid drug addiction.   Findings:  The physician reviewer found that there is no convincing evidence here to mandate a medical necessary inpatient program, particularly out-of-network. There is no evidence of sufficient medical or acute psychiatric risk factors to require inpatient care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for residential treatment services for treatment of her anorexia. Findings:  The physician reviewer found that there is more than adequate evidence that extended residential treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested sacral nerve stimulation for the treatment of her fecal incontinence. Findings:  Two physician reviewers found that the minimally invasive technique of sacral nerve stimulation (SNS) is safe and effective. Most adverse effects can be easily remedied. Data has demonstrated that SNS significantly improves patients quality of life, including their physical and psychological well-being. Sacral nerve stimulation is an effective and safe long-term treatment for fecal incontinence. Clinical outcome has been stable over time. There is adequate literature published regarding this issue and in this particular patient, sacral nerve stimulator is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin as a consequence of bariatric surgery. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the requested surgery is medically necessary for this patient. No photographs were available for review. However, based on the clinical information provided, it does not appear that the amount of excess tissue involved is sufficient to cause the patients physical complaints. There is no objective evidence of a chronic functional problem that has failed to respond to conservative therapy. Furthermore, it does not appear the requested procedure is reconstructive in nature. The patient has generalized skin laxity consistent with her history of massive weight loss, which does not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a partial nephrectomy performed by a urology oncologist who specializes in kidney surgeries for treatment of her renal cell carcinoma. Findings:  The physician reviewer found that a well-trained urologist should be able to perform a nephrectomy (either partial or total) using an open approach. A urologic oncologist may have additional skills for highly selected diseases and patients, but a partial nephrectomy would not likely fall within this spectrum.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for Botox injections for treatment of his condition.   Findings:  Two physician reviewers found that the Botox treatment pattern does not address the usual muscles for dystonia, but rather are more typical of sites used for treatment of migraine. The medical records do not address the frequency, severity or qualities of the patients pain, nor does it address the response to various treatments, including Botox. There is insufficient evidence to support the diagnoses of oromandibular dystonia or chronic migraine.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that this patient had been suffering a cough for two days, she did report chest pain as well as shortness of breath. Indeed, records note her to be in mild distress and she was immediately treated with inhaled bronchodilator therapy as well as intravenous steroids.  According to the documents provided, this patients symptoms of shortness of breath and chest discomfort met the prudent layperson criteria for an emergency. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition. Findings:  The physician reviewer found that this need can be met by taking frequent breaks while driving, or he can recline in a private vehicle being transported by someone else. There is no documentation that the patient has any unusual anatomy or skin breakdown such that he cannot be positioned in a private vehicle.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for Vanos (0.1%) topical cream for treatment of his stasis dermatitis.    Findings:  The physician reviewer found that it is reasonable to require the use of at least two alternative class-I steroid creams because this patient has not had trials of at least two Health Plan formulary topical steroids in the very high potency group, Vanos (0.1%) is not medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for Botox injections for treatment of his myofascial pain.   Findings:  The physician reviewer found that Botox has been proven to be useful in multiple conditions or pain disorders resulting from muscle spasms. Hence, the use of Botox therapy to relax muscle spasms in the TMJ area would decrease the pain and discomfort that he suffers from. In addition, the article cited above supports the use of Botox therapy to treat headaches related to temporomandibular dysfunction.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for continued skilled nursing for treatment of her back pain. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that although the patient was unable to complete a course of rehabilitation, she has been making some progress. While the patient is not likely to experience a dramatic recovery, additional skilled care services are appropriate to continue the gains she has already made.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a sixteen-year-old female enrollee has for continued eating disorder residential treatment for treatment of the enrollees bulimia nervosa. Findings:  The physician reviewer found that the medical records document that the patient is still quite fragile emotionally and is not stable enough to be treated at a lower level of care. The patient has failed outpatient treatment, intensive outpatient treatment and partial hospital and residential treatment in the past. She has tried multiple medications and therapy. The medical documentation demonstrates that the patient continues to need ongoing stabilization at the residential treatment facility.