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

The parent of a five-year-old male enrollee has requested continued occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the requested occupational therapy services are medically necessary for this patient. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process.  As such, occupational therapy for this patient at the frequency requested is necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for Gleevec for treatment of his metastatic mucosal melanoma. Findings:  The physician reviewer found that acceptable treatment for relapsed metastatic melanoma includes dacarbazine, high dose interleukin-2, dacarbazine-based or temozolomide-based combination chemotherapy/ biochemotherapy, temozolomide and taxane-based chemotherapy. The role of Gleevec in these tumors has been studied in several phase II trials without definite evidence of benefit.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for nasal surgery for treatment of his deviated septum.  Findings:  Three physician reviewers found that the clinical evidence documents significant nasal airway obstruction with almost 100% blockage on the right and 75% blockage on the left. Nasal surgery, including septoplasty and turbinate reduction is the standard of care for treatment of nasal airway restriction that is refractory to medical treatment.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for services provided by an out of plan/out of country provider on an urgent basis. Findings:  The physician reviewer found that out of plan emergency services are those obtained from an out of plan provider due to the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. Urgently needed services are those obtained due to an unforeseen illness or injury while traveling outside ones service area, when it would be unreasonable to delay services until a patient can return to his service area. This patients attacks of biliary colic and pharyngitis as well as the outbreak of herpes simplex were all due to unforeseen illness. The patient was suffering from chronic cholecystitis, and he had a dilated common bile duct, which raises the question of bile duct obstruction. Although he was not experiencing acute cholecystitis at any time, there was potential for him to develop total biliary obstruction and eventual cholangitis or pancreatitis. It would not have been prudent for him to travel the distance from Bolivia to California on a commercial aircraft until this situation had resolved. The cholecystectomy was urgently required, and the patient could not wait to return to his service area for this service. Cardiology clearance was required preoperatively on an urgent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a referral to a diethylstilbestrol (DES) knowledgeable doctor for the treatment of the enrollee, who is a DES daughter. Findings:  The physician reviewer found that this patient has already been properly evaluated for abnormalities, which has taken into account her history of DES exposure. She has had thorough breast and pelvic examinations, mammography, cervical and vaginal cytology and a screening vaginal and cervical colposcopy.  Her transient minimal pap smear abnormality was managed based on established national criteria, and this was appropriate as noted by the National Cancer Institute.  All of this is well within the realm of routine gynecologic care available within her Health Plan, and there is no medical indication for her to see another provider elsewhere for the same evaluation.  In summary, there is no medical indication for her to be seen by an outside or additional consultant at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for INBONE total ankle replacement surgery for treatment of her medical condition status post shattered ankle sustained in a motor vehicle accident.  Findings:  Three physician reviewers found that Total ankle arthroplasty is an increasingly utilized medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis is a long running clinical debate that has yet to be concluded. Thus, the long-term superiority of arthroplasty over arthrodesis has not been established. Moreover, given this patients young age, the possibility that the arthroplasty will wear and require revision is very likely.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for Aciphex for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although interpatient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for serologic diagnosis of celiac disease for evaluation of the enrollee in order to rule out celiac disease. Findings:  Three physician reviewers found that there was no clear indication for celiac testing in this case. If celiac disease was considered, then a serum tissue transglutaminase antibody and total IgA would have been sufficient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for continued intravenous Rocephin therapy for treatment of the enrollees Lyme disease. Findings:  Two physician reviewers found that there is no clear evidence that the patient has any infectious process to explain her symptoms. With regard to Lyme disease, there is no mention of a tick bite or an erythema migrans eruption.  The clinical symptoms described are all not specific and do not suggest a diagnosis of Borrelia infection. The definitive tests for Lyme disease (IgM and IgG Western Blots) have been equivocal on several occasions, although the positive IgG studies suggest that at some point the patient has been infected with Borrelia burgdorferi.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has for Nutropin AQ 10mg/2ml for treatment of the enrollees short stature.   Findings:  The physician reviewer found that From the standpoint of the FDA, GH is not indicated for those children whose predicted adult height is greater than 160 cm. Based on the information provided, the patients predicted adult height is near 510 (177 cm), and therefore the patient does not qualify for treatment with GH therapy under the FDA guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the lumbar spine and pelvis for evaluation of her lumbar back and leg pain.  Findings:  The physician reviewer found that the available clinical history indicates the patient has back pain, leg and hip pain, and weakness and atrophy of the leg. This history alone implies compression to a nerve, either in the lumbar spine or in the lumbosacral plexus in the pelvis. The possible causes include a disc herniation, lumbar spinal stenosis or lateral recess stenosis, an infection or a tumor involving the nerve root sheath in the spine or pelvis. The best available diagnostic test to rule out these possibilities is an MRI. This would avoid more indirect tests and it is non-invasive.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for enhanced external counterpulsation for treatment of her angina.   Findings:  Two physician reviewers found that it does not appear that repeat coronary angiography was considered post CABG; there are no documented contraindications to this procedure. The standard treatment in this case would first be a trial of maximal medical therapy and reexamination as to why she had angina after surgical revascularization, prior to consideration of EECP. EECP could be later reconsidered if the patient has continued Class III to IV angina, despite maximal medical therapy and the inability to further revascularize the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for laparoscopic band gastric surgery (bariatric lap band for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines set by the National Institutes of Health for weight loss surgery. There is a large amount of data that shows that non-surgical methods of weight control are inferior to surgical procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that there is no report of muscle hypertrophy, sensory trick, or indication of sustained abnormal posture despite muscle spasm. Cervical dystonia (CD) is a condition characterized by abnormal involuntary excessive muscle activity, with spasms, muscle hypertrophy, altered posture, and altered mobility. It is often associated with pain, may have dystonic tremor components, and often, patients have found sensory tricks that partly reduce symptoms. While Botox is indicated for the treatment of CD, the patients findings are not consistent with a diagnosis of CD. All told, the submitted records do not support the use of Botox in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for total hip resurfacing for treatment of her osteoarthritis.  Findings:  The physician reviewer found that there is no evidence of end-stage left hip disease. Physical examination indicates a lack of terminal left hip range of motion (ROM) parameters. While there are findings consistent with degenerative joint disease, the patient does not have end-stage pathology. Nor is there documentation of attempts at conservative treatment including physical therapy, home exercise program or non-steroid anti-inflammatory drugs (NSAIDs).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.  Findings:  Three physician reviewers found that guidelines from the American College of Cardiology (ACC) in 2006 regarding the recommended treatment of PAF. The decision to anticoagulate the patient with aspirin versus Coumadin is typically made by assessing her risk factors such as age, valvular disease or CAD. Real time telemetry has not been shown to change the assessment of the need for anticoagulation. Electrocardiogram monitoring has been recommended in the assessment episodes of asymptomatic PAF or to judge the adequacy of rate control. However, the guidelines do not, as of yet, recommend a real time component to the monitoring. Prolonged or frequent monitoring may be necessary to reveal episodes of asymptomatic atrial fibrillation (AF), which may be a cause of cryptogenic stroke. Ambulatory ECG (i.e., Holter) monitoring is also useful to judge the adequacy of rate control. This technology may provide valuable information to guide drug dosage for rate control or rhythm management.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for high dose radiation (HDR) brachytherapy for treatment of his prostate cancer. Findings:  Two physician reviewers found that within the guidelines supporting intermediate risk, recommendation for patients whose life expectancy is greater than ten years includes either radical prostatectomy or radiation. Interstitial implant alone as monotherapy is not listed as a viable option. Within the section for brachytherapy, it lists either iodine or palladium seeds. High dose brachytherapy is not listed as an option. In summary, using HDR delivered in two separate surgical procedures, delivering three fractions for each (six total) would not be considered standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested continued inpatient stay for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient has a dense compendium of psychiatric problems and was particularly ill across all diagnoses. The severity of her struggles with food continued throughout her stay. Both the pharmacologic as well as psychotherapeutic approaches appear to have been sound. The medical documentation, inclusive of the aforementioned notes, points to the persistence of the patients morbidity throughout the hospitalization. Transfer to a less restrictive setting during the period at issue posed a significant likelihood of deterioration in functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for intensity modulated radiation therapy for treatment of his moderately differentiated adenocarcinoma arising at the gastroesophageal junction. Findings:  The physician reviewer found that there is a lack of support in the literature demonstrating superior results of intensity modulated radiation therapy compared to 3D technique in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that Botox therapy has been widely accepted in specialty headache centers as a useful headache preventive regimen, based on published data as well as completed, but not yet published pivotal trial data from treatment of chronic migraine patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested for a vaginal birth after cesarean (VBAC) for treatment of her pregnancy.   Findings:  The physician reviewer found that there is no current medical evidence suggests that VBAC should be viewed as unsafe or below the generally-accepted standard of medical care. The American College of Obstetricians and Gynecologists (ACOG) has established guidelines and recommendations which need to be discussed with women who wish to undertake a VBAC, since, after a single low-transverse cesarean section, there is a slightly increased risk of uterine rupture with labor (0.5  1.0%). The vast majority of women who attempt VBAC do, in fact, have completely uncomplicated and straightforward vaginal deliveries, with no significant perinatal complications. Still, the role of VBAC remains controversial even in the current state of obstetric practice.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested radiofrequency neuroablation for the treatment of her thoracic spinal stenosis. Findings:  Two physician reviewers found that thoracic facet joints have been implicated as the source of chronic pain in the mid back or upper back in 34% to 48% of patients. Various therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include intra-articular injections, medial branch blocks, and radiofrequency neuroablation of the thoracic facet joint nerves. At this time, there is a lack of outcome data from large, long-term, well-designed studies  demonstrating that radiofrequency neuroablation of the thoracic facet joint nerves confers a superior benefit over standard therapeutic modalities available in this setting. Thus, there is no compelling evidence which clearly establishes that the disputed procedure has greater efficacy in the treatment of chronic back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested inpatient care for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient was suffering from both significant bulimia nervosa as well as major depression, and five days of inpatient treatment would have been insufficient for treatment of this patient.  The treatment notes demonstrate the extent of both of these problems for the patient.  Her psychiatrist approached her care with relevant and current pharmacologic considerations, although any of these medications take time to work.  The patients level of medical morbidity was substantial, and she warranted inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested a six month transition program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patient does have a chronic illness, and she has made clear and substantial progress during the last several months. Her weight is reasonably stable. The patient has been relatively free of eating disorder behaviors. She is attending school and making plans for the future. While she continues to require psychoactive medications, her mood is good, and the patient is functioning at a reasonably high level. It is medically sound and appropriate for the patient to transfer her care from the provider to that of the Health Plan, although a transition for a full six months is not medically necessary. A transition of the patients nutritional treatment services over a one month period is medically appropriate. All remaining services, including services provided by the provider, should be transitioned over a four month period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for lung surgery for treatment of his metastatic lung cancer.    Findings:  The physician reviewer found that a lobectomy, or surgical excision of a lobe, is likely required in this case and remains a contraindication for surgical resection. In addition, this patient has evidence of advanced lymph node disease (hilar and mediastinal nodes demonstrated on PET scan), and in this situation, surgical therapy is not considered first-line therapy. Treatment with chemotherapy and consideration of radiation therapy is appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested for residential treatment for treatment of her eating disorder, alcohol abuse and depression.  Findings:  The physician reviewer found that the patient continued to struggle with intrusive thoughts about disordered eating and body image. Additionally, there were significant symptoms related to her co-occurring disorders. There was an ongoing need for multiple medication adjustments.This level of care is consistent with the American Psychiatric Associations Practice Guidelines for the Treatment of Patients with Eating Disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for artificial intervertebral disc replacement for treatment of his multiple-level degenerative disc disease in the cervical spine. Findings:  Two physician reviewers found that there is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of reoperations, and the potential problems that may occur with longer follow-up have not been fully documented. Anterior cervical discectomy and fusion are considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. Among these, artificial disc replacement seems to be promising. However, segmental motion should be preserved. This is very difficult to judge and has not yet been proven.  No truly blinded studies have been done to establish efficacy, and the results are short-term at best.  Until this is a proven therapy, it cannot be considered to be equivalent or better than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  for acute inpatient psychiatric treatment for treatment of the enrollees autism and depressive symptoms. Findings:  The physician reviewer found that the documentation does not describe the patient as suicidal, homicidal, manic, psychotic, a danger to himself or others, unable to care for himself, or, as having an Axis III condition that required acute, 24-hour skilled and supervised nursing care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for Botox injections for treatment of her spastic paraplegia. Findings:  Three physician reviewers found that Spasticity in the hamstring muscle causes difficulty in widening of hips for access to the urethra, which is required for catheter insertion. Botox injections have been used for many years by physiatrists and neurologists to treat spasticity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested for a magnetoencephalography (MEG) for evaluation of his intractable epilepsy.  Findings:  Three physician reviewers found that MEG scans have been shown to be helpful in localizing an epileptic focus and aid in placement of a cortical grid or depth electrodes in preparation for epilepsy surgery. This patient is clearly a candidate for epilepsy surgery. MEG is widely used at comprehensive epilepsy surgery centers prior to epilepsy surgery and is appropriate for this patients pre-surgical workup.