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

A 51-year-old female enrollee has requested vaginal surgery for the treatment of her bladder problems. Findings:  The physician reviewer found that the treatment options for stress urinary incontinence (SUI) include surgical, pharmacologic, pelvic floor strengthening rehabilitation, and a combination of these options. However, it is extremely important that a firm diagnosis of SUI be made in order to have acceptable outcomes, as conditions other than SUI, or those in conjunction with SUI, may be present. The patients history, physical, and pelvic examination are crucial to evaluating these differential diagnoses. Urodynamic testing is an important component to the workup and standard of care. Cystoceles will commonly cause pelvic pressure and related symptoms, as well as predisposition to cystitis. The mere presence of a cystocele is not firm evidence of SUI; a urodynamics study is required to confirm the diagnosis of SUI. The urodynamics testing in this case did not support the presence of SUI. The history and pelvic examination do not support the diagnosis of a symptomatic cystocele, rectocele or enterocele. The proposed procedures for SUI, cystocele, rectocele and enterocele are therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Provigil 100mg for the treatment of her conditions. Findings:  The physician reviewer found that the solidity of the patients most recent depressive episode, sufficiently severe that she had not been able to work at a job she had done previously, in comparison to the notable improvement she had with the Provigil, Effexor, and Seroquel, it appears incontrovertible that Provigil should be continued.  There is never a guarantee of no relapse with any combination of medication, but to the extent that the patient is so much improved with the latter combination, there appears to be nothing to be gained by changing any of it currently. Provigil is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for the treatment of her interstitial cystitis. Findings:  Three physician reviewers found that PTNS is not likely to result in a lasting improvement as this therapy is entirely experimental and investigational. It has not been proven unequivocally to result in superior outcome over conventional therapy. There are no evidence-based studies which show superiority.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested ultraviolet light therapy for the treatment of the enrollees acne. Findings:  Three physician reviewers found that the interventions performed on many occasions on this patient are not the standard of care. There is no indication that the patient was treated with Accutane therapy or that such treatment was contraindicated. Accutane therapy was indicated for this patients condition and would likely have benefitted the patients condition more than the actinotherapy and the other treatments provided.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from an acute (although recurrent) headache of sufficient severity of pain that one would reasonably believe failure to obtain immediate medical attention could result in serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of a bodily organ.  Although she had a history of headaches in the past, the patient reported that her headache was severe.  The fact that her heart rate was elevated is evidence of severe pain.  In addition, her history of hypertension does put her at risk for a variety of potentially life-threatening disorders including hypertensive emergency manifesting with severe headache, intracerebral hemorrhage, and others.  It was important that the patient receive medical evaluation and treatment.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented with symptoms of heart racing, sweating, tremors, chills, shortness of breath and blurred vision.  This constellation of symptoms is consistent with a variety of disorders such as acute coronary syndrome including cardiac ischemia and myocardial infarction, cardiac dysrhythmia, hypoglycemia, hypertensive emergency, and other disorders.  The symptoms that he was experiencing were sufficient to cause a reasonable prudent layperson to believe that an emergency medical condition existed.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested Cyberknife stereotactic radiosurgery for the treatment of her spinal tumor. Findings:  Two physician reviewers found that Cyberknife radiosurgery has become a well-established treatment modality in the management of selected patients with spinal tumors. Spinal stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of benign spinal lesions. Its major potential benefits are the relatively short treatment time in an outpatient setting and the minimal risk of side effects. This new technique offers an alternative therapeutic modality for the treatment of a variety of benign spinal neoplasms in cases in which surgery cannot be performed, in cases with previously irradiated sites, and in cases involving lesions not amenable to open surgical techniques or as an adjunct to surgery. Cyberknife is an effective treatment for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested continued residential treatment care for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patients eating behaviors could not be adequately controlled outside of a 24/7 residential facility such as the one to which she had been admitted. Although not well documented, it appears that the patient had received prior outpatient care from both a psychiatrist and therapist. While she was reasonably stable medically, there were orthostatic issues and laboratory values of concern. She was clinically depressed and had just begun to voice suicidal thoughts. It would be unsafe and not prudent to treat this patient outside of a residential facility. This patients condition requires residential care. The continuing need for such care should be reviewed at least monthly.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female is requesting speech therapy for the treatment of the enrollee's pervasive developmental disorder (PDD), autism spectrum. Findings:  The physician reviewer found that virtually all medical studies of autistic spectrum children have established the need for speech therapy intervention. Multiple studies have concluded the need for speech therapy to be initiated at time of diagnosis and to continue until the child improves speech competency to an age-specific level.  In this child, the need for speech therapy is medically necessary.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

An enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient presented to the medical center complaining of abdominal pain which she described to be of sufficient severity that a prudent layperson would reasonably seek immediate medical attention due to fear for jeopardy to her health and/or function.  Although she ended up not having a life-threatening disorder causing her abdominal pain, the evaluation was necessary to ensure that her health was not in jeopardy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that fever and severe head pain in a young child may be indicative of a wide range of maladies, from ear infection to sinusitis to life-threatening meningitis. It is often quite difficult for children to accurately communicate the location of pain. Further, parents should not be expected to interpret their childrens symptoms. A clinical assessment most often is required to identify the source of the pain. In this childs case, the parents took appropriate action. They administered a pain reliever and waited for effect. When no effect was evident, they contacted their health care provider for advice. They were instructed to seek medical attention for their child. Only upon physical examination was the source of pain identified as an ear infection. Given the nature and severity of the childs symptoms, it was reasonable and appropriate for the patients parents to seek evaluation at the closest emergency department.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a two-year-old male enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the Health Plans definition of medical necessity for speech therapy includes congenital abnormalities, therapy with specific goals and reasonable outcomes and delivery by a qualified therapist.  The Health Plan specifically excludes speech therapy that does not result in practical improvement in a measurable time frame and treatment not supported by peer-reviewed medical literature.  These requirements are medically reasonable and appropriate. The speech therapy services provided were medically necessary and indicated for treatment of this patient.  However, speech therapy beyond the dates in question are not medically necessary at this time, as the patient requires repeat evaluation to determine if the services are being effective.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested lysis of epidural adhesions for the treatment of her cervical, thoracic and lumbar radiculopathy. Findings:  Two physician reviewers found that the practice guidelines previously cited support the use of percutaneous epidural adenolysis in this patient. These guidelines reviewed five randomized trials, two prospective evaluations and three retrospective evaluations for percutaneous lysis of lumbar epidural adhesions. The Health Plan policy incorrectly states the evidence is unchanged from 2005.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested reconstructive surgery to remove keloid scars for the treatment of her condition. Findings:  The physician reviewer found that the patients keloid scars are painful.  A study by Bock and colleagues found that keloids significantly impair quality of life when they cause pain, pruritis or restriction of mobility.  A study by Lee and colleagues found that pain and pruritis are common keloid symptoms, and the history of pain from the ear keloid is consistent with the known natural history of keloids.  This patients keloid is painful enough to interfere with her ability to sleep.  Treatment of the painful keloids is appropriate to treat the patients pain and improve her ability to sleep and the quality of her life.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested Luprolide Acetate Depot (Lupron) for the treatment of the enrollees Russell-Silver Syndrome. Findings:  The physician reviewer found that the additional administration of Lupron is clinically sound since the patient is already in established puberty. The addition of Lupron to the patients growth hormone regimen will delay full puberty and closure of the patients epiphysis. Since the patient meets FDA criteria for growth hormone, the concomitant use of Lupron is clinically appropriate and medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested speech therapy services for the treatment of his voice problems. Findings:  The physician reviewer found that this patients condition is related to chronic dysphonia, superior laryngeal nerve paresis, muscle tension dysphonia, vocal fold varicosity, and bilateral superior laryngeal nerve paresis and is not purely related to reflux laryngitis. The therapy at issue was requested and performed under a physicians order and oversight. The treatment was medically reasonable and necessary with an expectation for practical improvement. The patient had an identified condition of the vocal apparatus and the therapy provided was consistent with the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested a feeding therapy program for the treatment of the residual effects of the enrollees premature birth. Findings:  Three physician reviewers found that this patient appears to be doing well despite her multiple medical problems. Pertinent to feeding, she has had remarkable success with the intensive feeding therapy program she has participated in during the past several months. The patients growth chart demonstrates acceleration from less than the 3rd percentile to about the 25th percentile.  This result is comparable to a surgically placed feeding tube. Thus, in this case the feeding therapy program has been both efficacious and efficient in correcting the patients poor nutrition and poor weight gain without surgical intervention.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the Health Plans denial should be reversed because of the gross hematuria. The emergency room visit was justified. The prudent layperson would and often does seek emergency room care when he or she suddenly starts passing blood in the urine, no matter what the cause. The etiology of the blood is not known when it first develops and may represent a much more serious underlying condition. Also, most urinary tract infections do not cause gross blood in the urine.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that an individual must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention to result in serious jeopardy to her health. Although this patient did report pain, the pain started the day prior. She required only acetaminophen for pain control in the emergency department. The patient did not have the acute onset of any other symptoms of a severe ear problem such as dizziness, vomiting, or hearing loss. While her ear pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, her symptoms do not meet criteria for an emergency.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that a patient must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although this patient did report pain, the pain was not acute in onset. His testicular pain had been present for two months. Further, the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain. While his ongoing testicular pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, his symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested a bunionectomy on her right foot for the treatment of her foot pain.    Findings:  The physician reviewer found that hallux valgus deformity is a painful deviation of the great toe laterally, causing a pronounced bump to the medial aspect of the forefoot. Deviation of the first toe joint may also cause arthritis. As seen with this patient, the large medial bump can cause severe pain to the joint area, as well as severe friction with subsequent skin breakdown. Most patients instinctively try wider shoes to alleviate the pain. Currently, the standard of care is to surgically correct bunions to avoid medial eminence ulcerations. This is especially so for diabetics, such as this patient. Surgical correction of the bunion will afford better shoe fit, reduced chance of skin ulcerations, and comfortable ambulation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested continued Myobloc injections for the treatment of her cervical pain. Findings:  The physician reviewer found that there is inadequate documentation of the durational characterization of the patients cervical dystonia to support the need for Myobloc injections. Specifically, the degree of rotation, flexion and extension are not delineated. Additionally, there is no indication whether the dystonia occurs with specific actions, is characterized by overflow, or is present at rest. Nor is it documented whether certain sensory tricks temporarily suppress dystonia movements. Furthermore, the duration of the cervical dystonia is not clearly delineated in the records provided. As such, there are insufficient findings supporting the need for further treatment with Myobloc.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Enbrel 50mg twice a week for the treatment of her autoimmune inner ear disease (AIED). Findings:  Two physician reviewers found that the Health Plan has apparently acknowledged the appropriateness of using biologic agents including Humira and Enbrel to treat this patients illness. At issue now is whether the proposed dosing of Enbrel is likely to have greater efficacy for this patient than standard therapies. The patient and her physician report that Enbrel 50mg twice weekly has been clearly more effective than standard dosing. Based on this finding, the increased dose of Enbrel has already proven to be more effective than standard therapies for this patients illness. Accordingly, there is sufficient evidence of the benefit of twice daily 50mg Enbrel to support its use in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that this is not revisional surgery. The patient has multiple obesity-related comorbidities that will be ameliorated or eliminated by bariatric surgery. She has passed medical and surgical evaluations. The requested surgery is medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested emergency services for the treatment of her condition.  Findings:  The physician reviewer found that the patient was suffering from acute onset of abdominal pain of sufficient severity that a prudent layperson would seek immediate medical attention due to concern for potential jeopardy to her health or function.  Her pain was acute and not normal for her.  The constellation of symptoms that the patient was experiencing were consistent with a variety of potentially life-threatening disorders, including pulmonary embolism, acute coronary syndrome, as well as other disorders including acute cholelithiasis, hepatitis, pancreatitis, peptic ulcer disease, urinary tract infection and others.  It was important that the patient was evaluated to ensure that her symptoms were not due to a life-threatening disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition. Findings:  The physician reviewer found that there is a lack of documentation justifying the MRI scan. There is no orthopedic exam is available to review in order to justify the MRI scan.  The MRI report describes some vague findings with respect to the menisci.  Grade II signal commonly is associated with myxoid degeneration of the meniscus, and there is no unequivocal description of pathology within the knee which even retrospectively could be construed as findings requiring operative intervention or even more conservative management such as lack of weight bearing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a Power Scooter with lighting package for the treatment of her condition. Findings:  The physician reviewer found that in the medical records submitted the physician reports support that the patient is ataxic and can move about two steps independently. She holds onto the bar of a scooter to transfer. It is reported she has had a scooter for over 30 years for indoor and outdoor use. The requested equipment is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested robotic-assisted laparoscopic radical prostatectomy for the treatment of his prostate cancer. Findings:  Two physician reviewers found that this young patient with prostate cancer has requested a robotic-assisted prostatectomy procedure. The literature regarding robotic prostatectomy shows a decreased operative blood loss and decreased risk of transfusion of blood using the robotic approach. It also shows faster convalescence after robotic surgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Avastin for the treatment of her recurrent primary peritoneal carcinoma. Findings:  Two physician reviewers found that Avastin is a monoclonal antibody targeting VEGF. It is approved for the treatment of colon cancer, lung cancer and breast cancer. It has been studied in a number of other cancers, including primary peritoneal cancers. The use of Avastin in ovarian cancer (including primary peritoneal cancer) is endorsed by the National Comprehensive Cancer Network (NCCN). Based on the available evidence, the efficacy of Avastin in this setting has been sufficiently established.