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

A 55-year-old female enrollee has requested mammoplasty to replace mammary implants for the treatment of her condition. Findings:  The physician reviewer found that the patients implants were originally placed for cosmetic reasons.  Her implants were removed to allow an adequate evaluation of microcalcifications. She does not have breast cancer, and the implants were not replaced for a functional reason or to correct a congenital anomaly or to reconstruct a breast following cancer treatment. For this patient, her original and replacement implants were placed for the sole indication of enlarging otherwise normal breasts. This is the definition of a cosmetic breast augmentation. The insurer does not provide coverage for cosmetic surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested the medication Lyrica for the treatment of her neck and low back pain. Findings:  The physician reviewer found that Lyrica is FDA approved for treatment of fibromyalgia, epilepsy and neuropathic pain associated with herpes and diabetes based upon sufficient peer-reviewed, randomized, controlled trials. In this case, there is insufficient documentation to establish that the patient has a diagnosis of fibromyalgia. Specifically, there is no documentation of 11 out of 18 bilateral tender points above and below the waist, as would be necessary for a diagnosis of fibromyalgia.  Furthermore, the use of low-dose tricyclic depressants as well as gabapentin are standard of care medication trials for both fibromyalgia and off-label neuropathic pain, prior to use of Lyrica.  These medications have not yet been tried in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested continued skilled nursing facility services for the treatment of her condition. Findings:  The physician reviewer found that daily skilled PT and OT are not medically necessary when progress does not continue. Such intense services are not necessary to maintain functional gains. The intense skilled services are necessary to monitor and instruct a patient who is recovering from functional loss.  However, once the recovery has occurred or once a stable functional level has been attained, gains can be maintained with a stable exercise routine that does not require daily PT or OT oversight.  I concur with the denial as the requested services are not necessary, and are not reasonably expected to benefit the enrollee.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a PET scan for an evaluation of his renal cell carcinoma. Findings:  Two physician reviewers found that the patient has repeat testing showing a GFR of 46 and a creatinine of 1.6 places him at risk for contrast-induced nephropathy and contrast infusion would be a study with considerable risk.  In this case, since there is only one remaining kidney, a combination unenhanced CT with PET, would be the procedure of choice to evaluate for tumor staging.  The rationale is this:  An unenhanced CT would be of little value in the detection of abdominal metastases, especially liver.  The combination of a PET scan with an unenhanced CT would be the best way to search for local metastases in order to properly stage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested physical therapy for her rehabilitation status post hip replacement surgery. Findings:  The physician reviewer found that the initial evaluation documentation indicates the patient had a complaint of stiffness in the left hip and right sacroiliac joint.  The only objective information is 10o passive hip flex, 5o hip extension.  The only objective evidence of progress is in a reevaluation.  Physical therapy notes indicate that the patient had increased hip flexion to 125o but no increase in extension.  Most notes document the progress in general terms and statements such as feeling better everyday. Subsequent notes document no consistent improvement in symptoms of pain and stiffness or functional skills. Notes continue to describe progress in vague terms with little objective information. There is some range of motion measurements in the reevaluation but nothing for comparison.  Overall, the patients symptoms appear to be related to increases in ambulation with no evidence of objective progress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male is requesting the medication Aggrenox for stroke prevention. Findings:  The physician reviewer found that Aggrenox has been shown to be an effective medication for preventing strokes.  Although the official study is still pending, in a recent study, cited above, Aggrenox was shown that it has comparable results to Plavix.  Given that the patient has tolerated Aggrenox and has not had any events while taking it, it is medically reasonable to continue with this medication.  Given his successful history with the medication, it is clinically appropriate for the patient to continue treatment with Aggrenox and not discontinue this successful treatment with a trial of another medication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of an 11-year-old male enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no evidence that the patient has failed a standard growth hormone therapy provocative test. In addition, there is no evidence that the patient has a pituitary abnormality. Furthermore, the patients bone age is and has been within normal limits. Moreover, extended growth hormone therapy carries the risk of accelerating epiphyseal plate closure and in fact making the patient shorter than he might have been. For all these reasons, there is no evidence to support growth hormone therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a duodenal switch (DS) for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets the criteria set by the National Institute of Health for weight loss surgery.  A weight loss surgery should not only provide resolution of the co-morbid conditions, but should also have reproducible results, with a predictable outcome. An ideal surgical procedure should maximize benefits while reducing side effects and complications. The duodenal switch operation is an appropriate treatment option for this patient. The duodenal switch operation is a better option for this patient; it has a better long term success when compared to other procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Botox therapy for the treatment of her facial tics due to Tourettes syndrome. Findings:  Two physician reviewers found that there are no adequate large scale clinical trials demonstrating the benefit of Botox for Tourettes syndrome above standard therapies.  In addition, there are standard effective therapies available to this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female is requesting the medication Aciphex for the treatment of her acid reflux. Findings:  The physician reviewer found that PPIs continue to be the backbone of therapy for GERD and are superior to other treatments in providing excellent relief of symptoms as well as healing of erosive and non-erosive esophagitis.  For the most part, all PPIs are equally effective and equivalent in their potency and control of acid secretions.  However, patients differ in their response to specific PPIs. This differential efficacy between patients has been seen with PPIs because of differences in the individual levels of the polymorphically distributed cytochrome P450 (CYP) 2C19 enzyme. In this case, the patient has tried Protonix and Prilosec with no relief.  In addition, the patient has had allergic/adverse reactions with Prevacid and Protonix in the form of nausea, vomiting, headache and neck swelling. This is contrasted with the fact that Aciphex has provided the patient the greatest benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested osteopathic manipulation for the treatment of her heel pain. Findings:  The physician reviewer found that the requested therapy is not medically necessary for treatment of the enrollees condition. There are no Class-1, peer-reviewed data demonstrating that the requested therapy has been proved to be beneficial in systematic reviews of randomized, controlled-trials or from individual, randomized, controlled-trials to support its use in the treatment of heel pain.  Furthermore, there are no studies that have demonstrated the efficacy of this therapy for the treatment of heel pain.  It is not within the standard of care for treatment of heel pain, or part of any published guidelines regarding the treatment of heel pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Remicade infusion for the treatment of her systemic sarcoidosis. Findings:  Three physician reviewers found that cases of systemic sarcoidosis that are aggressive in which there are patients not tolerant of steroids or methotrexate are unusual.  In the absence of patient populations that support prospective clinical trials for evidence based medicine medical care must rely on insight based medicine.  Sarcoidosis in an idiopathic condition felt to be based on immunological derangements, similar to a number of other immunological based conditions.  In these conditions immunological agents such as infliximab are often used after standard treatment with steroids fails.  The safety profile of infliximab is well understood from the total of these clinical experiences.  In the literature, there are reports of the use of infliximab in over 50 patients with systemic sarcoidosis, all of whom responded.  In none of the reports were there unexpected or intolerable side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 18-year-old male enrollee have requested Adult Psychiatric Acute inpatient level of treatment for the treatment of the enrollees condition. Findings:  The physician reviewer found that whether the patient suffers from a psychotic Major Depression or Schizoaffective Disorder, it is clear that he was no longer actively suicidal. Residential or intensive outpatient treatment would appear better suited to helping him with these sorts of struggles than inpatient treatment.  Overall, I find that inpatient treatment was not medically indicated and recommend upholding the Health Plan denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested for abdominal panniculectomy for treatment of his excess skin. Findings:  The physician reviewer found that the records do not provide any objective medical documentation of infections or evidence that the patient has ever seen a physician for assistance with the medical management of infections.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is certainly not the case for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that a patient must be suffering from the sudden onset of symptoms, including severe pain, that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although the patient did report pain, he was not taking any pain medication. Further, the pain was not acute in onset.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for robotic-assisted prostatectomy for treatment of his prostate cancer.   Findings:  Three physician reviewers found that using Robotic-Assisted devices (like the DaVinci) to perform prostatectomies has quickly become an effective and safe operation for prostate carcinoma. It is no longer an experimental or investigational procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for bilateral bunionectomy procedures for treatment of her bilateral bunions. Findings:  The physician reviewer found that this type of surgery can be equally performed by either an orthopedist or a podiatrist. There is no data demonstrating a difference in outcomes depending upon the type of specialist (orthopedic surgeon versus podiatrist) in performing the procedure. There is no reason why this patient cannot be safely and effectively treated by a podiatrist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for Betaseron 0.3mg vial for treatment of her multiple sclerosis (MS). Findings:  The physician reviewer found that there are four, injectable disease-ifying agents (Avonex, Betaseron, Rebif, and Copaxone).  All of these agents have relatively similar efficacy depending on the study and their endpoint.  What is most important is that the patient starts one of these disease-modifying agents.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that there are several disorders that can cause these symptoms including: paronychia (infection around the nailbed), ingrown toenail, cellulitis of the toe, and inflammation of the toe joints.  It was important that the patient sought evaluation to determine the cause of her toe pain as therapy required varies depending on the diagnosis.  All of these ailments can cause extreme pain and without immediate treatment, can become more serious.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that a patient must be suffering from the sudden onset of symptoms of such severity that a prudent layperson would believe the lack of immediate medical attention to result in serious jeopardy to his health. Although this patient did report severe pain, the pain was not acute in onset. He had sustained an injury to his ankle. Further, the patient did not require any pain control in the emergency department. While his symptoms warranted medical evaluation, this care did not need to be provided on an emergent basis.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that due to his severe pain and feeling that he might faint, it is reasonable that the patient sought care at a closer emergency facility instead of attempting to drive a further distance.  The patient had no choice but to seek emergency care in order to achieve resolution of his severe pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male is requesting for a custom ACL brace for treatment of her torn anterior cruciate ligament (ACL).  Findings:  The physician reviewer found that there is no evidence establishing this patient has instability requiring an ACL brace. Without such evidence there is no indication of medical necessity for the requested equipment.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient was suffering from an acute injury (24-48 hours) involving severe and increasingly worse pain of a nature that would lead a patient to make a reasoned decision to seek immediate care due to potential jeopardy to his health or function.  According to the patient, he was unable to drive the distance required to be seen at the Kaiser Emergency Center and elected to go to a closer hospital for evaluation of his worsening leg pain and swelling.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for electronic-controlled thermal therapy (cooling device) post-operative use for treatment of his condition. Findings:  The physician reviewer found that there is a lack of medical evidence to support this manual therapy for the treatment of abdominal or pelvic adhesions.  The only studies in this area are uncontrolled pilot studies which do not provide sufficient evidence of efficacy to justify physical therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for a referral for treatment of her chronic vertigo and dizziness. Findings:  The physician reviewer found that this patient appears to have poor coping skills, and is unable to move forward despite her symptoms. The most effective treatment is likely to be psychological and behavioral rather than neuro-otologic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for Lyrica for treatment of her chronic pain. Findings:  The physician reviewer found that the use of Lyrica for the stated diagnosis of neuropathic pain from a scar is an off-label use of the drug and is not described in the literature. The fact that this pain is post-surgical and there is an umbilical hernia suggests that a surgical consultation is required.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for IVIG therapy for treatment of her statin-induced myopathy. Findings:  The physician reviewer found that IVIG is not indicated for this patients condition. This patient likely has statin myopathy, as there is no other obvious cause of myopathy. IVIG is not medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for IVIG therapy for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the patient has multiple sclerosis and has progressed on Copaxone and IVIG.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested for inpatient mental health treatment for treatment of her condition. Findings:  The physician reviewer found that the patient was noted to be significantly depressed. He had not responded to outpatient treatment. He was experiencing suicidal thoughts without plan or intent. He remained a serious suicidal risk, and continued inpatient care with 24 hours monitoring and professional supervision was clearly necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female is requesting for Orthovisc injections for treatment of her osteoarthritis of the knee.  Findings:  The physician reviewer found that there is no documentation of a trial and failure of nonsteroidal anti-inflammatory drugs or that the patient has attempted an intra-articular corticosteroid injection prior to the requested use of Orthovisc injections. The patient has tried prescription strength ibuprofen. However, there is no documentation of trial and failure of other NSAIDS. It is not uncommon for patients to fail to respond to one or more NSAIDS, but then to have adequate effects from other NSAIDS, particularly when medications from different NSAID classes are used. In addition, there is no documentation of any trials of corticosteroid injections of the knee. Corticosteroid injections are also a reasonable treatment modality for osteoarthritis of the knee, and some patients may notice improvement for extended periods of time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a nine-year-old male enrollee have requested  for speech therapy for treatment of his language disorder. Findings:  The physician reviewer found that this patient has been diagnosed with autism and has communication delays. Speech therapy is a frequently indicated treatment for autism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition. Findings:  The physician reviewer found that there was no indication that the patient was profoundly depressed, oppositional, suicidal or homicidal. He was not acting out in an overly aggressive or disturbed manner.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for a Hoveround power wheelchair for treatment of her condition. Findings:  The physician reviewer found that it appears that the mobility device is requested mainly for community mobility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female is requesting for a nerve block for treatment of her postoperative pain.  Findings:  The physician reviewer found that the nerve block at issue was not medically necessary for postoperative pain management of this patients condition.  Although nerve blocks may be used on an individual, elective basis for various types of orthopedic operations, it is not an integral part of any procedure, and its routine use is not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer.   Findings:  Three physician reviewers found that there is no pathology report for a Gleason score or the nature of histology and extent and volume of disease, and no urologist consultation to help with the stage of this cancer. IMRT and proton beam therapy are both conformal therapies and highly effective in treating prostate cancers. There is no proven survival advantage of either one, and there are minor differences in side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eleven-month-old female enrollee has requested for measles, mumps, and rubella (MMR) vaccines to be given separately, rather than in the combined version for treatment of the enrollee. Findings:  The physician reviewer found that there are no evidence-based, peer-reviewed studies to support a link between the MMR vaccine and autism. Furthermore, there is no published scientific evidence showing that there is any benefit to separating MMR vaccine into three individual shots.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested for Tramadol and Diovan for treatment of his diabetic neuropathy. Findings:  The physician reviewer found that Diovan is not medically necessary for this patient. The treatment of painful diabetic neuropathy may require opioid medications.The reasons for this discontinuity of care are not known. The patient should return to the neurologist as soon as possible to complete his evaluation and the course of action originally recommended to wean the patient off Tramadol.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for a Bionicare Unit for treatment of her arthritis.   Findings:  Three physician reviewers found that there is not sufficient evidence to support the use of the Bionicare device for the treatment of knee osteoarthritis. More long-term and class I data is needed to support the use of the Bionicare device for the treatment of degenerative joint disease of the knee.