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

A 61-year-old male enrollee has requested for radiofrequency ablation for treatment of his metastatic colon cancer.   Findings:  Two physician reviewers found that the primary role of RFA of hepatic lesions is to provide curative-intent therapy for those patients not amenable to surgical resection. As such, guidelines have limited the number and size of lesions to be treated. RFA is not considered to be a palliative intervention. In this patient, he is asymptomatic, and his CT suggests disease that cannot be ablated (both by the large size of the lesion, and the multiple lesions). While treatment options for his metastatic colon cancer are limited (i.e., clinical trials or re-treatment with chemotherapy), there is no evidence that RFA will provide any benefit (either palliative or curative).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for Avastin/Tarceva combination treatment for treatment of her non-small cell lung cancer.   Findings:  Two physician reviewers found that Tarceva has been approved in the treatment of metastatic adenocarcinoma of the lung after the failure of conventional chemotherapy. It does seem to be particularly likely to be useful in Asian female non-smokers. While the patient is Caucasian, records do indicate she is a non-smoker. Furthermore, if indeed she has bronchioaveolar subtype, this is a type of lung cancer that seems to have a poor response to chemotherapy and a somewhat better response to Tarceva. Though the histology is not entirely clear it is certainly possible that this is a bronchioalveolar subtype, especially in view of the ground-glass densities in her lungs. Thus, the use of Tarceva in this patient appears to be likely to be of greater benefit than other possible therapies. Avastin has been shown to improve the first-line efficacy of carboplatinum-taxol in metastatic non-small cell lung cancer. There is insufficient data to demonstrate usefulness of this drug in other combinations, such as with Tarceva.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old female enrollee have requested for inpatient psychiatric treatment for treatment of her bipolar and major depressive disorders. Findings:  The physician reviewer found that the patient may suffer from a Unipolar or a Bipolar Disorder, she does not appear to have had any concerted treatment on an outpatient basis at all. Outpatient treatment in the form of either intensive outpatient therapy or partial hospitalization was more appropriate for this patient and could well address the dynamics and result in some improvement. All told, the patient was not and is not so affectively stricken as to preclude outpatient treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nineteen-month-old male enrollee has requested for array comparative genomic hybridization testing for evaluation of the enrollees global developmental delay. Findings:  Two physician reviewers found that the major malformation is macrocephaly caused by polygyria and an increase in the amount of gray matter. This is the type of constellation in which the yield of testing to examine chromosomal fine structure would be expected to have a substantial diagnostic yield. The requested testing had its genesis in the genetic analysis of cancers, where it has been very useful in establishing the genetic nature of a variety of solid tumors.  It has been increasingly applied to patients with developmental delay in whom other methodologies have not yielded a diagnosis. In a series of such patients with global developmental delay, an etiologic yield was 6.4%, but half of those had minor malformations.  Furthermore, none of those had more than two malformations, while this patient has more than three.  In a study reported by Engels and colleagues examining patients with abnormal neurological imaging, the yield of etiological information from this testing was twice that of those without this testing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for a trabeculotome procedure for treatment of his pigmentary glaucoma.   Findings:  Three physician reviewers found that there is no information available in the literature to support a trabeculotome procedure over a trabeculectomy, with or without anti-metabolites. Although the trabeculotome procedure is newer than the gold standard trabeculectomy, and it could be considered slightly less invasive, the long-term benefits and side effects are not yet known.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested for additional physical and occupational therapy for treatment of the enrollees neurofibromatosis. Findings:  The physician reviewer found that the patient is has cognitive, functional, coordination, and visual deficits that all would likely benefit from PT and OT services. It is my determination that PT and OT services are medically necessary to treat this patients complicated medical condition. The requested PT and OT services do directly relate to a treatment regimen for the patients condition. While the patient does have a chronic condition, symptoms can fluctuate in severity over time and the patient can experience various manifestations of the disease at various times.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Aciphex (20mg/BID) for treatment of his GERD and dyspepsia. Findings:  The physician reviewer found that this patient has reflux esophagitis. He has tried and failed multiple proton pump inhibitors including, Protonix, Prilosec, and Prevacid. He could not complete the trial with Protonix because of nausea. Aciphex is the only medication that works for the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for bilateral reduction mammoplasty for treatment of her symptomatic macromastia. Findings:  The physician reviewer found that there is a lack of documentation of diagnosis and failure of conservative treatment for skin rashes, intertrigo or skin ulcerations secondary to macromastia. In terms of the reconstructive surgery considerations, the necessary criteria for that are not met. The patients breast size does not constitute an abnormal structure of the body. There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Therefore, the surgery cannot be considered as reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for brain MRI for evaluation of her severe migraines.    Findings:  The physician reviewer found that the incidence of intracranial pathology in patients with migraine is no different than the general population. The neuro-imaging guidelines from the US Headache Consortium and the American Academy of Neurology specifically state that neuro-imaging (CT or MRI) is not medically necessary unless the patient has atypical features.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for oral appliance therapy for treatment of her sleep apnea. Findings:  The physician reviewer found that The long-term prospective study published by Guilleminault and colleagues supports the fact that many patients such as this patient may go on to progress to more severe sleep disorders as well as mood disorders. Mandibular positioning devices are known to be useful in treatment of mild to moderate obstructive sleep disorders. Compliance is fairly good when compared to the use of CPAP, and clinical symptoms show significant reduction with this treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for an electric scooter for treatment of her diabetic neuropathy. Findings:  The physician reviewer found that there is insufficient documentation to support the use of the electric scooter for this patients condition. In order for the patient to qualify for the electric scooter, there should be sufficient documentation to support that a front-wheeled walker would not suffice. The patient does not meet this requirement, as she was noted to safely perform her activities of daily living in the home with the use of the front-wheeled walker. Additionally, the patient apparently intends to use the scooter primarily, if not entirely, for community use, and this is not an accepted criteria.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a fifteen-year-old male enrollee has requested for Nutropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that according to the predictive tables of the Greulich and Pyle Hand Atlas, the patients predicted adult height would be in the range of 67 inches. The patient appears to have constitutionally delayed puberty and should exceed the adult height FDA guideline from July 2003 for growth hormone therapy for idiopathic short stature.  He would thus be judged not to require growth hormone therapy, especially if his IGF-1 level has risen as expected with pubertal development.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for procedures provided by Encino Surgical Center for treatment of her back pain. Findings:  The physician reviewer found that there is no documentation to substantiate a rationale for the various, multiple procedures and no documentation to establish the response to each intervention. Multiple procedures were done at the same time, invalidating the assessment of the diagnostic procedures. Studies have shown intravenous sedation obscures assessment of diagnostic medial branch blocks. Not only was intravenous sedation given each time that diagnostic medial branch blocks were done, but other procedures were done concurrently, obfuscating any assessment of benefit. There is insufficient documentation to substantiate that the patient was adequately assessed for benefit after the diagnostic medial branch blocks. Rhizotomy of the facet joints is not indicated unless there is a clear, substantial benefit from diagnostic medial branch blocks. Again, there was not adequate documentation to assess pain and function after diagnostic medial branch blocks.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins.   Findings:  Three physician reviewers found that Ultrasound-guided foam sclerotherapy is investigational. This procedure is not more beneficial than available standard therapy. The current literature does not support the efficacy of this treatment over other available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for osteopathic treatment for treatment of his patellofemoral syndrome. Findings:  The physician reviewer found that there is no justification for osteopathic treatment due to knee pain. Osteopathic manipulation has not been proven safe and effective in the long-term treatment of chronic patellofemoral pain.  The patient has also had hip pain.  There is insufficient support for the request for osteopathic treatment due to chronic complaints of pain with the diagnoses of patellofemoral syndrome and left hip degenerative joint disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two-year-old male enrollee have requested for speech therapy for treatment of the enrollees bilateral sensioneural hearing loss and speech/language disorder.    Findings:  The physician reviewer found that research has shown that early intervention for children with hearing loss makes a significant difference in speech and language skills in the early school years. The highest degree of success is with infants identified before six months of age. However, with active family involvement, even children identified in later infancy can show significant improvement in development of speech and language skills. Degree of hearing loss plays less of a role in predicting outcome than family participation and aggressive intervention. It is therefore essential that this young patient continue to receive speech and language therapy twice weekly. Furthermore, it is extremely important in therapeutic situations to continue with a provider with whom the child has established a rapport. This patient has shown improvement with his current provider. Timing is essential for children with hearing loss. Establishing a new relationship could waste valuable time, ultimately affecting the outcome of therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-month-old male enrollee has requested for a Synagis injection for treatment of the enrollees respiratory distress syndrome with respiratory failure.    Findings:  The physician reviewer found that The American Academy of Pediatrics (AAP) guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. These factors include school-age siblings, day care attendance, airway abnormalities, neuromuscular disease and/or exposure to environmental air pollutants.Horn and Stout analyzed retrospective data from 304 infants less than one year of age with bronchiolitis or RSV pneumonia admitted to the hospital. Data were subdivided by gestational age and compared, looking at rates of intubation and intensive care unit admission, as well as length of stay. They found that infants less than one year of age born at 33 to 35 weeks gestation fared worse than those born more prematurely over all measures. They concluded that premature birth during this critical period of lung development may result in significant alteration in lung function and physiology.Finally, there are other risk factors that not only increase the chance of morbidity, but also mortality from RSV disease in infants up to twelve months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for a virtual colonoscopy for evaluation of her abdominal pain. Findings:  The physician reviewer found that the use of virtual colonoscopy is neither the standard of practice nor the community standard. If the patient is unable to tolerate the colonoscopy and the associated necessary sedation medications because of her allergy issues, then a barium enema is the next test that needs to be done.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of his speech disorder. Findings:  The physician reviewer found that the origin of the speech dysfunction is congenital, and its etiology is related to a brain neurodevelopmental dysfunction. The speech therapy as prescribed is the standard of care for the patients condition, and there is no documentation that suggests the patient will not benefit from treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for Allegra 720mg for treatment of her chronic uticaria. Findings:  The physician reviewer found that there must be documentation that trials of drugs in the same class have been unsuccessful or met with adverse reactions, and also that lower doses of the requested drugs did not work. Furthermore, there should be some evidence that the dose requested has been tolerated without toxic side effects. There is adequate documentation that other drugs have been tried, and that lower doses of the Allegra have failed. Furthermore, the Physicians Desk Reference demonstrated tolerability of the drug at this dose in other patients.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested for an electron beam computed tomography for evaluation of her hyperlipidemia. Findings:  Two physician reviewers found that there is no documentation of known heart disease or cardiac symptoms. An electron beam computed tomography was ordered to evaluate the need for more aggressive treatment of hyperlipidemia.In this circumstance, risk factor modification is indicated and should be implemented according to evidenced-based guidelines. In the case of cholesterol management, nationally accepted guidelines have been published and updated periodically. These guidelines do not recommend the routine use of or screening with electron beam computed tomography, largely because the incremental value of electron beam computed tomography in improving outcome above that which can be obtained with standard risk factor profiling has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested for Provigil 200mg for treatment of her sleep disorder with idiopathic hypersomnolence. Findings:  The physician reviewer found that there is documentation of treatment failure of Ritalin/amphetamines. There is documentation of effectiveness allowing the patient to function at an extremely high level, despite her hypersomnolence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for an X-Stop procedure at the L3-4 and L4-5 for treatment of his lumbar spinal stenosis at the L3-4 and L4-5.    Findings:  The physician reviewer found that the short-term literature of the X-Stop states that it is potentially efficacious and it is safe, but there is nothing to suggest medium to long-term data that is as good as or better than standard surgical treatment options.  As of this time, as with all surgeries, the requested X-Stop procedure has significant risks and benefits and the net benefits of X-Stop do not outweigh the net benefits of treatment with standard orthopedic surgical care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for continued acupuncture treatments for treatment of her chronic pain syndrome (thoracotomy syndrome). Findings:  The physician reviewer found that there is no other documentation regarding the effectiveness of any other acupuncture treatments received. The article cited above regarding treatment for complex regional pain syndrome indicates that acupuncture is not recommended for treatment based on 2 randomized controlled trials. It found there was no difference in analgesia in acupuncture-treated patients versus sham-treated patients. Based on current standards of practice and without any documented benefit in this patients case, the use of acupuncture as a long-term treatment/management option for patients with chronic pain is not indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for inpatient mental health services for treatment of her severe panic attacks and agoraphobia.    Findings:  The physician reviewer found that the severity of her multiple symptoms were such that it would have been very difficult for the patient to have left the house on a daily basis to attend a partial hospitalization program or to effectively engage in outpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for breast MRI with computer aided detection (CAD) for her breast cancer screening.    Findings:  The physician reviewer found that this use of the MRI is not purely for screening, but is to evaluate suspicious calcifications which apparently are not associated with a clearly palpable lesion in patients with very dense breast tissue. This represents a reasonable use of MRI to increase the sensitivity of detecting a cancer in that area. The above cited article by S. Harms outlines the difficulty in evaluating dense breast tissue and the utility of MRI in evaluating mammographic abnormalities in the setting of dense breast tissue.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that The patient was diagnosed with bronchitis, prescribed an oral antibiotic and inhaler, and discharged.The prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms were not sudden on onset but had been present for at least 5 days. Although the patient reported mild shortness of breath, her pulse and respiratory rate were normal, her oxygen saturation was 100%, and she was not exhibiting any signs of respiratory distress. No emergent medical intervention was required in the emergency department.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a three-year-old male enrollee have requested for speech therapy for treatment of the enrollees speech delay.    Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability, and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Untreated speech and language delay in preschool children has shown variable persistence rates (from 0% to 100%), with most studies reporting 40% to 60%.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood. In addition to persistent speech and language-related underachievement (verbal, reading, spelling), language-delayed children have also been shown to have more behavior problems and impaired psychosocial adjustment. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. Overall, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for use of vertebral axial decompression, mechanical traction therapy for treatment of his back pain.   Findings:  Three physician reviewers found that there is a lack of long-term outcomes data to support its use. More data is needed to establish the efficacy of traction for low back pain. There are other therapies that are likely to be more effective in this setting.