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

A 48-year-old male enrollee has requested left-sided C5-6 minimally invasive laminoforaminotomy with decompression of the nerve root for the treatment of his left arm and shoulder pain. Findings:  The physician reviewer found that the objective of minimally invasive spinal surgery is to achieve the clinical outcomes attainable with conventional open surgery, while minimizing the risk of treatment-related injury. Multiple new technologies including microsurgery, laser technology, endoscopy, and video and image guidance systems have paved the way for these procedures. At the present time, until better scientific evidence is available, minimally invasive laminectomy and foraminotomy should be regarded as research techniques. The patients underlying pathology is the cervical disc bulge at C5-6 as well as the disc-osteophyte complex. These problems will be satisfactorily addressed by the anterior fusion proposed by the in-Plan provider. There is no need for an out-of-Plan referral for the treatment of the patients spinal stenosis and degenerative disc disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female has requested an insulin pump for treatment of type 1 diabetes mellitus.    Findings:  The physician reviewer found that the patient is likely escaping from her relative remission period. She is thus an excellent candidate for an insulin pump. The requested insulin pump is medically appropriate and should be authorized. Adequate evidence has been provided to support the use of an insulin pump in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested physical therapy (PT) for the treatment of her laminectomy and spinal fusion. Findings:  The physician reviewer found that the submitted physical therapy notes do not reflect any changes in the type of therapy, but simply demonstrate a gradual increase in the number of repetitions to be performed for a designated exercise. The patient had been instructed in a home exercise program (HEP) by this time. The documentation does not support the on-going need for skilled PT services. The patient could have continued her HEP independently by that point in her therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 69-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of the enrollees amyotrophic lateral sclerosis (ALS).  Findings:  The physician reviewer found that the patients condition left no expectation of  improvement and the services of a qualified physical therapist were of no benefit to him. Although care was clearly needed, and appropriately provided, this care was custodial in nature. GT feedings and medication administration alone do not satisfy the criteria for a skilled nursing level of care. The patients inability to participate in physical therapy, by definition, excludes him from skilled coverage per the Centers for Medicare and Medicaid (CMS) Guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 71-year-old female enrollee has requested injectable methotrexate for treatment of her lupus anti-coagulant-type syndrome. Findings:  Three physician reviewers found that per the relevant literature, methotrexate is an appropriate treatment for undifferentiated connective tissue disease. The patient has achieved good results with methotrexate, but is unable to tolerate the oral form of the medication. Therefore, injectable methotrexate is clinically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested  for residential treatment services for treatment of her substance dependence.  Findings:  The physician reviewer found that the patients risk of complicated withdrawal and the risk of relapse due to withdrawal and depression supported the need for treatment in a structured setting such as residential care. The admission report also indicated that the patient engaged in violent/suicidal behaviors when intoxicated. Progress notes show that withdrawal from alcohol and Vicodin was the initial concern. Criteria I, II, and V of the American Addiction Medicine Patient Placement Criteria for Adult Residential Treatment were met in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested the Medtronic continuous glucose monitoring system (CGMS) for the treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that primary type 1 diabetes mellitus is an autoimmune disease and the patient has secondary diabetes due to pancreatectomy without the added comorbidity of autoimmunity. This may in fact significantly decrease his likelihood of developing the micro and macro-vascular complications found in true diabetes mellitus type 1. Additionally, a glucometer measures blood glucose and gives an instantaneous measurement of blood glucose values. The CGMS measures interstitial glucose levels and there can be a delay of up to 20 minutes before increases or decreases in blood glucose levels are reflected in interstitial fluid measurements. The CGMS will not prevent hypoglycemic events or provide an instantaneous warning in the event of a precipitous drop in blood glucose levels. The CGMS is not essential for accurate blood glucose monitoring.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested continued physical therapy (PT) for total hip replacement post-treatment.   Findings:  The physician reviewer found that he has already undergone extensive post-THA rehabilitation including a brief inpatient stay and approximately two months of outpatient therapy. Further outpatient PT is not likely to improve his contracture or functional outcome in a reasonable or predictable time period. The patient has, in all probability, maximized his post-THA rehabilitation potential as PT is most beneficial in the acute postoperative phase. Once contracture exists for several months after THA, on-going PT is generally considered maintenance therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested  for radiofrequency thermocoagulation facet rhizotomy for treatment of his back pain. Findings:  Two physician reviewers found that radiofrequency thermocoagulation of the median branches for the treatment of chronic low back pain secondary to facet joint pain is an accepted technique. There is documented evidence that the procedure is safe and effective when performed for patients with retractable pain. There is sufficient evidence of the procedures efficacy to warrant its repeat use in this case. It is recommended that the patient undergo a double diagnostic block paradigm prior to radiofrequency thermocoagulation, as this is the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested physical therapy and biofeedback services for treatment of her musculoskeletal pain.  Findings:  Two physician reviewers found that biofeedback is considered experimental for muscle re-education and is not generally considered a medically necessary component of PT. Although a fixed duration of PT can be useful in the management of knee pain, there is no clinical advantage unless clear progress is documented. In this instance, there was no objective evidence of progress in the PT documentation after the initial re-evaluation except for some change in the patients pain rating.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male has requested speech therapy services for the treatment of the enrollees autism.    Findings:  The physician reviewer found that autism is a disorder of communication, socialization and behavior and is long lasting.  The condition is generally not reversible. Although speech therapy is appropriate for this patients condition, it is not medically necessary. Such services should be delivered by the educational system as part of a comprehensive psycho-educational program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested a bilateral knee MRI for evaluation of his knee pain. Findings:  The physician reviewer found that the results of the patients examination combined with his treatment history do not support the need for an MRI study to further evaluate the cause of his pain. X-ray evaluation was essentially normal and there is no history of locking of the knee joint. A trial of physical therapy has not been attempted. In sum, MRI is not appropriate at this juncture.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested bariatric surgery for treatment of his morbid obesity.   Findings:  The physician reviewer found that With a weight of 435 pounds, a BMI of 75 and significant comorbid conditions, this young man would meet nationally accepted medical necessity criteria for consideration of weight loss surgery if he was an adult. His physicians indicate that all conservative efforts at weight loss have failed and they are in support of surgical intervention. Despite his age, it is highly likely that bariatric surgery will be beneficial for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for nasal surgery for treatment of her deviated septum. Findings:  The physician reviewer found that the defects described in the operative report include deviation of the septum and hypertrophy of the turbinates. These conditions cause functional impairment and needed to be corrected with septal and turbinate surgery. The remaining defects are cosmetic in nature; the rhinoplasty part of the surgery was largely concerned with correcting these defects.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested a transforaminal epidural block with instillation of hyaluronidase (lysis of adhesions), a ramus communicans block and a pulsed radiofrequency procedure of the ramus communicans of the sympathetic nerves for treatment of back and groin pain.Findings:  Two physician reviewers found that these procedures have been chronicled in the literature and are used for treatment of pain that is refractory to standard therapeutic regimens. Pulsed radiofrequency is FDA approved and is considered a useful tool in the treatment of pain that occurs in a well defined and fairly limited anatomic location. The most appropriate patients for pulsed radiofrequency and lysis of adhesions are those in whom reasonable conservative treatment has failed to provide adequate analgesia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested Subutex for the treatment of depression.  Findings:  The physician reviewer found that Subutex is not FDA approved or commonly used for treatment of depression. The short and long term effects of Subutex in patients with depression are not known. There are no double blind studies to support the efficacy of Subutex in depression.  Subutex is not the standard of care in the treatment of depression.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for the treatment of headaches.  Findings:  Two physician reviewers found that Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). Response is often greater over several treatment cycles.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested the medication Xyrem for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the patient does not have a diagnosis of narcolepsy.  She is on central nervous system depressants. Xyrem is not the standard of care for treatment of this patients conditions.  As such, the continued use of Xyrem is not clinically indicated and should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested X-Stop implantation surgery for treatment of spinal stenosis. Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is a superior treatment option. Simple laminectomy is the gold standard procedure for patients such as this patient. No study has demonstrated that X-Stop is more or as effective as laminectomy, particularly with a two-level procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a PET scan for evaluation of non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Blue Cross guidelines for the use of PET scan clearly state that this diagnostic procedure is indicated in the staging and restaging of lymphoma. There are no further clarifications in the policy. For patients with a relative recent history of cancer, performing serial PET scans is considered the standard of care. PET scan evaluation was medically indicated to rule out recurrence. Additionally, having prior studies available for comparison enhanced the value of the current PET scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a twenty-one-month-old male enrollee has requested a DOC cranial band for treatment of his plagiocephaly.  Findings:  The physician reviewer found that no controlled studies are available demonstrating the efficacy of the DOC cranial band. This is particularly true in patients over the age of 12 months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a motorized scooter for treatment of multiple sclerosis. The patient has a mobility deficit that is currently accommodated by a four-wheeled walker. The patient does not meet criteria for a scooter/power-operated vehicle. If the patient is limited in his mobility in the home and cannot be accommodated by an alternate gait aid, then a wheelchair should be considered rather than a scooter. Based on the information provided, there is no objective evidence of a need for a motorized scooter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested coronary CT angiography (CTA for evaluation of her chest pain.  Findings:  The physician reviewer found that CT angiography is not thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. In this instance coronary artery disease had been excluded based on cardiac catheterization which is a definitive test.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested psychiatric residential treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that while the patients issues were legitimate problems, there appears to be no documentation to support her being so compromised in function to warrant inpatient treatment of any kind. Family therapy was a necessary component of treatment, but this could have been approached on an outpatient basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a breast MRI for evaluation of her medical condition.  Findings:  The physician reviewer found that there are several indications for MRI of the breast which include evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High-risk patients also include patients with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. This patient has two of the above-mentioned indications for a breast MRI.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested  for hyperthermia therapy (in combination with radiation therapy) for treatment of her lung cancer. Findings:  Three physician reviewers found that a review of the literature shows that one relevant randomized trial has been performed. As reported by Mitsumori, et al, 80 patients with locally advanced non-small cell lung cancer were randomized to radiation (RT) or radiation plus hyperthermia (RHT). Although there was a statistically significant improvement in local progression-free survival favoring RHT, the study showed no differences in either the local response rate or the overall survival.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma. Findings:  Two physician reviewers found that avastin appears active in glioblastoma when combined with chemotherapy and continues to be used in randomized trials to evaluate its efficacy in this population. A phase II trial of Avastin and CPT-11 showed a 63% radiographic response rate with 72% progression-free survival at six months. In this study, all 32 patients had progressed despite radiation therapy and Temodar. In another retrospective study, chemotherapy (carbo/etoposide/or CPT-11) was used with radiation therapy with a report of responses in 7 of 14 patients treated this way.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested CyberKnife radiosurgery for treatment of prostate cancer.  Findings:  Two physician reviewers found that numerous treatment alternatives exist for early prostate cancer. Unlike CyberKnife, the more standard treatment options have a defined course and a predictable outcome in this setting. CyberKnife has not typically been used for prostate cancer. This technology has most commonly been applied to craniospinal tumors because of the bony landmarks necessary for the machine to work properly. There has not been sufficient study of CyberKnife in the treatment of prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that the American Society of Bariatric Surgery consensus conference states that candidates should have attempted to lose weight by self-directed dieting, nutritional counseling, commercial diets and hospital-based weight loss programs, but should not be required to complete formal non-operative obesity treatment as a pre-condition for the operation.  This patient has taken these steps. She is a super morbid obese individual. The Health Plans psychiatrist considered her to be motivated for the life style changes expected to occur after surgery.  Further delay of the surgical procedure places this patient at greater risk. The Health Plans bariatric surgeons state that 10% weight loss would make the planned surgery technically easier. However, there are options that are considered acceptable and valid techniques for patients such as this patient such as two-step procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested continued physical therapy (PT) for treatment of her back and neck pain. Findings:  The physician reviewer found that based on available records, PT has not resulted in any objective progress since 12/28/06. The submitted physical therapy notes do not demonstrate significant functional improvement and treatment goals have not been met. Additional physical therapy is not likely to result in an improved clinical outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 13-year-old male enrollee have requested group therapy for treatment of his Aspergers syndrome.  Findings:  The physician reviewer found that Aspergers syndrome, often considered a mild autistic spectrum disorder, is typically diagnosed based on a core group of behaviors. The presence of these behaviors indicate deficits in communication and social interaction. There are three recognized treatment options for this syndrome: (1) communication and social skills training; (2) cognitive behavioral therapy; and (3) medication, as needed, for co-morbid diagnoses including anxiety, depression and hyperactivity. For most individuals with AS, an extremely important aspect of their treatment strategy is an opportunity to enhance their communication and social correspondence. Social skills therapy enables the individual to cope better with social and interpersonal expectations. The patient is likely to benefit from this therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested excess skin and subcutaneous skin removal for the treatment of her excess skin condition. Findings:  The physician reviewer found that the medical records do not establish medical necessity for the proposed skin removal. The body contouring procedure has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patients history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in her skin folds. Nor is there photographic evidence documenting cellulitis, ulcerations or rashes. The submitted treatment records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either failed to respond to topical therapy or despite initial response, have recurred and caused significant functional impairment. The patients condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. 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 intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.