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

A 54-year-old female enrollee has requested for Nexium and Lipitor for treatment of her hypercholesterolemia and gastroesophageal reflux disease. Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression and continue to be the standard of therapy for the treatment of GERD. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. It is medically appropriate to require that the patient have a trial of formulary alternatives such as Omeprazole, Aciphex, or nonformulary alternative, Prevacid. It is also medically reasonable to base approval for Nexium upon failure to respond to adequate trials of these agents.Statins are widely prescribed for the treatment of dyslipidemia. Statins increase low density lipoprotein (LDL)-receptor expression on the hepatocyte surface, increase uptake of LDL and decrease circulating LDL. Statins also decrease triglycerides and modestly increase high density lipoprotein (HDL) levels. While all statins have the same mechanism of action, they differ in terms of chemistry, pharmacokinetics, potency and approved indications. Rosuvastatin (Crestor) and atorvastatin (Lipitor) are the most potent statins with respect to lowering LDL, followed by simvastatin (Zocor) and pravastatin (Pravachol). It is medically appropriate to require that the patient have a trial of formulary statins (Vytorin and Zocor). Approval for Lipitor may reasonably be made contingent upon the failure of these formulary agents.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for Lipitor 20mg for treatment of his hypercholesterolemia. Findings:  The physician reviewer found that there is no reason the patient cannot change to another agent which may be just as effective as Lipitor. There is a lack of evidence that Lipitor will improve the patients outcome over other medications, such as Zocor. The guidelines of the American College of Cardiology do not support the use of Lipitor preferable to other lipid-lowering medications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for PET/CT scan for evaluation of his aggressive digital papillary adenocarcinoma.   Findings:  Three physician reviewers found that Lymphatic mapping and sentinel lymph node biopsy are useful in detecting early metastases. There is also one report of a pulmonary metastasis detected with CT. In this patient, PET/CT did identify a positive axillary node (twelve nodes biopsied, one was positive). PET/CT is useful in this patients tumor. An initial follow-up PET/CT should be approved at six months. Subsequent scan approval should be based on the clinical situation at the time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her lumbosacral radiculitis. Findings:  The physician reviewer found that the FDA approved indications for Lyrica are limited, it is commonly prescribed for neuropathic pain when more conservative treatment strategies have proven to be ineffective, as in this case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested  for emergency services for treatment of the enrollees ear pain.  Findings:  The physician reviewer found that a prudent layperson parent with an average knowledge of medicine and a child with severe pain would reasonably expect the absence of emergency care to jeopardize their childs health. Although otitis media is not typically considered a medical emergency, significant pain is. A very young child may not be able to reliably locate their pain. Pain in the head may signify meningitis, lymphadenitis, parotitis, pharyngitis, or any number of other infections. Trauma must also be considered. Unless the child has a history of ear infection, which this child did not, a layperson cannot be expected to differentiate between an infection with a benign course such as pharyngitis or otitis media, or an infection with a potentially severe course such as meningitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for a Saunders Home Cervical Spine Traction Unit for treatment of his cervical stenosis and neck and arm pain. Findings:  The physician reviewer found that if there is a good response to physical therapy and cervical traction, a standard over the door home traction unit is appropriate and generally recommended. The home traction unit used by the patient was not the standard over the door unit. There is nothing in the record identifying any particular factors that would preclude the use of a standard traction unit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for IVIG therapy for treatment of her immunodeficiency. Findings:  The physician reviewer found that laboratory evaluation shows a reduced level of IgG and a poor response to pneumococcal serotypes, but the variance from normal is not so great that IVIG therapy, in the absence of recurring bacterial infections, is warranted. The patients sinus CTs are not consistent with a prolonged history of significant infection. Additionally, there is no history of pneumonia, skin infections or chronic urinary tract infections. Regular monitoring of IgG levels and on-going work up on the patients symptoms appears appropriate at this stage.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for emergency services for treatment of her upper respiratory infection (URI).  Findings:  The physician reviewer found that Although there is evidence that the patient was experiencing significant discomfort with 8/10 pain symptoms, her symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and nasal congestion, cough, chills and headache would not reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for pulmonary vein isolation and ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that ablation was not offered as a first-line treatment, and is being considered because of persistent and refractory symptoms. The patient is on a calcium channel blocker and Rhythmol therapy was unsuccessful. Long-term amiodarone in a middle aged patient is problematic given its potential toxicity. While pulmonary vein ablation is not superior to pharmacologic therapy, it can improve symptoms in those highly symptomatic patients intolerant of therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for Euflexxa injections for treatment of her temporomandibular joint (TMJ) pain.  Findings:  Three physician reviewers found that osteoarthritis of the TMJ is defined as the breakdown or degeneration of articular bone and soft tissue due to excessive joint loading or normal wear and tear. As a consequence, breakdown products including inflammatory mediators and lysozymes lead to secondary synovitis and capsulitis resulting in joint tenderness and pain. The treatment of DJD is challenging and advanced cases have been treated with open joint surgery with a variety of reconstructive techniques. Less invasive techniques that offer decreased morbidity have also been shown to be successful, such as sodium hyaluronate injections. These injections have clearly been an effective treatment for this patient and should be authorized at reasonable intervals for as long as there is sustained efficacy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old male enrollee has requested for residential psychiatric hospital services for treatment of the enrollees bipolar disorder and Aspergers syndrome. Findings:  The physician reviewer found that the patients behavior became aggressive and disruptive and required that he be treated with 1:1 staffing. He had continuing homicidal and suicidal ideas which were less intense than he previously held, but which still constituted a significant danger. He needed the supervision, staffing and structure of a residential facility.  Anything less would not have been safe and would not have met his medical needs.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for specially compounded hydrocodone for treatment of her chronic pain syndrome.  Findings:  The physician reviewer found that the control of chronic pain frequently involves a delicate balance between the benefits and side effects of the prescribed medications. It is often very difficult to replicate the success obtained with a certain medication when switching to a different drug without compromising patient care. Once adequate analgesia (without serious side effects) is obtained with a particular medication, changing to a different drug based on non-clinical factors is usually not in the patients best interest. Continuing to treat the patient with the compounded form of hydrocodone is likely to provide the greatest benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested  for non-Plan acute inpatient hospital services for treatment of the enrollees abdominal pain and vomiting.  Findings:  The physician reviewer found that yhe patient presented to the ED for vomiting and abdominal pain that started several days prior. She did not appear to be medically unstable in the ED. Labs and vital signs were unremarkable. A transfer to another hospital would not have put the patient at an increased risk of adverse outcome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for Nexavar for treatment of her metastatic ocular melanoma. Findings:  Three physician reviewers found that sorafenib is a multi-targeted tyrosine kinase inhibitor and raf-kinase inhibitor that has been approved for the treatment of renal cell carcinoma and hepatoma. Raf kinase inhibitors are of interest in the treatment of melanoma, owing to frequent raf kinase mutations in melanomas. There is limited clinical data available regarding the activity of sorafenib in the treatment of melanoma. From the data that is available (Eisen, et al), there does not appear to be any significant activity in this disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested for continued treatment with Sporanox (itraconazole) for treatment of his sinusitis.  Findings:  The physician reviewer found that it is believed that some cases of chronic rhinosinusitis may be the result of nasal colonization with fungi combined with an allergic reaction to fungal antigens. It is not clear how often this occurs, but it is a bona fide cause of at least some cases of this condition. A review of the literature identified instances where treatment with antifungals has essentially cured chronic sinusitis. An additional study (Rains & Minick) reported on some 139 patients with allergic fungal rhinosinusitis. The study abstract indicates there were no adverse reactions to the 36,000 doses of itraconazole given to the study participants.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for sleeve gastrectomy for treatment of her morbid obesity.   Findings:  Three physician reviewers found that the patient meets the criteria set by the National Institutes of Health (NIH) for weight loss surgery. There is mounting published evidence that the sleeve gastrectomy is an acceptable surgical option. The patient has an irreversible liver condition. Sleeve gastrectomy avoids the anatomy of the hepatic region and will cause less liver stress than any other operation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a 71-year-old male enrollee has requested reimbursement for skilled nursing facility services for treatment of the enrollees paraplegia and Parkinsons disease. Findings:  The physician reviewer found that the patient did not receive daily skilled rehabilitation services, as his neurologic status did not warrant these services, and he also had progressive paralysis and pain. He had no daily injections. The patients pressure ulcers were stage II and did not require wound care at a skilled nursing level. The patient did not receive daily skilled services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for a plastic surgery consultation for treatment of her back pain.   Findings:  The physician reviewer found that it is not reasonable to expect a primary care physician to know the requirements or the nuances of an examination that could provide useful information in that regard. Likewise, it would not be expected that a primary care physician would obtain photographs that could potentially support the patients request. A plastic surgeon with expertise in abdominoplasty/panniculectomy is the best physician to examine the patient, record appropriate findings/lack of findings and apply appropriate policy in determining whether the patient does or does not qualify for surgery. It is incorrect to apply surgical qualifications before an appropriate surgical consultation has occurred.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for Avastin therapy for treatment of her colon cancer.   Findings:  Two physician reviewers found that there is a lack of evidence in peer-reviewed, medical literature that supports the efficacy of single-agent maintenance Avastin for colorectal cancer. There were two studies cited on behalf of the patient. In the E3200 study, the overall survival as noted by the authors was probably due to post-progression chemotherapy. The progression-free survival of the Avastin-alone group was significantly lower than the chemotherapy group, and a decision was made to not study this group any further. Additionally, in response to the study noting two patients who crossed over to single-agent Avastin, a determination cannot be made as to the safety and risk/benefit ratio based on the responses noted in these two patients in a small study. The expert consensus panel recommendations from the NCCN do not support the use of single-agent Avastin, and Avastin is FDA approved specifically in combination with a 5-FU analog-based treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 61-year-old male enrollee has requested for inpatient rehabilitation services for treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that it is unlikely that an inpatient program aimed at traumatic brain injury compensatory strategies would significantly alter the patients functional status.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested  for a magnetoencephalography (MEG) with MRI of the brain for evaluation of the enrollees seizure disorder.   Findings:  Three physician reviewers found that the patient has a complicated cerebral architecture that is distorted by tuberous sclerosis and her prior operation.  In order to maximize the success for her subsequent surgery, MEG with MRI is required. There is adequate literature to support the use of MEG/MRI during selected circumstances.  One such circumstance is for children with tuberous sclerosis and intractable epilepsy. This patient meets those circumstances.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for Nexium for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that the patient has tried Prevacid, Protonix and Prilosec for one month and has had no response. The Health Plan requires formulary medications to be tried for 8 weeks prior to authorization and coverage for Nexium. This is a medically reasonable requirement that has not been documented in the provided records.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested  for emergency services  for treatment of the enrollees fever and vomiting.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with persistent vomiting and fever would reasonably expect the absence of emergency care to jeopardize the childs health. These symptoms are very concerning in a small child because dehydration can occur quickly. Vomiting and fever alone may signify acute gastroenteritis, food poisoning, urinary tract infection, or respiratory tract infection (sinusitis, pharyngitis, pneumonia), to name a few. The parent appropriately sought emergency medical care for the patient because of the persistence of her symptoms. Several days of fever and vomiting are enough to deplete a childs system of enough fluid to cause significant dehydration. In addition, these symptoms may suggest a serious condition such as pneumonia, pyelonephritis, or strep throat, all of which require antibiotic therapy. The presumed chest discomfort complicates the presentation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested for emergency services for treatment of his abdominal pain.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and one hour of moderate (5/10) abdominal pain associated with one episode of diarrhea would not reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for a CT scan of the chest for evaluation of her right lung nodule. Findings:  The physician reviewer found that according to a review article by Tan, et al, if a solitary pulmonary nodule (SPN) is unchanged for more than two years, it does not require further diagnostic evaluation. A clinical review article by Weinberger also indicates that no further diagnostic workup is needed if the nodule is unchanged for two years. The patient does not demonstrate any significant change in her clinical status. However, should the patient start to demonstrate clinical signs and symptoms such as chronic cough, weight loss, unexplained fevers, hemoptysis, chest pain, etc., then a repeat CT scan of the chest would be indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested for a second cochlear implant (bilateral) for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that while current literature suggests that there may be an additional benefit to binaural amplification for some patients, many of the studies involved small numbers of subjects and lacked controls for comparison. Many patients derive significant benefit from unilateral hearing amplification. In this instance, the patient is reported to be performing well in testing, socially and at school, with the single cochlear implant. A second Cochlear implant for any patient involves a small, but real, surgical risk. Rare complications of Cochlear implants include meningitis and other risks implied in a delicate surgical procedure in this area. The current evidence on the benefit of binaural implants is inadequate, and no implant has been approved by the FDA for binaural use. Should the current implant on the left side fail, the patient would require a replacement implant for the right ear.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for bilateral laser vitreolysis for treatment of his vitreous floaters. Findings:  Two physician reviewers found that laser vitreolysis is not a procedure practiced by the vast majority of vitreo-retinal specialists in the country. There is presently insufficient literature to establish this procedure as an efficacious modality in patients with vitreous floaters.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for a carotid duplex study for evaluation of the of her carotid arteries. Findings:  The physician reviewer found that there is a tradition of searching for carotid lesions with carotid ultrasound after Hollenhorst plaques are found. This is particularly important in patients with new visual symptoms. Atheromatous plaques in the carotid system may send platelet-fibrin-cholesterol emboli up into the retinal arterioles. As they briefly interrupt retinal blood flow, these `Hollenhorst plaques` often cause transient monocular loss of vision lasting from seconds to minutes. In middle-aged and elderly adults, abrupt transient monocular visual loss is presumptively caused by carotid-source emboli, although there can be other reasons, such as complex migraines.  Older studies linking Hollenhorst plaques to carotid artery disease generally involved symptomatic subjects. However, in this case no abrupt visual symptoms are described. The patient has asymptomatic Hollenhorst plaques without a carotid bruit on examination. Current data indicates the prevalence of significant carotid stenosis in patients with asymptomatic Hollenhorst plaques is 6% to 9%. With acknowledgement of this rate of carotid stenosis with asymptomatic Hollenhorst plaques, Guidelines from the American Society of Neuroimaging and the Society of Vascular and Interventional Neurology advise that, Screening for carotid stenosis among patients with asymptomatic Hollenhorst plaques is not recommended.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for bilateral liposuction of the axillary area for treatment of her breast asymmetry. Findings:  The physician reviewer found that medically supervised weight loss offers a non-surgical approach to treating this condition. At this juncture, axillary liposuction may be performed as a component part of the breast reduction surgery to shorten the axillary scars and provide a better cosmetic result. The records do not document that the patients axillary lipodystrophy is causing any functional problems.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-year-old female enrollee has requested for residential treatment services  for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that there was no medical necessity for a residential treatment center admission for this patient. Only outpatient treatment had been tried. No intensive outpatient or partial hospitalization program had been attempted. The patients weight was very near 100% of ideal body weight, and she had no compromise in her medical/psychiatric condition necessitating a 24-hour, structured, interdisciplinary milieu.