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

A 34-year-old female enrollee has requested for awake brain tumor resection with brain mapping for treatment of her brain tumor.  Findings:  The physician reviewer found that the patients tumor was in a high-risk area and standard non-awake craniotomy would have been a dangerous procedure with little likelihood of a positive outcome in terms of functional and cognitive preservation. Appropriate surgical intervention required state-of-the-art technology and an experienced surgeon. Awake craniotomy was the right procedure and was performed without apparent harm to patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested an out-of-network referral for CyberKnife radiosurgery for the treatment of the enrollees Ewings sarcoma. Findings:  The physician reviewer found that this 17-year-old boy has a Ewings sarcoma in the left aspect of his sacrum with pulmonary metastasis. All conventional modalities, including surgery, chemotherapy and radiation therapy, have been exhausted. Radiosurgery by CyberKnife has been denied by two experts from a major academic cancer center on the basis of no significant benefit and increased risk to permanently damaging skin.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested participation in the STOP-AF clinical trial of the Arctic Front Cardiac Cryoablation Catheter System for the treatment of his atrial fibrillation. Findings:  Two physician reviewers found that the patient is markedly symptomatic and would benefit from an ablation for symptom relief.  Medical therapy has failed to aid his overall symptoms secondary to paroxysmal atrial fibrillation. Electrophysiologic study combined with ablation for cardiac arrhythmias seems to have significant advantages over antiarrhythmic drug therapy and may improve outcome. Guidelines suggest considering the use of catheter ablation for failure to respond to antiarrhythmic drug therapy or when medical therapy is contraindicated because of comorbidity or intolerance.  The use of cryothermal ablation, rather than radiofrequency ablation, may decrease the risk of permanent heart block.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested magnetic resonance spectroscopy (MRS) for an evaluation of her glioblastoma multiforme. Findings:  Two physician reviewers found that the use of MRS in this situation is state of the art for neurosurgical practice. It will provide vital information in this situation and will be very helpful for the patient. The denial is not appropriate, and the MRS study should be approved. Thus, the requested diagnostic procedure is likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a virtual colonoscopy for colorectal cancer screening for an evaluation of his colon. Findings:  Three physician reviewers found that colonoscopy and barium enema are the first and second-line procedures used to screen for colorectal cancer. There is no record that either of these procedures has been attempted or is contraindicated for the patient. It does not appear VC would be utilized to follow-up on abnormal findings from an earlier study. Thus, the use of VC in this setting does not represent the most appropriate diagnostic procedure for the patient. VC is neither the standard of care nor the community standard for cancer screening.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested an Oxylite System, a lightweight portable oxygen delivery system for the treatment of her breathing problems.   Findings:  The physician reviewer found that the Oxylite System is requested for out-of-home use, such as for gardening and animal care on the patients ranch.  There is no evidence that the patient cannot use a standard oxygen system for routine activities of daily living.  Consequently, it appears that a lightweight oxygen system is a convenience item here.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for CEA CA15-3 testing for evaluation of her breast cancer. Findings:  Three physician reviewers found that the most recent ASCO Technological Assessment from 2007 does not recommend that tumor markers CEA or CA15-3 be used in routine surveillance of breast cancer patients following adjuvant treatment. This has been the ASCO position since 2000. The NCCN Guidelines for breast cancer (v.2.2008) affirm this opinion, noting no evidence to support the use of CEA and CA15-3 in the follow-up of breast cancer patients. Despite this consensus opinion, these tests are indeed widely used in the follow-up of breast cancer. Regardless of this practice pattern, there is no evidence to support the monitoring of CEA or CA15-3 over standard history and physical examination.
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 abdominal pain and vomiting.  Findings:  The physician reviewer found that She had recently been inpatient with right upper lobe pneumonia, fever and abdominal pain, and to rule out appendicitis. During that admission, she was noted to have bladder distention and urinary retention of unclear significance. Appendicitis was ruled out by the surgical service. The patient was discharged to complete a course of oral antibiotics. She was taken to the pediatricians office because of nausea, vomiting, and abdominal pain. The vomitus was non-bloody at that time. Her examination was remarkable only for tenderness on abdominal exam, without rebound or guarding. Tums were recommended for presumed gastritis and the family was instructed to complete the course of antibiotics. The patient was subsequently brought to the ED with increased abdominal pain and new onset of blood-streaked emesis. Physician history revealed vomiting twice per day for two weeks, with blood-streaked emesis on the day of presentation. Periumbilical pain was noted. Review of symptoms revealed a six-pound weight loss over the past 2 weeks, throat pain, decreased activity, decreased oral intake, and decreased urination. Physical examination was significant for pharyngeal erythema, slightly dry mucus membranes, decreased heart rate with regular rhythm and paraspinal tenderness. An acute abdominal series was negative for intraabdominal pathology and CT of the head was normal. Laboratory studies were remarkable only for a CO2 of 19 (mildly decreased), and a urine dip revealed a specific gravity of 1.010, with trace ketones and 2+ protein. The patient was given a fluid bolus, and admitted for evaluation of persistent vomiting. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a child with worsening abdominal pain and blood-streaked emesis would reasonably expect the absence of emergency care to jeopardize the patients health. The parents observed the patient to be in severe pain and dizzy and the patients blood pressure was less than the 50th percentile for age. Laboratory results support a diagnosis of mild dehydration and there was a recent six-pound weight loss. The patient was admitted to inpatient care directly from the ED.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Erbitux therapy for the treatment of her jejunal adenocarcinoma.  Findings:  The physician reviewer found that adenocarcinoma of the small bowel is an extremely rare entity. Because of this, there are no FDA approved or Compendia listed drugs for this indication. It is common practice in the oncology community to treat metastatic disease arising from small bowel adenocarcinoma with the same regimens used in large bowel (colorectal) adenocarcinoma. This is based on the similarities in anatomy, biology, clinical behavior and the prognosis of these tumors. Irinotecan in combination with Erbitux (cetuximab) is an FDA approved regimen for large bowel tumors refractory to irinotecan alone. The prescribed regimen of irinotecan and Erbitux is the best available treatment option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the medical records show that this patient has received extensive PT.  For the dates under consideration, the PT seems to be maintenance in nature.  The records do not provide clear-cut documentation of progress.  Also, at this time the patient is likely able to be independent with a home exercise program and could continue without professional supervision.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested full-body PET/CT for an evaluation of his metastatic myxoid liposarcoma. Findings:  Two physician reviewers found that available research does not include large patient series or trials for this uncommon neoplasm. The patients previous metastatic lesions were evident on MR imaging, and his radiation therapy was carried out using the MRI findings. It is not clear why PET/CT imaging has been selected to evaluate the patients current metastatic status. His previous metastatic lesions were evident on MRI imaging, and it would seem reasonable to do MRI imaging at this point in time. If the findings are inconclusive or there are any other unanswered clinical issues, PET/CT should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-month-old female enrollee has requested Dynamic Orthotic Cranioplasty (DOC) cranial banding for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that DOC banding is considered a reconstructive therapy and not a cosmetic one. There is mounting evidence that it prevents future complications with orbit, temporal jaw, and other bones of the head and face. A recent study demonstrated that a better outcome is achieved with orthotic therapy than with positioning. Conservative interventions have been ineffective and the use of the DOC cranial band is clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 26-year-old female enrollee has requested hospital services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the medical records reveal that the patient was no longer an imminent threat to herself or others. There is no evidence that she required 24-hour supervision/observation or that she had a medical condition that required the resources of an acute hospital. The patient had stabilized and progressed to a point were she could have been safely and effectively treated at a less intensive level of care. The patient had some insight into her condition and was cooperative with treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested CT scans of the brain and cervical spine for an evaluation of his migraine headaches and neck pain. Findings:  The physician reviewer found that this patient has no symptoms necessitating investigation by CT of the brain or cervical spine.  Imaging of the brain and cervical spine are indicated if the patient has neurological symptoms or findings pertaining to the brain or cervical spine.  CT of the head is appropriate when there has been recent trauma and there is concern for intracranial bleeding.  CT of the brain may also be indicated for the worst headache of your life as it may indicate a cerebral aneurysm.  CT of the cervical spine is utilized to evaluate for cervical spine fracture.  This patients symptoms do not warrant CT of the brain and he does not have neurological findings pertaining to the cervical spine.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested residential treatment services for the treatment of her substance abuse. Findings:  The physician reviewer found that the patients motivation for change was not internal but still external (legal pressure).  She was at high risk for relapse due to many factors. In sum, the patient needed the structure of a residential treatment facility to counter these relapse issues.  This care was necessary before a lower level of care (i.e., outpatient treatment) could be attempted reasonably.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a continuous glucose monitoring system for the treatment of her diabetes. Findings:  Two physician reviewers found that this patient would benefit from a continuous glucose monitoring system.  The system is designed with alarms to protect the patient from high and low glucose levels. Better control of glycemic states would allow more intense control of her condition. Continuous glucose monitoring may provide her with maximal glycemic control without significant and life-threatening complications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old female enrollee has requested Byetta for the treatment of her type II diabetes mellitus.  Findings:  The physician reviewer found that Byetta is used with insulin in the endocrine community. The manufacturer will soon have FDA approval for its concomitant use with insulin as well. Byetta is medically appropriate and indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has for the anti-malarial medication Malarone for her malaria protection.    Findings:  The physician reviewer found that the Infectious Diseases Society of America Guidelines state that any of these three drugs is appropriate first line prophylaxis for malaria in cholorquinine resistant areas, which includes this patients area of travel.  The Guidelines also state that in patients who cannot tolerate doxycycline or Larium, or when there is concern about the potential side effects of Larium, Malarone may be substituted.  If there is concern about Lariums side effects, it can be started a few weeks before the trip and changed if there are side effects.  In this case, the physician documents a severe reaction to tetracycline, which is closely related to doxycycline.  Also, given the family members reaction to Larium, there would be concern for its side effects.  However, it does not appear that the recommended few weeks trial period was available.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for continued acupuncture for treatment of her fibromyalgia. Findings:  The physician reviewer found that although there are notations showing a decrease in some symptoms, continued improvement is not demonstrated in the medical records. Unfortunately, there are notations showing flare-ups shortly after the reduction of symptoms. There does not appear to be any sustained continued improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has for Vyvanse for treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).   Findings:  The physician reviewer found that the FDA has approved Vyvanse for the treatment of ADHD. The age range specified in the package insert limits the age range that the manufacturer can use in advertising the product. The FDA does not regulate the practice of medicine and does not limit physicians to specific ages in the prescription of this drug. From a clinical standpoint, a patient 16 years of age is not very different from a patient 12 years of age in terms of expected response to a stimulant medication being used to treat ADHD. Moreover, this particular patient has demonstrated for a period of several months that he both benefits from and tolerates the drug in question. Accordingly, the patients treatment with Vyvanse is medically appropriate. It would be clinically inappropriate to ask him to switch to another compound merely because he is not in a particular age range. In view of his history, there is a reasonable expectation that such a switch may fail.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for distal left greater saphenous vein ultrasound-guided transcatheter endovenous chemoablation (sclerotherapy) for treatment of her varicose veins. Findings:  Two physician reviewers found that the reflux at the saphenofemoral juncture was successfully treated by VNUS Closure as proven by the latest venous Doppler study. Ultrasound-guided sclerotherapy is a logical approach to removal of the residual small segment of distal left greater saphenous vein. The greater saphenous vein toward the ankle is of much smaller diameter, therefore wall approximation after sclerotherapy is more easily accomplished. There is very little chance of injuring the saphenous nerve using sclerotherapy when compared to stripping or the VNUS techniques. The resultant neuropraxia can be very annoying and can even become permanent. The venous Doppler study showed no reflux or incompetence in either the greater or lesser saphenous systems on the right, therefore sclerotherapy for the solo right calf varicosity would also seem to be the best approach.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested for the Vest Airway Clearance System for treatment of his restrictive and obstructive lung disease. Findings:  The physician reviewer found that daily airway clearance is essential to maintain pulmonary hygiene. The enrollee has had multiple exacerbations of pneumonia and bronchitis requiring antibiotics.  On occasion, he has required acute hospitalization. Standard chest physiotherapy is not feasible since the enrollee does not have assistance, hence failure of standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that occipital nerve blocks are typically a local injection of anesthetic and steroids, not Botox.  It appears that this patient benefitted from standard occipital nerve block. Furthermore, there is insufficient scientific evidence to support the efficacy of Botox utilized in this manner. It is likely that standard occipital nerve blocks of anesthetic and steroids will provide benefit for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for Tarceva, Tykerb, Nexavar and sodium phenylbutyrate for treatment of his squamous cell carcinoma. Findings:  Three physician reviewers found that NCCN guidelines for the treatment of squamous cell cancer of the head and neck suggest clinical trial, as no optimal treatment regimen has been identified. In the absence of a trial, cisplatin-based chemoradiation is considered the standard treatment. In this case, the patient declined radiotherapy and was given a platinum-based combination using the biological agents Tarceva and Avastin along with sodium phenylbutyrate. Since his progression, he has received additional biologics, but he has never received radiotherapy. None of the agents in question are considered appropriate for the treatment of head and neck cancers outside of a clinical trial. There is some date for Erbitux (cetuximab), an EGFR inhibitor similar to Tarceva, as a systemic therapy, particularly in unresectable disease. Other standard therapies that hold promise for this type of cancer include taxanes (docetaxel or paclitaxel) and gemcitabine.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested for dental services for treatment of his fractured teeth.   Findings:  The physician reviewer found that although the hospital report at the time of the accident makes no mention of the patients teeth, given his other injuries, tooth pain would have been an inconsequential finding at that time.  Nonetheless, it is highly likely that the post accident tooth fractures were the direct result of trauma experienced during the head injury suffered.  The extent of the patients injuries, including broken neck vertebrae, indicates that he had a blunt force trauma to the head and face.  It would not be unusual for teeth to be severely stressed at that time and incur incipient fracturing.  These incipient fractures would ultimately evidence themselves months later after the continued stress of daily life, as seen in this case by the multiple fractures of #4, 12, and 13, and the symptomatology of tooth #31.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested emergency services for the treatment of her headache. Findings:  The physician reviewer found that the patient complained of headache in the occipital area for one week that had increased in severity. She also reported nausea and vomiting on one occasion. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and severe, worsening headache pain and vomiting would reasonably expect the absence of emergency care to jeopardize their health. The patient presented in distress with 9/10 pain and required multiple doses of narcotic pain medications to control her symptoms.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for emergency services for treatment of his skin rash.  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 a moderately itchy, swollen, rash gradually worsening over one years time, would not reasonably expect the absence of emergency care to jeopardize their health. Although this patients symptoms were significant and required evaluation on an urgent basis, this care could have been safely provided within the Health Plan and was not emergent.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for IVIG therapy  for treatment of his infections and immunoglobulin deficiency. Findings:  The physician reviewer found that he is a chronically ill man who is predisposed to serious, potentially life threatening pulmonary infections.  While low levels of IgG are seen with CVID, published studies do not use an absolute number as a cut off for potential benefit from IVIG.  Since using IVIG therapy, the patient has had fewer infections and hospitalizations.  His work-up did not validate a faulty response to pneumococcal vaccine, but it could be risky to discontinue therapy in order to perform the test.