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

A 60-year-old male enrollee has requested for the medication Epogen for treatment of his myelodysplasia.   Findings:  The physician reviewer found that Epogen is reasonable and necessary for treatment of his myelodysplasia syndrome. The records submitted establish that the patient meets accepted criteria for treatment with Epogen. It is not necessary to continue to monitor EPO levels. EPO levels are helpful as a baseline to determine the likelihood of a response.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Xibrom for the  treatment of her uveitis and cataracts. Findings:  The physician reviewer found that the patient has either episcleritis or scleritis. The best and most effective anti-inflammatory in cases such as this would be a steroid. However, if the patient has early cataracts, a steroid will hasten the need for cataract surgery, and possibly produce glaucoma. Although there has not been a long series confirming benefit, non-steroid anti-inflammatory (NSAIDs) are often used in this clinical setting in an attempt to avoid the complications associated with steroid use. A trial of the Health Plan formulary medications (Acular or Ocufen) is medically reasonable and appropriate in this case. The only benefit of Xibrom over the formulary NSAIDs is that it only requires twice daily dosage. As such, the use of Xibrom is not medically warranted in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for treatment of morbid obesity.  Findings:  The physician reviewer found that the patient meets nationally recognized criteria for authorization of bariatric surgery. The Medicare Coverage Database states gastric bypass, duodenal switch and Lap Band are covered in patients with a BMI greater than 35 and at least one obesity-related co-morbidity. Current literature indicates the Lap Band produces substantial weight loss with low morbidity. The weight-loss curve very closely approximates that of gastric bypass at five years and patients who undergo the Lap Band procedure are less likely to have potentially life threatening adverse events.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a panniculectomy, abdominoplasty and circumferential body lift for treatment of redundant skin condition.  Findings:  The physician reviewer found that a panniculectomy will most likely eliminate the infections that the patient has suffered from. Because the infections are recurrent despite adequate hygiene and topical antifungal medications, the proposed panniculectomy would be considered medically necessary according to the ASPS Position Paper.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for intensive outpatient program (IOP) services for treatment of her eating disorder.    Findings:  The physician reviewer found that the records clearly and consistently show that the patient continues to struggle with her eating disorder as demonstrated by binging and purging, her alcohol abuse and her feelings of helplessness, worthlessness and depressed mood. The patients symptoms and their intensity and frequency meet criteria for on-going treatment in the eating disorder IOP. Her symptoms have not stabilized to a point that she can transition to a lower level of care. The patients comorbid conditions of substance abuse and depression are also unresolved and have a significant impact on her eating disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested psychiatric residential treatment services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that neither the patients history nor her treatment course identified any treatment needs that could not have been addressed on a purely outpatient basis. For example, the patients response to stopping Zoloft and beginning Lexapro could have been monitored during outpatient therapy. Similarly, the patients history of unsuccessful personal relationships and overeating did not demonstrate a medical need for residential care. While these problems are relevant to the patients treatment, there is no evidence to suggest that these issues could not have been successfully addressed in an outpatient treatment program. A review of all the information submitted does not demonstrate any evidence establishing that residential services were medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested an EBCT scan for treatment of coronary artery disease.  Findings:  Three physician reviewers found that EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. EBCT is also not a medically acceptable substitute for coronary angiography, as the former would not be able to accurately confirm or exclude important coronary obstruction. The use of EBCT in the diagnosis and prognosis of coronary artery disease currently remains an unproven application of this technology and is not clinically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested artificial disc replacement surgery for treatment of cervical disc disease.  Findings:  Three physician reviewers found that while there is some support for the procedure, there is no long-term data to determine the ultimate effect of the artificial implant. There is simply not enough literature available to suggest that this procedure would be more beneficial in the treatment of single level degenerative disc change than traditional procedures such as anterior cervical discectomy with fusion. Although some studies have shown that there is preservation of cervical spine motion within the first six months after the surgery, those same studies have shown that motion decreases over time. While there is increasing interest in this type of treatment as an alternative to fusion, the data on failure including loosening and mechanical failure has yet to be gathered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested positional MRI of the lumbar spine (2 views) for evaluation of degenerative disc disease.  Findings:  The physician reviewer found that the record provided for review was very limited and did not include a complete history and physical, an evaluation by a surgeon or neurologist or an indication of how the results of the test would affect the patients plan of care. As such, there is insufficient medical information to establish the need for a lumbar MRI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested Provigil for the treatment of her extreme fatigue. Findings:  The physician reviewer found that Provigil is FDA approved for fatigue/somnolence associated with shift work disorder, sleep apnea and narcolepsy. The literature also suggests a benefit for patients with fatigue related to multiple sclerosis. There is no medical literature to indicate that Provigil is indicated for the treatment of chronic fatigue syndrome or fatigue of unknown etiology. It appears the patient is taking some sedating medications that may contribute to her symptoms. Chronic fatigue may also be a symptom of depression, and activating antidepressants such as Wellbutrin or Effexor may be more beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-month-old female has requested follow-up and testing at an infant development clinic for treatment of the patient who was born at 29 weeks gestation.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties including nutrition and growth problems, cerebral palsy and other motor difficulties, mental retardation and other neurodevelopmental disabilities, behavioral problems including ADHD, and sensory impairments. According to one source, up to 50% of infants born weighing less than 1500 grams and up to 60-70% of infants born weighing less than 1000 grams have problems at school, (e.g., learning difficulties, failing grades, special education requirements, etc.). They have a greater chance of experiencing language delay, visual-perceptual problems, and problems with attention and behavior. Per the authors of Handbook of Neonatal Intensive Care, Under ideal conditions parents of all NICU infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood. In a Cochrane review of the effectiveness of early developmental intervention post-discharge from hospital for preterm infants on motor and cognitive development, the authors concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short (0-2 years) and medium (3-less than 5 years) term.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male has requested continued inpatient hospitalization at a non-Plan facility for treatment of epidural abscess.  Findings:  The physician reviewer found that there is no clear evidence that the patients condition was truly stable or that adequate plans had been made for his outpatient care. Transfer was not reasonable at this juncture, as continuity of care and the seriousness of this infection required consistent attention to these and other important issues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested the medication Byetta for treatment of diabetes.  Findings:  The physician reviewer found that although Byetta has recently begun to be used off-label with insulin in patients with type 2 diabetes, there is no literature to support such use and the drug has not been approved for use with insulin. There is inadequate medical data demonstrating that the proposed use of Byetta will be safe and effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested prescription medication Qualaquin for treatment of leg cramps.  Findings:  The physician reviewer found that the use of Qualaquin for the treatment of nocturnal leg cramps is not clinically appropriate nor is it   consistent with that definition. The FDA has specifically stated this drug should not be prescribed for leg cramps because of its side effects. The patient has documented heart disease and Qualaquin is known to have a significant impact on the conduction system within the heart. Additionally, there is very limited evidence of the effectiveness of this drug in preventing leg cramps in the peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 17-year-old male enrollee has requested Penlac for treatment of onychomycosis.  Findings:  The physician reviewer found that Penlac nail lacquer is the only FDA-approved topical medication for the treatment of onychomycosis. Various studies demonstrate an efficacy range of 10% to 20% for this medication, however the side effects are minimal. Despite the warning in regard to hepatic complications, Lamisil is a very safe and effective treatment for onychomycosis and studies demonstrate a 70% to 90% efficacy range. Therapeutic side effects may occur in 1% to 2% of those treated with Lamisil and are reversible. There are no contraindications mentioned in the available documentation that would preclude this patient from taking Lamisil.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested a second cochlear implant for treatment of sensorineural hearing loss.  Findings:  The physician reviewer found that many patients continue to benefit from unilateral hearing aids. With regard to cochlear implantation, 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. No implants have been approved by the Food and Drug Administration for binaural use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a three-year-old male enrollee is seeking occupational and speech therapy services for the treatment of the enrollees developmental delay. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has a serious neurological and psychological medical condition that requires treatment. Other patients with similar findings have improved significantly with occupational and speech therapy to the point where they are able to function in school and society. The patient is an appropriate candidate for the proposed services, which are likely to result in clinical improvement in his condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested retreatment with Rituxan for the treatment of her rheumatoid arthritis. Findings:  Three physician reviewers found that Rituxan has received FDA approval for the treatment of rheumatoid arthritis. Its effectiveness has been repeatedly demonstrated in trials involving various regimens including steroids, methotrexate, and cyclophosphamide, as well as in patients who previously failed other immunologic modifiers. Treatment with Rituxan is not generally limited to one course of therapy and retreatment is considered appropriate management for patients who previously responded.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested growth hormone therapy for treatment of chronic pain and fatigue.  Findings:  The physician reviewer found that there is insufficient peer-reviewed data to support the utilization of growth hormone therapy to manage chronic pain syndrome. Furthermore, the use of growth hormone for the management of chronic pain syndrome is not within generally accepted medical management guidelines and does not meet standards of care. There are other available modalities for management of this patients chronic pain and fatigue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested for an intensive outpatient chemical dependency program for treatment of his chemical dependency. Findings:  The physician reviewer found that the patient had been using multiple drugs and alcohol for a very long time and had a significant risk of relapse. These factors support the need for on-going intensive outpatient intervention for continued sobriety.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a Phase I clinical trial of Avastin and valproic acid for treatment her colorectal cancer. Findings:  The physician reviewer found that avastin has been approved for use when combined with chemotherapy in the treatment of metastatic colon cancer. However, there is no convincing data that Avastin is efficacious when used later in the course of treatment, as is involved in this case. Further, valproic acid, a drug ordinarily used in seizure disorders, has some theoretical anti-cancer potential, but there is inadequate data demonstrating the drugs efficacy in this setting at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a bilateral reduction mammoplasty for the treatment of her macromastia. Findings:  The physician reviewer found that the submitted clinical notes do not contain findings of intertrigo. While the patients primary care physician makes reference to chronic shoulder, back and neck pain, treatment notes documenting the chronicity of these complaints have not been provided. The low back complaints are not attributable to breast hypertrophy, though the upper back pain can be causally related to large breasts or other intrinsic cervical or thoracic etiology, the source of which has not been adequately documented in the supplied records. All told, there is inadequate evidence that the proposed mammoplasty is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested an increased dosage of Symlin (120mcg three times per day) for treatment of Type I Diabetes.  Findings:  The physician reviewer found that the approved dosage of Symlin for type I diabetes mellitus is 60mcg before meals at maximum. There is no data to support higher doses as useful.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested a laparoscopic gastric bypass procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 49.8 and significant comorbid conditions, the patient is likely to meet nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient should not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, the National Institute of Health guidelines also indicate that gastric bypass surgery should only be considered for for well-informed and motivated patients with acceptable operative risks. This patient would appear to meet criteria for consideration of weight loss surgery, but she has not yet obtained medical, surgical, nutritional or psychological clearance for the procedure. A TSH level to document that there are no treatable metabolic causes for her obesity is also recommended.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a panniculectomy for the treatment of her redundant skin condition. Findings:  The physician reviewer found that the colored photographs reveal an overweight female with hypertrophic scars and stretch marks on the lower abdomen. The panniculus covers the upper portion of the mons pubis but does not extend below the inguinal ligament. There is some erythema in the suprapubic area and erythema of the umbilicus, but no skin ulcerations. The plastic surgery consultation note indicates low healed scar from cesarean sectionsskin quality is moderatemultiple stretch marksfat distribution copious... mild rectus diastasis. The provider also noted excoriation of the waistline and a little bit of redness of the umbilicus, but no intertriginous rash. The stated diagnosis was lipodystrophy. Although the patient was seen on several occasions for skin rash, the rash seems to be intermittent based on the records and medications for dermatitis, fungal infection or intertrigo were not prescribed on an on-going basis. It does not appear there has been a comprehensive skin care program for at least six months to control the intertrigo. The panniculus has not been demonstrated to interfere with activities of daily living.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a power-operated vehicle (POV) for mobility.  Findings:  The physician reviewer found that she does not meet Medicare guidelines for a POV. She is not totally non-ambulatory and does not have weakness of the upper extremities. Though the patient does have a mobility deficit, which can cause increased risk of morbidity during her activities of daily living, this can be corrected with the use of a manual wheelchair. Given the absence of any documented upper extremity complaints, the patient should be able to operate a manual wheelchair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested for a duodenal switch procedure for treatment of his morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is an appropriate surgical option that is approved by the American Society for Metabolic and Bariatric Surgery (ASMBS), the Society of American Gastrointestinal Endoscopic Surgeons and the American College of Surgeons based on sufficient scientific evidence.  Like all operations, the duodenal switch procedure has its own set of particular risks and benefits, but has been attributed with the greatest amount of weight loss when compared to purely restrictive operations or hybrid operations such as the Roux-en-Y gastric bypass.  This patient needs to lose over 200 pounds to improve his health.  The duodenal switch procedure is an appropriate surgical option for this patient who otherwise has no metabolic, dietary or psychological barriers to surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of an eight-year-old male enrollee has requested for a referral to a pediatric urologist for treatment of the enrollees phimosis. Findings:  The physician reviewer found that there is no evidence of penile abnormality other than phimosis with a redundant and periodically inflamed prepuce. The patients condition can be appropriately evaluated and treated by an adult urologist and does not require the services of a pediatric urologist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for Enbrel 50mg/ml twice weekly for treatment of her psoriasis. Findings:  The physician reviewer found that the safety profile of the injectable biologicals (Enbrel and Raptiva) for a young woman of childbearing age is much better than the safety profile of methotrexate, cyclosporine or Soriatane. Methotrexate and Soriatane are category X medications. The potential side effects of long-term cyclosporine, namely high blood pressure, kidney problems and skin cancer are greater than the side effects associated with biologicals. Furthermore, UVA or UVB phototherapy is less safe, especially in this patient who has an increased risk of skin cancer due to her fair complexion. There is no disputing the efficacy of Enbrel in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee, who is a hip disarticulation amputee, has requested a C-leg microprocessor controlled knee.  Findings:  Two physician reviewers found that this patient satisfies the Medicare criteria for a microprocessor-controlled knee. The requested microprocessor knee is medically appropriate and necessary in this young patient. It provides the necessary variability in cadence and support for an active amputee.