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

A 47-year-old female enrollee has requested physical therapy and occupational therapy for the treatment of her carpal tunnel syndrome. Findings:  The physician reviewer found that the therapy provided for treatment of carpal tunnel syndrome was medically indicated. This treatment was prescribed by a physician to relieve pain, to improve strength/range of motion in the affected body part and to improve functional status. In my opinion, these objectives were achieved to a good extent. Occupational therapy was provided for right carpal tunnel syndrome. The treatment provided was standard and widely accepted for treatment of this condition. Treatment on the date in question was not prescribed by a physician, and the diagnosis of DeQuervains syndrome does not appear to have been diagnosed by a physician. Hence, therapy from the date in question and ongoing was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested cryotherapy for the treatment of her cystic acne. Findings:  The physician reviewer found that this patient has cystic acne that has been resistant to treatment.  She has tried and failed topical retinoids and oral antibiotics, and neither is safe to use in pregnancy. Her pregnant state limits the options for treatment of her acne.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested acupuncture services for the treatment of her condition. Findings:  The physician reviewer found that the patient may have had eight prior acupuncture treatments for the same above complaints. A request by the patient's primary care physician for acupuncture treatment was denied as being not medically necessary or a benefit of the Health Plan. The use of acupuncture for the treatment of this patient's condition is a viable method of treatment and may be of benefit to the patient. Because the Health Plan does not indicate a recommended alternative service at this time, and the patient's primary care physician is requesting the acupuncture treatment, a course of eight visits at a frequency of twice a week could be considered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested continued acute hospital stay for her rehabilitation following laparoscopic cholecystectomy. Findings:  The physician reviewer found that the patient did not require continued acute hospitalization during the period at issue. The recommendation of discharge was appropriate. The patient was taking and tolerating her oral medications. She remained in the hospital because she refused to go home. Although she was not fully independent, below her baseline function, and potentially unsafe for discharge to her home, the level of care required was at a lower level of care than the hospital. As such, the patient did not require continued acute hospitalization.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested inpatient hospital services for the treatment of his alcohol dependence and depression. Findings:  The physician reviewer found that from the standpoint of indication for inpatient treatment per se, he was clearly no longer depressed nor suffering any symptoms acutely related to alcohol withdrawal.  The note is also reflective of his being remarkably devoid of any acute symptoms, and it is unlikely that he suddenly garnered huge therapeutic gain in but one more day of treatment. All told, there was no medical indication for inpatient treatment for the date of service in question.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested cryoablation of a kidney tumor for the treatment of his kidney tumor. Findings:  Two physician reviewers found that this patient has an enhancing small cystic left renal mass. This is suspicious for renal cell carcinoma. The patient has requested coverage for cryoablation of the kidney tumor. The Health Plan has denied this request, and the patient is appealing this denial. Ablative therapies of small renal masses have been shown to be very successful in the intermediate follow-up. The treatment of these lesions is still controversial. Options include observation, partial nephrectomy, and ablation procedures. Although long-term data is only available for partial nephrectomy, intermediate follow-up for observation and cryoablation appears to be very good. The requested procedure is reasonable and appropriate for this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested an electric scooter for the treatment of her medical condition. Findings:  The physician reviewer found that physiatry evaluation documents that the patients present assistive device is sufficient for her household mobility needs.  There is no evidence of impairment of mobility-related activities of daily living.  Therefore, although this patient has a mobility deficit, it is well addressed by the rolling walker with seat.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested an MRI of the brain for an evaluation of the enrollees medical condition. Findings:  The physician reviewer found that patients who present with headache without neurological symptoms or pertinent history usually have no abnormal findings on imaging studies.  According to the ACR, patients with headaches and no other clinical symptoms only showed abnormalities on imaging in 0.5% of cases. Therefore, the yield of imaging in patients with non-complicated headaches is very low, and imaging is not usually indicated for this population.  This patient has been diagnosed with migraine-type headaches but has no acute symptoms or neurological or other changes.  There is no specific indication for MRI in this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested robotic prostate surgery for the treatment of his prostate cancer. Findings:  Two physician reviewers found that the procedure of radical prostatectomy can be done through an open incision operation as has been routine for the last several decades. In the last few years, surgeons have learned to remove the prostate with laparoscopy. The addition of robotic assistance has increased the facility, speed, and safety with which this operation can be done. There are now multiple centers with extensive experience doing robotic assisted radical prostatectomy, and the frequency with which it is performed has increased in the last few years. The outcomes for cancer cure and continence appear to be equal to the open procedure. The blood loss and preservation of erectile function are better than open surgery. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it superior. It is therefore no longer reasonable (when more than half of all operations in the country are done this way) to declare it as experimental.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested bilateral bunionectomy surgery for the treatment of her medical condition. Findings:  The physician reviewer found that bunion deformities are orthopedic deformities of the first metatarsophalangeal joint which result in a painful bump of bone medially as well as first metaphalangeal joint pain, due to misalignment of the joint.  Once formed, the deviated toe and joint will not correct without surgery.  Without correction, the bunion deformity has the potential to progress, possibly causing the second toe to overlap the first.  This creates the potential for increased friction and ulceration.  In this case, the progress notes show that the patient has suffered with painful bunions for many years.  These have been non-responsive to conservative care, including medications and wide footwear.  Podiatry records document skin irritation over the bunion deformity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested sub-acute residential substance abuse treatment for the treatment of her substance abuse and depressive disorder. Findings:  The physician reviewer found that the records provided do not suggest that the patient required 24/7 supervised residential care during the period in question. Her clinical need for this level of care is not demonstrated. The patient had formulated a discharge plan. Both her anxiety and depression had improved. The patients treatment needs could have safely and effectively been met at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Provigil 200mg for the treatment of her depression. Findings:  The physician reviewer found that Provigil may have some place as an adjunctive agent in the treatment of certain patients with depression. However, in this clinical situation, it was not clearly established that the patients depression was resistant, or that there was a specific need for added treatment with Provigil. The trial of Effexor involved a significantly large dose, but only for about two weeks - an inadequate amount of time. Pristiq was begun, but its effects are not documented in the records provided. Thus, the only antidepressant whose use is clearly documented is Cymbalta. It is on this basis that it would not be appropriate to conclude that the use of an off-label drug such as Provigil is appropriate and medically necessary. Accordingly, I concur with the Health Plan. The clinical need for treatment with Provigil has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a PET scan for an evaluation of her breast cancer. Findings:  Three physician reviewers found that the use of PET scans in oncology cases is rapidly evolving and the indications are constantly changing. A recent position paper by the PET Oncology Registry has advocated the approval of PET scans in the evaluation of virtually all types of tumors.  What remains to be proven, however, is the efficacy of PET scans in the monitoring of patients with previously treated cancer. This particular patient had no physical findings at the time of the PET scan to indicate possible tumor recurrence. There is inadequate evidence to support yearly PET scans in this clinical setting in the absence of other findings indicating possible malignancy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested bilateral breast reduction for the treatment of her neck and shoulder pain. Findings:  The physician reviewer found that this patient has symptoms that are consistent with macromastia and has breast hypertrophy. It is certainly possible that her symptoms are due to the weight of her large breasts. Her orthopedist believes this to be the case. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve the patients pain, and it is likely the case that surgery will provide the only real chance for symptomatic relief. However, the submitted clinical records do not include the results of a plastic surgery consultation. Given the patients symptoms and the large size of her breasts, consultation with a plastic surgeon to determine if the patient is an appropriate candidate for breast reduction surgery is warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested a Dynasplint for the treatment of his knee condition. Findings:  The physician reviewer found that at this late date (10 months post-op) one would not expect any form of Dynasplint to make a difference. It must be realized that these are normally used within the first 1 to 3 months postoperatively.  Furthermore, it appears that the patient had achieved within 2 degrees of terminal extension as a result of physical therapy. Further improvement would not be expected with the use of a dynamic splint.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a computed tomography (CT) coronary angiography for an evaluation of her angina pectoris. Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. Additionally, CT angiography is not a medically acceptable substitute for coronary angiography, as CT angiography is not able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary disease in this patient subset currently remains an unproven application of this technology.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested continuous glucose monitoring device for the treatment of the enrollees type I diabetes mellitus. Findings:  Two physician reviewers found that continuous glucose monitoring devices are not experimental or investigational when used appropriately, on a periodic basis, under the auspices of an endocrinologist. In the case of patients with type I diabetes who have inadequate glycemic control despite frequent self-monitoring of their blood sugars, a CGMS becomes a necessary adjunct to standard care. Poor control with frequent hyperglycemia or recurrent episodes of severe hypoglycemia, in spite of frequent self-monitoring of blood glucose, requires the use of a CGMS device to initiate changes in food intake or insulin and thereby optimize blood sugar control.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Lidoderm 5% patch and Skelaxin 800mg for the treatment of his lower back pain. Findings:  The physician reviewer found that there are multiple generic muscle relaxants on the Health Plans formulary which were not tried by this patient; therefore, the use of Skelaxin was not warranted. In fact, the submitted records indicate Skelaxin was only minimally effective for the patient. Furthermore, the use of Lidoderm for low back pain is not within the standard of care and the scientific literature is limited to case series and open-label studies only.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested biofeedback therapy for the treatment of her fecal incontinence. Findings:  Three physician reviewers found that this patient had fecal incontinence and underwent a biofeedback session for her incontinence issue. Review of the relevant medical literature reveals adequate evidence that biofeedback results in positive outcomes in this patient population. Given the lack of treatment options available for the patients condition, the use of biofeedback therapy was medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested bilateral breast reduction for the treatment of her macromastia. Findings:  The physician reviewer found that this patient has the typical symptoms of macromastia. It is certainly possible that her symptoms are due to the weight of her enormous breasts. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve her pain, and it is likely in this case that surgery will provide the only real chance for symptomatic relief. However, the submitted clinical records do not include the results of a plastic surgery consultation. Given the patients symptoms and the massive size of her breasts, consultation with a plastic surgeon to determine if a breast reduction may alleviate her musculoskeletal symptoms is warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested IV Rocephin for the treatment of her stated condition of Lyme disease. Findings:  The physician reviewer found that there is no historical evidence (i.e. a tick bite history or typical rash) of Lyme disease. The patients symptoms are all non-specific. Serological testing has been negative. Evaluation by a member of the UCSF infectious diseases faculty concluded that the patient had never had Lyme disease. Therefore, an antibiotic (either oral or parenteral) is not medically indicated to treat this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Tarceva 150mg for the treatment of her metastatic lung cancer. Findings:  The physician reviewer found that Tarceva is approved for use in non-small cell carcinoma of the lung after failure of first-line chemotherapy. However, there appears to be certain situations wherein there is a particularly good chance of a response without the side effects of chemotherapy. The most prominent of such is in a patient such as this one. Thus, Tarceva would be considered a very reasonable and medically necessary treatment choice in this palliative situation. This would represent a fairly common decision amongst oncologists. Furthermore, there has been very poor correlation between an EGFR mutation and response to Tarceva, such that oncologists do not view this as a necessary test to perform prior to the institution of Tarceva.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested a second opinion bilateral breast MRI for an evaluation of her bilateral nipple discharge. Findings:  The physician reviewer found that this patient is faced with a considerable dilemma as most of her health care providers have indicated that there is no medical need for further diagnostic testing.  However, the second opinion received from USC recommends an MRI of the breasts to search for a possible malignant process not seen on mammography or ultrasound. This recommendation, coupled with a cytology report which includes papillary neoplasm as a differential diagnostic consideration, places the onus of excluding malignancy with the best possible tools available on her clinicians.  In this patients case, there is little choice but to proceed with the exam in order to give the best possible imaging exam which has not yet been done.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested an MRI scan of the cervical spine for an evaluation of her headaches and neck pain. Findings:  The physician reviewer found that the MRI was not medically necessary to treat the patients medical condition. There are no physical examination findings of a cervical spine condition and no documentation of conservative measures for the cervical spine in the form of physical therapy, anti-inflammatory medications, pain medications, or a home exercise program. There is also no documentation of epidural steroid injections.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested a PET/CT scan for an evaluation of her metastatic gastric cancer. Findings:  Two physician reviewers found that the use of PET/CT in this setting is consistent with the current standard of care. The patient is an appropriate candidate for the PET/CT scan and its use in this setting is most reasonable. No other diagnostic procedure is likely to provide results superior to the proposed PET/CT scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Aciphex for the treatment of her condition. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy.  All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion.  However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant difference in their effects with regards to clinical or endoscopic end points or side effects profile. In this case, the patient should be a given a complete trial with PPIs on the formulary. She should be given a trial of Protonix, single and double dose, for eight weeks each. If she fails to respond to these trials, then she should be approved for Aciphex.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-year-old female enrollee has requested for the treatment of the enrollees Prader-Willi syndrome (PWS). Findings:  The physician reviewer found that the patient may have GH deficiency based upon the IGF-1 level provided and the short stature despite GH therapy in the past. The value of GH therapy in adults is that treatment does improve lean body mass and fractional body fat without glucose impairment. However, GH therapy will not diminish appetite, and GH therapy in this instance is not medically indicated.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patients constellation of symptoms is consistent with a variety of medical disorders, some of which may be life-threatening. These include viral pharyngitis, strep pharyngitis, peritonsillar abscess, lymphadenitis, epiglottitis and others.  His condition was of acute onset.  He was suffering from severe pain (fever, sore throat, painful swallowing, difficulty speaking) of a nature that would lead a patient to make a reasoned decision to seek immediate care at the closest facility.  If he had not sought immediate care, he could have been at risk for dehydration, airway compromise, and continued spread of infection.  It was important that the patient seek medical care in order to rule out life-threatening disorders, determine the cause of his symptoms and initiate immediate therapy.