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

A 49-year-old male enrollee has requested substance abuse residential rehabilitation services for the treatment of his alcohol dependence. Findings:  The physician reviewer found that during the dates of service at issue, the patient was not in acute withdrawal, and he did not require 24/7 professional monitoring. There were no substantive medical or additional psychiatric impairments. There is no evidence that the patient was a threat to himself or others. No objective documentation that the patient had undergone prior attempts at substance abuse treatment has been provided. The patient did not meet the American Psychiatric Associations practice guidelines for treatment of patients with substance use disorders. He could have been safely and effectively treated at a lesser level of care than that which he received. The Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested Genotropin injections for the treatment of his short stature. Findings:  The physician reviewer found that this patient has been diagnosed with hypophosphatemic rickets. Stature in this disease appears to be determined by the vitamin D receptor genotype. While there are reports of metabolic benefits of growth hormone therapy, a recent meta-analysis of published studies did not confirm any clear growth benefits or studies on improved final adult height. Thus, the clinical value of growth hormone therapy in this patients case has not yet been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested total ankle replacement for the treatment of her left ankle post-traumatic arthritis. Findings:  Three physician reviewers found that patients are often mistaken and believe that ankle replacement surgery will allow them to resume an unrestricted lifestyle. In addition, ongoing conservative care with lightweight bracing, intermittent injections, anti-inflammatory medications, shoe wear modification, and activity modification often give patients significant improvement in their symptoms allowing them to do a large number of activities. Ankle replacement surgery is not a proven procedure with a good long-term outcome, and is not likely to be more beneficial for treatment of this patients medical condition than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Nexium for the treatment of her gastrointestinal condition. Findings:  The physician reviewer found that a number of studies demonstrate the efficacy of each of the PPIs for the treatment of both peptic ulcer disease and GERD. However, there is no data that demonstrates superior efficacy of one PPI above another. Given this, choice of PPI becomes a matter of individual tolerability and efficacy. The fact that a patient has been on a specific PPI for years does not mean that an alternate PPI will not be effective. The Health Plans requirement that the patient try 4 other PPIs prior to Nexium is medically reasonable given the fact that all PPIs have equivalent efficacy. In this case, the patient has tried 3 of the required PPIs in the past, although the dose and duration were not specified and therefore it is impossible to determine if these were given an adequate trial. In addition, the patient has no documentation of a trial of Prevacid.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old female enrollee have requested growth hormone therapy (Nutropin AQ 10mg) for the treatment of the enrollees growth failure leading to short stature. Findings:  The physician reviewer found that the patient appears to have constitutionally delayed puberty and should achieve an adult height beyond the lower limit set by the FDA in their 2003 ruling on the use of growth hormone therapy for idiopathic short stature. Thus, in this patients case, growth hormone therapy is not medically indicated or appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a contrast-enhanced computed tomography angiography (CTA) for an evaluation of her cardiac arrhythmia. Findings:  Two physician reviewers found that the patient has atypical chest discomfort, no documented cardiac risk factors, and a stress echo that showed no evidence of provocable ischemia at an adequate cardiac workload. In this circumstance, the post-test likelihood of significant coronary stenosis is negligibly low, such that additional cardiac testing for coronary stenosis is not warranted. The patient has no documented cardiac risk factors and no provocable ischemia on stress testing so her atypical chest discomfort is likely non-cardiac and related to her other conditions known to cause chest pain. Additionally, nationally endorsed appropriateness criteria for coronary CT angiography as discussed by Hendel and colleagues do not recommend using the test in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a gastroenterology consultation and endoscopy for an evaluation of her abdominal pain. Findings:  The physician reviewer found that the American College of Gastroenterology has updated its guidelines for the diagnosis and treatment of gastroesophageal reflux disease to reflect the continuing advances in this area. In patients with a history typical of uncomplicated gastroesophageal reflux disease, an initial trial of empiric medication and lifestyle changes are appropriate. Most patients with this condition experience symptom relief through medical therapy. A diagnosis of gastroesophageal reflux disease can be assumed in patients who respond to therapy. However, unresponsive symptoms do not rule out gastroesophageal reflux disease. In patients with symptoms of gastroesophageal reflux disease that are refractory to therapy, additional testing should be considered to exclude complications, and the diagnosis may need to be changed. Endoscopy is the preferred technique for diagnosing complications of gastroesophageal reflux disease because it allows for evaluation of the esophageal mucosa. However, endoscopy is medically appropriate and indicated when empiric therapy fails or in the presence of alarm symptoms. Alarm symptoms suggestive of complicated disease include dysphagia, odynophagia, bleeding, weight loss and anemia. This patient should undergo empiric therapy with proton pump inhibitors first. If she fails to respond, only then should gastroenterology consultation and endoscopy be considered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested Remicade, 300mg every two weeks for the treatment of his rheumatoid arthritis of the spine (ankylosing spondylitis). Findings:  The physician reviewer found that the medical literature failed to find support for a maintenance dose of infliximab (Remicade) at intervals of 2 weeks in ankylosing spondylitis. In one clinical trial published by van der Heijde and colleagues, the dose of Remicade was pushed to 7.5 mg/kg in patients who met defined criteria for disease activity, but the dosing interval was not shortened. The standard textbook of Rheumatology does not recommend a dose interval of less than 6 weeks for maintenance therapy in ankylosing spondylitis. Nor do the submitted medical records provide any insight into the rationale for giving a dose of Remicade which greatly exceeds the usual recommended dose, particularly when multiple upper respiratory infections have been documented.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested a continuous glucose monitoring system and related supplies for the treatment of her type I diabetes mellitus. Findings:  The physician reviewer found that there is evidence in the literature about the benefits of CGMS in adults and children and the device is accepted in the medical community that specializes in management of diabetes. This years American Diabetes Association's 2008 Standards of Medical Care in Diabetes states that, `continuous glucose monitoring may be a supplemental tool to SMBG (self monitoring blood glucose) for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the medical necessity of Lyrica 75mg daily is not established based on the records provided. While it is true that Lyrica is the first drug approved by the Food and Drug Administration for treatment of fibromyalgia, the other standard drugs used for this indication  are generic, and as such, FDA approval has not been sought for these agents. The Health Plans authorization criteria for Lyrica requires that the patient try and fail a course of one other formulary alternative before receiving Lyrica. The Plans criteria are medically appropriate and consistent with the standard of care. The patient reports that she has tried other medications, but this is not confirmed in the records provided. If objective documentation is presented which confirms that the patient has failed treatment with another formulary alternative, then the patients request for Lyrica should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested bariatric surgery/lap band for the treatment of her obesity. Findings:  The physician reviewer found that This patient is 410 and weighs 164 pounds, resulting in a body mass index (BMI) of 34. She does report comorbid conditions. However, she does not meet the National Institutes of Health guidelines for weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested Sculptra injections for the treatment of his lipoatrophy secondary to AIDS. Findings:  The physician reviewer found that this patient has facial lipoatrophy as a result of HIV infection and treatment with antiretroviral medications. Sculptra is considered safe and effective for treatment of the patients condition and is considered medically necessary for HIV patients to correct deformities resulting from loss of fat. Thus, the initial injections the patient received were medically necessary and should be covered by the Health Plan. However, given that this patient has already received two injections of Sculptra with good results, additional Sculptra injections are not indicated at this time. Photographs show an essentially normal facial contour with only minimal changes evident around the patients mouth. As noted in the Burgess and colleagues study, it was often the case that the desire for further dermatological enhancement was purely subjective. Based on a review of the submitted clinical evidence, the patients condition does not warrant additional Sculptra treatments at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested Menopur injections for the treatment of his hypogonadotrophic hypogonadism or Kallmanns syndrome. Findings:  The physician reviewer found that both testosterone and sperm are deficient in men with hypogonadotrophic hypogonadism. Some men require both LH and FSH replacement with an hMG such as Menopur to achieve full reproductive function. Thus, Menopur is being utilized in this case for purposes of sperm production to treat the patients infertility. There is no clinical indication for Menopur for treatment of the patients underlying conditions of hypogonadotrophic hypogonadism or Kallmanns syndrome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 71-year-old male enrollee has requested Lovaza 4 g and Ranexa 500 mg for the treatment of his coronary artery disease and angina. Findings:  The physician reviewer found that Ranexa is being used in combination with a beta-blocker and a long-acting nitrate. Therefore, a trial of Ranexa is supported by the record and is medically reasonable and appropriate in this setting. Likewise, the patient has significant dyslipidemia and is intolerant to multiple cholesterol medications. Given the history of the patients intolerance to multiple other lipid reducing agents and the effectiveness of Lovaza in this patient, the continued use of Lovaza is reasonable and medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested a computed tomography (CT) angiography for an evaluation of his cardiac condition. Findings:  Three physician reviewers found that this patient has several cardiac risk factors consistent with ischemia. In this circumstance, it is very likely the patient has significant coronary disease. Current nationally endorsed appropriateness criteria do not recommend obtaining coronary CT imaging in this setting of a high pretest probability of coronary disease in a patient with a chest pain syndrome (Hendel, et al.). Also, coronary CT angiography has recently been shown to be less accurate compared to invasive coronary angiography, and in this circumstance may not detect clinically important stenosis (Miller, et al.).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested spinal cord surgery to de-tether the spinal cord for the treatment of her tethered spinal cord syndrome. Findings:  The physician reviewer found that this patient has a severe spinal cord surgery who presents less than one year post-surgery. As expected, a block was seen at the injury site by myelography. The submitted treatment notes document that the patient noted improvement in her condition. No deterioration or worsening of neurologic condition is noted and no new symptoms are documented in the records provided. With no progression, no worsening and no new symptoms, surgery is not indicated for this patient. She does not have a progressive myelopathy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested chiropractic treatment for the treatment of his low back pain. Findings:  The physician reviewer found that additional chiropractic care is not medically indicated for this patient. The records do not show that the patient has a true functional deficit or that the treatment has resulted in significant change in the overall condition. Typically, chiropractic care is very comparable to that of physical therapy, and one would expect that one to two sessions of physical therapy for a low back strain/sprain and a home exercise program is sufficient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested a Real Time System Continuous Glucose Monitor Minimed Pump for the treatment of her type I diabetes. Findings:  Two physician reviewers found that the requested device would ensure proper insulin delivery with real-time glucose monitoring. The reasons this device would benefit this patient is that it would control her widely fluctuating glucose values versus using a syringe and vial system. This MiniMed CGMS would enhance her glucose control and delay or arrest future complications of her type I diabetes mellitus. An OmniPod pump using a finger stick glucose method is inferior to the requested device, and the patient is experiencing failure with her current system.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested inpatient brain-injury rehabilitation for the treatment of his traumatic brain injury. Findings:  Two physician reviewers found that although the head injury may have exacerbated the patients behavioral issues, it appears a thorough psychiatric evaluation would have been appropriate in this case, given the behaviors described by his mother. It is highly unlikely that the patients progression of symptoms several months after the trauma was attributable to the TBI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested inpatient psychiatric services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient presented with acute symptoms characterized by depressed mood, anxiety, poor sleep, suicidal ideation and a history of a psychotic break. The patient was unable to work. Suicide precautions were initiated on admission. The presence of a mood disorder, disorganized thoughts with suicidal ideation, and a history of psychosis, along with the presence of insomnia and anxiety, increase the risk of suicide (as noted in the American Psychiatric Association Practice Guidelines cited above). Therefore, acute hospitalization was warranted and medically necessary in order to initiate suicide precautions, monitor for safety, assess sleep, and assess reality testing and coping skills in a safe environment until the patient was clinically appropriate to discharge to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested Provigil for the treatment of his fatigue and sleepiness. Findings:  The physician reviewer found that the treatment of side effects of medications is a common practice in medicine. Provigil has been used for conditions not yet approved by the FDA, including multiple sclerosis, cancer, depression and other conditions. Despite appropriate therapy for vitamin B12 deficiency, this patients peripheral neuropathy is severe enough to necessitate administration of opiates and Lyrica. These medications have controlled pain and enabled the patient to function adequately. This appears to be the best regimen for his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested a consultation with a hand surgeon for the treatment of his chronic wrist pain. Findings:  The physician reviewer found that the standard of care in this setting requires excisional biopsy or first-stage biopsy to rule out malignancy. It is medically reasonable and appropriate to refer the patient to a board certified hand surgeon for this procedure. A hand surgeon has the appropriate level of expertise to evaluate the patients wrist mass and persistent pain and to perform a biopsy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 8-year-old female enrollee has requested ultraviolet B phototherapy administered in the home for the treatment of her scleroderma. Findings:  Three physician reviewers found that although there are case reports of linear scleroderma responding to narrow band UVB, this therapy has not been demonstrated to be effective in the majority of patients. An outpatient trial to assess response would be appropriate before using a home unit, particularly in light of the shallower penetration of UVB compared with UVA. Furthermore, if this patients condition is causing serious impairment, further systemic therapy should be considered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested inpatient treatment for the treatment of his psychiatric condition. Findings:  The physician reviewer found that the data reviewed in sum indicates the patient received little benefit from this program. Additionally, according to the American Psychiatric Association (APA) guidelines, patients should be treated in the least restrictive setting which is likely to be safe and effective. The information presented does not substantiate that an inpatient setting was the least restrictive viable treatment setting for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two-year-old male enrollee have requested for speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for the enrollees autism. Findings:  Two physician reviewers found that speech-language therapy is a well-established component of intervention for preschoolers and school-aged children with Autism Spectrum Disorders, ranging from basic interventions to develop spoken communication, to therapy working on pragmatic (social) language skills. Occupational therapy is often a useful adjunct to interventions for Autism Spectrum Disorders, aiding in the processing of sensory input with resultant improvements in behavior.  Applied Behavior Analysis (ABA), is a well researched, evidence-based technique of intervention for children with Autism Spectrum Disorders. It uses an intensive, behaviorally based approach to intervention often referred to as discrete trials instruction, among other strategies. There is good evidence that ABA therapy results in better developmental outcomes for children. Denying this patient behavioral-based therapy would be detrimental to his ultimate development.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for occupational therapy, speech therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that ABA therapy is an intensive therapeutic modality that has been available for the treatment of children with autistic disorders for some time. It is considered a health care service in the treatment of autism spectrum disorders. Several recent publications have suggested that ABA therapy can result in positive gains for autistic children.Occupational therapy has been widely utilized to improve motor skills in autistic children. The peer-reviewed papers referenced above discuss occupational therapy in autistic and developmentally disabled children. Occupational therapy is well established as beneficial and is often integral to the habilitation of autistic children.Speech therapy is also a well-accepted modality for children with autism and can play a vital role in helping improve communication skills in this patient population. A treatment plan with specific goals must be delineated and written, and progress must be measured using appropriate metrics on a relatively frequent basis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested  for continued intensive, in-home, one-on-one, ABA therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that the evidence for the effectiveness of ABA therapy with autism is extensive, and it is considered standard of care and the treatment of choice. Interventions must be intensive and should be started at an early age by trained professionals. The US Surgeon General supports ABA therapy as the recommended form of treatment for autism. It has been shown to be efficacious with several studies demonstrating sustained improvement in areas of functioning, including social and communication skills.