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

The parent of an 11-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient has a subnormal growth rate and has failed two growth hormone provocation tests. His ADD medications have been reported to have growth-retarding effects. His clinical and laboratory evidence is consistent with growth hormone deficiency, for which growth hormone therapy is appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for Strattera for treatment of her major depression. Findings:  The physician reviewer found that there is no objective basis for the conclusion that this patient has serotonergic syndrome. The latter represents a true, medical emergency for which inpatient medical treatment is indicated. Curiously, but significantly, the patient suffered from apparently similar muscle twitching when treated with a higher dose of Wellbutrin in combination with Strattera, and this wasnt deemed anything akin to serotonergic syndrome. Rather, it was recognized as a likely side-effect from the combination. Wellbutrin was simply decreased in dose. Finally, while adding a stimulant to an antidepressant regimen may have some value in treating depressive illness, it is unclear how the patient would have responded to a higher dose of Wellbutrin, sans Strattera.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female has requested a power operated vehicle (POV) for treatment of pain and neuropathy.  Findings:  The physician reviewer found that the medical records reflect the patients mobility limitation.  However, her mobility is accommodated through the use of two single point canes.  Her strength is documented as normal in her upper extremities, and she is able to ambulate one block with a walker.  Based upon this information, the patient is able to complete her mobility-related activities of daily living and ambulate in her home with this accommodation.  The records provided do not demonstrate that the patient meets nationally accepted criteria for authorization of a POV.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested an artificial disc replacement for treatment of neck and back pain.  Findings:  Two physician reviewers found that artificial discs are unproven as treatments for degenerative cervical disorders.  There is no long-term outcome data to establish the safety and efficacy of this procedure/device over accepted treatments. In addition, there is significant data related to failures and other morbidity. Given the lack of evidence supporting the efficacy and the known rates of morbidity, the procedure remains experimental.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female has requested Herceptin, Aloxi, Epogen and Navelbine for treatment of metastatic breast cancer.  Findings:  The physician reviewer found that the Health Plans denial of Herceptin with Navelbine should be overturned. Although the patient was treated previously with Herceptin, it was essentially a single-agent therapy. Although further study is necessary, there is data supporting Herceptin and Navelbine therapy and this could be considered the patients first Herceptin chemotherapy combination. The denial of Epogen should also be overturned as there is sufficient evidence and nationally accepted guidelines to support its use in this patient. In addition, Aloxi was and is medically necessary for the patient. There sufficient evidence to support the use of Aloxi for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested Intravenous Immune Globulin (IVIG) therapy for treatment of the degenerative cerebellar disorder.  Findings:  The physician reviewer found that at this time, there is no large scale placebo controlled trial to support the use of IVIG therapy for this patients symptoms. While individual reports exist regarding IVIGs benefit in paraneoplastic cerebellar diseases, it is not clear that this patient carries this diagnosis. The presence of autonomic symptoms is more suggestive of the alternative diagnosis of MSA (a non-IVIG responsive disorder). The presence of a positive ANA is a non-specific finding, and in isolation does not justify treatment. In addition, IVIG is not without side effects. Patients may experience headaches, aseptic meningitis, or life-threatening thrombosis. For these reasons, the use of IVIG in this patient is not justified at this time. If a malignancy is detected or if the patient is later found to have anti-Purkinje cell antibodies (anti-yo), then a trial of IVIG would be warranted. Until this time, the Health Plans denial is reasonable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male has requested Taclonex Ointment for treatment of psoriasis.  Findings:  The physician reviewer found that Donovex Cream is ineffective for this patient. Dovonex ointment does work, but is no longer available, except in Taclonex Ointment. Clobetasol was used, but didnt work. Clobetasol is stronger than Diprolene. The manufacturer no longer makes the ointment form of Dovonex. There is no medical reason to insist on using the combination the Health Plan requires.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested Synagis for treatment of the enrollee, who is status post bone marrow transplant.  Findings:  The physician reviewer found that in accordance with the American Academy of Pediatrics guidelines, California Childrens Services guidelines allow for palivizumab prophylaxis to immunocompromised children without age restriction. Children who have received bone marrow transplants have altered immunity long after their transplant has engrafted. In addition, those on immunosuppressant medications are also immunocompromised. Fighting RSV infection successfully requires all branches of the immune system to be intact. An absence or debility of any one branch may result in severe RSV infection, with resultant morbidity and even mortality. Although randomized controlled trials have yet to be performed (and may never be due to medicoethical reasons), one decision analysis model demonstrated a decrease in mortality in children after bone marrow transplant with the use palivizumab to protect against RSV-related lung disease.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested a continuous glucose monitor for treatment of diabetes.  Findings:  Two physician reviewers found that there are several articles that support the value of real-time continuous glucose monitor in improving diabetes control.  This patients autonomic neuropathy interferes with his diabetic management.  The patient is correct in stating that the symptoms of autonomic neuropathy mimic those of a hypoglycemic reaction.  This condition and his nighttime hypoglycemia place him at risk for hypoglycemic seizures, coma, and death during sleep.  His current monitoring leaves unattended gaps in his blood glucose excursions even though he monitors at increased frequency.  Due to his heightened risk for severe and life threatening complications, I have determined the requested continuous glucose monitor is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female has requested placement of bilateral cochlear implants for treatment of profound sensorineural deafness.  Findings:  The physician reviewer found that the information provided by the cochlear implant center provides results for the best aided condition of the left ear. There is no record of HINT or speech perception testing for the cochlear implant with the cochlear for the right ear. The last sentence on page five of this report states that the cochlear team decided against implantation of her left ear. Based on this information, there is no evidence to support the medical necessity of bilateral cochlear implants.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female has requested the medication Byetta for treatment of diabetes.  Findings:  The physician reviewer found that this patient meets the criteria for approval of Byetta.  Byetta is not being used to replace insulin therapy. This patient is not an insulin dependant (or insulin requiring) diabetic, and she will not be using insulin with the Byetta.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested coverage for inpatient care for treatment of her perforated appendix and appendiceal abscess. Findings:  The physician reviewer found that this emergent admission was necessary for treatment of the patients condition.it would not have been medically safe to transfer this patient to another facility prior to CT-guided drainage of the abscess.  This patient was in the early management stages of a critical status. A transfer would have placed the patient at an even higher risk. The emergency department nurse stated that the patient was stable to be transferred to the floor. This should not be construed to indicate that she would be stable enough to be transferred to another facility. The patient also would not have been considered stable after CT drainage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for skilled nursing facility (SNF) services for treatment of his Guillain-Barre Syndrome. Findings:  The physician reviewer found that physical and occupational therapy do not promote nerve recovery. The pace of nerve recovery is such that patients cannot benefit from daily skilled physical and occupational therapy. The patient required daily range of motion, but this could have been done via a home exercise program. He required only intermittent physical and occupational therapy, supervision and review of his status.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Gamma Knife radiosurgery for treatment of metastatic brain lesions.  Findings:  The physician reviewer found that there is no question that radiosurgery is a powerful tool in the delivery of localized radiation to a solitary brain tumor. However, evidence of efficacy is lacking in the setting of multiple intracranial metastases. Radiosurgery is also effective as a boost to the dominate mass following whole-brain irradiation and results are superior to whole-brain irradiation alone. Gamma Knife radiosurgery may also be appropriate in the event of an intracranial recurrence. However, whole-brain irradiation, in conjunction with recommended systemic therapies, is standard of care for a patient such as this patient. Treatment with radiosurgery alone to avoid the toxicity of whole-brain irradiation is to invite the toxicity associated with a growing intracranial tumor.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old male has requested Sutent for treatment of acute myeloid leukemia (AML).  Findings:  Two physician reviewers found that Sutent, a multi-targeted tyrosine kinase inhibitor, has shown activity in a number of solid tumors, especially advanced renal cell carcinoma (RCC) and gastrointestinal stromal tumors (GIST), for which it is FDA approved. Sutent has been studied in AML. There is no standard therapy for AML. Many patients with AML have mutations in FLT3, a tyrosine kinase that Sutent can inhibit.This patient has clearly responded, with reduction in his blast count and should continue on this therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male has requested acute inpatient psychiatric services for treatment of the enrollees intermittent explosive disorder and attention deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that at the time of admission, the patient was sleep-deprived and noted to be dysphoric and labile. He had no suicidal ideation, homicidal ideation, psychosis, hallucinations or medical issues. He did not require chemical or physical restraints. He was rude, disrespectful and did not follow rules during his hospital stay. However, he displayed no aggression or safety risk issues. He was given Vyvanse and Tripleptal. He participated well in family therapy. The clinical records do not support the medical necessity for acute inpatient treatment. The patient could have been treated at a lower level of care or had an urgent outpatient appointment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 17-year-old male enrollee have requested growth hormone (GH) therapy for treatment of short stature.  Findings:  The physician reviewer found that this request is for GH therapy for a 17-year-old male with short stature who has a predicted adult height of 54 against a mid-parental height of 58.5. A work-up prior to this excluded GH deficiency and other known causes of short stature including SHOX. A bone age was read as 16 years. The patients growth response after Lupron and GH therapy was initiated was 0.6 cm over five months for a low yearly rate of 1.44 cm. The pediatric endocrinologists note stated that, unless growth has increased during the next three to six months, any benefits of continued therapy may be minimal. Indeed, intervention at this late stage would be expected to be marginal.  However, the predicted height of 54 is borderline low for adult men in the United States, under the FDA guidelines for GH therapy for idiopathic short stature. Therefore, on clinical grounds, continuation of GH therapy would be appropriate to determine conclusively whether there is a therapeutic benefit in further treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female, who is pregnant, has requested delivery at a hospital with a Neonatal Intensive Care Unit (NICU).   Findings:  The physician reviewer found that her prenatal course reveals several visits to evaluate her for premature labor, and terbutaline, a tocolytic, at an unknown point during the pregnancy. However, there is no evidence that she has had a diagnosis of premature labor. Now at term, she is not at risk for prematurity. In addition, a review of the prenatal record reveals there is no evidence that the pregnancy is high-risk in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested an iBot Mobility System for his mobility.  Findings:  The physician reviewer found that the records provided are not supportive of the patients need for the iBot Mobility System to perform mobility-related ADLs. The patient has a long history of spinal cord injury and is currently using a POV. Modification to the living space is the appropriate means of gaining access to higher-level cabinets, etc. Additionally, the iBot Mobility System is still investigational at this time, and long-term outcomes have not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested the medication Forteo for the treatment of her osteoporosis.  Findings:  The physician reviewer found that the medical records did not reveal a work-up for postmenopausal osteoporosis to account for bone loss.  As the DEXA scan is the only scan available, there is no evidence demonstrating if the patient has a low baseline bone mass or is actively losing bone. In addition there is no objective evaluation of the patients osteoporosis and no evidence of trials of other therapies for her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has for laparoscopic biliopancreatic diversion with duodenal switch (LBPD/DS) bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is no data available that shows that nutritional deraignment after the LBPD/DS operation is more prevalent or more serious than what is encountered with the gastric bypass operation.  In fact, there is a large body of scientific evidence that shows superior short and long-term outcomes with the LBPD/DS when compared to the gastric bypass or the laparoscopic gastric banding procedures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 71-year-old male enrollee has requested for Meridia for treatment of his overweight condition. Findings:  The physician reviewer found that the 2008 Physicians Desk Reference states that Meridia is indicated for use in patients with a BMI greater than 30, and with a BMI greater than 27 if there are other risk factors.  There are very few medications that have been approved for use in assisting with weight loss.The prescribed weight loss regimen has been effective for the patient when diet and exercise alone have not and it is consistent with the standards of good medical care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female has requested IVIG therapy for treatment of multiple sclerosis.  Findings:  The physician reviewer found that this patient has had relapsing and remitting symptoms consistent with RRMS. A specific diagnostic test is available for neuromyelitis optica. Standard disease-modifying therapy for RRMS is relatively contraindicated given the patients breastfeeding status. IVIG is accepted as a second line therapy for RRMS. If lab testing for neuromyelitis optica is negative, IVIG should be started for RRMS. Once the patient is not breastfeeding, standard disease-modifying therapy may be initiated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female has requested rental of a continuous passive motion machine for treatment following total knee replacement.  Findings:  The physician reviewer found that the use of a CPM machine postoperatively is routine and standard of care following total knee replacement generally. The device is utilized in the immediate postoperative period in the hospital and at home after discharge. It is normally used for anywhere up to four weeks postoperatively. In this case, it was prescribed for approximately three weeks, which was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-year-old female has requested laparoscopic duodenal switch (DS) bariatric surgery in lieu of vertical sleeve gastrectomy (VSG) without completion of the Options Program for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 51.7 and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the Options Program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified 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 morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. If a psychological evaluation has not occurred, one should be conducted to ensure the patient is an appropriate candidate for surgical weight loss. The patient has a need for long-term treatment with NSAIDs making the Roux-en-Y gastric bypass (RYGB) procedure a less tenable option. Laparoscopic gastric banding is not likely to be as effective as other surgical alternatives. The VSG procedure is a component of the biliopancreatic diversion with duodenal switch procedure (BPD/DS). VSG is an appropriate first step and may facilitate adequate weight loss for the enrollee. VSG is a less risky procedure than the full BPD/DS and moderate weight loss will be achieved without severe side effects such as dumping syndrome or malnutrition. If weight loss is not adequate (< 40% of excess body weight) and/or comorbidities do not improve, a staged conversion to BPD/DS is possible and would be indicated if treatment with NSAIDs continues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested reimbursement for a CT scan of the chest for the evaluation of chest pain.  Findings:  The physician reviewer found that this patient had multiple neurological symptoms in addition to chest symptoms. Lung cancer can sometimes present with neurological symptoms secondary to a paraneoplastic syndrome. Clinically, the imaging exam of choice is a CT scan of the chest. The outcome of the chest CT would impact the treatment planning for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested fusion at L5-S1 and artificial disc placement at L4-L5 for the treatment of his degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement is no longer considered experimental by many surgeons. The device has FDA approval, and numerous studies have shown its success. In general, the advantage of artificial disc replacement is preservation of motion. However, the proposed surgery involving disc replacement and fusion has not been sufficiently studied and superior outcomes have not been demonstrated in the peer reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested reimbursement for repeat EMG/NCV testing for the evaluation of chronic inflammatory demyelinating neuropathy.  Findings:  The physician reviewer found that the patient has an apparent diagnosis of CIDP. Electrodiagnostic testing is clinically appropriate in making the diagnosis of CIDP. Repeat electrodiagnostic testing has no proven role in the management of CIDP. No evidence was submitted that would support the need for the very extensive electrodiagnostic testing that was performed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested continued acute inpatient rehabilitation services for the treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that while this patient made very minimal progress initially, his alertness and participation has improved considerably. It is noted that although he required cues before, this patient is now responding spontaneously and tracking conversations. He is now able to participate in hand over hand grooming and has been able to transfer side to side.  This patient was previously dependent. He has recently been able to take small bites of food and has answered appropriately to yes and no questions. Therefore, I believe it is medically necessary that this patient remain in inpatient acute rehabilitation for continued progress.