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

The parent of a 15-month-old female enrollee has requested Synagis to assist in the prevention of respiratory syncytial virus (RSV) infection. Findings:  The physician reviewer found that while the patient was born prematurely, and as such has experienced some of the complications of premature birth, her respiratory disease does not meet the accepted definition of chronic lung disease (CLD) of prematurity as she only received supplemental oxygen for 10 days in the NICU. The patient does not automatically qualify for a second year of Synagis therapy according to the AAP guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested reimbursement  breast reduction mammoplasty for treatment of her breast macromastia.  Findings:  The physician reviewer found that confirmatory evidence of symptoms such as a history of conservative therapy or physician visits for musculoskeletal symptoms are required to establish the medical necessity of mammoplasty for women with photographic documentation of smaller breasts. The submitted records do not provide adequate documentation to support the need for reduction mammoplasty in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested  kyphoplasty for treatment of her vertebral fractures. Findings:  The physician reviewer found that the patient suffered with compression fractures and attempted conservative treatment without success. After the failure of these measures, kyphoplasty was recommended. Kyphoplasty is a standard means of treating fractures of the vertebrae in patients with persistent pain. Kyphoplasty has been well studied and has been approved by the Food and Drug Administration. The procedure was necessary to alleviate the patients pain and was clearly successful in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested laparoscopic vertical gastroplasty for treatment of her morbid obesity.  Findings:  Two physician reviewers found that there is insufficient data demonstrating laparoscopic vertical gastroplasty is superior to standard bariatric procedures. In order for vertical gastroplasty to result in adequate weight loss, the stomach must be made extremely tight and narrow, resulting in significant reflux disease. Other weight loss procedures such as Roux-en-Y gastric bypass and duodenal switch are more effective in terms of weight loss and result in less morbidity
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a PET scan for evaluation of his pancreatic cancer. Findings:  The physician reviewer found that prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include pancreatic cancer on its list of indications for PET scan. However, the National Oncologic PET Registry (NOPR, www.cancerpetregistry.org) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. Pancreatic cancer is listed as appropriate for diagnosis, staging, restaging, and monitoring.  PET has shown itself to be sufficiently sensitive to be part of the evaluation of patients with pancreatic cancer.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested bariatric sleeve gastrectomy for treatment of his morbid obesity. Findings:  Three physician reviewers found that bariatric surgery is medically indicated in this patient who is morbidly obese with a BMI of 54. However, the patient does not have significant comorbid conditions such as diabetes warranting a two-staged procedure like sleeve gastrectomy followed by a restrictive procedure. A standard bariatric surgical procedure is medically reasonable and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested authorization  for speech therapy for treatment of the enrollees speech and language disorder.  Findings:  The physician reviewer found that there is no suggestion that the patients speech therapy was required due to a medical condition or to restore his speech to a previously attained skill level.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested authorization for a continuous passive motion (CPM) machine and a cold/heat therapy unit for treatment, status post anterior cruciate ligament (ACL) reconstruction.  Findings:  The physician reviewer found that while some orthopedists do use the CPM machine following ACL reconstruction surgery, there is a lack of peer-reviewed literature indicating a clear benefit from this device over physical therapy alone. Cold therapy following ACL surgery or injury is an accepted standard of care. However, there is no proven benefit from a cold/heat therapy unit over standard ice application. The peer-reviewed literature lacks well controlled studies of efficacy. While this type of unit is convenient, it is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested authorization for growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the information provided presents minimal evidence for the putative neuro-secretory defect; the patients shortest height appears to have been near the 10th percentile, and he is already beyond the height limit set by the FDA for idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 81-year-old male enrollee has requested authorization for cardiac EBCT for evaluation of his potential cardiac disease.  Findings:  Three physician reviewers found that Cardiac CT imaging is not a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease in asymptomatic patients. It is not a medically accepted replacement for conventional screening such as treadmill stress testing or an appropriate substitute for coronary angiography. EBCT cannot accurately confirm or exclude important coronary obstruction. The use of cardiac EBCT for the diagnosis and prognosis of coronary artery disease remains an experimental/ investigational application of this technology.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested authorization and coverage for a magnetic resonance (MR) spectroscopy for evaluation of his Addisons disease and adrenoleukodystrophy (ALD).  Findings:  The physician reviewer found that Adrenoleukodystrophy (ALD) is a rare neurodegenerative metabolic disorder, which is X-linked and leads to quadriparesis, blindness, dementia and death. Lorenzos Oil has been shown to slow the progression of ALD in those patients who are asymptomatic.MR spectroscopy has demonstrated excellent efficacy in monitoring the progression of ALD, and is routinely used at the ALD Centers of Excellence. By monitoring MR spectroscopy, the patients response to therapy with Lorenzos Oil can be assessed in order to avoid bone marrow transplantation, which is the only effective treatment once neurologic symptoms have started. MR spectroscopy is clinically indicated for this patient and should be approved on a yearly basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested authorization and coverage for OT, physical therapy (PT), speech therapy (ST) and applied behavioral analysis.Reviewers Findings:The reviewing physician found that there are no specific guidelines delineating educationally based therapies from medically based therapies. The records were reviewed to determine whether or not the goals and treatment plan for each therapy addressed functional motor deficits such as activities of daily living, oral motor skills or neurological abnormalities in gross and fine motor skills. The treatment plans in this case all primarily address educationally based goals and therefore are not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested cryosurgical ablation of the prostate for treatment of his prostate cancer.  Findings:  Three physician reviewers found that while the cryosurgery procedure has merit in low-stage and low-grade prostate cancers there is insufficient evidence-based literature to support the application of cryosurgical ablation in the treatment of high-grade (Gleason 4+4), bilateral disease with a PSA of 50. The procedure is not a standard form of therapy for a patient with these clinical indications. Cryosurgery is an accepted therapy for radiation failures and for initial low-grade, low-stage prostate cancer. Typically, this would mean a PSA less than 10 and a Gleason score lower than 7. There is no data showing a benefit for patients with high grade-cancers such as this patient. It is very unlikely a patient with these indications would benefit from any form of local therapy due to micrometastases and/or locally advanced disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested authorization for CT angiography for evaluation of coronary artery disease (CAD).  Findings:  Three physician reviewers found that the patient has low cardiac risk factors and appears to be asymptomatic while physically active. In this setting, continued risk factor modification is the best approach. Appropriateness guidelines for CTA have been established and are endorsed by several national committees. These guidelines do not support the use of CTA in low-risk patients such as this one.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old female with bilateral arm pain and weakness that has progressively worsened is requesting authorization for a muscle biopsy.  Reviewers Findings:  The reviewing physician found that Muscle biopsy is not medically indicated in the context of the patients isolated pain and the procedure might potentially exacerbate the patients progressive, chronic pain syndrome.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-two year-old female with a history of constipation and rectal bleeding is requesting authorization and coverage for Zelnorm.  The patient has tried laxatives and fiber, but continues to be symptomatic. The patients physician indicates a trial of Zelnorm provided good results.Reviewers Findings.  The reviewing physician found that this patient has tried multiple other alternatives for her constipation without relief. It also appears that the patient has had a positive response to a trial of Zelnorm.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-four year-old female who was diagnosed with major depression is requesting authorization and coverage for Provigil.  Reviewers Findings:The reviewing physician found that the submitted clinical information does not demonstrate Provigil is medically necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-nine year-old male with chronic back pain is requesting reimbursement for an MRI.Reviewers Findings:The reviewing physician found that the patient underwent an orthopedic spine consultation in which the MRI study was a vital element utilized in determining that the patient may require surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested knee replacement surgery for treatment of her knee pain.  Findings:  The physician reviewer found that the submitted records document limited conservative care. In order to fully exhaust conservative measures, consideration should be given to corticosteroid injection. Based on the information provided, it appears only one injection has been administered and that was in 2002. Visco supplementation therapy could be considered as well, which might allow this patient to participate in exercises in order to lose the necessary weight. Furthermore, it does not appear that the patient has been tried on chondroitin sulfate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested artificial disc replacement for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that although the artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine, there is no evidence supporting the safety and efficacy of a two-level disc replacement. Current data for single level disc replacement demonstrates that the majority of the procedures may be  successful in the short term, however the long-term outcomes are unknown and complications may be severe.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a right cutaneous mastectomy for treatment of his unilateral gynecomastia.  Findings:  The physician reviewer found that male breast cancer is quite rare. In a comprehensive review on the topic of enlarged male breasts, Volpe and others recommended evaluation of a mass with ultrasound and mammography followed by fine needle aspiration. Mammography can accurately distinguish between benign gynecomastia and male breast cancer. Needle aspiration cytology is also helpful in distinguishing male breast cancer from gynecomastia. The literature supports a conclusion that male breast enlargement in the presence of a normal mammogram and a normal fine needle aspiration is not likely due to malignancy. The patients mammogram did not suggest cancer and he elected to forego needle cytology. Under those circumstances, the necessity of surgical excision had not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested bilateral breast MRI for evaluation of her breast cancer. Findings:  The physician reviewer found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high-risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High-risk patients also include those with biopsy-proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. For this patient, the procedure was performed to determine the pre-operative extent of her cancer and that is a valid indication for breast MRI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested authorization and coverage for intravenous (IV) antibiotic therapy (with home health skilled nursing care for treatment of the enrollees chronic Lyme disease.  Three physician reviewers found that a portion of the therapy at issue was  medically necessary, stating that this case does not demonstrate convincing evidence for the presence of late-stage Lyme disease or babesiosis. However, considering the uncertainties of medicine, authorization of one four-week course of IV antibiotic therapy is clinically reasonable. Any additional antibiotic courses, oral or intravenous, for any time period should be denied.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested authorization for a CT angiography for evaluation of his coronary artery disease.  Findings:  Three physician reviewers found that CT angiography is not thus far a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography would not be able to accurately confirm or exclude important coronary obstruction. There is insufficient evidence supporting the use of CT angiography in the diagnosis and prognosis of coronary artery disease at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested authorization for residential treatment services provided for treatment her eating disorder.  Findings:  The nursing and progress notes reflect that the patient was not having symptoms as of a certain date and was doing well. The patient no longer met criteria for continuing stay at a residential treatment level of care as of a certain date.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for Provigil for treatment of her hypersomnolence.  Findings:  The physician reviewer found that this patient has hypersomnolence that interferes with her activities of daily living and her quality of life. Some consideration should be given to the patients regular nightly use of Valium as it may contribute to her excessive daytime sleepiness; the newer sleep agents are less likely to produce this effect. Nonetheless, Provigil was prescribed over one year ago and there has been a very good subjective response. Within the neurological community, idiopathic hypersomnolence is commonly treated with Provigil.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested authorization and coverage for 240 tablets of hydrocodone 5/500 monthly for treatment of her low back pain.  Findings:  The physician reviewer found that the requested number of hydrocodone tablets does not meet generally accepted standards of medical care for treatment of non-specific chronic low back pain. The standard of care in cases such as this is to determine the etiology of the patients low back pain and then incorporate other pain medications (long-acting) in concert with physical rehabilitation and other modalities to help diminish the patients excessive use of hydrocodone.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested authorization for 30 days of inpatient drug rehabilitation services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that the patients relapse potential was high due to chronic ADD/bipolar disorder. Even during her inpatient stay the patient showed reluctance to accept structured living placement for long-term structure and stability. Her impulsivity and reactivity remained evident throughout her stay in the inpatient chemical rehabilitation program. She was at high risk for relapse on drugs and psychiatric decompensation. She needed the structure of a therapeutic facility during the period at issue for stabilization.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested authorization and coverage for the prescription medication Focalin XR, at a dosage of 30mg per day for treatment of attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that it is not uncommon to utilize a higher dosage of a medication with a 200-pound adult who has documented ADHD. As trials of other medications have failed and this medication is effective, the higher dosage is clinically reasonable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male enrollee have requested authorization for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that medically necessary therapy requires medical oversight and clearly identified functional goals. In reviewing the documentation from the earlier speech therapy, educational goals are not clearly distinguished from functional goals. An additional concern is the lack of physician involvement. When therapy is continued for an extended period as it has been in this instance, it must be physician-directed to insure adequate progress is being achieved. The patients functional status should be assessed at regular intervals by a qualified physician for appropriate decision-making with regard to the course of the therapy. The physician should also ensure the goals of the therapy address community based/functional issues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested authorization and coverage for Hyalgan injections for treatment of her osteoarthritis.   Findings:  The physician reviewer found that the patient has achieved significant pain relief with Synvisc and Hyalgan in the past. There have been no documented side effects or other complications from the therapy. The patient is attempting to avoid knee replacement surgery at an early age. Repeat Hyalgan injections are medically reasonable and appropriate at this time to alleviate her pain and to postpone surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.  Reviewers Findings:  The reviewing physician found that the relevant literature concerning MR spectroscopy shows there is insufficient proof of its value in this clinical setting at this time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a seven-month-old female born at 33-6/7-weeks gestation with a birth weight of 1910 grams with mild respiratory distress and mild hyperbilirubinemia are requesting Synagis for the remainder of the RSV season.Reviewers Findings:  The reviewing physician found that the patients birth weight and gestational age place the patient at risk for severe RSV disease, similar to the risk faced by extremely premature infants.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services.Reviewers Findings:The reviewing physician found that the patient appears to have been greatly compromised by her eating disorder.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two year-old female with primary ciliary dyskinesia and Kartageners syndrome are requesting authorization of two Synagis treatments (100mg) for respiratory syncytial virus (RSV) prophylaxis.Reviewers Findings:The reviewing physician found that primary ciliary dyskinesia, particularly as part of Kartageners syndrome, is a rare disorder that disrupts mucociliary clearance resulting in chronic sinusitis, chronic bronchitis, chronic cough and ultimately, bronchiectasis.  The reviewing physician found that the Health Plan denial should be overturned.