Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Three physician reviewers found that Oncotype DX tumor assay predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. It has become very important, particularly in this group of breast cancer patients in which it is very difficult to make recommendations about adding adjuvant chemotherapy.  Based on the accumulating data suggesting its validity in predicting risk, the Oncotype DX tumor assay has found its way into the clinic and more oncologists are relying on the recurrence score to make adjuvant treatment recommendations as to who should get and (more importantly) who may not need chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female, with failed back syndrome and chronic pain, has requested authorization for the prescription medication Lyrica. Reviewer's Findings:The reviewing physician found that the patient has failed several standard treatments, but Lyrica samples gave her moderate pain resolution. There is no FDA approved medication specific for the treatment of chronic low back pain.  The patient has found Lyrica to be the most effective medication used to date.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested a bariatric surgery consultation prior to the completion of the 24-week Options Program for treatment of her morbid obesity.  Findings:  The physician reviewer found that with a BMI of 41.27 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for her. Furthermore, the patient does not require the completion of the Options Program prior to surgical consultation. There is no scientific evidence demonstrating that there is any benefit in delaying weight loss surgery in order for a patient to complete a health plan mandated program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Kineret 100mg for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that the patients rheumatologist indicates the patient has failed Plaquenil, sulfasalazine, doxycycline, methotrexate, Arava, and is currently failing quinacrine. Furthermore, the rheumatologists position that any TNF inhibitor would pose a greater risk to this patient than Kineret, is well supported in the medical literature. Kineret has long been an FDA approved treatment for rheumatoid arthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her bipolar disorder. Findings:  Three physician reviewers found that it is clear from the submitted clinical history that this patient is significantly burdened by her psychopathology. However, despite this patients need for symptom relief, there is little evidence VNS will be any more effective for her than conventional therapies. Concern regarding VNS as a treatment modality began with the approval process in early 2005. Despite FDA approval of VNS, the efficacy studies to date have not yielded unequivocal data in support of VNS over placebo. When VNS was approved by the FDA in July 2005, it concluded a process that was marked by two reversals of the decision. Final approval was met with surprise by many psychiatrists and the controversy has continued. The source of the controversy lies with the efficacy data. The FDA requires two randomized, double-blind, placebo-controlled trials that prove a proposed treatment is statistically superior to placebo. In the case of the VNS approval, both of these pivotal studies had serious design and methodology problems that left many scientists wondering what the data actually meant.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-five year-old female with breast hypertrophy is requesting authorization for a bilateral breast reduction.Reviewers Findings:  The reviewing physician found that this patient has symptomatic macromastia, and that the complaints are functional rather than cosmetic, the proposed reduction may be too small to relieve the symptoms.  The reviewing physician fund that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old male with a history of developmental speech apraxia are requesting reimbursement and prospective authorization and coverage of speech therapy.Reviewers Findings:  The reviewing physician found that therapy for the treatment of developmental speech apraxia would typically fall under the auspices of the school system through an Individual Education Plan.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-five year-old female with diagnoses of eating disorder NOS, severe recurrent depression and character disorder is requesting reimbursement and prospective authorization of a partial hospitalization program.Reviewers Findings:  The reviewing physician found that successful treatment requires a treatment plan with measurable objectives, a program able to carry out those objectives and a patient who is motivated to participate in the program.  There is little evidence to suggest that this patient is motivated to cooperate in a program such as this one.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-eight year-old female who is diagnosed as having myasthenia gravis (MG) is requesting authorization and coverage of past and future at-home IVIG treatments.  Reviewers Findings:  The reviewing physician found that Typically, IVIG is used in MG as an acute therapy for MG crisis. It has been shown to have similar efficacy to plasmapheresis in the treatment of acute MG exacerbations.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-three year-old female diagnosed with right breast cancer, high-grade, poorly differentiated probably infiltrating ductal is requesting authorization of a PET scan.  Reviewers Findings:  The reviewing physician found that the PET scan has been shown to be more sensitive, specific, accurate, and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-two year-old female who had a sudden onset of low back pain is requesting authorization of artificial disc replacement utilizing the Pro Disc.Reviewers Findings:  The reviewing physician found that artificial disc replacement has not yet been proven to be superior to standard surgical treatment and the procedure is still in investigative trials.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of his depression. Findings:  Two physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested CyberKnife radiosurgery for treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that the patient presented with stage IV non-small lung cancer. His initial work up included a PET-CT which showed bilateral pulmonary metastatic disease and diffuse osseous metastatic disease. In the presence of active extracranial systemic disease, it is more reasonable to treat this patient with conventional whole brain radiation. CyberKnife radiosurgery cannot be recommended in this instance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma. Findings:  Two physician reviewers found that the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant, which can be performed with curative intent for myeloma. Thus, no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma. Given this patients age and prognosis, the proposed clinical trial is likely to be his best opportunity for disease control/eradication under these clinical circumstances. The proposed post-transplant randomization does not compromise the standard of care, and appears to be testing the role of a drug known to be active in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty year-old female with end stage renal disease is requesting authorization of Forteo.Reviewers Findings:  The reviewing physician found that the patients nephrologist states a diagnosis of adynamic bone disease and bases the request for Foreo on the patients severe tissue calcification and vascular insufficiency, the prescription is medically appropriate.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 17-year-old male who has been using alcohol and drugs are requesting reimbursement and prospective authorization and coverage for the subacute substance abuse rehabilitation services. Reviewers Findings:  The reviewing physician found that the patient did not meet medical criteria for admission to the subacute rehabilitation facility nor is continued treatment at that level of care medically indicated, the patient could have been treated effectively at a lower level of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-one year-old female who developed new headaches, episodic tingling, unsteady gait, and lightheadedness is requesting coverage for auditory evoked potentials testing (BAER test).  Reviewers Findings:  The reviewing physician found that the BAER test is clinically useful when looking for subclinical lesions to assist in diagnosis of multiple sclerosis (MS), and as a screening test for schwannoma of the eighth nerve. The BAER test is occasionally helpful in identifying a central site for vertigo. In this case, the clinical notes do not suggest this patient has vertigo, hearing loss or MS.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her major depression.  Findings:  Two physicians found that while long-term data regarding the efficacy of VNS is not yet available, the submitted documentation demonstrates the patient has been refractory to all treatments for her depression. Though she has had adequate trials of more than four antidepressants, electroconvulsive therapy and various psychotherapeutic modalities, her depression is unrelenting and life threatening. In light of the severity of the patients illness and the lack of benefit with standard treatment, the use of VNS is this particular case is warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-eight year-old female who was clinically evaluated for bilateral breast masses is requesting authorization of a breast MRI.  Reviewers Findings:  The reviewing physician found that this patient does not have any of the indications for breast MRI.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a three-year-old male with a history of limited expressive language, poor play and very impaired social development are requesting authorization for early childhood partial hospitalization services.Reviewers Findings:  The reviewing physician found that the submitted clinical information indicates the patient was making progress with treatment, but progress was not yet maximized.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested a bone growth stimulator for treatment of the enrollees radial fracture. Findings:  Three physician reviewers found that electrical bone growth stimulation is appropriate in some instances of non-union. However, it typically takes seven to nine months to establish a clear diagnosis of non-union. In this instance, only three months had passed since the patients surgery and bone growth stimulation was not clinically indicated. Bone growth stimulators are indicated for skeletally mature patients with established non-union and when surgery is not indicated. In some cases, bone growth stimulation may be appropriate for a fresh fracture in an area that is notorious for the development of non-union. This patient is not skeletally mature and a diagnosis of non-union has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty year-old female diagnosed with diabetes mellitus type 1 is requesting authorization for an Insulin Management System.  Reviewers Findings:  The reviewing physician found that this is a new product and its performance and viability have not been established to the same extent as many other insulin pumps with proven performance.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-one year-old obese female with Crohns disease and comorbidities including arthritis and hypertension is requesting authorization of a Lap-band procedure.Reviewers Findings:  The reviewing physician found that with the significant comorbidities the patient meets medical necessity criteria for weight loss surgery.  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 seven-year-old male with a history of Downs syndrome and autism with significant speech delay are requesting coverage of both past and future speech therapy.Reviewers Findings:  The reviewing physician found that in comparing the progress reports it is clear that although the gains are slow, the patient is making gains in functional communication.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a nine-year-old male with diagnoses of dystonia and chorea are requesting authorization of a gait trainer with arm prompt set, hip positioner and hip positioner pad.  Reviewers Findings:  The reviewing physician found that the current physical therapy notes show that the patient has not yet achieved functional use of the gait trainer. As such, the gait trainer is currently considered exercise equipment without a clear medical indication.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty year-old female who was diagnosed with cholangiocarcinoma is requesting authorization for thermoradiation therapy, hyperthermia and low-dose radiationReviewers Findings:  The reviewing physician found that there is insufficient rigorous evidence in the literature to support thermoradiation therapy, hyperthermia and low-dose radiation for this or any other indication.  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 seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).  Reviewers Findings:  The reviewing physician found that RSV infection has been associated with tachyarrhythmias including SVT that may be hemodynamically significant in infants such as this one.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested desensitization therapies prior to renal transplant (IVIG, plasmapheresis and Rituxan.  Findings:  Two physician reviewers found that the currently available standard therapy for end-stage renal disease is a living donor kidney transplant. In this case, there is an ABO incompatibility (ABaB). The potential recipient has a mildly positive anti-A titer (1:16) with her donor. The patients treatment center has developed techniques to reduce the deleterious anti-ABO antibody and improve transplant rates among this population that was previously considered untransplantable in most cases. The proposed desensitization treatment with IVIG, plasmapheresis and Rituxan for ABO incompatible living kidney donor and recipients with relatively low anti-A titer is an acceptable and reasonable option. It is important to include Rituxan (anti-CD20 monoclonal antibody) if the recipient is not to undergo a splenectomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old male diagnosed with plantar fasciitis is requesting authorization of prolotherapy.  Reviewers Findings:  The reviewing physician found that the peer-reviewed literature does not support the premise that prolotherapy offers a statistically proven advantage for optimal recovery.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-four year-old female with a history of autoimmune disorder and recurrent miscarriage is requesting reimbursement for the IVIG therapy.  Reviewers Findings:  The reviewing physician determined that treatment with IVIG for recurrent miscarriage has not yet been shown to be clearly effective.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male with diagnoses of Aspergers disorder, anxiety disorder and attention deficit hyperactivity disorder (ADHD) is requesting authorization and coverage for Provigil.Reviewers Findings:  The reviewing physician found that based upon the information provided, there is no medical necessity for authorizing Provigil for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-six year-old female with a fracture of the fourth toe proximal phalanx is requesting authorization of a bone growth stimulator.  Reviewers Findings:  The reviewing physician found that there was nothing at the time of the initial request to suggest that the fracture would not heal without a bone growth stimulator.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-four year-old male with multiple chronic problems and deconditioning is requesting authorization of acute inpatient rehabilitation services.  Reviewers Findings:  The reviewing physician found that there is no evidence in the literature that acute rehabilitation is superior to a less intense rehabilitation program for general reconditioning of chronically ill individuals.  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 2-year-11-month-old female with multiple medical problems, including possible Mobius syndrome, arthrogryposis, restrictive lung disease, and gastrostomy dependence are requesting authorization of Synagis.Reviewers Findings:  The reviewing physician found that children with neuromuscular conditions who have a poor cough due to weak or ineffective respiratory muscles and cannot adequately clear respiratory secretions are included in patients for whom palivizumab prophylaxis (Synagis) would be appropriate. This patient would fall into this category.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old male who underwent resection of a right breast lump is requesting authorization of left breast liposuction.  Reviewers Findings:  The reviewing physician found that the patient has slight breast asymmetry, however the record does not document related functional problems, a concern for malignancy or significant pain requiring analgesics.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-two year-old female with a long-standing history of left knee pain is requesting reimbursement for the Supartz injections.  Reviewers Findings:  The reviewing physician found that there are articles that indicate repeat courses Visco supplementation (Supartz injections) were well tolerated and appropriate therapy for relief of osteoarthritis pain in the knee.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An eighteen year-old male with diagnoses of attention deficit disorder (ADD), depression, and temporal lobe dysfunction have requested authorization of Provigil.Reviewers Findings:  The reviewing physician found that although the current literature does suggest some degree of efficacy for Provigil in the treatment of ADD, it is not yet an FDA approved indication.  The reviewing physician found that the Health Plan denial should be upheld.