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

A 64-year-old male enrollee has requested Sprycel (dasatinib) for the treatment of his pancreatic cancer. Findings:  Two physician reviewers could not find any clinical data supporting the use of dasatinib in the treatment of metastatic pancreatic cancer. One pre-clinical study in mice has been reported. Dasatinib has been primarily studied in the treatment of Philadelphia chromosome positive leukemias. There is no  clinical evidence supporting the theory that dasatinib will be more effective than more standard treatments is this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested high-dose rate (HDR) brachytherapy for treatment of prostate cancer.  Findings:  The physician reviewer found that the patient's large volume of cancer cannot be readily irradiated with conventional external radiation, IMRT or proton beam radiation with only 7000 cGy or 8000 cGy. Brachytherapy on the other hand, provides a biological dose of 14,000 cGy to 18,000 cGy on a regular basis. HDR is a method of brachytherapy that provides a uniform dose of radiation. It is superior to low-dose I-125 brachytherapy because it routinely irradiates the seminal vesicles, which is essential for this patient. Low-dose rate I-125 cannot irradiate the seminal vesicles. HDR brachytherapy is clinically indicated in this instance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested for a MRI of the brain for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that an MRI of the brain is standard procedure before starting growth hormone therapy to rule out cystic lesions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested for participation in a clinical trial of ZIO-201 for treatment of her desmoplastic small round blue-cell tumor. Findings:  Two physician reviewers found that isophosphoramide mustard is an investigational agent of no known benefit in sarcomas. It is currently being studied in a phase IB/IIA trial, with focus on determining dose and toxicity. This drug is undergoing study in a clinical trial without any evidence as yet of clinical benefit. Given that it has no proven clinical benefit, there is inadequate evidence to support its use in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for acupuncture for treatment of her low back pain.  Findings:  The physician reviewer found that MRI confirms degenerative disc disease, and thus far, treatment with multiple modalities has not provided relieve. Acupuncture is a readily accepted treatment for musculo-skeletal symptoms and the record indicates the patients previous experience yielded positive results. A trial of acupuncture is clinically appropriate at this time. A reasonable trial would include up to 10 treatments over two months. If treatment is successful, authorization for additional sessions should be considered on an as-needed basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for 24 additional sessions of physical therapy (PT) for treatment of her thoracic outlet syndrome.  Findings:  The physician reviewer found that there is limited documentation of one-to-one skilled therapy. Details of the pool program including specific exercises or the number of repetitions completed is lacking. There is no objective documentation of functional progress in terms of activities of daily living. The patient could have reasonably transitioned to a home exercise program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested for a PET scan for evaluation of his neurological problems. Findings:  Three physician reviewers found that review of the peer-reviewed literature reveals multiple articles supporting the use of PET scan in the evaluation of neurologic paraneoplastic syndrome. One article described the use of the PET scan in the diagnosis of malignant thymoma (these tumors can be associated with paraneoplastic syndromes). As standard imaging (including CT, ultrasound and MRI) showed no evidence of cancer and no cause of this patients paraneoplastic syndrome, PET scan was medically appropriate for the diagnosis and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested for polydynamic therapy (Blue Light therapy) for the treatment of her cystic acne. Findings:  Three physician reviewers found that the Journal of the American Academy of Dermatology recently published guidelines for the treatment of acne vulgaris and Blue Light therapy is not considered standard of care. In addition, there is no evidence in the literature to suggest that Blue Light and Levulan would be more effective for this patient than standard acne treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for Prevacid 30 mg tablets for treatment of her gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD).  Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the mainstay of therapy for acid suppression and are standard care for the treatment of GERD. All PPIs decrease acid secretion by inhibiting the parietal cells proton pumps. From a biochemical and pharmacodynamic points of view, subtle differences among the various PPIs may influence the clinical response. Inter-patient variability in efficacy has been noted with the PPIs because of their dependence on the polymorphic distribution of P450(CYP) 2C19. This inter-patient variability in efficacy is seen most often with Nexium (esomeprazole) and Protonix (pantoprazole), and least often with Prevacid (lansoprazole) and Aciphex (rabeprazole).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested for Humira for treatment of the enrollees juvenile rheumatoid arthritis. Findings:  The physician reviewer found that while the FDA has not approved Humira for patients under the age of 18 year, the drug is approved for rheumatoid arthritis and there is an application by the manufacturer in process with the FDA to extend approval to children. In addition, ongoing studies are being conducted (e.g., Dr. Dan Lovell in Cincinnati) that indicate benefit in children. Furthermore, the pediatric rheumatology community is using Humira in children who resistant to other therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that although there are no significant studies showing that GH therapy can be used to induce increased growth in cystic fibrosis or to counter growth retardation from therapeutic steroids, it appears to have yielded positive results in this instance. Given the severity of the patients growth failure, I believe a six-month trial of GH therapy is clinically indicated to see if additional growth can be induced.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested the medication Lyrica for the treatment of her neuropathy.  Findings:  The physician reviewer found that this patient has chronic neuropathic pain, with painful polyneuropathy. She has tried Neurontin with excessive side effects. Trial of Lyrica has been beneficial, and well tolerated. The Health Plan has denied Lyrica as not medically necessary and has based their denial on the fact that the FDA has only approved Lyrica for the treatment of post-herpetic neuralgia, diabetic neuropathy pain, and epilepsy. Because of their relatively high prevalence and therefore ease of study, post-herpetic neuralgia and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain. Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy, as well as the patients experience with treatment on a sample basis.  One standard treatment for neuropathic pain has been tried and provided inadequate relief. A trial of a tricyclic agent such as amitriptyline should be pursued. However, if a trial of a tricyclic agent is ineffective or poorly tolerated, the Health Plan should provide authorization for Lyrica.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for medication Fentora for treatment of his chronic pain syndrome. Findings:  Three physician reviewers found that Published studies on the use of rapid-onset opioids have focused on measuring analgesic effects in patients with cancer related pain. Additional research with regard to chronic, non-cancer pain is needed to measure both analgesic effect and  patient functioning. Other unanswered questions involve the potential for an increased risk for opioid misuse and abuse, the potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around the clock. The record does not indicate that more standard alternatives such of MS IR and OxyFast have been tried.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested  for intravenous Rocephin for treatment of her Lyme disease. Findings:  Three physician reviewers found that treatment of Lyme disease with long-term antibiotics is a controversial area as is evidenced by the included literature. Currently, there are two sets of guidelines (IDSA and IILADS). For the patient presented, there is no objective evidence of persistent infection with Borrelia (Lyme) or other infectious agent. Numerous long courses of antibiotics have been used without success. Further treatment with intravenous Rocephin for greater than 30 days would be considered experimental or investigational in nature, since no large scale, controlled trials have concluded that the proposed treatment is effective.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a referral to a sarcoma specialty center for the treatment of her uterine leiomyosarcoma. Findings:  The physician reviewer found that there certainly is value to consulting a specialist.  In rare tumors such as this, there is often no consensus as to the appropriate treatment plan, especially in the adjuvant setting. If the out-of-network sarcoma specialist is able to provide the patient the opportunity to participate in a treatment strategy (such as a clinical trial) that cannot be provided in-network, then the treatment should be covered out of network.  If not, the patient should be covered for her initial out-of-network consultation as well as for further consultations with the sarcoma specialist as needed, such as in the setting of a recurrence, or at times when treatment decisions may need to reviewed in response to changes in her clinical course.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested orthotics for the treatment of his Achilles tendonitis and plantar fasciitis. Findings:  The physician reviewer found that custom triplanar orthotic therapy has been used to treat heel pain for many decades. Orthotic treatment is well established in the podiatric and orthopedic communities. Orthotic therapy for the treatment of plantar fasciitis and Achilles tendonitis is appropriate and necessary for the treatment of this patient. Orthotic therapy is within standards of good medical practice within the organized medical community and should be authorized in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for the medication Rituxan for treatment of his  multiple sclerosis.   Findings:  Two physician reviewers found that although clinical trial data examining the role of Rituxan in multiple sclerosis is limited, there is scientific rationale for the use of Rituxan in this setting. In this particular case, given that the patient has failed previous therapy, and his symptoms have progressed, Rituxan is medically appropriate and warranted for treatment of his patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested inpatient mental health services for treatment of depression. Findings:  The physician reviewer found that based on a review of the submitted clinical evidence, the patient did not meet medical necessity criteria for continued stay at an acute inpatient psychiatric unit. It is clearly and consistently documented in the records that during the period in question the patient was not actively suicidal, homicidal, or psychotic. Furthermore, the patient did not have any surgical or medical complications that required 24-hour monitoring or supervision. The treatment the patient received during this period could have been effectively provided at a lower level of care (i.e., partial hospitalization or intensive outpatient).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for the medication Provigil for treatment of her depression. Findings:  The physician reviewer found that there is no valid research establishing that Provigil is clinically effective in treating hypersomnia/insomnia or depressive symptoms in patients with a primary diagnosis of major depression. One study cited by the provider indicated that there was no significant difference in the mean reduction of Fatigue Severity Scale (FSS) scores and Brief Fatigue Inventory (BFI) scores between the placebo and Provigil groups. The other study cited  was for patients with bipolar depression. Provigil it is not considered a standard medication for the relief of depressive symptoms and there are other more conventional medications available to the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested the X-Stop procedure for the treatment her lumbar spondylolisthesis. Findings:  Two physician reviewers found that there is no outcome data to demonstrate that the X-Stop procedure is more effective for treatment of degenerative spondylolisthesis than laminectomy and fusion.  Laminectomy and fusion is the gold standard procedure for the patients condition. More outcome data is needed to establish the X-Stop procedure as an effective, long-term treatment for this diagnosis. Additionally, outcome data showing that the X-Stop procedure is more effective than laminectomy and fusion is lacking.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested for the medication Provigil for treatment of her potential monosymptomatic narcolepsy.          Findings:  The physician reviewer found that the patient has submitted documentation of her response to Provigil, reporting her daily functioning has improved. The patients provider is an experienced sleep medicine expert at a nationally recognized sleep medicine center. He has particular experience in diagnosing neurologically based hypersomnias and in treating sleep disorders in a younger population.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A-37-year-old female enrollee has for panniculectomy/abdominoplasty, brachioplasty, liposuction and thigh lifts for treatment of her redundant skin condition.          Findings:  The physician reviewer found that the photographs reveal an obese female with multiple body folds, but no evidence of intertrigo, rashes, skin ulceration or hyperpigmentation consistent with chronic skin infections. There is no documentation of conservative management over a period of time with failure of such interventions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for neurological testing and sleep therapy for treatment of the enrollees Celiac disease. Findings:  The physician reviewer found that a review of the submitted records indicates that the testing requested by the patients physician was not limited to that of intelligence testing or the evaluation of learning disabilities alone. The physicians concern was cognitive difficulties and multiple neurologic problems related to Celiac disease. The latter might logically incorporate the psychological evaluation of a potential mental illness, such as, but not limited to, Attention Deficit Hyperactivity Disorder.However, with regard to the sleep therapy services the patient may have received, the submitted clinical evidence does not provide any information documenting a need for such therapy or precisely what the therapy entailed. As such, the medical necessity of sleep therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  for a central auditory processing disorder (CAPD) evaluation for evaluation of the enrollees hearing problems. Findings:  The physician reviewer found that the results of the patients auditory evaluation seem to suggest educational/developmental issues other than auditory dysfunction. While there is some evidence of difficulty hearing in competing background noise, there are several other concerns that appear to be less auditory in nature. As such, there was no clear-cut medical indication for the referral for CAPD testing
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested  for minimally invasive spinal surgery for treatment of his cervical stenosis. Findings:  The physician reviewer found that the objective of minimally invasive spinal surgery is to achieve the clinical outcomes attainable with conventional open surgery, while minimizing the risk of treatment-related injury. Multiple new technologies including microsurgery, laser technology, endoscopy, and video and image guidance systems have paved the way for these procedures. At the present time, until better scientific evidence is available, minimally invasive procedures such as laminectomy and foraminotomy should be regarded as research techniques. The patients underlying pathology is cervical disc bulge as well as disc-osteophyte complex. These problems can be satisfactorily addressed by anterior fusion but will not be addressed by a posterior procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for an MRI of the left breast for evaluation of her breast calcifications.  Findings:  Three physician reviewers 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested for growth hormone (GH) therapy with Humatrope for treatment of her presumed hormone deficiency.         Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists guidelines indicate that adults selected for GH therapy should have an easily recognized cause, clear cut clinical features of the adult syndrome and non refutable laboratory evidence of growth hormone deficiency. The guidelines also indicate that stimulation tests using arginine and growth-hormone-releasing hormone (GHRH) have been accepted as more stringent than tests using arginine or levodopa alone. Other studies that indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested growth hormone (GH) therapy with Humatrope for the treatment of the enrollees linear growth failure. Findings:  The physician reviewer found that the pituitary microadenoma may be an incidental finding lacking clinical relevance, the patients crossing of percentile growth lines is remarkable as is his response to GH therapy. Thus, partial GH deficiency and gonadotrophin deficiencies may explain his growth failure. Given these clinical indications, GH therapy should be continued while growth response is sustained.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Botox injections for treatment of her chronic pelvic pain and vaginismus. Findings:  Two physician reviewers found that botox is currently being investigated for the treatment of pelvic floor dysfunction. While there is some data suggesting that it may be helpful for the treatment of vaginismus, the short and long-term efficacy remains unproven. Risks and side effects are still being studied. At this time, there is no evidence that the proposed therapy is likely to be superior to standard treatments in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested physical therapy services for the treatment of her proximal femoral focal deficiency. Findings:  The physician reviewer found that the physical therapy progress notes demonstrates steady improvement in range of motion in left knee, and hip, and continued difficulty with increased weight bearing due to limited bone growth. Left knee flexion was reported to be 130 degrees, and extension -20 degrees. The patients pain decreased to 2-6/10, knee flexion was increased to 128 degrees, knee extension was 16 degrees active and 10 degrees passive, hip flexion increased to within normal limits, hip extension increased to 10 degrees and strength in the knee muscles increased to 4/5. The patient was ambulating 2 minutes without crutches at 50% weight bearing, but still not at her prior level of functioning. She received continued physical therapy with exercises, and manual treatment. The patient continued to show progress in all areas especially with range of motion and strength in the left knee/hip/ankle. Gait remained an issue due to continued bone regeneration, but the patient was able to improve in other areas with continued therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested for an acute hospitalization for treatment of her endometriosis.  Findings:  The physician reviewer found that the surgeon noted extensive intra-abdominal/pelvic lesions at that time which biopsy identified as endometriosis. According to the enrollee, she had a 13-year history of pelvic pain and also had gastrointestinal symptoms and respiratory symptoms during menstruation. The enrollee indicates that her symptoms worsened after September 2006. She consulted with a specialist within the Health Plan who reportedly offered partial laser excision of the endometriosis.