Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested emergency services for the treatment of her leg pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and 10/10 hip and leg pain developing over the course of a few hours would reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms were clearly severe, based on her 10/10 pain scale rating and her requirement of narcotic medications for pain control.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested Rituxan therapy for the treatment of his cerebellar degeneration. Findings:  Two physician reviewers found that there are no large-scale studies documenting the usefulness of Rituxan for a progressive cerebellar process. This being said, there have been some incidental reports speculating about its usefulness in subsets of patients. Given that this patient has autoantibodies by laboratory examination and has responded to Rituxan in the past, continued use of this investigational therapy is medically reasonable and appropriate for his cerebellar dysfunction and related symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for the treatment of her depression. Findings:  Three physician reviewers found that VNS therapy remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research-centered, clinically-based and reproducible studies showing that VNS therapy is any better than sham treatment. VNS therapy is not a part of the established principles of health care practice for the management of refractory depression. VNS remains an experimental 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested the medication Xolair for the treatment of his allergic rhinitis. Findings:  The physician reviewer found that in this particular patient, Xolair was clinically effective when standard therapies failed. The patient has experienced marked chronic discomfort and insomnia despite standard therapy.  Xolair has been demonstrated to help patients with allergic rhinitis, and in particular this patient.  It appears this patients illness has evolved from standard allergic rhinitis to combined rhino-sinusitis with associated nasal polyposis.  This patient represents a small percentage of rhinitis patients, and Xolair is medically necessary due to a lack of other options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested biofeedback therapy for the treatment of her incontinence. Findings:  Two physician reviewers found that standard treatments for fecal incontinence include diet modifications, education and advice, anal sphincter exercises/pelvic floor training.  Randomized controlled trials of biofeedback for fecal incontinence have not supported this modality over standard medical treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Lexapro for the treatment of her depression. Findings:  The physician reviewer found that the documentation provided is sparse in terms of descriptive details about the extent of the patients depressive illness. Specifically, there is no time course, mental status examination or exact diagnosis.  It is unclear how long the patient received the Celexa. All told, there is a lack of documentation by which one could properly conclude that the patient failed Celexa and was in need of another antidepressant.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a duodenal switch procedure for the treatment of her obesity. Findings:  The physician reviewer found that there is no question that BPD-DS is appropriate, and even more so than other popular obesity procedures, such as banding and Roux-en-Y gastric bypass, in treating this enrollees obesity. There are many reasons cited in the literature that may have convinced the enrollee to be so committed to undergoing BPD-DS.  These include data from Hess et al that show the best long-term results for weight loss while ameliorating the highest percent of co-morbidities. Anthone also agrees with the above and states that patients ingest about 2/3 of their pre-op dietary intake without any specific food intolerance. Ninety-eight percent maintained normal albumin levels three years post-op. Vitamin B-12 deficiencies are less likely to occur and, if they do, they are much easier to treat. Patients do not show any clinical evidence of hypocalcemia or bone loss. Furthermore, Baltasar et al, along with the other authors, agree that where the pylorus is preserved dumping is almost non-existent; biliopancreatic reflux is prevented, which would improve the patients GERD; and vomiting is very rare.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms. Findings:  Two physician reviewers found that the use of subcutaneous hormone replacement therapy (HRT) has been reported for many years. Subcutaneous HRT is particularly useful when patients require testosterone supplementation. Subcutaneous testosterone supplementation has been shown to be effective in improving bone density and treating reduced libido and other psychosexual problems. There is no other option currently available (such as transdermal patches) that is as reliable as this method. Transdermal creams and gels cannot be delivered in consistent, accurate doses. Estradiol replacement can be offered simultaneously with subcutaneous testosterone supplementation, providing good benefit and convenience.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested a color doppler transrectal ultrasound for an evaluation of his prostate cancer.  Findings:  The physician reviewer found that this test was necessary in this case to determine if there was pubic arch interference which would preclude use of brachytherapy.  As this patient has a high risk prostate cancer, brachytherapy was recommended as part of his treatment.  Therefore, the ultrasound was necessary to assist in determining the patients treatment plan. Specifically, the disputed procedure was medically necessary to determine the feasibility of brachytherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested the prescription medication Restasis for the treatment of her ocular rosacea. Findings:  The physician reviewer found that although the patient has tried standard first line therapies for her condition, she continues to be plagued by symptoms.  Second line therapy would include Maxitrol and Pandel.  These are not long-term solutions, but they should be tried before Restasis.  Restasis in this setting would be considered investigational at this time, although it is showing some promising results in on-going clinical trials.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections for the treatment of her pelvic pain. Findings:  Two physician reviewers found that while there is substantial interest in the use of Botox for various conditions, its efficacy in treating myofascial pelvic dysfunction has not been established. The use of Botox to paralyze pelvic floor muscles as a treatment for chronic symptoms is clearly still in the early stages of investigation. Until further studies document the safety and utility of this therapy, there is no clear clinical indication for the use of Botox in the treatment of persistent pelvic floor pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested a continuous positive airway pressure (CPAP) machine for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient has clear symptoms of obstructive sleep apnea and his sleep study had an AHI of 12.  Based upon these findings, the patient meets accepted criteria for authorization of CPAP. The utilization of CPAP is medically indicated and prudent for effective treatment of this patients documented sleep apnea.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of a 14-year-old enrollee has requested care at a residential treatment facility for the treatment of the enrollees psychiatric problems. Findings:  Two physician reviewers found that the experiential care of this particular residential treatment facility allows patients to be in the field visited by a nurse once a week.  The program did not incorporate all of the professional care this patient requires.  For this reason I do not find evidence demonstrating it is more effective than a standard residential treatment facility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested DRX 9000 spinal decompression for the treatment of his low back pain. Findings:  The physician reviewer found that among the therapeutic options to emerge for the treatment of back pain and radiculopthy are a number of treatments aimed at lowering intradiscal pressure through spinal decompression.  Non-surgical spinal decompression systems such as the DRX have been considered appropriate therapies to replace traditional open surgery in operations requiring discectomy, decompressison, and fusion.  Initial results show much promise for non-surgically reducing pain and disability.  However, there is a lack of randomized, double-blinded or comparative long-term outcome trials on these systems.  The clinical safety and efficacy of this therapy is not yet established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested full body scans for an evaluation of his prostate cancer. Findings:  The physician reviewer found that whole body scans, either CT or MRI, have been shown to not be efficacious in screening for cancer.  Screening whole body scans have shown no clear health benefit.  In addition, CT scans utilized for whole body scans expose patients to unnecessary radiation.  When there is evidence of recurrent or metastatic disease, individual imaging tests are reasonably ordered pertinent to the patients specific symptoms (e.g., a bone scan for persistent bone pain).  The American College of Radiology does not support the use of whole body screening exams.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Synvisc injections to her left knee for the treatment of her knee pain. Findings:  The physician reviewer found that this patient has osteoarthritis of the knee that is very painful.  Although she had tried several medications to reduce her symptoms, there is no evidence of any cortisone injections. A trial of cortisone injections prior to proceeding with Synvisc injections is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a now deceased 58-year-old female enrollee has requested for skilled nursing facility services for the enrollees care.  Findings:  The physician reviewer found that the patient had multiple chronic medical problems and a gastric feeding tube. The patient had been cared for at home for several months, and the record does not indicated a significant change in her condition at the time of admission to the skilled nursing facility.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for Sutent therapy for treatment of the enrollees neuroendocrine tumor (NET).  Findings:  Two physician reviewers found that Sutent is one of a new class of drugs that inhibits a variety of tumor-related factors such as vascular epithelial growth factor. It has been approved for use in renal cell carcinoma and is being actively studied in other cancer types. Submitted with the appeal are two abstracts from ASCO. One study demonstrated some impact of the drug on biologic markers expressed in such patients, but was not intended to assess clinical benefit. The other study focused on safety and pharmacokinetic issues in the use of Sutent in patients with a variety of cancer types. One response was noted in a patient with neuroendocrine tumor, although, again, there was no information as to the real clinical benefit of the drug. Additionally, a variety of serious toxicities were seen. As yet, there is very little information as to the possible clinical advantage of this drug in the treatment of pancreatic neuroendocrine carcinoma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for a pelvic CT scan for evaluation of her ovarian mass.   Findings:  The physician reviewer found that pelvic CT was not medically to assess the patients condition as ultrasound is generally superior in assessing adnexal structures and it had already been performed.  It is unclear what additional information could have been obtained from pelvic CT.  In addition, it is unclear how the results of the CT scan would have impacted the patients treatment plan based upon the results of the ultrasound. As such, there is no evidence establishing the medical necessity of the pelvic CT scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient is morbidly obese and has tried non-surgical approaches to weight loss and these have been unsuccessful.  However, she presently does not have medical evidence of a significant comorbid condition.  The patient recently cancelled an evaluation that would have confirmed or ruled out obstructive sleep apnea, one such comorbidity.  Based upon the information provided there is no evidence the patient meets nationally accepted criteria for consideration of gastric bypass surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested  for a Lexis lightweight power scooter for her mobility. Findings:  The physician reviewer found that there is no documentation of a mobility deficit affecting the patients ability to perform mobility-related activities of daily living (MRADL) within her home.Additionally, the provided documentation does not address whether the patients mobility deficit can be aided by a walker or cane. The patient may be able to reduce the risk of falls by using an assistive device or manual wheelchair to perform MRADL within her home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested  for compression stockings for treatment of her lymphedema. Findings:  The physician reviewer found that is a complication from lymph node removal due to her cancer. Compression stockings increase tissue pressure which promotes filling of lymph vessels. Compression stockings are standard treatment for lymphedema and the patient is symptomatic. Compression stockings are the appropriate medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for IV Rocephin infusions for treatment of her stated condition of Lyme disease.   Findings:  Three physician reviewers found that treatment of Lyme disease with long-term antibiotics is a controversial subject. Currently, there are two sets of guidelines (IDSA and IILADS). There is no objective evidence of persistent infection with Borrelia (Lyme) or other infectious agent in this particular patient. Numerous long courses of antibiotics have been used without success. Therefore, I would consider further treatment with intravenous Rocephin for greater than thirty days to be experimental or investigational in nature, since no large-scale, controlled trials have concluded that the proposed treatment is effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for the prescription medication Fentora for treatment of his back pain.  Findings:  The physician reviewer found that it is not possible to ascertain how the diagnosis of intractable back pain was reached from these records. The progress notes submitted are succinct and provide very little clinical information regarding the providers evaluation of the patients response to previous pharmacological and non-pharmacological interventions or the patients physiological response to the current pain management regimen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested  for laparoscopic placement of an adjustable gastric band (LAP-BAND) of her morbid obesity. Findings:  The physician reviewer found that if the patient has educated herself about the surgical options available to her, including duodenal switch, gastric bypass and LAP-BAND, and she is familiar with the long-term outcome of each, she should be offered to undergo a weight loss surgical procedure of her choosing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 14-year-old female enrollee has requested  for a lumbar spine MRI for evaluation of the enrollees back pain.    Findings:  The physician reviewer found that an MRI of the lumbar spine is a useful imaging tool to evaluate for spinal disease, including disc herniation and spinal stenosis.  An MRI of the lumbar spine is medically appropriate for evaluation of back pain in certain instances, including patients with neurological deficits and those patients who have worsening symptoms following conservative therapy (i.e., physical therapy and NSAIDs). This patient has no neurological abnormalities on physical exam, and there is no documentation of a trial of physical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for a breast MRI for evaluation of her breast condition. Findings:  The physician reviewer found that this patient has an asymmetric density (not a mass) within the superior aspect of the right breast. As this abnormality was only noted on a single mammogram projection and was not visualized on ultrasound, biopsy of this abnormality is not possible.  In order to perform a biopsy, the lesion needs to be visualized in two separate projections on mammography, visualized on ultrasound, or physically palpable. A breast MRI can further evaluate the right breast to determine if there is a persistent suspicious lesion. This area can then be biopsied under MRI guidance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for acute inpatient hospital services for treatment of his seizure disorder. Findings:  The physician reviewer found that there are no records to support continued acute hospitalization.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Flomax for treatment of his benign prostatic hypertrophy. Findings:  The physician reviewer found that Cardura, Hytrin, and Minipress are non-specific alpha-blockers with significant non-prostatic effects when therapeutic doses for the prostate are reached. Flomax is a specific prostate alpha-blocker.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested for Procrit injections for treatment of her colitis-related anemia. Findings:  The physician reviewer found that Procrit was prescribed to help with anemia which was related to blood loss from the ulcerative colitis and possibly gastritis. The patient had been on steroids and Plavix, possibly contributing to the bleeding risk. One note commented on the use of Procrit to offset the chemotherapy effects of 6MP. Whereas 6MP may technically be considered chemotherapy, in this dose and setting, it was not very myelosuppressive and would not typically justify the use of Procrit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested  for Diovan HCT 160 mg for treatment of her hypertension. Findings:  The physician reviewer found that this patient has responded to higher doses of Diovan. While the patient did not respond to Diovan 80 mg, the requested higher dose of the medication has been effective in treating this patients hypertension. She has tried and failed Toprol XL. As long as the patient is responding to this medication, it should be continued.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for IVIG therapy for treatment of her non-specific autoimmune disease and antiphospholipid antibody syndrome.   Findings:  Three physician reviewers found that IVIG remains controversial and/or investigational in the treatment of APS (antiphospholipid syndrome). The role of natural killer cells in recurrent miscarriage also is controversial or investigational. Its use outside of research protocols remains investigational.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for artificial disc replacement for treatment of his cervical disc disease.   Findings:  Three physician reviewers found that although artificial disc replacement represents a novel surgical technique in the management of symptomatic disc disease, there is insufficient peer-reviewed evidence and randomized controlled trials reporting on its long-term safety, efficacy and its capacity to preserve motion and prevent adjacent-level disease comparable to or superior to that of traditional anterior cervical discectomy and fusion (ACDF). ACDF remains the standard of care surgical procedure for this condition according to most spine societies and spine surgeons.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for a spinal cord stimulator for treatment of his back pain.    Findings:  The physician reviewer found that a spinal cord stimulator is used for severe, chronic, disabling neuropathic pain with a clear etiology (e.g. post-laminectomy syndrome or perineural fibrosis).  This procedure is not generally performed for primarily back pain radiating to the leg with no clear neuropathic cause.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for Botox injections for treatment of her headaches. Findings:  Two physician reviewers found that Botox injections are not yet considered standard treatment for migraine or chronic daily headache. In this case, there is a likelihood of medication-overuse headache and Botox injections would not be expected to improve the patients symptoms.