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

A 60-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that the patient has a history consistent with disabling migraine. She is not a good candidate for triptans due to CAD, and opiates have been of limited benefit, implying a need for preventative treatment. The frequency of attacks appears to be high, as a wide variety of preventatives have been employed. Success has been limited due to side effects or lack of adequate improvement. There is considerable data demonstrating Botox has a positive benefit as a migraine preventative, especially when the frequency of attacks is high (chronic migraine). There are no FDA approved treatments for chronic migraine, and the standard medications used as migraine preventatives have already been tried in this case, with the exception of Depakote. Individuals who try and fail three migraine preventatives are often considered refractory, and do not tend to respond well to oral preventatives. However, refractory migraine may still respond to Botox.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of four-year-old male enrollee has requested growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has idiopathic short stature of sufficient magnitude that he is on track to become a short adult without intervention because of his extreme short stature and modest growth rate. His low IGF-1 level suggests that he may respond well to growth hormone therapy. A one-year trial of growth hormone is medically indicated and appropriate since the patient falls within the 2003 Food and Drug Administration guidelines for growth hormone therapy for idiopathic short stature. He is also close to qualifying as a child with intra-uterine growth retardation who has not caught up. If there is documented improvement after the one-year trial of growth hormone, the therapy should be continued with periodic re-evaluation every six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested authorization for re-treatment for a six-month period with Lamisil for treatment of her onychomycosis.  Findings:  The physician reviewer found that treatment of the patients onychomycosis is medically necessary secondary to pain, swelling and functional impairments. Medically appropriate treatment is at least three consecutive months of Lamisil. Based on the records provided, it appears the greatest duration of treatment the patient may have received was two consecutive months. Therefore, the patient did not receive the minimum medically acceptable treatment. Furthermore, treatment for a three-month period is a guideline, not an absolute. It may be that a longer course is necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested authorization  for the medication Byetta for treatment of her morbid obesity and diabetes.  Findings:  The physician reviewer found that the patient was denied Byetta because she did not fulfill the Health Plans requirement of a hemoglobin A1C of 6.5% or higher for authorization of Byetta. This is a morbidly obese patient who has been taking Amaryl, Actos and insulin. All three of these medications cause weight gain. In addition, Actos and insulin cause fluid retention. This patient already requires two different kinds of diuretics. Taking these medications will make it very difficult for this patient to lose weight.  The patient is likely to benefit greatly by taking Byetta and discontinuing Actos and insulin. She has already achieved great blood glucose control and weight loss with a trial of Byetta.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested authorization for a PET/CT scan for evaluation of her metastatic gastrointestinal stromal tumor. Findings:  The physician reviewer found that the previous Centers for Medicare and Medicaid Services (CMS) indications for PET scans did not include GIST. However, the National Oncologic PET Registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and other indications not previously eligible for Medicare reimbursement. The diagnosis, initial staging, restaging, and monitoring of connective tissue and other soft tissue tumors are now listed as indications for PET scan. It has been shown that PET (PET/CT) is helpful in the staging and restaging of GIST and has an impact on clinical decision making for these patients. Tumor response to treatment with imatinib was best assessed with combined morphologic and functional imaging, specifically PET/CT. In addition, having the prior PET scans available for comparison increases the value of the recent examination. In this instance, a PET/CT would have been helpful in determining future care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested authorization and coverage for the prescription medication Subutex (or Suboxone) for treatment of her opiate dependence. Findings:  The physician reviewer found that the patient recognized her opiate dependence and began treatment with a specialist in the field of addiction medicine. Subutex was prescribed to assist her with detoxification from opiate pain medications. In this instance, Subutex has been used specifically for the treatment of opiate addiction, which is the intended purpose of this medication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for the prescription medication Provigil for treatment of her attention-deficit disorder (ADD).  Findings:  The physician reviewer found that the specific ADD symptoms for which Provigil was felt to be helpful are not clearly differentiated from symptoms secondary to depression. Additionally, the trials of conventional ADD/ADHD medications do not appear to have been adequate in time or dosage. Provigil is not FDA approved for the treatment of ADD. It does not appear the patient has exhausted standard treatment options
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested authorization for intravenous chelation therapy and outpatient laboratory testing for treatment and evaluation of his hypertension and general health status. Findings:  The Physician reviewer found that the current guidelines from the American College of Cardiology (ACC) do not support the use of chelation therapy in the treatment of ischemic cardiomyopathy or atherosclerosis.  The current ATP III guidelines do not recommend routine measurement of inflammatory markers for the purpose of modifying LDL goals in primary prevention.  Homocysteine, CEA and lipoprotein (a) are not currently recommended by the ACC in the screening of high-risk patients with existing CAD and decreased heart function.  The PSA, testosterone, DHEA, magnesium, lipid profile (liminted), uric acid, glycosolated hemoglobin, fructosamine, insulin, CBC, urinalysis, metabolic panel 1, iron and thyroid studies are all reasonable and medically necessary for this patient given his respective diagnoses of prostate nodule, fatigue, CHF, CAD, elevated uric acid with diuretic therapy, obesity, CHF, systemic hypertension, and hypothyroidism.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee is requesting authorization and coverage for intravenous immunoglobulin (IVIG) therapy for treatment of her severe hyperimmunoglobulin E with chronic sinusitis and/or recurrent miscarriage.  Findings:  Two physician reviewers found that the use of IVIG to treat chronic pansinusitis and presumed asthma has not been established to be superior to standard treatments in this situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-one year-old female with a left leg above-the-knee amputation is requesting authorization of the C-leg microprocessor-controlled knee-shin system.  The patient appears to be at least a K3-level ambulatory.  Reviewers Findings:  The reviewing physician found that the patient satisfies the Medicare criteria for a microprocessor-controlled knee in that the patient is a K3 level or above ambulator.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a deceased forty-three year-old female diagnosed with hepatitis B, cirrhosis, hepatocellular carcinoma is requesting reimbursement for emergency and acute inpatient care.  Reviewers Findings:The reviewing physician found that because of the seriousness of the patients condition the emergency and acute impatient care were medically necessary.   The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-three year-old female who was diagnosed with stage IIIC endometrial cancer is requesting authorization of a PET/CT scan.Reviewers Findings:The reviewing physician found that a PET/CT scan will be very helpful in determining future care for this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested an electron beam CT scan (EBCT) for evaluation of his chest pain.  Findings:  Three physician reviewers found that EBCT remains an unproven diagnostic modality at this time. Overall, data demonstrates that there is variable sensitivity and specificity associated with EBCT. Available studies of EBCT are limited by small sample size and have not involved clinically relevant patient populations. There are other proven modalities for chest pain evaluation such as exercise or pharmacologic nuclear SPECT imaging, which would have been more appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-seven year-old female who underwent left ACL reconstruction and partial meniscectomy is requesting reimbursement for the rental cost of a continuous passive motion (CPM) machine.  Reviewers Findings:  The reviewing physician found that a CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction.  Many surgeons find that patients regain their range of motion faster and have better pain control with the device.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-four year-old male who underwent a total knee replacement is seeking reimbursement for use of a cold pump therapy unit.  Reviewers Findings:  The reviewing physician found that the literature does not support the medical necessity of a cooling device after total knee replacement.  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 a thirteen year-old male with the diagnosis of autism is requesting reimbursement and prospective authorization and coverage for speech therapy.  Reviewers Findings:The reviewing physician reviewed of the progress reports from the patients speech therapy and found that they do not indicate there has been functional gain from report to report.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.  Findings:  Three physician reviewers found that Desmoid tumor (aggressive fibromatosis) can be a recurrent, though not metastatic, form of neoplasia. Standard chemotherapy has rarely been of much value. Gleevec, which is approved for use in chronic myelogenous leukemia and gastrointestinal stromal tumors, has indeed been reported to have some efficacy in desmoid tumors. There are multiple papers documenting this as cited above. Because of the rarity of desmoid tumor, Gleevec will probably never be approved for treatment of this condition. However, there is enough data to believe it is more likely to be effective than any of the more conventional forms of chemotherapy than might be offered.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested authorization for hip resurfacing arthroplasty for treatment of her post-traumatic arthritis.  Findings:  Three physician reviewers found there have been significant design improvements during the last decade. At this point in time, hip resurfacing with metal-on-metal implants is promoted as an alternative to total hip replacement for younger patients with osteoarthritis or avascular necrosis who would like to maintain a more active lifestyle.  In May 2006 the Food and Drug Administration approved the Birmingham Hip Resurfacing System. It is likely that within several months the remainder of the surface implants will be approved as well. Hip resurfacing at this juncture should not be considered investigational or experimental. The procedure represents a viable option for patients with disabling arthritis. Very young patients such as this one can be expected to derive more benefit from hip resurfacing than a conventional hip replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a one year-old male with a history of positional plagiocephaly are requesting authorization of a Dynamic Orthotic Crianioplasty (DOC) cranial band.  Reviewers Findings:The reviewing physician found that the medical literature regarding DOC banding and positional plagiocephaly supports an attempt at physical therapy and repositioning prior to the use of the DOC band.  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 one-year-old male with a history of torticollis with positional plagiocephaly are requesting authorization of physical therapy.Reviewers Findings:The reviewing physician found that based on the submitted therapy notes and progress report, it appears that the patient has made sufficient gains and therefore, it is medically appropriate to transition him to a home program performed by his parents.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-two year-old obese male with asthma, degenerative disc disease, diabetes, Guillain-Barre syndrome and recent fractures involving his foot and great toe is requesting authorization for continued use of the bariatric bed.   Reviewers Findings:The reviewing physician found that the patient does not meet medical necessity requirements for a bariatric bed.   The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-one year-old female with a history of vocal cord nodules is requesting authorization for a videostroboscopy.  Reviewers Findings:The reviewing physician found that the patients condition can only be adequately evaluated by using videostroboscopy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-six year-old obese female is requesting authorization for Lap-Band surgery.  Reviewers Findings:The reviewing physician found that because of the patients current BMI and the absence of significant comorbid conditions, the patient does not meet the guidelines set by the National Institutes of Health for weight loss surgery.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested authorization for a robotic-assisted laparoscopic prostatectomy for treatment of prostate cancer.  Findings:  The physician reviewer found the open surgical approach is a well-established treatment with good long-term results regarding survival and complications. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. Open radical retropubic prostatectomy is considered standard of care for curable prostate adenocarcinoma.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an eight-month-old ex-33 12 week gestation, premature male with a birth weight of 2450 grams are requesting reimbursement and prospective authorization of Synagisn for RSV disease.Reviewers Findings:The reviewing physician found that the patients gestational age and birth weight 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: Upheld Decision of Health Plan

A fifty-two year-old female with a history of constipation is requesting authorization of Amitiza.  The patient has tried several over-the counter medications and dietary fiber.  Reviewers Findings:  The reviewing physician found that Amitiza has been approved by the FDA for the treatment of idiopathic constipation and is not generally a first-line medication. A reasonable trial of the available alternatives is appropriate prior to the authorization of Amitiza.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty year-old male with a history of coronary artery disease is requesting authorization of a CT angiography.  Reviewers Findings:The three reviewing physicians found that CT coronary angiography is a rapidly developing technology for visualization of the coronary arteries, but is still not considered the standard of care for evaluation of coronary disease.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a twelve year-old female with cystic fibrosis are requesting authorization for the Vest Airway Clearance System.  Reviewers Findings:The reviewing physician found that there is sufficient scientific evidence demonstrating that the Vest System is safe and effective for patients with cystic fibrosis.   The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old female with chronic heel pain is requesting authorization of extracorporeal shock wave therapy (ESWT).  The patient has under gone a number of procedures with out success.  Reviewers Findings:The reviewing physician found that it is medically reasonable and appropriate to attempt ESWT given the failure of multiple modalities.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old female with a diagnosis of major depression is requesting authorization for vagus nerve stimulation (VNS) therapy.  Reviewers Findings:The reviewing physician found that the efficacy of VNS therapy remains unproven and it cannot be considered medically necessary for treatment of the patients medical condition.  The reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A thirty-seven year-old female in the 29th week of pregnancy with antiphospholipid antibody syndrome is requesting reimbursement and prospective authorization for IVIG therapy.Reviewers Findings:The three reviewing physicians found that IVIG therapy has been proposed as a treatment for recurrent miscarriage due to immunologic causes. By the standard of care, recurrent miscarriage is defined as the occurrence of two or more miscarriages. The patient in this instance does not have a diagnosis of recurrent miscarriage. The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The care giver of a fifty-eight year-old male with advanced dementia is requesting authorization of medication management and psychiatric stabilization services.  Reviewers Findings:The reviewing physician found that the patient required frequent medication adjustments during the early part of the stay and is now responding predictably to medications administered on a as needed basis.  The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-nine year-old female diagnosed with stage IC endometrial carcinoma of the ovary is requesting authorization for a PET scan.  Reviewers Findings:The reviewing physician found that the PET scan has not been proven to be more effective than standard imaging studies for the staging of ovarian cancer.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-seven year-old male who underwent arthroscopic subacromial decompression, acromioplasty, glenohumeral debridement, labral resection, synovectomy and manipulation of the right shoulder is requesting authorization for continuous passive motion machine.  Reviewers Findings:The reviewing physician found that the orthopedic community has long recognized the benefit of early range of motion following joint surgery and the use of the CPM machine in this instance was medically appropriate.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty year-old female with irritable bowel syndrome, gastroesophageal reflux disease and diverticulosis is requesting authorization for a consultation with a nutritionist.Reviewers Findings:  The reviewing physician found that this patient does not require a consultation with a nutritionist for dietary recommendations.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-five year-old female who underwent bilateral prophylactic mastectomies and reconstruction with implants is requesting reimbursement of revisional breast reconstruction. Reviewers Findings:The reviewing physician found that although revision of the reconstruction was appropriate to improve the aesthetic outcome of the reconstruction, the procedure did not treat a functional problem and was not medically necessary by conventional standards.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old male who has degenerative disc disease and pain is requesting reimbursement and prospective authorization for physical therapy.Reviewers Findings:The reviewing physician found that based on the available records, further physical therapy was not medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.