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

A 27-year-old female enrollee has requested acupuncture for the treatment of her low back pain. Findings:  The physician reviewer found that the patient has undergone physical therapy for her symptoms from the time of the injury until being discharged from physical therapy with regard to her low back. She appears to have continued with physical therapy for her neck and left shoulder symptoms, and was on disability, per the records reviewed. X-rays of the lumbar spine, pelvis and thoracic spine were normal.  An MRI of the lumbar spine showed moderate stenosis of L5/S1 and some annular fissures.  The patient was seen by a doctor who ordered the MRI and wanted to add acupuncture to her low back treatment. The patient continues to complain of low back symptoms, especially with regard to sitting, standing and bending.  This patient is still experiencing discomfort in the low back which limits her ability to work and/or perform activities of daily living.  Acupuncture has proven to be of benefit in situations such as this one. The requested acupuncture treatment is reasonable and may be of benefit in relieving this patients symptoms and enabling her to return to work and perform daily activities more easily.  A trial course of 8 to 10 treatments at a frequency of two to three times a week could be rendered with re-evaluation at the conclusion of the course of treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Accolate 20mg for the treatment of her capsular contracture. Findings:  The physician reviewer found that there is a lack of recent validated research showing Accolate to be beneficial in the treatment of capsular contracture. The studies referenced above are preliminary reports of non-randomized and poorly controlled studies that show that Accolate is effective for capsular contracture. In this case, high quality, prospective, randomized studies of this treatment have not been published. The scientific quality of the studies referenced is poor. Therefore, the use of Accolate is not medically indicated for treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested an emergency room visit for the treatment of his abdominal pain, blood in his stool and diarrhea. Findings:  The physician reviewer found that the patient's abdominal pain and other physical findings were deemed severe enough to require blood work, urinalysis, and a CT scan while in the emergency department. The examining physician was concerned that the patient might be suffering from appendicitis, which is a potentially life-threatening disorder. It is entirely reasonable and appropriate that the patient sought immediate medical attention for his complaints of abdominal pain, blood in his stool and diarrhea.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the enrollee was suffering from acute abdominal pain. Although it is difficult to assess the severity of pain as it was reported as crampy and intermittent, the mother reports that at one point, the pain was so severe that she was not able to walk or stand up. In addition, the physicians caring for her had a broad differential diagnoses to rule out including volvulus, appendicitis, urinary tract infection and others. Many of these conditions can be medical emergencies that are life-threatening if diagnosis is delayed. It is reasonable that a prudent layperson would choose to seek immediate emergency medical evaluation for abdominal pain of such severity due to potential jeopardy to her health or function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees difficulty with speech articulation. Findings:  The physician reviewer found that the medical records submitted reflect a young patient with problematic speech and a mild hearing deficit.  She has difficulty with speech articulation, and thus has responded well to speech therapy.  The patients records provide objective evidence that she is making excellent progress with this therapy to date.  The patient has a condition which is known to benefit from speech therapy, and a significant benefit has been documented.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested the prescription medication Actiq (1200 mcg x 210 lozenges for the treatment of his pain. Findings:  The physician reviewer found that Actiq is currently FDA approved only for opioid resistant breakthrough cancer pain syndromes.  This is because of a significant and potentially fatal side effect profile, which includes addiction and respiratory depression. Actiq has not been studied for this patients clinical pain syndrome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a one-year-old male enrollee has requested dynamic orthotic cranial (DOC) banding for the treatment of the enrollees head shape. Findings:  The physician reviewer found that malformation of the head can influence the development of the jaw, temporal bone and eye orbit bones.  In addition, it has been associated with neurodevelopmental, visual, and auditory delays.  This patient has a short, wide head shape, brachycephaly, for which repositioning was unsuccessful.  DOC banding is a reconstructive measure in this instance with proven efficacy.  Because of the patients condition and the failure of repositioning, DOC banding was medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested ultrafast computed tomography (CT) of the heart for an evaluation of his potential coronary artery disease. Findings:  The physician reviewer found that this patient has severe hyperlipidemia. He had an ultrafast CT of the heart performed for coronary artery disease screening.  The patient had risk factors for coronary artery disease (CAD), which included a family history of CAD and hyperlipidemia.  At present, ultrafast CT scans are considered experimental. For screening asymptomatic patients such as this patient, there is limited data regarding the tests sensitivity and specificity. These factors, coupled with relatively high radiation doses, argue against use of the ultrafast CT scan in patients such as this patient.  Furthermore, there are other proven modalities for assessing this patients cardiac risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested for the prescription medication Lyrica for treatment of his pain.    Findings:  The physician reviewer found that Lyrica is approved for neuropathic pain secondary to diabetes mellitus and the herpes simplex virus. Lyrica use is similar to Neurontin in MS patients and is an appropriate use.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Byetta 5mcg/0.02ml injectable for the treatment of her diabetes. Findings:  The physician reviewer found that the patients hemoglobin A1c is at a level considered to be the upper end of adequate control by the American Association of Clinical Endocrinologists and good control by the American Diabetes Association. Actos has in fact been shown to probably decrease heart disease. Although Actos may have contributed to weight gain initially, data suggests that by one year of treatment, weight is back at baseline. The requested medication is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The spouse of a 62-year-old male enrollee has requested for a PET scan of the brain for evaluation of the enrollees dementia. Findings:  Three physician reviewers found that PET scans of the brain are typically indicated for localization of seizure foci.  No such foci are suggested in this patient, nor does he have a seizure history.  PET imaging of the brain can also be indicated in cases where a cerebral malignancy is suspected.  There is no suspicion of such a malignancy reported in the record.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a four-year-old male enrollee have requested partial hospitalization program services for the treatment of the enrollees condition. Findings:  The physician reviewer found that this autistic child had failed extensive prior early intervention therapy and was directly admitted to the intensive ECPHP day program. Although early intervention is the therapy of choice at the time of diagnosis of autism, this child had already received intensive therapeutic attempts to modify his behavior, with limited success. At the age of entry into ECPHP, he was eligible for a public school early intervention program. At the conclusion of the ECPHP program (which states significant improvement in language and behavior), he made a successful transition to the public school program. The lack of a physician referral and the availability of the public school program would negate the medical necessity of the ECPHP program, and I concur with the denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 14-year-old female enrollee has requested speech therapy for treatment of the enrollees apraxia. Findings:  The physician reviewer found that the records provided do not demonstrate that the additional therapy provided the patient greater benefit than the benefit she was already receiving. Furthermore, the records provided do not demonstrate that this patient required further therapy or that the therapy she was receiving was in some way lacking.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old enrollee have requested for partial hospitalization program services for treatment of the enrollees autism, attention deficit/hyperactivity disorder, obsessive compulsive disorder and anxiety. Findings:  Three physician reviewers found that there was no attempt at local alternative facilities, in-home Applied Behavior Analysis, child psychiatrists, or other in-home programs. There is no physician referral recorded recommending the ECPHP program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for inhome hemodialysis for treatment of her chronic kidney disease, secondary hyperparathyroidism and hypertension. Findings:  Two physician reviewers found that home hemodialysis is usually performed at night five days a week.  This provides for an improved clearance as well as better control of hypertension, volume status and electrolytes.  This results in improved cardiovascular performance.  Nocturnal dialysis also allows patients to live an improved productive lifestyle, as they are not committed to a dialysis center three times a week. Finally, in-home dialysis generally results in a better performance status at time of consideration for transplant.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Provigil for treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that Provigil is FDA approved for obstructive sleep apnea/hypopnea syndrome, excessive sleepiness due to narcolepsy and shift work sleep disorder.  The patient does not have, according to the documentation furnished, any of the above.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin condition. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While this patient has some hanging skin, it is quite limited and does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection and the amount of excess skin is not so great as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment. The submitted photographs do not show any skin breakdown or rashes. An office visit note states there was no intertrigo. There is no description of office visits or physician treatment for skin rashes due to sagging skin. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 14-year-old male enrollee have requested sub-acute residential services for the treatment of the enrollees biochemical abnormalities. Findings:  The physician reviewer found that although the patient was admitted to a sub-acute residential facility, there are no notes indicating the patients mental status examination nor is there any type of psychiatric evaluation done by the facility staff for that date of service.   There is also no evidence that the patient was seen by a psychiatrist while at the facility. The documentation does not support the need for the sub-acute residential level of care. The services at issue were not indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Orthovisc injections for the treatment of her torn knee cartilage. Findings:  The physician reviewer found that Orthovisc injections are indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and to simple analgesics, such as acetaminophen. The articular cartilage defect(s) described in this case are comparable to osteoarthritis. In view of her age and the findings and failure to respond to the conservative treatments which have been tried, the injection series at issue is reasonable, appropriate and medically necessary for treatment of the enrollees condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an enhanced external counterpulsation (EECP) for the treatment of her angina. Findings:  Two physician reviewers found that the patient has nitrate responsive chest discomfort that may represent angina given her known coronary disease. However, it is not certain the patients chest discomfort represents angina (no stress test demonstrating provocable ischemia). The severity, frequency, disability, and limitation of the chest discomfort are not documented, and medical treatment has not been optimized (long-acting nitrate or Calcium blocker not prescribed). Medical treatment needs to be optimized prior to consideration of EECP.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested the medication Aciphex for the treatment of her chronic dyspepsia. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) and dyspepsia continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms of dyspepsia and healing of erosive as well as nonerosive esophagitis. PPIs continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours, and act by covalently binding to cysteine residue in H, K-ATPase (the proton pumps) in the membrane of the secretory canaliculi of parietal cells. Differences in the molecular structures of specific PPIs result in different cysteine residues targeted. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effects profiles. This patient has not tried eight week trials of Omeprazole, Prevacid and Protonix, taken as both a single and double dose. If she fails the trial with these PPIs, then she should be approved for Aciphex. Aciphex is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested the medications Lyrica and Ambien CR for the treatment of her conditions. Findings:  The physician reviewer found that current RSD practice guidelines suggest an anti-convulsent such as Lyrica may be helpful. It is also the most appropriate choice here since it is also indicated for fibromyalgia. The denial should be reversed with respect to Lyrica, as Lyrica is medically indicated. The use of Ambien CR is not approved for use beyond two weeks according to the package insert. The trials of other sleep aids that are required by the Health Plans policy are appropriate. The Health Plans denial for Ambien CR is appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested intravenous immune globulin therapy (IVIG) for the treatment of her multiple sclerosis. Findings:  Two physician reviewers found that this patient has been on Copaxone, Betaseron, Novantrone, steroids and Cytoxan. She has also been on Baclofen, Aricept and Namenda. The patient has had a course of IVIG with some reported benefit. Although IVIG therapy has been shown to have some benefit in multiple sclerosis in a number of small trials, there is a lack of data regarding combination therapy with Copaxone. While there is supportive data regarding IVIG monotherapy, the recommended combination therapy cannot be recommended at this time due to a lack of data and potential risks. The therapy at issue is not likely to more efficacious for this patient than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested lumbar fusion surgery for the treatment of his low back pain. Findings:  The physician reviewer found that there is data to support the role of single level fusion surgery in improving the quality of life in patients with degenerative disc condition. Its use in single level cases is within the standard of good care. This patient has tried and failed physical therapy, and this has been documented. Due to the patients pain and one-level degenerative pathology, he is a candidate for the fusion procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a bone marrow transplant at the Mayo Clinic using the Bone Transplant Protocol for the treatment of his multiple myeloma. Findings:  The physician reviewer found that this patient was initially referred to Stanford University. However, he wishes to get the transplant at Mayo Clinic since they use a melphalan-based transplantation which avoids cardiotoxicity, and he considers it to be safer. The patient is under the impression that the Stanford protocol uses high-dose Adriamycin. The bone marrow protocol from Stanford University which has been attached uses cyclophosphamide/etoposide as induction regimen for stem cell collection followed by BCNU/melphalan as high-dose therapy prior to the transplant. This regimen from Stanford is considered a standard regimen for the autologous stem cell transplantation. I do not see evidence of the use of Adriamycin in this treatment plan as contended by the patient. The Mayo Clinic protocol has not been submitted. In view of this, the Health Plans decision should be upheld because the autologous stem cell transplantation at a center of excellence (Stanford University) is not inferior to the standard of care. There is no medical necessity for the patient to receive treatment at the Mayo Clinic.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested for lymphoscintography and sentinel node biopsy performed by a surgical oncologist rather than a plastic surgeon for treatment his melanoma. Findings:  The physician reviewer found that given the importance of correctly identifying lymph drainage areas from the anterior abdomen and the importance of correctly identifying and evaluating lymph nodes in situ and correctly removing for analysis such sentinel nodes, the requested services are medically indicated and necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested Herceptin biochemotherapy and immunoassay CA19-9 testing for the treatment and an evaluation of his metastatic gastroesophageal cancer.  Findings:  Two physician reviewers found that although the patient is said to be responding, based on notes about the PET and despite what appears to be a rising CA19-9, the rationale for this regimen is extremely weak, and approval is not recommended based on the available data at the time the regimen was begun. The recommendation for a multi-drug regimen with two antibodies and 2 drugs was based on extrapolations rather than data, and based on claims of benefits from single-arm trials compared with historical controls. According to the provider, the patient was responding to that regimen, although this was not apparent from the submitted documentation. The provider provides data from molecular analysis of the patients tumor cells directed at expression of the pathways that represent targets for the drugs under consideration. However, this rationale is unfounded by any correlative data from solid clinical trials. Further, there are serious safety reservations for a regimen of three cardiotoxic drugs given together. There is no published information about addition of Sunitinib, a known cardiotoxic agent.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Provigil for the treatment of the enrollee's attention deficit disorder (ADD) and attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plan provides coverage for Provigil for excess daytime sleepiness due to narcolepsy, fatigue associated with multiple sclerosis, obstructive sleep apnea/hypopnea syndrome and shift work sleep disorder. These criteria are medically appropriate and reasonable, and the patient does not meet any of these criteria.