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

The mother of a 16-year-old female has requested Botox injections for treatment of headaches.  Findings:  Two physician reviewers found that botox therapy is an accepted treatment for persistent migraine in adult patients who have been given adequate but unsuccessful trials from three or four classes of drugs. This is not the case here. The patient is a minor, and trials of Botox therapy are usually only given to adults. A trial of Depakote, Verapamil, Inderal or Zanaflex may be beneficial. There is inadequate evidence to support the use of Botox in this minor patient who has not exhausted standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female has requested Rituxan for treatment of rheumatoid arthritis.  Findings:  Two physician reviewers found that the use of Rituxan in this clinical setting is not investigational or experimental. This medication is FDA approved for use in rheumatoid arthritis that has failed methotrexate and at least one tumor necrosis inhibitor medication. She has had an initial response to the Rituxan infusion therapy, and given that the natural history of the course of this disease can be quite disabling, the patient should be allowed coverage for continued therapy with this medication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female has requested a referral to a high level orthopedic center for leg surgery services for the treatment of a leg injury.  Findings:  The physician reviewer found that this is a very specialized treatment and only limited orthopedic surgeons have the knowledge and expertise to manage the soft tissue contractures, especially in the presence of a free flap and significant prior skeletal trauma. It is doubtful that any typical soft tissue lengthening procedure would be a reasonable option in light of the prior free flap that was placed and the significant soft tissue and bony trauma. Most physicians do not use the Ilizarov frame and therefore, are not competent in this area. It has not been demonstrated that the Health Plan has an orthopedic surgeon who has expertise with using an Ilizarov frame.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested continued Rocephin IV treatment for treatment of Lyme disease.  Findings:  Three physician reviewers found that Rocephin IV antibiotic therapy beyond four weeks duration is considered experimental/investigational for the treatment of Lyme encephalopathy. Literature reports indicate the benefits of IV antibiotics are short-lived and cognitive impairments return after therapy. To date, there is no convincing, published data that repeated courses of oral or intravenous antibiotics are effective for Lyme encephalopathy. This has been the consensus of the Infectious Diseases Society of America Expect Panel. At this time, there is insufficient evidence to regard chronic Lyme disease or Lyme encephalopathy as appropriate indications for extended IV antibiotic therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested monthly treatment with intravenous immunoglobulin (IVIG) for the treatment of her common variable immune deficiency (CVID). Findings:  The physician reviewer found that the history as presented by the requesting physician and the documents submitted are not sufficient to justify the use of IVIG. Although the patient appears to have a blunted immunological response to pneumococcal antigens, it is not known if  she was prescribed systemic steroids over the past few years. If so, this could account for the blunted response as well as the borderline low IgG. In any case, there is evidence of a response, thus the patient is not a non-responder. Given the borderline low IgG, lack of response should be a prerequisite for the use of IVIG. Lastly, the immune response to pneumococcal antigens resides in IgG subclass 2, and this value is normal.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested artificial disk replacement for the treatment of her degenerative lumbar disc disease. Findings:  Three physician reviewers found that the proposed procedure is in fact experimental. Current data for single-level disc replacement demonstrates that the majority of the procedures may be  successful in the short term, however there is not enough long-term, follow-up data to clearly establish efficacy. This is particularly true for multi-level disc replacement. Additionally, the potential long-term complications of total disc replacement have not been fully explored and there is not yet adequate data on the durability of this approach.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested sacroiliac (SI) joint injections with arthrography for treatment of back pain.  Findings:  Two physician reviewers found that SI joint injections with local anesthetic and steroid for the treatment of chronic low back pain are an accepted therapeutic modality. There is documented evidence that the procedure is safe and has at least short-term efficacy when performed for patients with intractable pain. Bosewell and others state, the evidence for intra-articular SI joint injection was moderate for short-term relief and limited for long-term relief. A joint arthrogram is part of the standard procedure in conducting an SI joint injection.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female has requested botulinum toxin injections for treatment of muscle spasms.  Findings:  Two physician reviewers found that botulinum toxin is an accepted treatment for cervical dystonia and various types of headaches in patients who have failed standard therapies. In this instance, the patient has severe muscle spasms refractory to medications and non-pharmacological interventions. She did however respond to a trial of Myobloc. As is the case with migraines, since standard interventions were not helpful, a trial of botulinum toxin was clinically reasonable and was shown to be effective for this patient. Continued treatment with Myobloc is indicated as long as a positive response is documented.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested an Oncotype DX tumor assay for the evaluation of breast cancer.  Findings:  The physician reviewer found that there is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very useful, particularly in this group of breast cancer patients for whom it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients, and Medicare has approved its use.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested a PET scan for the evaluation of near syncope accompanied by altered sensorium.  Findings:  Three physician reviewers found that PET scans have been shown to be clinically useful in the evaluation of certain diagnosed cancers, to evaluate solitary pulmonary nodules and for surgical planning for patients with poorly controlled epilepsy. PET scans are also sometimes utilized to evaluate patients with seizures that fail to respond to medical therapy. This patient has no history of cancer, no solitary pulmonary nodule and has not yet failed medical therapy for epilepsy. Therefore, a PET scan of the brain in this case is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male has requested bariatric surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that the patient meets the National Institutes of Health (NIH) guidelines for weight loss surgery. There is no scientific evidence that any pre-operative weight loss predicts the long-term outcome of weight loss surgical procedures. Nor is there scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested intensity modulated radiation therapy (IMRT) for treatment of prostate cancer.  Findings:  The physician reviewer found that medicare guidelines show approval of IMRT for the treatment of prostate cancer. In this instance, the patient has undergone prostatectomy, but prostascint indicates there is residual tumor in the prostate bed. The patients diabetes also supports the use of IMRT. This is a more precise form of radiation therapy and will minimize injury to the surrounding structures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female has requested Lyrica for treatment of fibromyalgia and neuropathic pain.  Findings:  The physician reviewer found that the patient has had better control of pain with Lyrica.  In an Arthritis & Rheumatism 2005 article on the use of Lyrica for the treatment of fibromyalgia, there was a significant reduction in pain compared to placebo and improvements in fatigue. Lyrica has recently been FDA approved for the treatment of fibromyalgia. It is within standards of good medical practice to use Lyrica for chronic pain management. A dose of 75mg three times a day would be medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female has requested Byetta for treatment of diabetes.  Findings:  The physician reviewer found that the patient has become a candidate to continue the Byetta under the Health Plans prior authorization guidelines since she is no longer taking Januvia. Furthermore, records indicate that the patients hemoglobin A1c fell after taking Byetta, indicating good control of her blood sugar. As such, Byetta is clinically appropriate and indicated for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female has requested hip resurfacing for treatment of osteoarthritis.  Findings:  The physician reviewer found that the patient is not a  reasonable candidate for hip resurfacing. Long term data has not demonstrated superior wear results with hip resurfacing as this is only a theoretical benefit in terms of 10 to 15-year follow-up.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for the treatment of the enrollees morbid obesity. Findings:  Three physician reviewers found that with the exception of her age, this patient meets criteria for the Lap Band procedure inasmuch as her BMI is greater than 40 and she has failed non-surgical interventions, supervised and not. The patient has undergone pre-bariatric surgical evaluations by pediatrics, surgery, psychiatry and nutritional services as well as laboratory and radiologic evaluations and no contraindications for the Lap Band procedure have been identified. While surgical weight loss for patients under the age of 18 is still controversial, research studies are on-going in multiple centers. The majority of the evidence in the peer reviewed journals shows that the benefits of bariatric surgery outweigh the potential risks. This is particularly true for an adolescent such as this one who is less than one year shy of the age requirement. The Expert Committee recognizes that gastric banding for minors is not currently FDA approved, but recommends surgery for select patients when provided by experienced programs with established clinical protocols.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that it is not clear from the record whether the patients symptoms are due to fibromyalgia or a primary depression with secondary sleep disturbance and associated depressive symptoms. The reported sleep disturbance with recurrent wakening at 4 am is a classic symptom of depression. It is also possible that the patients depression is secondary to fibromyalgia. Nonetheless, assuming a primary diagnosis fibromyalgia, it does not appear from the record the patient has been treated with any of the agents typically used for this condition. Given the prominence of depression-related symptoms, a trial of at least one antidepressant as well as Neurontin is reasonable. Should such trials prove ineffective, then treatment with Lyrica would be appropriate as it is the only agent specifically approved for the treatment of Fibromyalgia. Additional medication failures should not be required.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for the treatment of the enrollees morbid obesity. Findings:  Three physician reviewers found that while gastric banding for patients under the age of 18 is still controversial, research studies are on-going in multiple centers. The majority of the evidence in the peer reviewed journals shows that the benefits of bariatric surgery outweigh the potential risks. This is particularly true for an adolescent such as this one with several comorbidities due to her obesity. Without effective weight loss, the patient has a worrisome prognosis in view of her joint problems, hypertension and hyperlipidemia at the age of 15. The Expert Committee recognizes that gastric banding for minors is not currently FDA approved, but recommends surgery for select patients when provided by experienced programs with established clinical protocols.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for wireless capsule endoscopy for evaluation of her iron-deficiency anemia and obscure bleeding. Findings:  The physician reviewer found that Wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. WCE offers the following potential advantages over other more broadly used imaging techniques. It offers the potential to directly visualize the entire mucosal surface of the small bowel. It has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. It is less invasive than conventional endoscopy. It does not require sedation or anesthesia. It is well accepted by patients. At the present time, WCE is approved for the evaluation of patients with obscure GI bleed, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease and other small bowel diseases such as small bowel tumors, family polyposis syndrome and arteriovenous malformation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for brain surgery for treatment of her meningioma. Findings:  The physician reviewer found that there has not been any specific medical issue raised that would necessitate treatment at UCSF Medical Center. I see no clinical indication for an out-of network referral in this instance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a PET scan for evaluation of her lipoma versus liposarcoma. Findings:  The physician reviewer found that the literature regarding liposarcoma and PET scan is limited. There are a few studies showing good sensitivity and specificity for higher-grade tumors. However, it is difficult to differentiate lipoma from low-grade sarcoma. CT or ultrasound guided biopsy would be a more appropriate next step rather than a PET scan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for a PET/CT scan for evaluation of her breast cancer. Findings:  The physician reviewer found that treatment monitoring and re-staging of breast cancer. PET/CT scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. PET/CT scan has also been shown to be more sensitive, specific and accurate and to have better positive and negative predictive values than conventional imaging for detecting local recurrence and distant metastases. PET/CT scan has a significant impact on the care of breast cancer patients, influencing both their clinical stage and their treatment management.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for a CT colonoscopy (virtual colonoscopy) for her colon cancer screening following a failed colonoscopy. Findings:  Three physician reviewers found that virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both 2-dimensional and 3-dimensional views of the colon and rectum using data derived from computed tomography. This imaging modality has been explored as an alternative to conventional endoscopic colonoscopy, particularly as an alternative screening tool for colorectal cancer. Virtual colonoscopy is being studied as a method for non-invasive evaluation of the colon for colon cancer screening and currently has mixed results. However, a virtual colonoscopy is a useful tool for evaluation of patients when the conventional colonoscopy fails due to either redundancy of the colon or obstructive lesion in the colon.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for a custom knee brace for treatment of the enrollees left knee post ACL reconstruction. Findings:  The physician reviewer found that there are insufficient reports in orthopedic sports medicine literature supporting the use of either prophylactic bracing or functional bracing of a stable, successfully reconstructed knee following ACL surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested for an Oncotype DX tumor assay for evaluation of her history of breast cancer. Findings:  Three physician reviewers found that Oncotype DX assay is a 21-gene assay that has been shown to predict the risk of recurrence of a patients breast cancer if treated systemically with hormonal therapy alone, without chemotherapy. In the appropriate patient the test is no longer considered investigational and is an accepted standard of care in the oncology community. However, there is no data as to its usefulness in answering the clinical question being asked in this situation, i.e., whether an aromatase inhibitor after tamoxifen would be useful.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested diagnostic tests  for an evaluation of her multiple symptoms including headache, stomach problems, abdominal cramps, mood changes, fatigue, mental dullness and bloating. Findings:  The physician reviewer found that the submitted clinical information has demonstrated that the studies obtained were not medically necessary. There was no documentation of a physical exam or specific diagnosis or impression that would warrant the medical need for the tests provided. The patient had been thoroughly evaluated by the listed specialty services. Furthermore, there is no standard for evaluation of the accuracy of the tests obtained related to the patients specific medical conditions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the prescription medication Lialda for the treatment of her ulcerative colitis. Findings:  The physician reviewer found that mesalamines are a class of drug that act topically on the colonic mucosa to reduce inflammation. They are considered first-line therapy for active, mild-to-moderate ulcerative colitis. Lialda is a recently approved, high-strength, oral formulation mesalamine with a unique delivery system allowing complete colonic distribution. It was found to be effective in inducing remission in intractable disease. This patient has failed treatment with all of the other mesalamines, and treatment with Lialda is warranted due to its improved delivery system and superior efficacy in inducing and maintaining remission. It is also known to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for acute inpatient psychiatric services for treatment of her eating disorder and depression. Findings:  The physician reviewer found that no admission psychiatric assessment was provided and there is not a single body weight recorded. The psychiatric notes are insufficient in terms of the frequency of visits, body weight, mental status examination and treatment planning. No documentation of discharge planning is evident via social work notes or notes from other providers. In light of the documented interventions and treatment planning and the patients limited improvement after a month of inpatient psychiatric care, continued treatment in this setting cannot be endorsed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a PET/CT scan for evaluation of her endometrial cancer. Findings:  Two physician reviewers found that it is important to note that the disease recurrence was confirmed by biopsy, disregarding the suspicion raised on the original PET/CT scan. Because the patient has histologically confirmed disease that is measurable with other forms of imaging, the addition of PET to CT scan would add no clinical benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 16-year-old male enrollee has requested for Humatrope (growth hormone therapy) for treatment of the enrollees short stature. Findings:  The physician reviewer found that ge has had normal GH responses to stimuli, two normal IGF-1 levels with respect to his stage of sexual development and a normal brain MRI (albeit chronic sinusitis was reported). His FSH and LH levels were prepubertal. His adult height predictions made by the endocrinologist were normal at 59.5 - 510. There was no workup to suggest that Kallmans syndrome or treatment with an aromatase inhibitor had been considered.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for a Saunders home lumbar traction unit for treatment of his lumbosacral neuritis. Findings:  Two physician reviewers found that lumbar traction for nerve root compression remains controversial. There is little consensus on its efficacy. The Health Plan recommends a standard over-the-door traction unit not requiring a frame or stand. The superiority of the Saunders lumbar traction unit over a standard lumbar traction unit has not been demonstrated in the medical literature.