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

A thirty-four year-old female with metastatic breast cancer is requesting authorization for Sutent therapy.Reviewers Findings:The reviewing physician found that Sutent is still an experimental treatment for metastatic breast cancer and cannot be considered medically appropriate at this time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-three year-old morbidly obese female with multiple comorbid conditions is requesting authorization for laparoscopic Roux-en-Y gastric bypass with cholecystectomy.  Reviewers Findings:The reviewing physician found that laparoscopic Roux-en-Y gastric bypass with cholecystectomy is medically indicated and necessary, the patient will not be able to lose weight and maintain the weight loss through non-surgical means.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old female who has unattractive scars following a thyroidectomy is requesting authorization for scar revision surgery.Reviewers Findings:The reviewing physician found that the patient is concerned about the aesthetic appearance of the scars, but the records provided do not document that the scars are causing a functional problem such as pain or pruritus.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-seven year-old male with arthritis in the right hip is requesting authorization of a metal on metal hip replacement with computer navigational assistance.  Reviewers Findings:The three reviewing physicians found that the patient can be appropriately treated without the use of computer navigational assistance.  The three physicians concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-eight year-old morbidly obese female diagnosed with a metatarsal stress fracture is now requesting authorization for an electric wheelchair.  Reviewers Findings:The reviewing physician found that there is no documentation demonstrating that the patient is confined to a wheelchair or is unable to walk. Nor is there evidence that the patient is unable to propel a manual wheelchair.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old female with a long history of migraine headache is requesting reimbursement for a dental splint, Botox therapy, and the increased quantity of Amerge.  Reviewers Findings:  The reviewing physician found that past and future Botox therapy is not medically necessary for treatment of the patients medical condition.  The physician also found that NTI splint and 18 tablets of Amerage on a one-time basis are medically necessary.  The physician concluded that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a fifteen year-old male with short stature are requesting authorization of Increlex because of a putative diagnosis of IGF-1 deficiency. Reviewers Findings:The reviewing physician found that the patient had IGF-1 deficiency and thus should be allowed to continue treatment with Increlex long enough to show an adequate (or inadequate) growth response.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a four-year-old male with a history of speech delay are requesting reimbursement and prospective authorization and coverage of speech therapy.Reviewers Findings:The reviewing physician found that the earlier speech therapy evaluation documents improvement with therapy, no goals or objectives were established to indicate whether the therapy was medically or educationally based.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year-old male with episodic cluster headaches is requesting reimbursement for up to six injections of Imitrex 6mg per day as well as prospective authorization for three Imitrex 6mg injections per day.Reviewers Findings:The reviewing physician found that the use of greater than two 6mg Imitrex injections per day is not recommended, and may be unsafe.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-seven year-old female who has had progressive alopecia of her left parietal scalp is requesting for reimbursement and prospective authorization for the intralesional corticosteroid injections.Reviewers Findings:  The reviewing physician found that this patient has a progressive scarring alopecia. Intralesional steroids do not reverse alopecia when there is scarring but they may be effective in the prevention or slowing of further scarring.  The physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-four year-old suicidal female is requesting for reimbursement for acute inpatient psychiatric services.  Reviewers Findings:The reviewing physician found that the patient has a complex set of diagnoses in addition to her underlying depression and a strong family history of bipolar disorder.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a sixteen year-old female with a history of drug and alcohol use is requesting reimbursement for residential treatment services.  Reviewers Findings:The reviewing physician found that a transition from inpatient psychiatric treatment to residential treatment was recommended by the patients outpatient therapist, however the specific indications for this level of care are not clear.  The physician also found that the services at issue were not medically necessary for treatment of the patients medical condition.  The reviewing physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-four year-old female with a history of an eating disorder is requesting coverage of psychiatric treatment services.  Reviewers Findings:The reviewing physician found that treatment at a less intensive level of care then what the patient was receiving would have been appropriate during the period at issue.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old male who has had total knee replacement is requesting reimbursement for physical therapy.  Reviewers Findings:The reviewing physician found that the skilled physical therapy intervention was not medically indicated because the patient had good functional mobility.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A fifty-three year-old female with a history of constipation and recent fecal incontinence is requesting coverage of a colonic motility study and biofeedback therapy.  Reviewers Findings:After reviewing the requested procedures 2 out of 3 physicians found that the colonic motility study was necessary, and 2 out of 3 physicians found that the biofeedback was not necessary.  The reviewers found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a ten year-old male with type I diabetes mellitus are requesting reimbursement and prospective authorization of growth hormone therapy.Reviewers Findings:The reviewing physician found that the information submitted does not establish the medical necessity of growth hormone therapy.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year-old female who has a diagnosis of fibromyalgia and a long-standing complaint of left leg and hip pain is requesting authorization of hip and thigh liposuction.   Reviewers Findings:The reviewing physician found that liposuction is a body contouring procedure, not a treatment for chronic hip pain and that there is no clear clinical basis for this treatment recommendation.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-seven year-old male who sustained a right wrist fracture is requesting reimbursement for the bone growth stimulator.Reviewers Findings:The reviewing physician found that the use of the bone growth stimulator was indicated under these specific circumstances to aid in the bone healing.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-five year-old female with chronic constipation is requesting authorization and coverage of Amitiza.Reviewers Findings:The reviewing physician found that Amitiza has provided the patient with some relief form the chronic constipation and is the agent of choice in this clinical situation.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-three year-old female with myelopathy, arthralgias and severe fatigue is requesting coverage of interferon alpha injections.  The patients treating neurologist reports the patient has partial reactivity to HTLV2 and low b12. The patient reports that the fatigue is better with interferon alpha injections.Reviewers Findings:The reviewing physician found there is no evidence that interferon-alpha has any role in the treatment of HTLV2 associated myelopathy. As such, treatment with interferon-alpha is of unproven efficacy in this clinical situation and is not medically indicated.  Therefore, 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 six year-old male diagnosed with  developmental coordination disorder, ADHD, and disorder of written expression is requesting authorization for occupational therapy.  The patient has received a number of on-going occupational therapy sessions for these disorders.  Reviewers Findings:The reviewing physician found that the literature and the clinical record do not support the medical appropriateness of on-going occupational therapy sessions.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three year-old male who was diagnosed with, and treated for a posterior fossa ependymoma are requesting reimbursement for the radiotherapy provided at Saint Jude Childrens Research Hospital.  Reviewers SummaryThe reviewing physician found that the services sought by the parents could have been safely and effectively delivered at one of the local Cancer Centers not just Saint Jude.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-nine year-old female with nipple retraction is requesting authorization for an MRI of the breast. A mammogram was negative with heterogeneous breast tissue. An ultrasound of the breast performed three months after the mammogram was also negative. The patient has been seen several times by her clinician since that time and no breast masses were palpated.  Reviewers Findings:The reviewing physician found that the physical finding of new nipple retraction can indicate an underlying malignancy. In light of the results of the physical exam, the negative ultrasound, and the heterogeneous dense breast tissue on mammogram, an MRI is warranted in this setting for purposes of problem solving.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-six year-old female diagnosed with recurrent disc dislocation, polymyalgia, myositis, cephalgia and capsulitis is requesting reimbursement for a neuromuscular scan, unlisted diagnostic radiologic procedure and electromyography.  Reviewers Findings:The reviewing physician found that the procedures at issue were either not medically necessary or not likely to be more beneficial than any standard treatment for evaluation of the patients medical condition.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-two year-old woman with stomach bloating, poor digestion and irritable bowel syndrome is requesting reimbursement for a Heidelberg gastrogram and median stress assessment.  Reviewers Findings:The reviewing physician found that the details of the patients illness are not documented in the included materials and the complaints are quite broad and non-specific.  Also, these tests are of unproven efficacy and are not considered community standard of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-four year-old male with diabetes mellitus type 1 is requesting authorization for a continuous glucose monitoring system (CGMS).  The patient currently checks his own blood sugar four times daily and states hypoglycemic unawareness until blood sugar is 40mg/dl.  Reviewers Findings:The reviewing physician found that the patient may be an appropriate candidate for a CGMS, but a three to six-day CGMS study should first be performed. If the results document frequent hypoglycemic events at times other than when the patient is self-monitoring, the requested device should be authorized. If the results do not document frequent hypoglycemic events at times other than when the patient is self-monitoring, the requested device should not be authorized.  Therefore, at this time the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-nine year-old male diagnosed with diabetes mellitus type 1 is requesting authorization for an insulin pump.  The patient reports hypoglycemic unawareness and widely fluctuating blood sugars. The patients A1c over the last year has varied from 6.5% to 7.5%. Reviewers Findings:The reviewing physician found that the patients blood sugar levels are not less than 60 and or greater than 300. Nor is there evidence of widely fluctuating pre-meal blood sugars or hospitalizations for diabetes-related issues.  The reviewing physician found that an insulin pump is not clinically indicated for management of this patients diabetes and the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-five year-old male diagnosed with metastatic colon cancer is requesting authorization for the use of Erbitux.  The patient was initially treated with a number of procedures and there was reduction of liver tumors seen on a CT scan.  However, another CT scan revealed progression of metastatic disease.  The patient was then treated with Erbitux and Camptosar (CPT-11).Reviewers Findings:The reviewing physician found that the submitted medical records do not clearly document that the patient was treated with CPT-11 alone prior to the initiation of Erbitux. Thus, based on the information provided it is not clear that the use of Erbitux in this setting is within clinical guidelines. Therefore, the reviewing physician found that the Health Plan denial should be upheld
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two-month-old premature female whose gestation was complicated by polyhydramnios are requesting authorization of Synagis.  The patient was admitted to the neonatal intensive care unit and was intubated for increased work of breathing and hypoxia and received one dose of surfactant. The patient remained intubated for two days and continued on nasal cannula oxygen, the patient was then discharged with an apnea monitor.Reviewers FindingsThe reviewing physician found that the patients gestational age places the patient at risk for severe respiratory syncytial virus.  The patient also has the additional risk factors that increase both morbidity and mortality.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two-month-old premature female who has experienced recurrent syanotic episodes requiring admission to the neonatal intensive care unit are requesting authorization of Synagis.  Reviewers FindingsThe reviewing physician found that the patients gestational age places the patient at risk for severe respiratory syncytial virus.  The patient also has the additional risk factors that increase both morbidity and mortality.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fifty-eight year-old female diagnosed with pancreatic cancer that has metastasized to the liver is requesting chemotherapy with oxaliplatin, Taxotere and Avastin.  The patient has undergone a Whipple procedure, chemotherapy, chemo-embolization.Reviewers Findings:The reviewing physicians found that the proposed treatment is not likely to be more beneficial than standard therapy for this patient.  They also found that this proposed combination is not included in the compendia or other standard guidelines for the treatment of this disease. There is no good evidence to suggest that this combination will be superior.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-six year-old male with chronic asthma is requesting Xolair.  The patient requires frequent oral steroids and inhaled steroids.  The patients optimum FEV1 is supranormal despite a maximized therapeutic regimen. Reviewers Findings:The reviewing physician found that the submitted records demonstrate the patient has reversible lung disease.  The patient is on a number of therapies and yet still is not controlled.  Therefore, the reviewer found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year-old female with fibroids, ovarian cyst, menorrhagia, dysmenorrheal and dyspareunia is requesting a total abdominal hysterectomy.  Reviewers Response:The reviewing physician found that the submitted documentation reveals little objective evidence to support immediate surgical treatment. At this time, the patients symptoms are not so definitive as to preclude a trial of medical therapy to ensure that conservative treatment has been exhausted.  Therefore the reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A sixty-three year-old male with severe stenosis at L4-5 and spondylolisthesis and disc protrusion at L5-S1 is requesting coverage for an X-Stop decompression procedure.Reviewers Findings:One of the three reviewing physicians found that the patient has long-standing pain and has attempted conservative treatment.  The procedure is medically reasonable for the patient in an attempt to alleviate pain.  This reviewer found that the Health Plan denial should be overturned.Two of the reviewing physicians found that the X-Stop does not have long-term outcome studies to justify its use in patients with stenosis with spondylolisthesis.  Therefore, this procedure would not be more beneficial for treatment of the patients medical condition.  These two physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five year-old female with a history of stuttering is requesting reimbursement for speech therapy services.  Reviewers Findings:The reviewing physician found that the medical literature for this patient suggests that although much time is spent on speech therapy for dysfluency/stuttering, there is little evidence that the therapy improves recovery over natural recovery rates. Therefore, 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 an eleven year-old female with a height below the 3rd percentile is requesting authorization for GH therapy.  The patient took part in a research study and was treated with GH. The documents provided indicate the growth rates, but do not include any biochemical results or bone ages.Reviewers Findings:The reviewing physician found that in order to establish medical necessity for GH therapy, a recent bone age with an accurate height measured near the time of the X-ray is needed so that an adult height prediction can be made.  This information is not present in this case.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a fourteen year-old male is requesting reimbursement for a Magnetoencephalography (MEG) study.  The patient is being evaluated through a university epilepsy program for possible surgical intervention. PET, EEG and MRI have given somewhat conflicting results regarding seizure focus.Reviewers Findings:One of the three reviewing physicians found that the MEG remains an experimental and investigational technology. The patients seizure foci were identified via EEG and PET, and MEG did not add new information, nor was it likely to alter the patients care.  This reviewer found that the Health Plan denial should be upheld.  Two of the three reviewing physicians found that MEG is a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to identify deep seizure foci.  Because of this information these reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A nineteen year-old male who has cocaine and marijuana dependence with a comorbid diagnosis of bipolar disorder is requesting authorization for continued psychiatric residential treatment services.  The patient has had multiple hospitalizations followed by entry into a dual diagnosis residential program. Reviewers Findings:The reviewing physician found that the submitted medical record reveal that the patient no longer meets medical necessity criteria for residential treatment.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-five year-old male with a high body mass index and multiple comorbidities is requesting authorization for Lap-Band surgery.  Reviewers Findings:The reviewing physician found that based upon the clinical information provided, the patient is a suitable candidate for Lap-Band surgery.  Also, Lap-Band surgery presents less risk than other bariatric procedures.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.