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

A forty-five year-old male is requesting norditropin (adult human growth hormone).  The submitted records include a single IGF-1 value of 171 ng/ml. In the records provided, there are no discernable symptoms noted by the patients physician.Reviewers Findings:  The reviewing physician found that the clinical documentation provided is insufficient to establish the need for growth hormone.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity.  Findings:  The physician reviewer found that since FDA approval of the Lap Band in 2001, the medical literature has consistently documented its efficacy. While it is true that the initial weight loss is more modest with the Lap Band than with the Roux-en-Y gastric bypass or the duodenal switch procedure, the morbidity is significantly less. Furthermore, there is increasing evidence that weight loss continues for as long three years with the Lap Band, resulting in weight loss levels similar to the more invasive procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested authorization and coverage for Natrecor therapy for treatment of his congestive heart failure and cardiorenal syndrome.  Findings:  Two physician reviewers found that the submitted records do not document severe heart failure symptoms or findings. Such evidence is a pre-requisite for treatment with Natrecor, particularly since there is no evidence that Natrecor infusions improve outcome measures other than symptoms. The records provided do not document the cause of the patients renal failure. There is also no objective documentation of benefit after Natrecor. Nor is there evidence the patient has been tried on standard medications that are proven to be beneficial in advanced renal and cardiac failure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested authorization and coverage for occupational therapy (OT) with sensory integrationfor treatment of the enrollees gross motor skill and sensory integration deficits.  Findings:  The physician reviewer found that despite its application in the treatment of autism for many years, there are few objective studies showing the benefit of sensory integration. The studies currently in publication deal primarily with the use of sensory integration therapy in the treatment of preschool children ages 18 months to three years. A search of the literature produced no studies which have specifically targeted school-aged children. Given the lack of sound peer-reviewed evidence supporting the efficacy of sensory integration therapy for older school-aged children, it cannot be concluded that such therapy is medically indicated. Treatment through an individualized education plan would be clinically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested authorization for artificial disc replacement surgery for treatment of his degenerative disc disease.  Findings:  Three physician reviewers found that the ProDisc disc device has not been approved by the FDA for replacement at greater than two levels. A review of the relevant peer-reviewed literature indicates artificial disc replacement at three levels is considered to be inconsistent with the standard of care.  There are no long-term studies addressing multi-level disc replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a sixteen year-old male who was suicidal ideation concurrent with a worsening of depression are requesting reimbursement for the acute inpatient psychiatric treatment services.  Reviewers Findings:  The reviewing physician found that the entire course of the patients stay was necessary.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a twelve year-old female with frequent secondary generalized refractory seizures are requesting authorization of magnetoencephalography (MEG).   Reviewers Findings:  Two of the three reviewing physicians found that MEG, in this clinical setting, may provide useful information not available by other methods.  The third physician found that there are inadequate scientific studies establishing the unequivocal value of MEG in the evaluation or treatment of patients with epilepsy.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-seven year-old male who was diagnosed with sarcoid is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that the Centers for Medicare and Medicaid Services indications for PET scans do not include treatment monitoring for sarcoid.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old female who has diffuse pain, muscle spasms and lower extremity weakness as well as left-sided paresthesias is requesting authorization for a power-operated vehicle.  Reviewers Findings:  The reviewing physician found that the records provided for review are not supportive of the need for a power-operated vehicle.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty year-old female is status post anterior cruciate ligament transplant and now has loss of cartilage and arthritic changes resulting in left knee pain is requesting authorization of Synvisc injections.  Reviewers Findings:  The reviewing physician found that although the patient will eventually require knee replacement, a series of Synvisc injections is the best treatment alternative at this time.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fifty-three year-old male who has been diagnosed with advanced osteoarthritis is requesting authorization for hip resurfacing arthroplasty.   Reviewers Findings:  Two of the three reviewing physicians found that the limited evidence of long-term safety and efficacy it cannot be said the proposed hip resurfacing is likely to produce a better clinical result than conventional total hip replacement.  The third physician found that the procedure represents a viable option for patients with disabling arthritis, particularly those under 55.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male with a diagnosis of autism are requesting continued authorization of individual speech therapy. The record also indicates that the patient is receiving speech therapy through the school system one hour per week along with the individual speech therapy.Reviewers Findings:The reviewing physician found that the literature reveals there are no outcome studies or randomized controlled studies demonstrating that individual speech therapy improves pragmatic speech and communication in patients with autism or that an increased frequency of speech therapy is more beneficial than the standard one time per week therapy.  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 year-old male with a past medical history significant for tracheoesophageal fistula are requesting authorization for Synagis injections for RSV prevention.  Reviewers Findings:The reviewing physician found that it is medically necessary and appropriate to provide Synagis to this patient for RSV prophylaxis for the duration of RSV season.  The reviewing 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 female with previously diagnosed major depression, recurrent and fibromyalgia is requesting authorization of Provigil.  The patient has been treated with a number of antidepressants, but they were ineffective.  Reviewers Findings:The reviewing physician found that this patient has tried various antidepressants and dosage adjustments without sustained improvement in her depressive symptoms and that Provigil is a reasonable approach.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-seven year-old female who had a gastric bypass with substantial but incomplete weight loss is requesting authorization of a gastric bypass surgery with the duodenal switch procedure.  Reviewers Findings: The reviewing physician found that the patient is not likely to lose an adequate amount of weight by non-surgical means.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested authorization for a needle aponeurotomy for evaluation of bilateral Dupuytrens contracture.  Findings:  Two physician reviewers found that review of the medical evidence reveals insufficient peer-reviewed data demonstrating the efficacy of needle aponeurotomy for treatment of patients such as this patient. Standard treatment for worsening Dupuytrens contracture is not a needle aponeurotomy, but rather, surgical release.  Although there seems to be higher patient satisfaction with needle aponeurotomy, review of the relevant literature demonstrates that results are not superior to those of percutaneous fasciotomy. The data shows needle aponeurotomy carries with it a greater chance of recurrence and incomplete correction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 A fifty-nine year-old female with a history of metastatic leiomyosarcoma is requesting authorization to participate in a Phase II clinical trial of ET-743 (Yondelis).  The patient has progressed on several regimens and currently has progressive disease.  Reviewers Findings:Two of the three reviewing physicians found that the patient has exhausted standard treatment; given previous trials of Yondelis, it seems the patients participation in the proposed trial is a rationale approach to the management of the malignancy.  The third physician found that although the patient is no longer a surgical candidate to palliate her disease, it does not appear she has had an adequate trial of Doxil chemotherapy to determine whether the patient would benefit from treatment.  The reviewers found that the health plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eighteen year-old male who sustained a neck injury and underwent C5-6 anterior discectomy with instrumented fusion is requesting reimbursement for the cost of the bone growth stimulator.  Reviewers Findings: The reviewing physician found that the use of a bone growth stimulator was not warranted in this clinical situation.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a fourteen year-old male who has a bone age of eleven years and six months are requesting authorization for growth hormone therapy.  Reviewers Findings:The reviewing physician found that the growth hormone therapy is not medically necessary for treatment of the patients medical condition.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty year-old-male who has a productive cough and shortness of breath with mild exercise is requesting authorization of a CT scan.  Reviewers Findings:The reviewing physician found that the value of a CT scan in the diagnostic evaluation of the chest is well established. This request for a CT scan by the pulmonologist is valid and the examination is medically indicated.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-two year-old female who is status post a right shoulder arthroscopy for adhesive capsulitis is requesting coverage for a continuous passive motion (CPM) device.Reviewers Findings:The reviewing physician found that the use of CPM in this case was clinically appropriate and within the standard of care. The patient has a condition that causes limited shoulder motion.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-nine year-old male with hyperlipidemia, cardiac asthma, and chest pain is requesting coverage for a CT angiography.Reviewers Findings:The three reviewing physicians have found that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  The physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fifty-four year-old female who is status post a buniectomy with left foot pain is requesting authorization of interferential stimulation therapy.Reviewers Findings:The three reviewing physicians found that there is insufficient evidence to show that the proposed therapy would help alleviate post-operative pain and swelling.  The physicians concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-three year-old male with right shoulder pain is requesting authorization for an MRI of the shoulder.Reviewers Findings:The reviewing physician found that the patient requires further workup before an MRI is appropriate.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A sixty-three year-old female with a history of bilateral tinnitus is requesting authorization for consultation and auditory rehabilitation/tinnitus management.  Reviewers Findings:The three reviewing physicians found that although the process of auditory rehabilitation/tinnitus management does show some promise in lessening the severity of tinnitus, there has not yet been sufficient study to establish efficacy.  The reviewing physicians concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-seven year-old female with a history of excessive daytime somnolence and chronic fatigue is requesting for reimbursement and prospective authorization for Xyrem.  Reviewers Findings:The reviewing physician found that the patient has been evaluated and does have alpha-wave intrusions during stage III and IV sleep, and Xyrem is known to reduce alpha-wave intrusions and to improve stage III and IV sleep.  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 a fibroid uterus is requesting authorization for another procedure to accomplish embolization of the contralateral side.  The patient had undergone a previous uterine artery embolization, but the right uterine artery apparently went into spasm and embolization could not be achieved.Reviewers Findings:The reviewing physician found that the procedure at issue is not a second embolization, but rather, a continuation of the original procedure.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-nine year-old female who underwent gastric bypass surgery and now has infections under the panniculus and chronic back pain is requesting authorization of a panniculectomy.Reviewers Findings:The reviewing physician found that the records do not establish medical necessity for the proposed panniculectomy.  This physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-one year-old male with bipolar disorder is requesting authorization for continued acute inpatient psychiatric treatment.  Reviewers Findings:The reviewing physician found that there is sufficient evidence that a more extensive hospitalization was medically necessary.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an eight-year-old male with a diagnosis of cerebral palsy with spastic diplegia associated with periventricular leukomalacia are requesting for authorization of continued intensive physical therapy.  Reviewers Findings:The reviewing physician found that there is no evidence that these therapies provide long-term benefit above and beyond standard therapy and home programs.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a thirteen year-old male with severe Crohns disease are requesting initiation of growth hormone therapy with Nutropin.  Reviewers Findings:The reviewing physician found that a six-month trial of growth hormone is medically appropriate to learn whether the complete cessation in growth can be overcome in this case.  The reviewing physician 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 marked obesity, degenerative joint disease, stress-related symptoms, disturbed sleep, chronic headaches, fibromyalgia, and recurrent sinusitis is requesting reimbursement and prospective authorization of Ambien CR.  The patient had been treated with one other sleep aid with limited benefit and is said to be sleeping better with Ambien CR.Reviewers Findings:The reviewing physician found that it is not unreasonable for the Health Plan to require a trial of two formulary agents with a demonstrated lack of efficacy, before authorizing Ambien CR.  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 an eight-year-old male with diagnoses of ADHD and Aspergers syndrome are requesting authorization of additional occupational therapy.Reviewers Findings:The reviewing physician reviewed of the patients goals as outlined in the submitted monthly progress notes, the goals that have been met are functional goals and not those based in sensory integration.  Because the goals are functional not sensory goals the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A sixty-four year-old male with chest pain is requesting reimbursement for CT angiography.Reviewers FindingsAfter reviewing the request, 2 of the 3 reviewing physicians found that the CT angiography was likely to be more beneficial for evaluation of the patients medical condition.  The third physician found that a CT angiography would not be able to accurately confirm or exclude important coronary obstruction.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-one year-old female who has anorexia nervosa and depressive disorder is requesting authorization for residential treatment.  The patient has an enormous anxiety about eating and needed constant supervision to complete doing so.  Reviewers Findings:The reviewing physician found that the patients enormous resistance to eating requires the need for much more intensive treatment.  The reviewing physician concluded that the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-four year-old female with severe rosacea is requesting reimbursement and prospective authorization and coverage for IPL/laser therapy.  The patient has been treated with intense pulsed light IPL/laser therapy for a number of years with some success.  Reviewers Findings:The reviewing physician found that the only intervention that is effective in treating the associated severe redness and flushing is IPL/ laser therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-one year-old female who underwent right knee surgery is requesting reimbursement for electronic controlled thermal therapy device and an ambulatory infusion pump.  Reviewers Findings:The reviewing physician found that both the electronic controlled thermal unit and an ambulatory infusion pump could not be recommended as medically necessary for this patient.  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 sixteen year-old female with a progressive nasal congestion and deformity condition are requesting aurtorization for a rhinoseptoplasty, rib graft, and fascia graft.  Reviewers Findings:The reviewing physician found that the proposed procedures are clinically indicated to correct an abnormal structure caused by a congenital deformity and are necessary to improve function.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.Reviewers FindingsAfter reviewing the requests, two of the three physicians found the electrogastrogram was not likely to be more beneficial for evaluation. Two of the three physicians found that antroduodenal motility/manometry studies were likely to be more beneficial for evaluation.  The reviewing physicians found the Health Plan denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A fifty-two year-old female with osteoarthritis of the left hip is requesting authorization of a hip resurfacing arthroplasty.Reviewers Findings:After reviewing the request, 2 of the 3 physicians found the patient is an appropriate candidate for hip resurfacing arthroplasty.  The third physician found that there are no long-term prospective studies that show that hip resurfacing arthroplasty has clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-nine year-old male diagnosed with idiopathic hypersomnolence is requesting reimbursement for the cost of Provigil.Reviewers Findings:The reviewing physician found that the consulting neurologist did not eliminate Provigil as a treatment option, he clearly indicated it was not the healthiest option.  Also, the patient does not meet typical criteria for Provigil.  The physician concluded that the Health Plan denial should be upheld.