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

The parent of a 4-year-old male enrollee has requested for occupational and physical therapy services for treatment of the enrollees autism.  Findings:  Three physician reviewers found that tt is through their sensory experience that children develop connectedness with the world. When children show sensory dysfunction, it is harder for them to interact and learn about the world. These children are then less able to successfully participate in and develop the occupations of childhood, such as play, social interaction, and learning. Children with ASD (autism spectrum disorder) have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties.Generated by an occupational therapist and developed primarily within the profession of occupational therapy, sensory integration theory and its application provide an important set of knowledge and skills for practitioners. Sensory integration is also one of the first theories generated within occupational therapy to undergo the rigor of providing evidence that validates its constructs while providing direction for the strategies clinicians use to remediate the underlying sensory issues that affect performance. Research demonstrating the efficacy of sensory integration treatment based on sensory integration theory has been published. Its theories provide a framework from which occupational therapists can generate treatment plans for children with sensory integration disorders that will allow them to successfully participate in the occupations of childhood.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested sclerotherapy injections for the treatment of his varicose veins. Findings:  Three physician reviewers found that repeat sclerotherapy injections will not likely be more beneficial than any available standard therapy. Most varicose veins are secondary to venous insufficiency and reflux which most commonly arises in the greater saphenous vein. In the presence of venous reflux, repeat sclerotherapy injections will likely fail due to recurrent varicose veins. Once venous reflux is diagnosed with a duplex exam, treatment of the valvular incompetence of the greater and/or lesser saphenous vein should be performed. As mentioned by the Health Plan, this treatment can be performed with surgical ligation, endoluminal radiofrequency ablation, or endoluminal with ablation. If, after treatment of the incompetent vein, varicosities persist, sclerotherapy could potentially be indicated at that time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested for acupuncture for treatment of his rhinitis.   Findings:  Two physician reviewers found that there are still numerous options and strategies that have not been utilized and are still available. Furthermore, the Practice Parameter for Diagnosis and Management of Rhinitis Complete Guidelines of Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology does not list acupuncture as a treatment option for rhinitis. To date, there is a lack of sufficient evidence to support the use of acupuncture in patients with allergic rhinitis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that The use of Botox injections for the management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse, and Botox injections are helpful in managing refractory headache syndromes. Pharmacological treatments have not provided good long-term pain relief for patients.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for Rituxan infusion therapy for treatment of his multiple sclerosis.    Findings:  Three physician reviewers found that Rituxan is an anti-neoplastic monoclonal antibody used in treating rheumatoid arthritis. There is no evidence in the literature to support its use in RRMS. Rituxan remains an unproven therapy for the treatment of multiple sclerosis, as there is insufficient evidence in the peer-reviewed medical literature to support the long-term safety and efficacy of this drug for the patients diagnosis. As such, its superiority over other available therapies in this setting has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for cognitive rehabilitation therapy for treatment of her primary sleep disorder and post traumatic stress disorder (PTSD).    Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of anxiety, PTSD or sleep disorders within the organized medical community. The current practice guidelines for anxiety, PTSD or sleep disorders do not include neurofeedback (see NIH and VA/DoD guidelines cited above). The references submitted with this appeal are not sufficient to demonstrate the efficacy of neurofeedback in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a nine-year-old male enrollee have requested for neurofeedback for treatment of his autism. Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of mild traumatic brain injury within the organized medical community. The current practice guidelines for mild traumatic brain injury do not include neurofeedback treatment. As such, the clinical utility of neurofeedback has not been established in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old male enrollee have requested for neurofeedback for treatment of the enrollees autism. Findings:  The physician reviewer found that Neurofeedback is not currently within the standards of good medical practice for the treatment of autism within the organized medical community. There have been a few small studies utilizing neurofeedback in autism, mostly in high-functioning individuals. One study had matched controls, but was not blinded and the outcome measure was subjective (parental report of functioning).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for neurofeedback for treatment of his mild traumatic brain injury. Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of mild traumatic brain injury within the organized medical community. The current practice guidelines for mild traumatic brain injury do not include neurofeedback treatment. The references submitted with this appeal are not sufficient to demonstrate the efficacy of neurofeedback in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Avastin in combination with temozolomide for treatment of his anaplastic astrocytoma. Findings:  The physician reviewer found that Avastin is an inhibitor of vascular endothelial growth factor and presumably acts by inhibiting the development of a blood supply to tumors. It has been approved for use with chemotherapy, in metastatic colon, breast and lung cancers. In brain tumors, there is some acceptance that it is beneficial when combined with irinotecan. ASCO Abstract 11522 indicated that some patients demonstrated dramatic improvement clinically and radiographically with the use of Temodar and Avastin. In the above cited abstract by Perry and colleagues, 42% of patients with anaplastic astrocytoma were progression-free at six months when treated with this combination. Cloughesy and colleagues also noted activity of Avastin alone in recurrent gliomas.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for hepatectomy (resection of liver and partial lobectomy) for treatment of her recurrent metastatic ovarian cancer. Findings:  Two physician reviewers found that the most important predictor is complete removal of disease. This patient is likely to benefit from liver-directed surgery as well as resection of the left lower quadrant mass. The concept of tumor debulking is well-established and associated with prolonged survival. It is unlikely that further chemotherapy would provide similar benefit. Current CT scans suggest that the recurrent cancer is amenable to surgical debulking.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set by the National Institutes of Health for weight loss surgery. The Swedish Obese Subjects (SOS) study has demonstrated that there is no long-term success to dietary plans. The efficacy of weight loss surgical procedures has been well established, and the requested consultation is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Aciphex 20mg/day for treatment of her GERD. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy in optimizing acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. 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 end points or side effects profile.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for Provigil for treatment of his low back pain. Findings:  The physician reviewer found that there is no documentation that the patient has narcolepsy apnea or shift work disorder. It appears that Provigil is being used to counteract sedation and lethargy from the Duragesic patch. Provigil is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for residential treatment care for treatment of the enrollees substance abuse and major depression. Findings:  The physician reviewer found that the patient could have been treated at a lesser level of intensity at that time, such as partial hospitalization.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a total hysterectomy and bilateral salpingo-oophorectomy utilizing the da Vinci Surgical System for treatment of her stage IV endometriosis. Findings:  The physician reviewer found that the surgical treatment of stage IV endometriosis is one of the most difficult procedures facing the non-oncologic gynecologic surgeon.  The da Vinci Surgical System is an appropriate alternative to both the traditional open approach as well as conventional laparoscopy. The robotic platform allows the most complex procedures to be performed with incredible precision. For a patient with stage IV endometriosis who requires a hysterectomy or ureterolysis or enterolysis, it would most likely allow significantly less postoperative pain, less blood loss and quicker recovery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a thirteen-year-old male enrollee has requested for occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy has improved this patients fine motor skills to the point of being able to tie his shoes, utilize buttons and overall improve his fine and gross motor skills. Occupational therapy has been utilized for many years to improve motor skills in autistic children. The peer-reviewed papers referenced discuss occupational therapy in autistic and developmentally disabled children. Occupational therapy is well established as beneficial for this disabled pediatric population, and it is medically indicated for treatment of the motor deficiencies in patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for a breast MRI with computer aided detection (CAD) for evaluation of the enrollees high risk for breast cancer. Findings:  Three physician reviewers found that as outlined by Saslow et al., breast MRI is recommended for women with approximately 20-25% lifetime risk of breast cancer. This includes women who have a strong family history of breast or ovarian cancer, and women treated for Hodgkins disease. The patient in this case falls into the latter category.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for out-of-network services at UCSF for treatment of the enrollees headaches. Findings:  The physician reviewer found that the indisputable reputation of that staff in headache management, the patients diagnosis and subsequent treatment has not substantially changed from the specialist care she received in-network. While one of the out-of-network providers is an adult (as opposed to pediatric) neurologist, there is no evidence that similar services from an adult neurologist were not available in plan. Furthermore, at this patients age of 15, her treatment going forward can be appropriately managed by an in-network adult neurologist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for MRI guided steroid injections for treatment of her pudendal neuralgia.   Findings:  Three physician reviewers found that there is a lack of scientific literature supporting this approach. These services were of unproven efficacy and not medically indicated in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for a BioniCare Knee Device for treatment of his tricompartmental osteoarthritis. Findings:  Two physician reviewers found that there is no class one data to support the use of the BioniCare Knee Device for the treatment of tricompartmental knee osteoarthritis. More quality outcomes data is needed to support this treatment option, and this device is not currently an accepted modality in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for panniculectomy/belt lipectomy for treatment of his redundant soft tissue.    Findings:  The physician reviewer found that there is not significant ptosis of the mons area. There is no photographic documentation of intertrigo, skin infections, and skin ulcerations on any area of the torso. Nor do the submitted clinical notes indicate the patient has had a problem with chronic skin infections, intertrigo, rashes or ulcerations that have been diagnosed and treated with conservative management over a period of time with failure of treatment.  The physical exam does not mention any rashes, intertrigo, skin ulcerations or hernias.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested for Celebrex for treatment of his pain secondary to diabetic neuropathy. Findings:  The physician reviewer found that the patient has tried multiple medications for his neuropathy without benefit.  He has not been able to tolerate an NSAID (with PPI) because of a gastrointestinal disturbance.  He has been able to tolerate Celebrex in the past (with noted benefit); therefore it is a reasonable choice as a therapeutic agent.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 72-year-old female enrollee has requested for Nexium for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. However, interpatient variability of the efficacy has been seen with PPIs. Milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant difference in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for CT angiography for evaluation of his coronary artery disease. Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset and is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress test. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography for evaluation of graft patency is an uncertain indication with todays technology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested for continued skilled nursing facility care for treatment of his recovery from multiple injuries and ischemic attack.   Findings:  The physician reviewer found that the patient should be making functional gains and have the potential to continue to functionally improve with his physical, occupational and speech therapy services. The patient was not making those gains, and does not have the potential to make further gains at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested for artificial intervertebral disc replacement surgery for treatment of his back pain. Findings:  Two physician reviewers found that lumbar artificial disc replacement is still experimental for the treatment of lumbar degenerative disc condition. There are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long term. Fusion or non-operative management remains the gold standard treatment. Furthermore, outcomes with respect to two-level artificial disc replacement in the long term are not known.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for acupuncture for treatment of his weight control and digestion.    Findings:  The physician reviewer found that no evidence to support acupuncture for the treatment of constipation. There are numerous available safe and effective remedies (e.g., high dose fiber sorbitol and PEG) for constipation. These remedies are addressed in the review articles referenced above. In addition, there is no evidence to support the use of acupuncture to control or reduce excess body weight. As such, the use of acupuncture in this setting is not medically justified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for Botox injections for treatment of her chronic pain.    Findings:  The physician reviewer found that Botox is not of proven efficacy in case-controlled, peer-reviewed literature in the treatment of chronic back pain or myofascial pain. Furthermore, a response to trigger point injection is not known or proven to be a reliable predictor of a positive response to Botox injections. Because of the lack of evidence supporting the use of Botox in this setting, the medically necessity of Botox for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eleven-year-old male enrollee has requested for foot orthotics and follow-up with a podiatrist for treatment of the enrollees bilateral pes planus. Findings:  The physician reviewer found that orthotics is medically indicated for children with structural deformities, hallux valgus deformities and abnormal gait. These findings are not supported in the documentation provided. Foot orthotics is indicated for pes planus when there is documentation to support a fixed arch or a severe ankle varus. Diagnoses of corns, calluses and hammertoes usually respond to over-the-counter inserts and shoe modification. The patient has yet to fail on conservative treatment consisting of rest, ice, over-the-counter gel inserts, injections or medications to decrease inflammation, splints, exercises and immobilization.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for the Paradigm Real-Time continuous glucose machine and sensors for treatment of her diabetes mellitus. Findings:  Two physician reviewers found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin-treated patients who are not in good control. Recent reports of monitoring up to three to six months in adults have shown improvement in A1cs and decrease in hyperglycemic and hypoglycemic episodes. There is sufficient evidence of the efficacy of the Paradigm Real-Time continuous glucose monitor to support the use of this device in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for a PET scan for her cervical cancer.   Findings:  Three physician reviewers found that The main medical reason for not recommending a PET scan is its false negative incidence in certain cancers. In this patient, a PET scan was positive for her previous CT scan-proved pulmonary metastases. This patient now has an unknown mass in her left pelvis, found by a CT scan. A PET scan could confirm whether it is malignant, and in addition, it could show the presence of other metastatic lesions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for subacute residential level of care for treatment of her substance abuse and major depression. Findings:  The physician reviewer found that the diagnoses of Major Depression and Oppositional Defiant Disorder are not clearly established.