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

A 46-year-old female enrollee has requested continued use of Percocet for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that oral opioids can be effective in treating the pain that frequently accompanies multiple sclerosis. A study by Svendsen demonstrates that MS patients have a high prevalence of pain, and that pain was likely to be described as constant and a significant interference in the daily life of patients with MS. In the study by Rowbathan, MS patients with central neuropathic pain responded better with high dose opioid treatment than with lower dose treatment. This patient has muscle spasms from her MS as well, which also respond in part to opioid treatment. The patient has used both long acting pain medication (MS Contin) as well as short acting medications for breakthrough pain (Vicodin and Percocet). Abrupt discontinuance from long-term opioids can have untoward consequences, including increased pain and precipitation of withdrawal symptoms. It should not be undertaken without close MD supervision. Therefore, there should be a conditional overturn of the Health Plans denial. The patient should continue with her current Percocet dosing until the patient is seen in consultation by a Pain Specialist, who can make recommendations regarding the specific opioid medications and dosing to be used.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested inpatient care at a neuropsychiatric hospital for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the American Psychiatric Association Practice Guidelines for patients with eating disorders, patients with inadequate motivation or support who are discharged from inpatient to partial hospitalization programs before they are clinically ready often have high rates of early relapse, greater struggles with recovery, and slower rates of progress, necessitating longer future inpatient stays. When transitioning to a lower level of care, it may be destabilizing for a patient and it is important that patients be able to transition smoothly to the next (less intensive) level of care. The guidelines also state that attainment of weight goals alone should not be the sole basis for the decision to discharge a patient from the inpatient setting, but the entire bio-psychosocial picture of the patient needs to be taken into account. Using these criteria, I find that there is clear medical necessity, based on the patients admission history and course, for the beginning dates of service in question. This is evidenced by the patient demonstrating motivation and active independent compliance with multiple aspects of the treatment program, as well as showing a realistic appraisal of her situation. However, medical necessity is absent from the remaining dated in question as the documentation does not support the need for, or show additional benefits as a result of, continued hospitalization.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that an allergic reaction to a medication is termed a drug eruption. It may occur while a patient is currently taking a medication, or, as in this case, within a week afterward. Some semi-synthetic penicillins may cause drug eruptions even later. Skin manifestations may include uriticaria, erythema, and pruritis. More serious cases may include bronchospasm, laryngeal edema, and shock, producing an anaphylaxis syndrome. This patient was experiencing a drug eruption only. She had no symptoms of anaphylaxis. Drug eruptions are treated by removing the offending agent and prescribing a course of antihistamines such as Benadryl. Steroids may be added as well. This patient had already been adequately treated for her symptoms and was improving. Her symptoms on the date in question were not of a sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to his health and/or bodily function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested an anterior lumbar interbody fusion for the treatment of his discogenic low back pain. Findings:  The physician reviewer found that the patient has failed conservative treatment. Continued attempts at conservative management are not likely to be effective. Surgical treatment is indicated for this patient. Anterior lumbar interbody fusion is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Provigil for the treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that this patient has long-standing excessive daytime sleepiness. Polysomnography demonstrated very mild obstructive sleep apnea, but a multiple sleep latency trial (MSLT) demonstrated profound sleepiness.  In fact, the MSLT results show narcolepsy-range sleepiness. However, other aspects of this study are not consistent with narcolepsy.  These results are most consistent with idiopathic hypersomnolence. Provigil is an accepted and commonly prescribed therapy for this condition.  Provigil is medically indicated and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Rituxan therapy for the treatment of her Polyarteritis Nodosa (systemic vasculitis). Findings:  Three physician reviewers found that Rituximab is appropriate in cases in which there is clear evidence of continuing active necrotizing vasculitis despite treatment with virtually all other conventional agents. There is significant case-report evidence of the effectiveness of rituximab in treating ANCA associated vasculitides, and less substantial, but still meaningful evidence of its effect in treating PAN. In the case of this patient, the submitted records do not present evidence that the requested rituximab treatment is appropriate, as the patients current diagnosis and degree of disease activity are not substantiated in the medical documentation provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested continued rehabilitation therapies and skilled nursing services for the treatment of the enrollee, who is status post pelvic fracture. Findings:  The physician reviewer found that the patient was not safe for discharge during the dates of service at issue, and he was progressing with physical therapy and occupational therapy. His needs were not custodial. The prevailing practice standard is to complete rehabilitation for patients transferred to a skilled nursing facility for rehabilitation. In this case, the patients skilled nursing facility-based rehabilitation was not complete as of the last authorized date of service and it would not have been reasonable to provide the patient with a lower level of care. The Health Plans assessment of the patients needs was not consistent with his clinical course in rehabilitation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 30-year-old male enrollee has requested the Ensure supplement for the treatment of the enrollees anorexia. Findings:  The physician reviewer found that there is no indication in the submitted clinical records that the patient cannot eat. The normal albumin level indicates that the patient is not malnourished. Additionally, he was noted as well-nourished, and his weight has been stable. The above cited website by the Williams Syndrome Association indicates that feeding difficulties tend to resolve as children get older. The patients weight of 108 pounds is only slightly below average when using a weight chart specific for male Williams Syndrome patients. The documentation does not suggest that the patient is unable to take other forms of nutrition, even if the Ensure is responsible for his current state of health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested cardiac ablation pulmonary vein isolation for the treatment of his atrial fibrillation. Findings:  Three physician reviewers found that while first-line therapy of atrial fibrillation consists of drug therapy and cardioversion if necessary, second-line therapy has evolved over the last 15 years.  Rate control of chronic atrial fibrillation with drugs and anticoagulation is reasonable for most patients, but those patients who continue to be symptomatic despite medications, or are allergic to medications, require alternative therapy.  The ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation are in support of alternative therapy for these patients.  In the past, AV node ablation with pacemaker implantation was the best alternative in the second-line limited group of patients as discussed by Pappone, et al.  Cardiac ablation pulmonary vein isolation has proved to be a better alternative to AV node ablation and pacemaker implantation.  The benefits of cardiac ablation pulmonary vein isolation are discussed further in Mohammed, et al.  Pulmonary vein isolation is not experimental or investigational and is an accepted treatment of chronic atrial fibrillation in patients who have failed medical therapy as is discussed in Wazni, et al.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Orthovisc injections for the treatment of her knee pain. Findings:  Two physician reviewers found that the use of Orthovisc is not experimental for treatment of osteoarthritis of the knee. However, documentation that a full course of conservative treatment for patellofemoral arthritis has been tried and failed is lacking. The documentation does not support an adequate course of NSAIDs, physical therapy, or cortisone injections, as discussed in the reference by Zhang and colleagues. Before the use of viscosupplementation is appropriate, a trial of conservative measures must be documented.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested the Vest Airway Clearance System (the Vest System) for the treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that CPT was not performing the necessary job of mobilizing secretions, resulting in atelectasis and air trapping on chest CT scan. In addition, CPT was becoming impractical because of the patients resistance, making it difficult to perform optimally. The literature supports the use of the Vest System, and it is the community standard for those in whom CPT cannot be performed adequately. Use of the Vest System is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nineteen-year-old female enrollee has requested an Easy Standing Frame for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that this patient has significant lower extremity spasticity, and the requested equipment should help in that regard. Respiration, bowel function and bladder function have been shown to improve with maintaining an upright position, and this patient noted improvement in respiratory status and bowel function with prior use of the Easy Standing Frame. She is less likely to develop muscle contractions with less sitting. There is also a concern that the patient could develop a decubitus ulcer with prolonged sitting. As discussed in the references, the medical effects of standing, including as a result of the use of a standing device, are numerous and act to prevent several complications of the severity of the patient's disability. The inherent spasticity is reduced by standing, as discussed in the reference citations by Tremblay and colleagues and Dunn and colleagues. Further, as discussed by Henderson and colleagues, non-weight bearing patients are at high risk for osteoporosis due to immobility, which can be partially offset by consistent maneuvers to promote weight bearing, such as with the requested equipment. Finally, multiple other associated complications, such as urinary retention and urinary tract infections, constipation, and skin infections, can be prevented, at least in part, with the use of standing devices as indicated by Dunn and colleagues.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested artificial disc replacement for the treatment of his low back pain. Findings:  Three physician reviewers found that the requested procedure (artificial disc replacement) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Specifically, artificial disc replacement has not been shown in long-term peer reviewed studies to be more beneficial than standard fusion techniques.  Though early reports may be encouraging, the long-term data is not yet available. Research shows insufficient evidence to draw extensive efficacy/effectiveness conclusions comparing artificial disc replacement with a broad range of recommended treatment options, including conservative non-operative care since, other than spinal fusion, there are no direct comparison studies.  Therefore, it has not been established that artificial disc replacement is more beneficial in the long-term compared to fusion, and it is also impossible to determine comparisons with conservative non-operative care at the current time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a ten-year-old male enrollee have requested Strattera 25mg for the treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there are several established, well-tolerated and beneficial agents for the treatment of ADHD. This patient was initially started with Strattera samples and did respond well. However, a trial of other typical psychostimulants of potential benefit has not been attempted as appropriately required by the Health Plan. The guidelines regarding ADHD treatment by the American Academy of Pediatrics recommend the initiation of stimulant medication (methylphenidate or dextroamphetamine). This is based on the fact that there is a large body of data that has demonstrated efficacy of these medications in the treatment of ADHD. There is no evidence that Strattera is superior to the alternative stimulants offered by the Health Plan, either in terms of efficacy or safety. The patient has not tried any of the stimulants, and there are no specific contraindications to use of the traditional stimulants. There is no evidence of tics or major anxiety symptoms that would support the use of Strattera. The requested medication is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Lp-PLA2 testing for an evaluation of her hyperlipidemia. Findings:  Three physician reviewers found that the literature indicates that the predictability of Lp-PLA2 testing is no longer statistically significant after adjustment for other risk factors. There is insufficient evidence that Lp-PLA2 testing is useful in evaluating stroke risk. To date, it would be considered complementary to traditional risk factor stratification for identifying individuals at increased risk for stroke. The consensus is that there is lack of evidence from prospective clinical studies that incorporation of Lp-PLA2 testing in cardiovascular risk assessment improves clinical outcomes. Adult Treatment Panel III guidelines do not include a recommendation for Lp-PLA2 testing in assessment of coronary artery disease risk. The benefit of this testing has not been scientifically established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for Botox injections for treatment of the enrollees intractable headache disorder as a result of a traumatic head injury. Findings:  Two physician reviewers found that there is no generally accepted recognition of Botox injections for the treatment of chronic pain and headaches complicating post-concussion syndrome. There are reports of experimental use of botulinum toxin Type A for tension-type headaches by Straube and colleagues. The Physicians Desk Reference, 62nd Edition mentions its use in cervical dystonia, but no FDA approval of its use for chronic daily headache. There is no evidence to suggest that the requested therapy would be more effective for the patient than other available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for TOBI (tobramycin inhalation solution) for treatment of his chronic sinusitis. Findings:  The physician reviewer found that antimicrobial therapy delivered via nebulization technique can potentially benefit patients. However, careful review of the long-term outcome does not show any significant benefit over other more common therapies. Usually, the topical administration of nebulized therapy is an adjunct to other medications and other therapies. The current medical literature does not establish a standard for this medication under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for a lymphedema pump for treatment of his venous stasis dermatitis.  Findings:  The physician reviewer found that the use of the pneumatic compression device in the setting of chronic venous insufficiency remains controversial. However, in this patient it is medically necessary because this patient has failed to improve despite very significant weight loss, an aggressive use of diuretics, elevation, and the regular use of compression stockings. A brief trial of pneumatic compression in the past was helpful in relieving her symptoms, and is thus likely to be helpful for her now.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for Cyberknife stereotactic body radiotherapy (SBRT) for treatment of her adenocarcinoma of the prostate.   Findings:  Three physician reviewers found that he would be deemed a low recurrence risk based on current National Comprehensive Cancer Network (NCCN) practice guidelines.  In addition, with life expectancy greater than 20 years, options regarding definitive treatment would include observation, radical prostatectomy, 3D conformal irradiation, or interstitial implant. Furthermore, within the NCCN guidelines under Principles of Radiation Therapy, it states that 3D conformal or IMRT techniques should be employed.  Doses of 70 to 79 Gy in 35 to 41 fractions to the prostate appear to be appropriate for patients with low risk cancer.  This dose fractionation is not consistent with stereotactic body radiosurgery which typically employs large doses over a short period of time. The NCCN guidelines do not state that Cyberknife treatment is considered optimal or even an option if stereotactic body radiosurgery is utilized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for an interdental fixation device for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that long-term studies support the fact that many patients such as this patient may progress to more severe sleep disorders as well as mood disorders. Mandibular positioning devices are known to be useful in treatment of mild to moderate obstructive sleep disorders. Compliance is fairly good when compared to the use of a continuous positive airway pressure (CPAP) device. Clinical symptoms show significant reduction in apneas with this treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Genotropin for treatment of her adult growth hormone deficiency (AGHD).   Findings:  The physician reviewer found that the current gold-standard test is insulin-induced hypoglycemia. An inadequate response of growth hormone to insulin-induced hypoglycemia is diagnostic of AGHD.  Alternatively, testing with the combined administration of growth hormone releasing hormone (GHRH) plus arginine testing can achieve comparable separation between normal and hypopituitary subjects.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested for speech therapy for treatment of his speech delay.   Findings:  The physician reviewer found that this patient has a significant congenital language handicap that has been resistant to nearly four years of speech therapy. Despite some gains, he continues to have significant delay in the initiation of speech, which is a congenital dysfunction. He is beyond the age when most grammatical dysfunction shows spontaneous improvement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for thighplasty surgery for treatment of her excessive skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons (ASPS) criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper cited above, when surgery to remove extensive skin redundancy is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Only in rare circumstances will buttock or thigh lifts be needed to treat functional abnormalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for a right knee replacement for treatment of her knee pain. Findings:  The physician reviewer found that total knee replacement or arthroplasty is an extremely successful procedure for end stage arthritis of the knee. The success rate is very high with 15-20 year follow-ups in the literature at 90+% successful.  Pain relief and improved function make total knee arthroplasty (TKA) a successful procedure. TKA in young patients has a more variable result. Patients younger than 40 years of age may have a failure rate of 12% at 8 years, which is higher than observed in most older age groups (see Archibeck, et al.). Total knee replacement in obese patients was associated with lower functional scores, increased patella pain and increased incidence of non-progressive radiolucent lines. Although postoperative knee scores were lower, improvement in knee scores was higher and revision rates were similar in these patients when compared with non-obese patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for intensive outpatient program services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that based upon the nature of the patients symptoms over the years and the symptoms exhibited at the time of admission, it was likely that her gains were not internalized. If she were discharged from the intensive outpatient program prematurely, there was a strong possibility of serious clinical regression.