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

A 45-year-old female enrollee has requested OrthoVisc injections for the treatment of her knee pain. Findings:  The physician reviewer found that this particular patient has a long and complicated orthopedic history relative to her right foot, cervical spine and right shoulder.  She also has ongoing right knee symptomatology.  While the patient is noted to have degenerative changes in the right knee, there is no documentation that the patient has tried and failed an appropriate course of conservative treatment.  The patients current degree of symptomatology and limitations are also unknown.  Hyaluronan injections such as the Orthovisc injections requested are generally prescribed for documented knee osteoarthritis in patients who have failed to respond to other standard forms of conservative treatment.  These treatments would include physical therapy, activity modification, routine dosing of anti-inflammatory medications and an intra-articular cortisone injection.  Therefore, without knowledge of her current functional limitations and without evidence that the patient has attempted an appropriate course of conservative treatment, the request for OrthoVisc injections cannot be recommended at this time.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested emergency services for the treatment of her jaw pain. Findings:  The physician reviewer found that this patient is a 45-year-old female who was evaluated in the emergency department with complaints of right-sided lower jaw and tooth pain. Her symptoms had been present for three days. She reported that she had used Vicodin and topical Oragel for pain at home without relief. The patient described her pain as throbbing and rated it a 10 on a scale of 1 to 10. Her past history was significant for a tympanic membrane repair with subsequent recurrent and persistent right facial pain. Physical exam revealed some swelling in her right lower mouth.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for the prescription medication Lipitor for treatment of his hypercholesterolemia.    Findings:  The physician reviewer found that there is no documentation provided demonstrating that Lipitor is medically necessary for this patient at this time. The most recent recommendation from the American College of Cardiology is to maximize the statin dose prior to using additional medications.  It is medically reasonable for the patient to attempt a trial of Zocor prior to treatment with Lipitor. If Zocor proves ineffective or has untoward side effects, the Health Plan should provide coverage for Lipitor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for Focalin XR 25mg for treatment of her attention deficit disorder. Findings:  The physician reviewer found that the clinical trials that led to FDA approval for this compound did include a proportion of subjects who were given more than the 20mg per day dose. While the subjects who received 30 or 40mg per day did not demonstrate increased efficacy over those who received 20mg per day, the higher dose groups did experience a higher frequency of several side effects. There appears to be little benefit in providing doses beyond 20mg per day, and there is increased risk. The provider does not provide any basis for the statement that the patient quickly metabolized the drug.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient does not meet nationally accepted criteria for authorization of bariatric surgery. Her BMI is less than 35 and she is not 100 pounds over her ideal body weight. Her sleep apnea symptoms have not been documented by a formal sleep study and there is no evidence that she has been fitted for CPAP. In addition, no fasting glucose has been submitted demonstrating the patient is diabetic. Furthermore, given the patients current condition there is a good chance that she can lose weight through conservative means.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 84-year-old male enrollee has requested for an X-Stop procedure for treatment of his lumbar stenosis.   Findings:  Three physician reviewers found that there is no documentation in the medical literature that multiple level X-Stop procedures perform any better than standard traditional care for spinal stenosis. Additionally, there is the risk of component malalignment or slippage. There are no good long-term studies documenting the efficacy of this procedure in multilevel cases.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 80-year-old male enrollee has requested for anodyne therapy for treatment of his gait instability. Findings:  Three physician reviewers found that two randomized, double-blind studies relating to anodyne therapy showed no benefit in terms of sensation/quality of life. The third study showed improvement only in patients with non-severe symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for the Novolog 100u/ml insulin pen for treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that there is no contraindication to the use of the Humalog pen identified in the records or evidence supporting the excuse use of the Novolog pen. A trial of the Humalog pen is reasonable under these circumstances. Should Humalog not be effective or well tolerated, coverage of the Novolog pen would be appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for Supartz injections for treatment of his arthritic knee.    Findings:  The physician reviewer found that the site of the prior injection is not known, if it was to the right knee subsequent steroid injections would be contraindicated and if it was to the left knee other alternatives should be considered. Because of the patients previous Staph infection and failure of anti-inflammatory medications.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for hyperbaric oxygen (HBO) therapy for treatment of her postoperative suture line. Findings:  Two physician reviewers found that HBO potentially minimized the amount of eventual debridement and allowed primary closure of the defect.  HBO has been shown to be of benefit in clinical situations such as described in this case.  The main problem is that there is no other available standard form of therapy that could potentially alter the inevitable progression of tissue ischemia to tissue necrosis that in this case might have required more extensive reconstruction, including skin grafting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested for Guardian RT continuing sensors for treatment of her diabetes.   Findings:  Three physician reviewers found that the data is clear that the lower the A1C, the lower is the risk of microvascular complications. The requested equipment is approved for the use for which it has been requested and has sufficient data to support its efficacy. Furthermore, this patient has obtained objective benefit from the device.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested for partial hospitalization services for treatment of her bipolar disorder, bulimia, panic disorder, polysubstance abuse and attention deficit disorder (ADD). Findings:  The physician reviewer found that there is no evidence that the patients treatment plan is being re-evaluated and amended.  There is no documentation of serious risk on the patients part.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-month-old female enrollee has requested Synagis injections for treatment of the enrollee. Findings:  The physician reviewer found that according to the guidelines published by the American Academy of Pediatrics in 2003, to understand the epidemiology of RSV in their area, physicians should consult with local health departments, diagnostic virology laboratories or the Centers for Disease Control and Prevention, if such information is not available locally. Decisions about the specific duration of prophylaxis should be individualized according to the duration of the RSV season. The CDC surveillance database, as of 4/08/08, is still reporting greater than 10% positive RSV tests. Some authorities consider any RSV in the community risky for susceptible infants. The majority, however, consider 10% positive the cut-off for establishing the end of the RSV season.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for a PET scan for evaluation of her abdominal pain. Findings:  The physician reviewer found that labs are sparse, and a tumor marker course is lacking. It is assumed that the patient has been referred directly to PET scan for abdominal pain, and it is impossible to ascertain whether she had an exam, a CT.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested emergency services for the treatment of her leg pain. Findings:  The physician reviewer found that the patient had an acute event that required an emergency room visit. Based upon the evidence in the record including the patients statements and the hospital staff this acute event was unforeseen. The patients objective examination by the emergency room staff revealed significant enough abdominal findings to warrant an admission and observation. The patient underwent imaging that localized the cause to a left ovarian cyst. The cyst was large enough to cause significant pain. The surgeons findings at laparoscopy confirm the presence of the cyst, and clear evidence of a rupture with some hemorrhage. This finding was very significant in that it is a significant cause of acute pain in women, which occasionally requires surgical intervention. Attempts at excision of the cyst were reasonable in that the type of cyst was unknown. Based upon this information, there was adequate medical justification to admit the patient and perform the surgery due to the severe nature of the pain and tenderness. A prudent layperson with an average knowledge of medicine with this patients symptoms would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for bilateral breast reduction for treatment of her condition.   Findings:  The physician reviewer found that there is no evidence of shoulder grooves, inframammary fold rashes, skin ulcerations or kyphosis.  There are no medications indicating treatment of rashes or intertrigo listed in the medication list. There is also no loss of function evident.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his spinal stenosis.   Findings:  Three physician reviewers found that there is inadequate documentation in the peer-reviewed literature of randomized, long-term outcome studies to prove the effectiveness of artificial disc replacement when compared to standard surgical procedures and conservative measures for degenerative disc disease.  Most published studies consist of retrospective case series of small sizes and short-term uncontrolled retrospective studies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for a breast MRI for evaluation of her breast condition. Findings:  Three physician reviewers found that the report could not rule out ductal carcinoma or papillary tumor, and an MRI was recommended. The American College of Surgeons has issued guidelines for the use of breast MRI.  It is used to look for breast cancer recurrence or to evaluate multicentric disease.  It is used in some cases for assistance in treatment.  It is used for screening high-risk women.  It is also used to evaluate indeterminate findings on ultrasound, mammography, and examination.  This patient has suspicious findings on ultrasound.  However, ductogram or biopsy would be more useful than MRI. MRI findings would not change the patients clinical management and would not provide a definitive diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested for growth hormone therapy for treatment of her short stature.    Findings:  The physician reviewer found that this patient has consistently dropped percentiles on the growth chart from the 25th to the 3rd percentile.  Growth hormone therapy with Nutropin will help stimulate her growth and improve her height.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for surgical excision of the axillary sweat glands for treatment of her hyperhidrosis. Findings:  Two physician reviewers found that excision of axillary sweat glands is an invasive/destructive procedure. There exist other non-invasive treatments that the patient has not yet tried such as Botox or iontophoresis.  Should these methods be ineffective or contraindicated, axillary excision would be reasonable given the widespread effects of sympathectomy. However, a trial of non-invasive therapy is reasonable before undertaking surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for PET scan for evaluation of his diffuse fibrosis of the peritoneum, retroperitoneum and pituitary gland.   Findings:  Two physician reviewers found that PET scans have been shown to be clinically relevant for certain cancer diagnosis (including melanoma, lymphoma, NSCLC and colorectal cancer) and to evaluate solitary pulmonary nodules. The use of PET scans for retroperitoneal fibrosis is not universally accepted. Some institutions have utilized PET scans to differentiate between malignant and benign retroperitoneal fibrosis. This patient has biopsy-proven benign retroperitoneal fibrosis. There are also anecdotal cases of false positive PET scans in patients with retroperitoneal fibrosis. At this time, the use of PET scan for retroperitoneal fibrosis is experimental and investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested physical therapy for the treatment of her neck pain. Findings:  The physician reviewer found that the medical records demonstrate that the patient was taught proper body mechanics and a home exercise program during the first five physical therapy visits. However, the progress notes for the patients physical therapy do not show significant progress in terms of pain and function.  Based on this documentation and the patients diagnosis, she would have been expected to perform range of motion and strengthening exercises without supervision in the form of a home exercise program after five skilled physical therapy visits.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested biofeedback therapy for the treatment of her abdominal pain. Findings:  The physician reviewer found that there is limited objective scientific data available regarding the use of biofeedback for the treatment of IBS. Although there is some evidence that behavioral therapies, one of which is biofeedback, may have some benefit in IBS, this evidence is limited and limited in its objectivity. In addition, there is limited evidence that biofeedback may be helpful in treating IBS with constipation.  Also, there is little evidence that biofeedback may assist with completion of evacuation of stool. In general, the efficacy of biofeedback therapy for the treatment of IBS is not supported by peer-reviewed data. The patients primary care provider has suggested a course of counseling/therapy, which is a reasonable medical recommendation at this point.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female enrollee has requested occupational therapy (OT) for the treatment of the enrollees autism.  Findings:  Three physician reviewers found that autism, or PDD-NOS, is defined in the DSM-IV as a disorder of communication, socialization and behavior. Standard treatment is psycho-educational and involves a team approach. This is usually carried out through the school system rather than independent therapy. The available records do not reflect any services the patient is currently receiving through the educational system. Sensory integration is a theory proposed about 40 years ago. Over the part 40 years, there has been a lack of scientific evidence accumulated to support it.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested physical therapy for the treatment of her back pain.  Findings:  The physician reviewer found that The patient is suffering from chronic symptoms with intermittent flare-ups.  She has had no neurological deficits on physical examination.  Additionally, she has had minimal pain at rest, with pain occurring primarily with activities such as walking, running, hiking and weight training. The additional physical therapy modalities utilized have little proven benefit in the medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested for proton beam therapy for treatment of his hepatocellular carcinoma.   Findings:  Three physician reviewers found that proton beam therapy is not approved by Medicare for hepatocellular carcinoma. As of February 2008, the patient is asymptomatic of the hepatocellular carcinoma (HCCa). HCCa has responded favorably to the chemoembolization of the liver. As of February 2008, there are four sites to be treated with proton beam therapy, and this is not practical even if it were approved by Medicare.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that IMRT, Image Guided Radiation Therapy (IGRT) and proton beam therapy are equivalent as to their approach in controlling cancer. Neither one has been shown to have survival benefit over the others. No clinical trials data are published as of now. Any of these modalities is equivalent in effectiveness and side effects for this patients prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested home uterine monitoring and a subcutaneous terbutaline infusion pump for the treatment of her preterm labor. Findings:  The physician reviewer found that the use of subcutaneous terbutaline as maintenance therapy for prevention of premature labor is extremely controversial. At present there is no firm evidence to support its use. The long-term or maintenance use of -mimetic drugs has been championed by clinicians who advocate detection and suppression of contractions to prevent preterm labor. Protocols for the continuous subcutaneous infusion of terbutaline have been reported to have fewer side effects than oral administration but have had no effect on rates of preterm birth or perinatal morbidity in randomized placebo-controlled trials.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-month-old female enrollee has requested Synagis for the treatment of the enrollee's potential respiratory syncytial virus (RSV). Findings:  The physician reviewer found that after a very detailed examination of the physician progress notes, respiratory therapy notes, and nursing notes, it is clear that this preterm infant received supplemental oxygen for the majority of the time from birth. This meets the generally accepted definition for chronic lung disease. Given that she has chronic lung disease, and that she has required oxygen and medications to treat respiratory problems during RSV season, she qualifies for Synagis based on both American Academy of Pediatrics (AAP) guidelines and Health Plan criteria. It is therefore both medically necessary and appropriate to provide this infant with palivizumab for the duration of the RSV season.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a ten-year-old female enrollee has requested Vyvanse for the treatment of her attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the patients diagnosis (ADHD) is not contested, nor is her need for treatment. A review of the records provided indicates the patient was given Concerta (methylphenidate class). A statement made by the treating physician indicates that she may not have tolerated this particular drug. However, I can find no record that she was treated with a drug in the amphetamine class. The Health Plan requires that the non-formulary compound (Vyvanse) be provided only after formulary drugs (compounds in both the amphetamine and the methylphenidate classes) are found to be unsatisfactory.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested bilateral breast MRI for an evaluation of her breast cancer.  Findings:  Two physician reviewers found that the request was made for bilateral breast MRI for disease surveillance. This request was denied in that it was considered investigational/experimental by the Health Plan. Information and references were provided regarding the use of MRI for screening in patients at high-risk of developing breast cancer as well as the pre-treatment evaluation of local disease. These references do not address the issue of surveillance following the treatment of breast cancer. At the present time, routine radiologic surveillance using any method (mammogram, ultrasound, MRI, etc.) is not recommended following mastectomy. There is insufficient data that routine MRI performed following a mastectomy is helpful for breast cancer surveillance. The patients oncologist noted the patients breasts were without evidence for palpable or visible local recurrence The provider further noted an area of probable area of fat necrosis in the left breast.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for a bilateral mastopexy for treatment of her mammary ptosis with intertrigo. Findings:  The physician reviewer found that American Society of Plastic Surgeons, breast reduction surgery is medically necessary for intertrigo unresponsive to medical management. This patient has intertrigo that is unresponsive to medical management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested for the prescription medication Lipitor for treatment of his high cholesterol.    Findings:  The physician reviewer found that it does not appear the patient has tried and failed treatment with Zocor, to a dose maximum of 80mg,or had a reasonable trial of Vytorin, with  appropriate dose adjustments.