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

The parent of a 17-year-old female enrollee has requested for Residential Eating Disorder Treatment for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient does require ongoing and further care, but she does not meet the necessary criteria for the RTC level of care for her diagnoses. Her family should be able to provide the patient with adequate support while she is in an IOP.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for Nexavar, administered as part of Protocol 06-03 for treatment of his metastatic melanoma.   Findings:  Two physician reviewers found that the clinical trial offered to this patient is well-designed and offers him chance of benefit. Bevacizumab is active in a wide variety of cancers and is promising in melanoma given the high levels of VEGF in this disease. Sorafenib (Nexavar) targets pathways implicated in melanoma. Oxaliplatin has been shown to be active with bevacizumab.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested for a whole body Positron Emission Tomography (PET) scan for his medical condition. Findings:  Two physician reviewers found that it appears a colonoscopy is indicated to further assess the computed tomography findings. There are no findings to date to suggest an occult primary malignancy. As such, a PET scan is not the appropriate next step in the care and management of this patients erythroderma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for an electric scooter for treatment of her condition. Findings:  The physician reviewer found that there is insufficient documentation to support the use of an electric scooter for this patients condition. In order for the patient to qualify for an electric scooter, there should be sufficient documentation to support that a manual wheelchair would not suffice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for psychotherapy for treatment of her condition. Findings:  The physician reviewer found that there is no indication given as to why the patient needs therapy at the continuing rate of four times weekly, as her condition is chronic and not at all acute.  The patient does not appear to need a higher level of care, such as an intensive outpatient program.  In addition, there is no documentation that the therapy given is for symptom reduction. The treatment goals are not measurable and not specific. There is no plan for any type of maintenance therapy.  The patient is also noted not to be in any acute distress that would need a higher level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a thirteen-year-old female enrollee has requested for Humatrope for treatment of the enrollees condition. Findings:  The physician reviewer found that this patient with idiopathic short stature is destined not to reach a normal adult height.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for IVIG therapy for treatment of his medical condition. Findings:  The physician reviewer found that electromyography and nerve conduction velocity testing confirmed neuropathy with significant slowing of multiple sensory nerves. While the neuropathic syndrome is not a classic syndrome for CIDP, CIDP can present with a variety of manifestations.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that the standard of care medications for the treatment of fibromyalgia include Cyclobenzaprine and Gabapentin. Although Lyrica can be effective in some patients with a diagnosis of fibromyalgia, such is also true of the other standard medications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested  for speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that motor apraxias in children usually respond well to speech therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for excision of skin lesions for treatment of her skin cancer.    Findings:  The physician reviewer found that there was no acute change in her condition, and no emergent medical intervention was required. This patients symptoms do not meet the prudent layperson criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for intensive outpatient services for treatment of her condition. Findings:  The physician reviewer found that the American Psychiatric Association treatment guidelines for the treatment of an eating disorder, the trauma work and processing of the memories of sexual abuse did not meet the eating disorder intensive outpatient level of care guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 14-year-old male enrollee have requested for a knee orthosis for treatment of the enrollees femoral fracture.   Findings:  The physician reviewer found that there is no mention or documentation of a problem that requires the use of a brace (such as knee joint instability).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for acellular dermal allograft for treatment of her capsular contracture.   Findings:  Two physician reviewers found that a study by Spear of 100 patients undergoing implant expander coverage with Alloderm has shown no incidence of hematoma, seroma, infection, or implant exposure as well as a decreased incidence of capsular contracture.  Other studies show that Alloderm can prevent rippling, symmastia, implant malposition, and bottoming out. These are all common problems with expander-based breast reconstruction when Alloderm is not used. Alloderm is incorporated into the surrounding tissue, and late re-operative biopsies show that over time Alloderm takes on the histologic characteristics of fascia.  Immediate breast reconstruction with Alloderm is a standard of care for post-mastectomy breast reconstruction.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for Rocephin for treatment of her condition.   Findings:  Three physician reviewers found that there is a lack of evidence in the medical literature that intravenous ceftriaxone will enhance the sensitivity or specificity of the Lyme urine antigen test, or that the test results would be useful in the diagnosis or treatment of Lyme disease.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for the use of Dexcom continuous glucose monitor and sensors for treatment of her diabetes.   Findings:  Two physician reviewers found that scientific literature demonstrates that the efficacy of continuous glucose monitoring is well-established. Among the articles cited above, is a recent study by the New England Journal of Medicine which supports the advantages of continuous glucose monitoring in the management of type 1 diabetes (Tamborlane, et al.). The submitted clinical evidence demonstrates the patient meets the critical criteria for use of the device.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for a referral to a neurologist, an MRI and/or a full body CT scan for treatment and evaluation of her condition. Findings:  The physician reviewer found that there is no role for CT or MRI imaging as a screening test for diffuse pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested for Lexapro for treatment of his condition. Findings:  The physician reviewer found that this patient has a long history of success with Lexapro. His depression returned. It would now be unsafe and inappropriate to deny the patient treatment with the drug that was shown to work.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for laboratory lipid studies for evaluation of her hypertension. Findings:  Three physician reviewers found thatthe patient had no significantly increased risk for coronary artery disease or cerebrovascular disease. She had mild hypertension, hypothyroidism and a mildly elevated lipid profile. Although her lipid profile was mildly elevated, there is no substantial evidence that lipid fractionalization testing is of more use in making treatment decisions or result in better outcomes than standard lipid profiles in this clinical situation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient was diagnosed with sinusitis, prescribed an oral antibiotic and discharged.The prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms were not sudden on onset but had been present for one week. There was no acute change in her condition such as shortness of breath or chest pain. No emergent medical intervention was required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested for DEXA bone density testing for evaluation of her low bone mass. Findings:  The physician reviewer found that it is well-documented in the peer-reviewed literature that follow-up bone density scans performed on a different DEXA machine may not be as accurate as those follow-up studies performed on the same equipment. This is due to the use of different DEXA equipment in addition to the use of similar DEXA equipment which cannot be calibrated in an identical manner. To properly treat patients with known low bone density, it is imperative to have accurate data on the follow-up DEXA scan. The American College of Radiology states that the most valid follow-up DEXA scan is on the same device.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested for an 18-day intensive feeding program for treatment of the enrollees medical condition.   Findings:  Two physician reviewers found that this difficult case involves gastostomy tube transition and oral intake failure. The patients feeding problems are complex and refractory to standard therapies. While additional data regarding the recommended approach is needed, it appears that the only other alternative for this patient is a lifetime of tube feeding and recurrent hospitalizations. All told, there is sufficient evidence that the proposed treatment program is likely to be more efficacious for this patient than standard therapies, which have for the most part failed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for VitalStim therapy for treatment of his condition.   Findings:  Two physician reviewers found that there is very little information or support for the use of this in post-radiation patients who are likely to have severe fibrosis of the soft tissue and musculature of the pharynx, as opposed to incoordination or weakness of the swallowing apparatus.  The one group that studied post-radiation patients specifically looked at patients who had undergone therapy two to four months post-radiation. There were 12 patients studied.  As such, at this time, it is not possible to state that VitalStim therapy would be any more effective than any standard swallowing therapy for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for continued occupational therapy for treatment of her condition. Findings:  The physician reviewer found that occupational therapy is the most appropriate intervention for patients such as this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested emergency medical transportation for the treatment of her condition. Findings:  The physician reviewer found that this patients symptoms had been present for one week. There is no documentation to support that the patient was suffering any acute difficulty breathing. She was not oxygen dependent and did not require oxygen or any other medical intervention during transport. This patient could safely have been transported to the hospital by transportation other than ambulance. She did not require services that only a fully equipped ambulance could provide.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested continuous glucose monitoring for the treatment of her diabetes. Findings:  Two physician reviewers found that the majority of insulin pump patients use the available CGM systems episodically in order to change their insulin prescription because they have not reached their glycemic goal, or are having unexplained hypo- or hyperglycemia. This is particularly important for patients who have hypoglycemia unawareness. We do not know if this is a problem for this patient.  In most situations, several 72 or more hour readings may be needed several times a year.  The Health Plan is apparently willing to cover the cost of the CGM up to two times a year if the patient meets its criteria. More frequent continuous glucose monitoring would not be warranted for most patients. This patient does not need to be on the system for her entire lifetime.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a Computed Tomography (CT) scan for the evaluation of her condition. Findings:  The physician reviewer found that a CT of this patients structures was not unreasonable. Although lipomas are benign entities, they can grow and invade nearby structures. Given that this patient was symptomatic, understanding the size and depth of the lesion was advisable and constituted good medical practice.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested ongoing hormone replacement therapy (testosterone pellet) for the treatment of her condition. Findings:  Two physician reviewers found that this patient has menopausal symptoms and is not a candidate for estrogen therapy to treat her symptoms due to a previous medical condition. There is evidence that testosterone supplementation is efficacious, and it has been used to relieve menopausal symptoms and sexual dysfunction. As this patient cannot take estrogen, testosterone is medically appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The representative (spouse) of a 49-year-old male enrollee has requested for brain injury rehabilitative/coma stimulation for treatment of the enrollees anoxic encephalopathy.   Findings:  Two physician reviewers found that the patient has been receiving all three available therapies (occupational, speech, and physical). Progress is documented, but it has been very slow. There is no evidence submitted or in the literature that would support coma stimulation as yielding better outcomes that standard therapies. Continuation of this patients current therapies (OT, ST, and PT) are indicated if the patient continues to progress, but coma stimulation is not indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for Provigil for treatment of his condition. Findings:  The physician reviewer found that the documentation does not demonstrate that the patient has exhausted more regular avenues towards therapeutic gain. The current dose of Remeron is also quite high.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for a consultation with a neurologist for treatment of her condition. Findings:  The physician reviewer found that a trial of preventive therapy with agents such as topiramate or amitriptyline appears indicated. The trial should start at a low dose, increasing to therapeutic range, and be maintained for at least one month, if tolerable. If there are abnormalities on the exam or other alarming features to the history, or lack of benefit from a prevention regime, neurology consultation should be pursued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for Azor 5mg/20mg for treatment of his condition. Findings:  The physician reviewer found that with suboptimal blood pressure control on single therapy, there are several drug classes that have been used with success. These include diuretics, ace inhibitors, and calcium channel blockers which have been used successfully in dual therapies as a second tier blood pressure control agent. These medications are medically acceptable therapies within the standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for Provigil 200mg for treatment of his condition. Findings:  The physician reviewer found that this patients depression is quite serious, and his response to Provigil augmentation has been established. The depression recurred when the Provigil was discontinued. The use of a psychostimulant to augment treatment of antidepressants is well-established. Provigil has benefitted this patient, and he has demonstrated a specific need for Provigil to reduce and maintain his depressive symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for MRI of the lower leg for evaluation of her right knee and leg pain. Findings:  The physician reviewer found that it is not at all clear as to what exactly the requested MRI would show, since that diagnostic scan is not a mainstream test to determine whether or not there is arterial disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested for physical therapy for treatment of her condition. Findings:  The physician reviewer found as per the ISSVD Vulvodynia Guideline, physical therapy also may decrease pain with intercourse and gynecological examinations. Physical therapy treatment techniques include internal (vaginal and rectal) and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, instruction in dietary revisions, therapeutic ultrasound, and home vaginal dilation. The proposed physical therapy treatments in this case have the support of nationally recognized medical specialty organizations.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for hormone replacement implants for treatment of her menopause.   Findings:  Three physician reviewers found that the use of testosterone in surgical postmenopausal women is controversial and there are no good long-term studies of administration of the testosterone by subcutaneous pellet implantation that would justify its use. The last Endocrine Society Task Force for Androgen Therapy in Women recommended against the use of testosterone in general.   There is no supporting medical evidence for the use of pellet implantation for hormone replacement in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her morbid obesity and hypertension.     Findings:  The physician reviewer found that it is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with a decreased over all mortality for the morbidly obese
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Lovaza (6g/day) for treatment of his hypertriglyceridemia.  Findings:  The physician reviewer found that there are no other viable alternatives and since he has had a marked favorable response to 4 grams, it is reasonable and appropriate to try a higher dosage (6 grams/day) to see if it will result in any further reductions in his triglyceride levels. Although a higher dose has not been systematically evaluated, this dose should be safe since the medication is composed mostly of fish oil. A favorable response to the higher dosage should be documented before this dosage is approved continuously over the long-term.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a leg prosthesis with a Rheo Knee for the treatment of her medical condition.  Findings:  Two physician reviewers found that microprocessor-controlled knees such as the Rheo Knee are generally not considered investigational by the community of providers practicing in prosthetics. They have been approved by the Veterans Administration for at least six years. The patient is a demonstrated K4-level ambulator.  She does not have any physical, cognitive, or neuromuscular conditions or diseases which impair her abilities. The patient is an appropriate candidate for the Rheo Knee, which is likely to result in superior functionality over a standard prosthesis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested chiropractic manipulation and PT therapeutic activities for the treatment of her degenerative disc disease and stenosis of her cervical spine. Findings:  Two physician reviewers found that there was documented improved cervical range of motion, less pain and improved function. The patient has ossification of the posterior longitudinal ligament which is an uncommon condition that can benefit from such treatment. Facetogenic pain related to cervical spondylosis can also respond to such treatment. However, this patient did not require 6 months of chiropractic manipulation. For patients with this type of neck pain, a short course of treatment (either chiropractic or physical therapy) is indicated. Usually, after several weeks of treatment, a home exercise/stretching regimen is appropriate. Therefore, an additional 4 weeks (or 8 sessions) of the continued chiropractic treatment should be reimbursed.