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

A 58-year-old female enrollee has requested Avastin therapy for the treatment of her breast cancer. Findings:  The physician reviewer found that Avastin in combination with paclitaxel has been shown to prolong survival in front-line advanced breast cancer therapy. Avastin has also been shown to significantly increase response rates in second-line therapy in combination with capecitabine (Xeloda). In the recurrent metastatic breast cancer setting, Avastin has shown a 9.3% objective response rate and stable disease in 16% of patients at six months as a single agent. In this instance, the patient has been exposed to known-active agents for breast cancer treatment without response. Avastin has been shown to have clinical benefit at various stages of breast cancer treatment and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 46-year-old female enrollee has requested Gleevec for the treatment of the enrollees meningioma. Findings:  The physician reviewer found that meningioma is a rare brain tumor typically treated with radiation and surgery. Various agents have been utilized for metastatic disease outside of the brain with very little proven efficacy. There is limited experience regarding systemic therapy for metastatic meningioma and the current evidence is largely anecdotal. Systemic therapy has only been used in a few patients with recurrent, unresectable malignant meningiomas. The phase II trials citied above involved a combination regimen of hydroxyurea and imatinib mesylate in small numbers of patients with higher grade brain tumors (not meningiomas). Success was limited and it is not possible to discern the value of Gleevec for patients such as this patient based on those studies. There are no published data on the efficacy of imatinib mesylate in meningiomas currently available in the literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested speech therapy services for the treatment of the enrollees congenital muscular dystrophy, dysarthria and mental delay. Findings:  The physician reviewer found that because the patients oral-motor speech disorder (dysarthria) is due to his congenital disorder, treatment for the speech disorder should be considered medically necessary. It appears that the private speech-language pathology services being provided have different goals than those provided under his school-based Individualized Educational Plan. The private therapy emphasizes oral-motor skills in its goals, and is showing greater results in this domain than school-based therapy, which successfully emphasizes functional augmentative communication strategies. The private therapy is also addressing saliva management, which will have a medical impact (e.g., helping to minimize the risk of aspiration, facial skin irritation, etc.). Thus, these therapies complement each other. The records demonstrate that private speech therapy has been and continues to be a medically necessary intervention based on the patients medical condition. The therapy should be continued at a frequency of two hourly sessions per week. The patient should be re-evaluated in six months to determine if continued therapy is indicated at that time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male has requested speech therapy for the treatment of the enrollees autism and speech impairment. Findings:  The physician reviewer found that speech-language goals are educational in nature and should be part of this patients school program. While autism is clearly a medical diagnosis and many therapeutic interventions for the condition are considered medically necessary, it is also a condition that is addressed in school programming. The goals outlined in the patients evaluation are not addressing specific medical conditions associated with autism, but rather, the educational and rehabilitative needs of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested prescription medication Strattera for treatment of attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry (AACAP) notes that although stimulants are generally endorsed as first-line treatment for ADHD and are  purported to have a greater treatment effect than atomoxetine (Strattera), there are additional considerations in this instance. The AACAP also indicates that atomoxetine may be an appropriate first-line medication in persons with an active substance abuse problem, anxiety or tics. The AACAP also recognizes that each patients treatment must be individualized and that family and clinician preferences should be recognized. Given the family history, treatment of the patients ADHD with Strattera is medically indicated and  consistent with the AACAP practice guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested growth hormone (GH) therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient exhibited obvious short stature, had a decreased annual growth rate and marginally low IGF levels before beginning GH therapy. His bone age study indicated the epiphyses were open. The patient began GH therapy and has had a positive response. The findings suggest a degree of GH deficiency in addition to short stature. It does not appear the patient would achieve his mid-parental height without GH therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested biofeedback therapy for treatment of her incomplete evacuation.  Findings:  Three physician reviewers found that Based upon the clinical information provided, the patients problem appears to stem from slow transit time causing constipation. Biofeedback therapy is not likely to be more effective than standard therapies in this setting. There are other available treatment options that are likely to be of greater benefit to this patient than biofeedback therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for an MRI of the right knee for evaluation of the her knee pain. Findings:  The physician reviewer found that an MRI is indicated to evaluate the possibility of meniscal tear on other significant internal abnormality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested intravenous (IV) antibiotics for treatment of Lyme disease.  Findings:  Three physician reviewers found that there is no peer-reviewed data supporting more than 30 days of treatment for Lyme disease in any form. The submitted materials do not include substantial data supporting use of an extended period of antibiotic therapy. Furthermore, in this case there is no clear objective evidence of ongoing or recurrent infection. Therefore, given the controversy surrounding treatment, long-term antibiotic therapy remains experimental/investigational and is not recommended for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested weekly or bi-weekly individual therapy services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that review of the submitted clinical information does not demonstrate that weekly or bi-weekly individual therapy services are medically necessary. Though medications alone cannot be the mainstay of her treatment because of issues related to tolerability of side effects, small group therapy sessions are likely to keep the patient stable and prevent deterioration. Since small group therapy sessions will serve the necessary therapeutic function, one to one weekly or bi-weekly individual sessions are not required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that Oncotype DX assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very important as it is particularly in this group of breast cancer patients that it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients and Medicare has approved its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for the medication Provigil for treatment of her fatigue.    Findings:  The physician reviewer found that fatigue associated with radiation therapy has been recognized for many years, although the mechanism is not understood. No specific treatment to date has been shown to ameliorate this condition, which can have a profound effect on patient functioning and quality of life. Considerable interest has been devoted to the use of Provigil for radiation related and other forms of treatment related fatigue in cancer patients. There are four ongoing or recently completed studies of Provigil on the National Cancer Institute web site, all of which address fatigue associated with cancer treatment. Since the safety of Provigil has been established for the other approved indications and there are no other available therapies for fatigue related to cancer treatment, the current studies are sufficient to support the off label use of Provigil by this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested continued Avastin therapy for treatment of colorectal cancer.  Findings:  Three physician reviewers found that Avastin has not been studied as a single agent, as a maintenance therapy or as an adjunct to a 5-FU regimen in patients who are resistant to 5-FU. There is no data to indicate that Avastin is effective as a single agent in either primary or maintenance therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested a PET/CT scan for an evaluation of his gastric cancer. Findings:  The physician reviewer found that PET/CT scans are not routinely utilized for the diagnosis or the staging of malignancies involving the stomach. However, the peer reviewed literature has shown that PET/CT is useful for patients with recurrent gastric carcinoma and that PET/CT can impact treatment planning for these patients. This patient has had recurrent disease diagnosed by PET/CT imaging only. PET/CT scan is medically indicated at this time to evaluate the patient for recurrent gastric carcinoma.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested re-treatment with Rituxan for treatment of rheumatoid arthritis.  Findings:  The physician reviewer found that Rituxan has received FDA approval for the treatment of rheumatoid arthritis. Its effectiveness has been repeatedly demonstrated in trials involving various regimens including steroids, methotrexate, and cyclophosphamide, as well as in patients who previously failed TNF inhibitors.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested medication Cialis for treatment of erectile dysfunction (ED).  Findings:  The physician reviewer found that the enrollee does not have a documented diagnosis of  hypertension, diabetes, vascular disease, Peyronies disease, spinal cord injury, multiple sclerosis, or a corrected hypogonadism, nor has he undergone radical prostatectomy, radiation therapy for prostate cancer or cystectomy. Although there may be an organic basis for the patients ED, it has not been identified and therefore there is no clear medical basis for prescribing Cialis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee, who had a shoulder injury, has requested authorization for physical therapy services as well as prospective authorization for additional physical therapy services.Findings:  The physician reviewer found that this patient had sufficient physical therapy prior to the specified date to be able to establish a home program. The therapy did not have an appropriate short or long-term goal that would meet criteria for anything beyond maintenance treatment and passive modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for the treatment of her hypogammaglobulinemia. Findings:  The physician reviewer found that monthly infusions of IVIG are medically necessary for this patient. Laboratory records indicate the patients base immunoglobulin levels are low. IgA and IgM are absent. This is a significant finding, indicative of hypogammaglobulinemia. When the patients IgG level was measured after missing IVIG treatments for at least two months, IgG was low at 640 (normal 700-1500). This finding, in combination with absent IgA and IgM, indicates hypogammaglobulinemia. As the patients provider points out, the fact that the patient had normal IgG levels while under treatment does not mean that she has normal immunoglobulins. The reason for the frequent testing of levels is to confirm that the IVIG replacement therapy is adequate. A normal level is expected with adequate therapy. As noted above, when the patient was not receiving therapy, her IgG level fell to below normal.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a myomectomy performed by a non-Plan provider for the treatment of her uterine fibroids. Findings:  The physician reviewer found that with the size of the patients uterus and the symptoms caused by her fibroids, it warrants surgical intervention. However, she was correctly counseled that a myomectomy would be a more risky procedure and that it may not provide definitive treatment. Studies have shown there is approximately a 15% chance that a second surgical procedure will be needed after conservative fibroid treatment and the likelihood increases when larger and more numerous fibroids are present. Moreover, the potential blood loss and need for blood transfusion are also greater with myomectomy versus hysterectomy. Nonetheless, myomectomy should still be considered a medically necessary treatment for this patient. When respectful persuasion fails to convince a patient that a hysterectomy would be the better procedure, myomectomy is in fact a relatively safe and effective option that should be available to those women wishing to retain their uterus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female has requested Humatrope for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that celiac disease should first be considered as there is likely autoimmune thyroid disease present, increasing the chances of a second autoimmune disease being present. If celiac disease is excluded, it would need to be determined if the patients epiphyses are open in order for growth hormone to be clinically useful. Furthermore, growth hormone therapy would only be appropriate if the patients adult predicted height is found to be less than 59 inches.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested an MRI of the lumbar spine for an evaluation of his back pain. Findings:  The physician reviewer found that this patient clearly does not meet the established guidelines for MR imaging of the lumbar spine. There are no significant neurological deficits and x-rays show degenerative disc disease and mild lumbar stenosis. He has not yet had a trial of physical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a virtual colonoscopy procedure for an evaluation of his colon. Findings:  Two physician reviewers found that colonoscopies and barium enema are the first and second-line procedures used to screen for colorectal cancer. Having failed these two methods, likely due to significant diverticulosis, a virtual colonoscopy is an appropriate alternative. With this technology, the CT scan can also look at the structures extrinsic to the bowel to help explain the difficulty with the initial procedures and to look for possible lesions outside of the bowel wall. Research has found that the sensitivity of virtual colonoscopy approaches that of colonoscopy, especially for polyps larger than 1 cm.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested hippotherapy for treatment of the enrollees cerebral palsy.  Findings:  Three physician reviewers found that hippotherapy is considered investigational, as there have been no significant studies documenting its effectiveness. While there have been some anecdotal reports of benefit, these reports are not sufficient to establish that hippotherapy results in a superior clinical outcome to standard physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested applied behavioral analysis (ABA) services (25 hours per week of ABA therapy and 6 hours per week of professional progress assessment and evaluation) for treatment of his autism. Findings:  Two physician reviewers found that the use of ABA in autism or in other Pervasive Development Disorders is not standard practice. While some components of the therapy may have utility, the use of ABA for such an extended time period is not supported in the recognized medical literature and is, at this time, investigational. There is no evidence such an approach will be more effective than standard interventions. ABA therapy is considered by many to be an educational intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested naturopathic consultation and therapy for treatment of her gastrointestinal symptoms.  Findings:  The physician reviewer found that the patients symptoms are consistent with IBS and it does not appear that all of the commonly prescribed therapies for this condition have been exhausted. There is no scientific evidence supporting a naturopathic approach in the treatment of IBS and it is not consistent with the standard of care nor recognized as being potentially beneficial within the gastrointestinal community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for bariatric surgery/laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 40 and significant co-morbidities, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Her co-morbid conditions will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% weight loss requirement, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. However, although the 10% weight loss requirement should not preclude consideration for weight loss surgery, the requirement that she stop smoking for three months prior to surgery is a reasonable one.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male has requested the medication Vytorin for the treatment of his high cholesterol. Findings:  The physician reviewer found that with the records provided for review, Vytorin is not medically necessary. The patient has been taking Tricor and Vytorin (which contains Zocor). It may be quite possible that treatment goals are achievable with the medications Tricor and the current dose of Zocor (in the Vytorin) alone, without adding the zelia component. Since it is not clear that treatment goals cannot be met with Tricor and the current dose of Zocor that the patient is already receiving, treatment failure with Zocor has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested an electroencephalogram (EEG) procedure for evaluation of her condition prior to hysterectomy.  Findings:  The physician reviewer found that there is no current medical indication to perform an EEG in this case. There is nothing in the patients history, CT scan, MRI study, or examination that suggests a need for an EEG, nor is there any reason to hold off on surgery on this basis. The recommendation to perform an EEG appears unjustified and is not pertinent to the patients current medical issues.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a kyphoplasty for treatment of his compression fractures. Findings:  Three physician reviewers found that Kyphoplasty remains an unproven technique for the management of vertebral compression fractures. Among individuals age 50-80 years, 5-20% have one or more vertebral crush fractures. One-third of these patients require treatment for acute or chronic pain. Vertebroplasty and kyphoplasty were introduced over the last two decades as treatments for incapacitating pain from osteoporotic vertebral fractures. The use of kyphoplasty for traumatic thoracic fractures remains an unproven procedure without established clinical efficacy. Additionally, patients should exhaust all non-operative measures prior to considering surgical intervention.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Alimta for treatment of neuroendocrine small cell cancer.  Findings:  Two physician reviewers found that Alimta has been studied in refractory small cell lung cancer with response rates of approximately 20%. Alimta does appear to be an active drug in these diseases and as such, offers greater potential for an improved outcome than any standard therapy.