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

A 37-year-old female enrollee has requested CT scans of the abdomen and chest for evaluation of her stomach and back pain. Findings:  The physician reviewer found that the indications for a CT scan are rather elemental. Per American College of Radiology guidelines, abdominal pain is a sufficient symptom for evaluation by CT scan.  Furthermore, imaging of the left upper quadrant can be limited with ultrasound because of bowel gas, and CT is almost always superior to ultrasound in this area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested bilateral reduction mammoplasty for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the patients breasts were enlarged due to a developmental abnormality. Reduction mammoplasty was performed, not to enhance, but rather to normalize his appearance. Surgical intervention was consistent with the ASPS guidelines as the patient had grade III gynecomastia that had persisted for longer than one year and his endocrine evaluation was normal.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a PET scan for evaluation of his pulmonary nodules and mediastinal lymph nodes.  Findings:  The physician reviewer found that a PET scan may be positive in both inflammatory and malignant disease. It can also be negative in some malignancies. As such, a PET scan was not able to definitively determine the etiology of the patients left lower lobe densities. A biopsy would have been the next procedure of choice. If a malignancy was found on biopsy, a PET scan might then have been helpful in the staging evaluation. However, a PET scan prior to lung biopsy was not clinically useful or indicated in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested Lyrica for treatment of his nerve pain secondary to reflex sympathetic dystrophy (RSD).  Findings:  The physician reviewer found that this patient has chronic pain syndrome without a clear diagnosis. The submitted clinical information does not support a diagnosis of chronic regional pain syndrome or RSD. A dermatomal somatosensory evoked potential study is not a standard diagnostic test and results have unclear implications. Furthermore, there is no evidence that this patient has received standard medical therapies such as physical therapy, muscle relaxants and anticonvulsants in the past two years. Moreover, there is no clinical data to suggest that Lyrica is effective in treating chronic non-neuropathic pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested speech therapy services for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient has cerebral palsy and other neurological and nutritional problems resulting from prematurity. Data from this patients Fast ForWord intervention shows that she responded to the treatment and made some strides. The patient was an appropriate candidate for the program based on her neurological deficits and did in fact experience some improvement in her functional status.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a Roux-en-Y gastric bypass for treatment of her obesity. Findings:  The physician reviewer found that with a BMI greater than 35 and a number of documented comorbidities, laparoscopic Roux-en-Y gastric bypass is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested the prescription medication Celebrex for treatment of her spastic paraparesis. Findings:  The physician reviewer found that this patient has had progressive spasticity and pain due to diagnosed HSP. Numerous medications have been tried to manage her disruptive symptomatology. A combination of medications addressing spasticity, mood, fatigue and pain has been found most effective. Celebrex has been used successfully in this patient with good tolerance and improved pain control. However, there is no documentation in the submitted records of a trial of other NSAID medications. Therefore, the Health Plans denial should be upheld at this time. At least two other NSAID medications in lieu of Celebrex should be tried over a one-month period while other medications remain unchanged. If there is lessened pain control or if GI side effects are noted on the other NSAIDS, then Celebrex should be authorized by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a panniculectomy/abdominoplasty for treatment of her recurrent incisional hernias.  Findings:  The physician reviewer found that the patients MRI studies do not show any hernias. She has fascial laxity without a true hernia. The abdominal wall procedures will improve contour but will not treat a true hernia. Panniculectomy/abdominoplasty to facilitate hernia repair is not necessary because the patient does not have a true hernia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male, who is HIV positive with hypercholesterolemia, hypertension, and hypogonadism, requests authorization for the medication Penlac.Reviewers Findings:The reviewing physician found that the records provided did not include any information from the patients physicians confirming the presence of a fungal infection (onychomycosis). It is not clear if the patient was treated with other drugs for the infection, and if so, when this occurred. In the absence of documented evidence of a fungal infection, the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has chronic migraines. Review of the submitted clinical information indicates the patient has failed almost all of the FDA-approved preventive agents. As such, continued treatment with standard pharmacologic agents is not likely to be of benefit. Botox injection therapy has been shown in several studies to be effective in the treatment of chronic migraine. Given that the patient has exhausted standard options, treatment with Botox is a medically reasonable and appropriate treatment option.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested 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. It has become very important, particularly in this group of breast cancer patients in which it is very difficult to make recommendations about adding adjuvant chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Gamma Knife stereotactic radiosurgery (STR) for treatment of the enrollees Cushings disease.  Findings:  The physician reviewer found that Gamma Knife STR for treatment of residual tumor was clinically appropriate in this case and consistent with the standard of care. Gamma Knife is very precise treatment for tumors such as this that are close to optic apparatus. The immobilization during Gamma Knife treatment is rigid and more precise. Furthermore, Gamma Knife is a one-day procedure compared to other STR options. Gamma Knife was the most beneficial option for treatment of the patients recurrent disease, and was medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee, with breast cancer, has requested authorization for bilateral breast MRI.  Findings:  The physician reviewer found that an MRI can identify multi-focal and multi-centric disease and allow the surgeon to plan accordingly. Breast MRI is also appropriate to evaluate for breast cancer in the other breast according to the American Cancer Society. The American Cancer Society also advocates for breast MRI of the contralateral breast for newly diagnosed breast cancer patients. Further imaging of the patients breasts prior to additional breast surgery is imperative for her health and well-being.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested authorization and coverage for the medication Tarceva for treatment of his metastatic prostate cancer.  Findings:  The physician reviewer found that Tarceva is an oral chemotherapeutic medication used mainly for pancreatic or non-small cell lung cancer; it is not used extensively for prostate cancer. Tarceva is however, a tyrosine kinase inhibitor and an inhibitor of human epidermal growth factor receptor type 1/epidermal growth factor receptor (HER1/EGFR). The immunochemical testing of the biopsy specimen was very positive for EGFR. The providers rational for choosing Tarceva is well considered and well documented. This medication appears to be an appropriate chemotherapeutic agent at his juncture in the patients treatment for prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee, who was involved in an accident, which resulted in a right femur fracture and left tibial plateau fracture, has requested authorization for knee surgery.  Findings:  The physician reviewer found that the patients left tibial fracture was approximately three weeks old and clearly appeared to be healing. Two orthopedic surgeons reviewed the most recent studies and found the fracture to be well aligned and not in need of repair. Surgical intervention would not guarantee the most optimal result. While surgery may have been considered at the time the femur was rodded or soon after the date of injury, it was not indicated at that time. If the fracture displaced, surgical intervention would then be required. However, based on the evidence available at the time, surgical intervention was not clinically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested 3D-conformal therapy and Cyberknife stereotactic radiotherapy boost concurrent with capecitabine for treatment of her recurrent cholangiocarcinoma.  Findings:  Two physician reviewers found that utilization of image guided radiation therapy via Cyberknife has scientific merit.  Historically, patients with Klatskins disease have been treated in multiple approaches that attempt to deliver higher doses of radiation therapy primarily to the tumor while minimizing excess dose to critical surrounding tissue. Current technology today using image guided radiation therapy approach as a boost may not be the national standard of care, but the reason for this is that this technology is still relatively new. Given that Klatskins tumor is relatively rare, it is not possible to have large published series utilizing image guided radiation therapy. In fact, there is no evidence of any randomized study, published result on the appropriate treatment of Klatskins tumor/recurrences. Although data regarding the use of 3D conformal therapy and Cyberknife stereotactic radiotherapy with capecitabine in this particular setting is lacking, the beneficial aspects of the proposed therapy allow for delivery of radiation in a higher dose to the tumor bed, thus minimizing excess dose to the normal surrounding tissue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 17-year-old female enrollee, who has undergone a gradual, but alarming, escalation in self-destructive behaviors with a corresponding decline in academic performance, has requested authorization for residential treatment services.Findings:  The physician reviewer found that there are no indications of suicidal or homicidal ideations and no evidence of a thought disorder that would indicate a medical need for residential care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain. Findings:  The physician reviewer found that it is clear from the clinical record that standard measures have not adequately addressed the patients  severe, on-going pain. It is also clear that surgical correction of the lumbar radiculopathy or the carpal tunnel syndrome is not feasible because of other complicating medical problems. This is not a situation where high-potency narcotics are being utilized as an off-label substitute for more definitive measures to resolve the pain. Rather, this is a case in which the best available means of pain management has been employed and found to be effective.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a 16-year-old female enrollee have requested magnetoencephalography (MEG) for evaluation of the enrollees epilepsy. Findings:  Three physician reviewers found that over the past decade, MEG has been increasingly utilized for presurgical localization of epileptiform discharges, presurgical localization of the sensorimotor or visual cortex and preoperative planning to guide the placement of a grid for epilepsy surgery. Compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of his neurological condition. Findings:  Three physician reviewers found that this patient does not meet the clinical criteria for either multi-focal motor neuropathy with block or chronic inflammatory demyelinating polyneuropathy required for diagnosis. Clinically and by electrodiagnostic testing, it appears the patient has ALS, lower motor neuron variant. There is no evidence that IVIG under these circumstances would be helpful or result in an improved clinical outcome. The patients condition is consistent with ALS based on EMG and laboratory results.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested occupational therapy (OT) for treatment of his nonverbal learning disorder.  Findings:  The physician reviewer found that the goal of a medically necessary rehabilitation treatment modality, such as occupational therapy, is to restore an individual's ability to function as normally as possible after a disabling illness or injury. According to the documentation provided, the patients cognitive issues are mild and he is not disabled by them nor is he recovering from an illness or injury that resulted in a loss of function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested a HIDA scan for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that biliary dyskinesia is a potential cause of biliary colic in pediatric patients. A combination of symptoms and signs including abdominal pain, absence of gallstones, and abnormally low CCK-stimulated gallbladder ejection fraction are used to diagnose the disorder. In several small pediatric case series, cholecystectomy resulted in symptomatic improvement in the majority of patients with biliary dyskinesia. The possibility of biliary dyskinesia is a reasonable consideration in the differential diagnosis and should be ruled out. It appears the patient has not yet undergone a gastric emptying study and video capsule endoscopy. These procedures, which have been authorized by the Health Plan, are the next appropriate step in the diagnosis of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Roux-en-Y gastric bypass for treatment of his morbid obesity. Findings:  The physician reviewer found that with a BMI of 47.5 and documented comorbidities, laparoscopic Roux-en-Y gastric bypass is medically indicated and necessary for this patient, as it is not likely that he will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there is no indication the patient had the standard recommended treatment for ADHD and ODD or that he and his parents had intensive family therapy prior to his residential treatment admission. The patient was not suicidal or homicidal nor was there evidence of a thought disorder at the time of his residential treatment admission. There was no evidence of self-destructive behaviors, psychotic behaviors or substance abuse problems that would suggest the residential treatment admission was medically appropriate for the primary diagnoses of ADHD and ODD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees speech and language delays. Findings:  The physician reviewer found that there is no evidence that this childs speech abnormality was greater than a 2 SD variant from the norm. Finally, there is no evidence the articulation difficulties would not have resolved with maturation or with a speech therapist-guided home intervention program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that it is a well-accepted fact within the medical community that a diabetic with a lower hemoglobin A1c has a correspondingly lower risk of further deterioration of all at-risk bodily systems including the eyes, the nerves and the kidneys. Byetta is specifically approved for use in combination with metformin. In the case of a type 2 diabetic, it is not an insulin substitute as it would be for a type 1 diabetic, it is simply a better method of managing blood glucose. Previous use of insulin is not a contraindication for treatment with Byetta, particularly in light of the benefit the patient has derived from this medication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested intensive outpatient (IOP) treatment for her behavioral health problems. Findings:  The physician reviewer found that without an ongoing intensive outpatient program, it is highly likely the patient would have relapsed back into depression and anorexia nervosa. The services at issue are considered standard of care by most providers in the psychiatric community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a reconstructive surgery consultation following her double mastectomy. Findings:  The physician reviewer found that post-mastectomy breast reconstruction is medically necessary. This patient has undergone medically necessary mastectomies and has not yet had a reconstruction. The Womens Health and Cancer Rights Act (WHCRA) mandates insurance coverage for all stages of reconstruction. This patient has not had all stages of reconstruction. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested laparoscopic adjustable gastric banding (Lap-band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that with a BMI of 38 and comorbid conditions including degenerative joint disease, the patient is likely to benefit from Lap-band surgery. However, there is no evidence the patient has obtained psychological clearance for weight loss surgery. Given the patients significant history of mental health disorders, the patient must be formally evaluated in order to determine if he is an appropriate candidate for weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a DEXA scan for evaluation of her osteopenia. Findings:  The physician reviewer found that the patient has had bone-density scans every year for the past three years. Her T-scores for the lumbar spine and hip have been fairly stable for all these years. The patient is not on steroid therapy and does not have a diagnosis of osteodystrophy or hyperparathyroidism. Every two years is a reasonable interval for follow up DEXA scans.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested a CT angiography for evaluation of possible coronary artery disease. Findings:  Three physician reviewers found that currently, CT angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. Additionally, the test is not supported by the American Heart Association (AHA) as evidenced by an AHA consensus statement in 2006, which indicated the test was not ready for widespread use. Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, need to use contrast and radiation exposure. To date, clinical trials are small, and overall, the clinical utility of CT angiography remains unproven.Thus, while the noninvasive nature of CT coronary angiography makes it an attractive option, its exact role in the diagnostic algorithm of coronary artery disease has not yet been defined. Furthermore, a recently published trial (Budoff, et.al)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested the medication Cialis for treatment of his erectile dysfunction (ED).  Findings:  The physician reviewer found that based on the records presented for review, the patient has identifiable causes for his ED including fatigue, stress, and medication. The medication that he takes for environmental allergies, Allegra, is an antihistamine. Antihistamines have long been identified as a causation factor for ED. Thus the medication that he takes to treat an organic illness, his environmental allergies, is contributing to the ED.