Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested participation in the Mayo Clinical trial MCO48A for treatment of his multiple myeloma.  Findings:  Two physician reviewers found that there is no available informative data regarding the safety and efficacy of the therapeutic regimen in the proposed trial.  The crux of the matter has to do with the Phase I status, which automatically infers that there is little or no data, other than an empiric rationale, that this approach will benefit the patient more than standard therapy. This patient appears to be eligible for high-dose therapy in-plan.  In the evaluation by the Mayo Clinic physicians, standard/autologous transplant was recommended, after a trial of debulking using a Velcade-anchored regimen, a plan which the patient is presumably following. In sum, no data is available or has been presented that argues for participation in a Phase I trial and against standard high dose chemotherapy and stem cell rescue in this patient, only an urgency that he move toward autologous transplant in a timely fashion.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-nine year-old male with severe dermatitis is requesting authorization of a course of Sporanox.  Reviewers Findings:  The reviewing physician found that it is clear that the patient improved clinically while he was taking Sporanox.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-nine year-old female diagnosed with multifocal motor neuropathy (MMN) is requesting approval for a course of IVIG. Reviewers Findings:  The reviewing physician found that there is strong evidence to support a diagnosis of MMN in this case. IVIG is recognized as the standard of care treatment of MMN.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Remicade for treatment of the enrollees idiopathic immunological disorder. Findings:  Three physician reviewers found that the patient suffers from a very rare disorder which is not well understood or well controlled at the present time. It is not surprising that Remicade has not been specifically approved for the treatment of such a rare condition. The patients provider is appropriately concerned about the consequences of long-term treatment with oral steroids for this young patient. The proposed trial of Remicade to treat the patients acute exacerbation is theoretically sound and likely to be helpful in the management of his symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A twenty-nine year-old female who underwent right above the knee amputation is requesting authorization of a microprocessor controlled C-Leg.Reviewers Findings:  The reviewing physician found that the submitted clinical information demonstrates a prosthetic with a microprocessor knee is medically necessary for this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-two year-old female with a history of caloric restriction and bulimia is requesting reimbursement for residential treatment services.Reviewers Findings:  The reviewing physician found that the patient is in need of appropriate care for the patients serious eating disorder, this calls for 24-hour, supervised medical and nursing care. Yet this is exactly what is missing at the facility where the patient received treatment. The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old female with severe urticaria is requesting authorization of Xolair.Reviewers Findings:  The reviewing physician found that the FDA approved indication for Xolair is moderate to severe persistent asthma in patients who have: a positive skin test or in vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and pre-treatment total IgE levels of 30 or greater. The submitted records document the patient does meet the criteria. The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-two year-old male with degenerative disc disease of the lumbar spine with radiculopathy is requeting authorization for percutaneous disc decompression.  Reviewers Findings:  The reviewing physician found that at this time percutaneous disc decompression is an unproven procedure without established clinical efficacy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 17-year-old female enrollee has requested acute inpatient psychiatric treatment services for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient's complex history necessitated her stay for a portion of the requested time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her bipolar disorder and depression. Findings:  Two physician reviewers found that VNS remains experimental at this time and is not likely to be effective in this clinical setting. Furthermore, based on the records provided, it does not appear the patient has been treated with electroconvulsive therapy or MAOIs. Thus, there are alternative standard therapies available that are likely to be more efficacious than VNS therapy, which remains clinically unproven.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 13-year-old male enrollee have requested growth hormone therapy for treatment of the enrollees growth hormone deficiency.  Findings:  The physician reviewer found that the patients workup was initiated when he was at the 10th percentile. His IGF-1 level was borderline low, and the GH stimulation testing was incomplete. Therefore, there is limited evidence to support a diagnosis of GH deficiency, especially because the patients bone age was reported as normal to advanced. Although the patients possible adult height prediction is borderline low there is no evidence of a falling growth rate prior to therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested laparoscopic restrictive vertical gastroplasty/gastrectomy for treatment of his morbid obesity. Findings:  Two physician reviewers found that the record indicates the patient is not considered a viable candidate for the Roux-en-Y gastric bypass  procedure because of his need to take NSAIDS and the risk of ulcer disease. This is a reasonable assessment. However, the Lap Band can provide everything a vertical gastroplasty/gastrectomy can provide. The Lap Band procedure has no staple line and has lower morbidity rates because there is no risk of leakage, erosion or mesh migration. The Lap Band is also adjustable over time versus the fixed characteristic of the vertical gastroplasty/gastrectomy. Although the vertical gastroplasty/gastrectomy is a novel approach, support cannot be provided for the procedure at this time as there are other safe and proven surgical options available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested authorization for removal of bilateral breast implants and bilateral reduction mammoplasty for treatment of her intracapsular rupture.  Findings:  The physician reviewer found that although the literature does not support routine breast implant removal for ruptured implants, the FDA Advisory Panel, in agreement with breast implant maker Inameds recommendations, has stated that ruptured silicone implants should be routinely removed, and this portion of the patient's request is medically necessary.  However, mastopexies are commonly performed following implant removal to improve the appearance of the breasts. This patients reduction is too small to have any significant impact on her musculoskeletal pain. The reduction is actually a cosmetic breast lift and is not eligible for coverage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested physical therapy for treatment of the enrollees cerebral palsy post surgery. Findings:  The physician reviewer found that based upon the physicians notes the patient appears to be making progress after the surgery. However, no specific goals are established by the physician or the therapist for the patient. It is clear that ambulation is a goal; however, the providers do not specifically document where the patients function is prior to surgery or how his gait is changing with therapy. The providers also do not set specific goals for other activities of daily living or transitions. Although there is documentation that they are working on transitions from floor to stand and walking on knees, they set no short-term or long-term goals.  Physical therapy is standard of care post surgery for children with cerebral palsy, but no objective evidence has been provided documenting that the patient is making progress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a ten-month-old male enrollee has requested Synagis for treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  The physician reviewer found that while the patient does not meet strict AAP criteria for RSV prophylaxis based on gestational age and the specified risk factors, he has other risk factors that increase his likelihood of morbidity and mortality from RSV infection. It is therefore appropriate that he receive palivizumab for the duration of the 2006-7 RSV season.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested the medication Byetta for treatment of his type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin or sulfonylureas, alone or in combination, but have not achieved adequate control. Adequate control is defined as a hemoglobin A1c of less than 6.5%. Patients who are not well controlled on oral agents generally progress to insulin therapy. Byetta, which is at least as effective as insulin in improving blood sugar control, may have an advantage in patients such as this man. Treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain. The patient was not well controlled on metformin and insulin. When Byetta was added to these agents, his blood sugars improved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a four-year-old male enrollee has requested continued occupational therapy for treatment of the enrollees cerebral palsy, hydrocephalus, and developmental delay.  Findings:  The physician reviewer found that the progress notes and reports do not document functional gains. Little progress has been made through the on-going therapy. Without a reasonable expectation of significant  functional gain, continued OT is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested the Crystalens accommodating intraocular lens (IOL) for treatment following bilateral cataract surgery. Findings:  The physician reviewer found that the Crystalens is an IOL that utilizes a new technology and this lens can provide good reading vision as well as good distance vision, without the need for glasses. Since reading glasses may be worn after cataract surgery to provide near vision, this type of lens is a wonderful convenience, but it is not a medical necessity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for Copaxone, Provigil, and intravenous immune globulin (IVIG) for treatment of systemic lupus erythematosus (SLE) and lupus cerebritis. Findings:  The physician reviewer found that the records provided offer no meaningful support for either a diagnosis of SLE or a diagnosis of lupus cerebritis, nor is there any explanation for the chosen and ongoing therapies. There is no evidence in the records to confirm a diagnosis of SLE or lupus cerebritis. In the absence of established diagnoses of SLE and lupus cerebritis, and in the presence of apparently normal findings by two neurologists, neither past nor present treatment with IVIG, Copaxone, and Provigil is appropriate. Further neurological and rheumatological evaluation of this patient is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a thirteen year-old male with optic dysplasia and idiopathic short stature is requesting reimbursement and prospective authorization and coverage for growth hormone (GH) therapy.  Reviewers Findings:The reviewing physician found that although the patient is clearly short for his age, the delayed bone age projects a normal adult height and the patient has not been shown to be GH deficient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year-old male with a history of benign prostatic hypertrophy and an abnormal digital rectal exam is requesting authorization of proton beam therapy.Reviewers Findings:  The reviewing physician found that the current National Comprehensive Cancer Network Guidelines do not include proton beam irradiation as the standard of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-seven year-old female diagnosed with colon cancer and early metastatic disease in the liver is requesting authorization of selective internal radiation therapy (SIRT).  The patient underwent surgical excision of the primary tumor and then received chemotherapy. Unfortunately, the metastatic liver disease progressed.Reviewers Findings:  The reviewing physician found that SIRT has been recommended as a promising, therapeutic approach that targets the liver exclusively.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-six year-old female with metastatic rectal carcinoma is requesting authorization for Avastin and Erbitux.   The patient is currently receiving treatment with Camptosar, Avastin and Erbitux.Reviewers Findings:  The reviewing physician found that the submitted clinical records do not document the failure of second and third-line therapeutic regimens.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-nine year-old male with a history of recurrent glioblastoma multiforme (GBM) is requesting authorization of treatment with erlotinib (Tarceva).   Reviewers Findings:  The reviewing physician found that Tarceva has been studied in recurrent GBM. Several phase I and II studies have reported modest activity with Tarceva either as monotherapy or in combination with other agents.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Avastin therapy for treatment of her glioblastoma.  Findings:  Two physician reviewers found that there has been increasing interest in the use of endothelial (vascular) growth receptor inhibitors such as Avastin in the treatment of brain tumors. Avastin has been found to be useful, along with chemotherapy, in lung and colon cancer. As yet, however, there is no convincing data to indicate that Avastin, by itself or in combination with the proposed CCNU chemotherapy, will prolong survival or offer significant clinical benefit. Accordingly, the use of Avastin in the treatment of brain tumors must be considered investigational and of no proven clinical value.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-six year-old male with diabetes type II and cardiac and renal complications is requesting reimbursement, authorization, and coverage for continuation of treatment with Byetta.  The patient was not optimally controlled on three oral agents and a very small dose of bedtime NPH insulin.Reviewers Findings:The reviewing physician found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type II who are taking other medications, alone or in combination, but have not achieved adequate control.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis. Findings:  Two physician reviewers found that the patient is relatively young and has severe osteoarthritis in his left knee.  Although he will eventually require knee replacement, a second series of injections is a reasonable alternative at this time. The first series was performed more than eight months ago and resulted in significant relief. A repeat series of Synvisc injections is medically appropriate and can reasonably be expected to alleviate his pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-one year-old female with a history of chronic migraine is requesting authorization for 18 Imitrex 100mg tablets monthly.Reviewers Findings:  The reviewing physician found that no more than 12 Imitrex 100mg tablets per month are indicated for this patient, as there is inadequate documentation the patient has received appropriate trials of preventive medications.  The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-six year-old male who has chronic hepatitis C, genotype 1a is requesting authorization of treatment with Infergen and ribavirin.  The patient was a non-responder to previous Pegintron and ribavirin therapy.   Reviewers Findings:  The reviewing physician found that Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year-old male who has a history of asthma and allergic rhinitis is requesting for authorization and coverage for Xolair.  Reviewers Findings:  The reviewing physician found that the patients IgE level is elevated beyond the scope of approval of Xolair.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested an NDO plication procedure, upper gastrointestinal endoscopy,laparoscopic hernia repair, laparoscopic fundoplasty, and surgical diaphragm repair) for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Three physicicians found that endoluminal therapy has not been sufficiently studied, and is not yet considered a substitute for the traditional fundoplication procedures for the management of GERD. Long-term study results are lacking as are studies comparing these new endoluminal anti-reflux therapies with established treatments such as the Nissen fundoplication.  Although this approach is rapidly evolving and has generated a significant amount of interest within the GI community, endoscopic gastroplication procedures such as the NDO plication must be considered experimental/investigational at the present time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested authorization of a continuous passive motion (CPM) machine for treatment of her right knee cartilage defect.  Findings:  Two physician reviewers found that while the benefit of continuous passive motion has been established and accepted following total knee arthroplasty, there is a lack of evidence showing improved results with continuous passive motion following knee chondroplasty as compared to standard rehabilitation with physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested vagus nerve stimulation therapy (VNS) for the treatment of her depression. Findings:  Three physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research-centered, clinically-based and reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested meniscal allograft transplantation for treatment of her deteriorated meniscus.  Findings:  Three physician reviewers found that little is known of the long-term effects of meniscal allografts since the procedure is relatively new and no long-term results have been published. Complications of the procedure are not known (e.g., re-tear of meniscus, wear rates, incorporation of the meniscus). To date, it has not been shown that meniscal allograft transplantation is effective on a long-term basis, has an acceptable complication rate, and is beneficial to a particular patient group. Furthermore, at age 50 the patient is not an appropriate candidate for the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a temporomandibular occlusal splint for treatment of her temporomandibular joint pain. Findings:  The physician reviewer found that pre-auricular facial pain in the absence of ear pathology is almost always directly associated with acute and chronic intracapsular TMJ pain. This is true even in the absence of joint pathology noted on MRI. The combination of medical management with pharmacologic agents and the daily use of a dental occlusal splint is the most common form of therapy for this type of TMJ dysfunction.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested vertebroplasty / kyphoplasty for treatment of his back pain. Findings:  The physician reviewer found that the patient has multiple vertebral compression fractures that have been recalcitrant to conservative measures. Vertebroplasty and kyphoplasty have been shown to be very effective for immediate and lasting pain relief. Vertebroplasty has been used for over 20 years with excellent results. The submitted records indicate the patient has exhausted conservative treatment and he is an appropriate candidate for the proposed surgery.