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

A 60-year-old female enrollee, who has had a history of intermittent, incapacitating pain which radiates from the back to the anterior abdomen, has authorization for MRI of the thoracic and lumbar spine.Findings:  The physician reviewer found that the reason given for the MRI of the thoracic and lumbar spine was to rule out possible nerve entrapment or neuroma, based on the patients sensory myelopathy and radiculopathy. However, there is no comprehensive neurological examination included in the record. A prior MRI of the lumbar spine showed no masses. Evaluation by a neurologist may have been helpful at this juncture, prior to additional imaging.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee, who was found to have a 1.5cm by 2.3cm mass in the mid pole of the left kidney, has requested authorization for CT and ultrasound-guided radiofrequency ablation (RFA).Findings:  Two physician reviewers found that RFA is not supported as an established cancer surgery. No improvement in health outcomes following such a procedure has been established, nor has this approach received general acceptance in the medical community. The standard of care for a renal mass suspicious for renal cell carcinoma is partial or complete nephrectomy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX is a clinically validated assay of the breast tumors expression of 21 genes. This tumor assay quantifies the likelihood of distant recurrence in a select group of women. The assay has been validated for ER/PR positive, HER-2/neu positive or negative and node negative patients. The patient in this instance is a premenopausal woman with early stage breast cancer. Favorable characteristics include small size, ER/PR positive, and HER-2/neu negative. Complicating the issue is the micrometastasis. In this setting, the Oncotype assay offered no additional information. It is well understood that for staging considerations, the patient may be considered node negative. However, recent data presented at the SABC in December 2006 suggests that micrometastasis may be more significant than originally thought. The issue of micrometastasis has not been studied prospectively, and as such the assay remains investigational in that setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee, with glioblastoma aphasiahas, requested authorization for brain surgery and related services performed at UCSF.Findings:  The physician reviewer found that clinical evidence does not demonstrate the patients brain surgery was necessary on an emergent or urgent basis at UCSF. . There was no urgency indicated in the medical record. The patient did not undergo surgery until a week after being admitted to the ER. She could have been safely transferred to an in-plan facility for her brain surgery. There is no demonstrable evidence indicating a need to have the surgery performed at UCSF.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee, with long-standing fibromyalgia, has requested authorizaton for the compounded medication guaifenesin.Findings:  The physician reviewer found that there is no peer-reviewed literature to support the beneficial use of guaifenesin in the treatment of fibromyalgia. This agent is touted as being useful in fibromyalgia based on anecdotal and testimonial reports. The use of guaifenesin in fibromyalgia has not produced results better than placebo; one occasionally sees an initial apparent benefit that is eventually lost over time. As a result, guaifenesin is not an accepted therapy for fibromyalgia among rheumatologists.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee, who underwent foot surgery, has requested authorization for a continuous passive motion (CPM) machine.  Findings:  Two physician reviewers found that the medical literature does not demonstrate any specific references regarding the use of a CPM machine for orthopedic rehabilitation following ankle surgery. Although there is a possible reduction in the risk of deep vein thrombosis, there are no studies concerning the speed of recovery, improvement in the ultimate range of motion or other objective orthopedic parameters. While there is data supporting the efficacy of a CPM machine following shoulder or knee surgery, there is no evidence to support its use in this clinical context.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee, who was chemically dependent on multiple chemicals including alcohol, cannabis, methamphetamine and opiates, has requested reimbursement for chemical dependency residential treatment services.Findings:  The physician reviewer found that given the biopsychosocial risk of relapse due to her unsafe living situation and husbands drug use, the patient would have been at major risk for a relapse with outpatient treatment. The patient required a reasonable period of recovery from the acute effects of the chemicals that she was using as well as time to implement sobriety tools.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee, with a history of degenerative disc and joint disease, has requested authorization for physical therapy (PT) provided on the specified dates and prospective authorization for additional PT.  Findings:  The physician reviewer found that the patient had a flare of his condition and saw his provider following his previous PT regimen. The provider prescribed an additional 14 PT sessions. The patient had responded to PT in the past, and it was medically appropriate to attempt this therapy again. Considering that the patient has been previously trained for a home exercise program (HEP), six sessions with a reassessment and transition to a HEP should be adequate for treatment of his recurrence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee, who is status post gastric bypass with a subsequent weight loss of over 100 pounds, has requested authorization and coverage for bilateral thigh lift.Findings:  The physician reviewer found that there is no medical documentation of on-going infections in the thigh skin folds and the photographs do not suggest cellulitis, ulcerations or rashes. There is no evidence of frequent office visits to a primary care provider or dermatologist for the management of clinically significant dermatologic problems that have either not responded to topical therapy or despite an initial response, have recurred and caused significant functional impairment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee, who has a mitochondrial disorder with gastrointestinal, cardiac and muscular manifestations, has requested authorization for single proton emission computed tomography (SPECT) scanFindings:  Three physician reviewers found that SPECT scanning was not likely to add any clinical value to the management of the patients condition. SPECT scan does not address the elements of differential diagnosis and would not be expected to impact the patients treatment. SPECT scan is of unproven efficacy in this context and it is not standard of care for patients such as this one.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested the medication Subutex for treatment of her migraine headaches. Findings:  The physician reviewer found that the available medical records suggest Subutex is keeping the patient in some kind of functional balance. She is having a difficult time transitioning from Subutex to Suboxone. Switching to Subuxone is a regular medical option, but this patient is still dealing with active addiction issues despite IOP treatment. She may require a high level of care or more structured care with addiction and psychiatric issues as the main focus. In the meantime, Subutex should be continued for two months from the date of this decision. Contemporaneously, attempts should be made to have an addiction psychiatrist assess the overall care plan and devise other treatment strategies to help the patient maintain sobriety and manage her pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a PET scan for evaluation of her thymoma. Findings:  The physician reviewer found that there are only several small studies and case reports examining the role of PET scans in thymic tumors. A study of 25 patients with thymic pathology concluded that PET is useful in patients who have undergone thymoma excision when there is suspicion of recurrence or metastasis (El-Bawab, et. al.). In another study involving 33 patients it was felt that PET scan was useful for differentiating subgroups of thymic epithelial tumors and for staging the extent of the disease (Sung, et. al.). However, at the end of the discussion the authors acknowledged that the study was small and that further studies were needed such as direct comparison between PET and the relationship between SUV values and patient outcomes. Finally, a study of 31 patients, which included 9 thymic carcinomas, showed a SUV of 5 achieved a sensitivity of 84.6% in differentiating thymic cancer from thymoma (Sasaki, et. al.).Because only small studies have been performed, the role of PET in thymic tumors is still unproven. Considering that the density in the patients anterior mediastinum had been stable since July 2004, and there was no evidence given for suspicion of recurrence, a follow-up diagnostic CT would have been the examination of choice in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested physical therapy for rehabilitation following anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the physical therapy services the patient received during the period at issue were medically necessary. The patient had 16 PT sessions over a two month period and she had weakness and functional limitations mostly with descending stairs. By this point in time therapy was directed toward strengthening and proprioception. After the number of PT sessions the patient had participated in, the stated goals could reasonably have been achieved with a daily home exercise program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested CT angiography (CTA for evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found CTA is not, thus far, a generally accepted screening or confirmatory test for the evaluation of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in this clinical setting remains an experimental/investigational application of the technology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested neuro/biofeedback therapy for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that in 1997, the use of neuro/biofeedback for the treatment of ADHD was reviewed extensively by the American Academy of Child and Adolescent Psychiatry as part of the process of defining treatment parameters. There was no evidence to support the efficacy of this therapy at that time and current literature on the subject has not risen to the level of controlled, double-blind, research-centered, clinically-based, reproducible studies. The use of neuro/biofeedback is, at best, investigational and it is not medically indicated for the treatment of ADHD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested the medication Xifaxan for treatment of his irritable bowel syndrome. Findings:  The physician reviewer found that although the Food and Drug Administrations approval for this medication is for travelers diarrhea, there are many peer-reviewed articles supporting the usefulness of Xifaxan in the setting of IBS. A study by Pimentel, et. al. concluded Xifaxan improves IBS symptoms for up to 10 weeks after discontinuation of therapy. Another study by Sharara, et. al. showed that Xifaxan is safe and effective for abdominal bloating and flatulence in IBS patients. All told, there was sufficient evidence of the efficacy of Xifaxan in this setting to justify its use by this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Supartz injections for treatment of his osteoarthritis. Findings:  The physician reviewer found that the patient is not a good candidate for Supartz injections. The arthritis in his left knee is severe and these injections will provide little, if any, relief. A cortisone injection may provide a temporary benefit for the patient. However, considering the patients age and the severity of his arthritis, serious consideration should be given to knee replacement surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested acute inpatient hospital services for treatment of her depression and post-traumatic stress disorder. Findings:  The physician reviewer found that the patient did not require inpatient care as of the date in question as her depression was not major and she presented no acute safety issues. She showed no serious withdrawal symptoms. The patient was stable and under control, and had reached probable maximum benefit by the date in question. She was appropriate for transfer to an outpatient level of care after the last authorized date of service.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested acupuncture services for treatment of her ulcerative colitis. Findings:  The professional medical reviewer found that although the patient reports that treatments have improved her health dramatically, there is no objective substantiation of this in the progress notes or other evidence submitted. The patients pain level is consistently reported as low severity and on the Summary of Clinical Treatment form is listed between 6 and 8 on an analog scale of 0-10.  Based upon the information set forth above and review of all available case file documentation, there is no evidence the acupuncture treatment in question was curative in nature. Rather, it was for the purpose of maintenance as the patient appears to have plateaued with treatment and is being seen approximately once weekly without any measurable improvement in her symptom or complaints.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three year eleven month old female enrollee has requested speech therapy for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that the submitted clinical evidence reveals no medical records documenting hearing loss or other illness or injury supporting the medical necessity of speech therapy.  There is an initial speech therapy report, which documents an articulation disorder and speech delay, but no formal follow-up report documenting improvement. Based on the information provided, the articulation disorder appears to be developmental. Therapy for the patients deficits is educational in nature rather than medically warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested extracorporeal shockwave therapy for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that the patient is requesting ESWT treatment without giving adequate time for healing. Generally, surgery or ESWT is performed after nine months of failed conservative treatment. Some studies show plantar fasciitis resolves in nine months in most cases. Based upon the information provided, the patient should continue with conservative therapy. If her condition is not resolved by September 2007, ESWT should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested electroconvulsive therapy (ECT) for treatment of her behavioral health problems. Findings:  The physician reviewer found that based upon the patients attitudes toward treatment and people in general, it appears there is significant underlying personality pathology which is not clearly amenable to treatment with ECT. Further evaluation is necessary to confirm the patients diagnoses. Moreover, it is not apparent that this patient has exhausted less invasive, known effective and available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested physical therapy services for treatment of her neck and shoulder pain. Findings:  The physician reviewer found that based upon the information provided, the patient had maximized her rehabilitation potential by the date in question. She had already received several months of therapy by that date and her pain is chronic in nature. Furthermore, she had ample time to master a home exercise program by the last authorized date of service. A physical therapy note from the date in question reports the patient was showing good progress with minimal follow-ups. Also, it was noted at that time that the patient had completed her exercise program for treatment of established thoracic and shoulder complaints. Additional treatments beyond the date in question were primarily passive in nature and not likely to improve the patients function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a two-year-old male enrollee has requested an EZ Rider pediatric wheelchair (EZ12T) and a Columbia positioning seat for treatment of the enrollees autism. Findings:  The physician reviewer found that it does not appear that the patients refusal to walk when in public places is a behavioral target included in the applied behavioral analysis program. In addition, the medical records do not address this behavior and do not provide evidence in support of the necessity of an adaptive stroller (wheelchair). With regard to the positioning seat, there is no documentation that this child has insufficient trunk or head control which would necessitate an adaptive car seat. Current laws require a child be in a car seat until the age of  six years or sixty pounds. There are car seats available with five point restraints that can accommodate a child up to 80 pounds
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the medication Byetta for treatment of her diabetes. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates the patient has experienced improvement in her health since she began taking Byetta. She has lost weight, and as a result has less joint pain. She also experienced improvement in her glucose variability. Furthermore, the patients hemoglobin A1C dropped to 5.7% on Byetta without significant hypoglycemia.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male, with dyspnea on exertion, has requested authorization for CT angiography (CTA).Reviewers' Findings:Two out of the three reviewing physicians found that a CTA is appropriate for a symptomatic patient when there is an uninterpretable or equivocal stress test. In this instance, dyspnea on exertion can be considered an anginal equivalent and the patients stress test was consistent with an equivocal interpretation; thus establishing a valid basis for the application of CTA.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a deceased 91-year-old female enrollee has requested ongoing skilled nursing facility services for treatment of the enrollee, status post cerebrovascular accident (CVA). Findings:  The physician reviewer found that the patient had reached her maximum rehabilitation potential as of the date the health plan denied further care. She was near her baseline with ADLs when OT was discontinued and had received several weeks of therapy. The patient could not demonstrate consistent improvement beyond the level that had been achieved by that time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested PET scans for evaluation of his cholangiocarcinoma. Findings:  The physician reviewer found that review of the scientific literature reveals several papers supporting the use of PET in patients with cholangiocarcinoma. The sensitivity and specificity of PET (alone or PET/CT) are 92-94% and 93-100% respectively, which is better than CT alone. PET/CT is particularly valuable in detecting unsuspected distant metastases, which are not diagnosed by standard imaging. Thus, PET/CT staging has an important impact on selection of adequate therapy. PET/CT resulted in a change of management in 10-30% of patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested the prescription medication Provigil for treatment of the enrollees attention-deficit hyperactivity disorder.  Findings:  The physician reviewer found that although the current literature does suggest some degree of efficacy for Provigil in the treatment of ADHD, it is not yet an FDA approved indication. As such, the failure of all standard treatments should be plainly demonstrated before a non-standard treatment approach is adopted. In this instance, the records provided do not clearly show that the patient cannot tolerate the conventional drugs approved for the treatment of ADHD. In fact, it appears he did have some favorable responses to them.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested bilateral breast reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that this patient complained of back, neck and shoulder pain, which is typical of symptomatic macromastia. The surgeons preauthorization letter indicates that the patients symptoms were mild and does not document that she had tried any conservative therapies for her musculoskeletal symptoms. While conservative therapy is of little value in the management of symptomatic macromastia, attempts at conservative therapy provide credence to the patients complaints and indicate that symptoms are severe enough that the patient is compelled to search for treatments. The records do not include any supporting documentation from the patients PCP that confirms that this patient had disabling musculoskeletal symptoms from her macromastia. In addition, the weight of the reduction (right  340 grams, left  360 grams) falls below the 22nd percentile on the Schnur scale, which is an accepted guideline to determine if a reduction is medically necessary or cosmetic.