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

A 58-year-old female enrollee has requested Lyrica for the treatment of her lumbar stenosis. Findings:  The physician reviewer found that the indications for Lyrica include neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, as an adjunct therapy for adult patients with partial onset seizures, as well as fibromyalgia. Lyrica is not recommended for lumbar spinal stenosis.  There are no studies of Lyrica in spinal stenosis. One group recently attempted to stratify medications used for all types of neuropathic pain. They looked at 105 studies of various medications used to treat neuropathic pain and found that in general, tricyclic antidepressants had the highest efficacy, followed by opioids, and finally pregabalin (Lyrica). In this patient, there is no documentation of trials of other medications that could be used for general neuropathic pain, including tricyclic antidepressants. The requested medication is not medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her condition. Findings:  The physician reviewer found that there is no peer-reviewed class 1 literature to support the efficacy of the CPM machine for autologous chondrocyte transfer procedures. There is no data to show improved outcomes in the mid-term and long-term with the use of the CPM machine after this type of knee surgery. The requested equipment is considered to be experimental in this case. Standard postoperative management in the form of rehabilitation and physiotherapy without the CPM machine is medically appropriate for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Avastin and Abraxane combination regimen for the treatment of her breast cancer. Findings:  Two physician reviewers found that the efficacy data of Abraxane with Avastin was presented from a preliminary phase II study at the ASCO 2008 meeting, however, its combination use remains unproven in this setting. As such, it is not possible to conclude that the proposed therapies are likely to result in a better clinical outcome than standard therapies. Based on the evidence available to date, the use of Avastin with paclitaxel would be more appropriate for the treatment of the patients metastatic breast cancer following completion of oral chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a right breast lumpectomy to be performed in an Outpatient Hospital setting rather than in an Ambulatory Surgery Center for the treatment of her breast mass. Findings:  The physician reviewer found that there is nothing specifically complex about this patients surgical procedure that would require care in a hospital-based setting. There is nothing specifically hazardous that may compromise patient safety in transporting the patient from the hospital to the surgery center once the needle-localization is performed. All told, there is no objective reason (medically or safety-directed) that necessitates surgical treatment in the Outpatient Hospital setting, and the proposed use of an Ambulatory Surgery Center is appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested Magnetic Resonance Imaging (MRI) of the lumbar spine for an evaluation of his peripheral neuropathy. Findings:  The physician reviewer found that the patient has a history of chronic low back pain with radiating pains. A prior MRI done for similar symptoms showed no central or lateral foraminal stenosis. There is no clinical evidence of the development of radiculopathy or myelopathy by available reports. Additionally, there is no evidence that physical therapy is contraindicated in the setting of lumbar impingement or stenosis. Furthermore, an MRI is not generally indicated for the evaluation of peripheral neuropathy. Thus, an MRI of the lumbar spine should not be approved at this time. It would be appropriate to try a course of physical therapy, and if there is still no improvement, to then pursue a lumbar MRI. However, ultimately, the choice of diagnostic testing should be guided by expectation that the results will be of value in treatment planning.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested partial gastrectomy and re-anastomosis of pouch for the treatment of her medical condition. Findings:  Three physician reviewers found that the size of the gastric pouch does not remain constant and is likely to stretch again with overeating.  Counseling to help modify eating habits would be beneficial here.  There is no anatomic complication of the previous surgeries. Thus, a second revision procedure is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested a laser resurfacing procedure for the treatment of his acne scarring. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the proposed procedure is medically necessary. The requested laser resurfacing for acne scarring does not meet the definition of reconstructive surgery. The patients acne scars do not constitute an abnormal structure of the body. Even if the patients scars were considered an abnormal structure, it is not clear that laser resurfacing will offer more than a minimal improvement in the patients appearance. Furthermore, there is no evidence that the patients acne causes a functional impairment, which would render the proposed therapy medically necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was suffering from low back pain over a four day period of time.  There was no report of an acute increase in her pain on the date in question.  There also is no report of her having taken any over-the-counter medications such as ibuprofen and/or Tylenol in order to treat the pain at home.  It seems reasonable that she could have made an appointment to see her physician over the previous four days.  It is unlikely that failure to obtain immediate medical attention on the date in question would have resulted in any serious jeopardy to her health or serious dysfunction of any bodily organ.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a lap band procedure for the treatment of her medical condition. Findings:  The physician reviewer found that there is concern regarding postoperative compliance at this time.  The patient gained weight while in a bariatric surgery program.  She appears unwilling to complete the surgical preparatory process.  Her written communications reflect significant anxiety and unrealistic expectations regarding the procedure.  The notes document non-compliance with surgical directions. If the patient remains compliant with the bariatric surgery program for one year and quits smoking, then coverage for the surgery should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested eye surgery for the treatment of her eye problems. Findings:  The physician reviewer found that the proposed surgery is a reconstructive procedure rather than cosmetic in nature. The patient has elevation of the eyeball relative to normal position. This constitutes an abnormal structure of the body. This condition occurred as the result of trauma. The proposed procedure has been recommended to create a normal appearance to the extent possible. It is anticipated that the requested surgical procedure will offer more than a minimal improvement in the patients appearance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested orthognathic surgery and one extra day of hospitalization for the treatment of the enrollees maxillary hypoplasia. Findings:  The physician reviewer found that the patient has mandibular hyperplasia and maxillary hypoplasia. He has significant negative overjet and definite maxillary hypoplasia evident, both clinically (from the provided photographs) and radiographically. Appropriate management of this requires both a maxillary and mandibular procedure. Surgically correcting the mandible alone can lead to an unstable result, with the potential to compromise the posterior airway space. Performing surgery on both the upper and lower jaws will result in a better functional outcome. Given the nature of the surgery, which involves procedures of the upper and lower jaw, a two-day hospitalization is appropriate. It is impossible to predict the patients post-op course.  However, given the type of surgery proposed, a request for a two-day stay is reasonable.  This will ensure that the patient has adequately recovered and can be safely discharged. Thus, the maxillary surgery (LeFort procedure) and additional day of hospitalization are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 80-year-old female enrollee has requested the medication Malarone for the treatment of her malarial prophylaxis. Findings:  The physician reviewer found that the patients dermatologists recommendation not to take doxycycline due to the patients skin conditions was medically appropriate. The remaining choices available to the patient were Lariam and Malarone. Malarone would be the preferred agent for this patient because of the dizziness that Lariam can cause as indicated in the medications warning brochure. In addition, it is noted that dizziness may persist after taking the medication. Thus, the use of Lariam was not optimal given the patients medical history of blackouts and dizziness. All told, Malarone was the most appropriate antimalarial drug for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested LASIK surgery for the treatment of his medical condition. Findings:  The physician reviewer found that the inability to feel glasses sitting on half of the face should not impact the ability to maintain them in a reasonable position.  The patient can still use his right hand to feel the position of the glasses on his face, he can use a mirror, and he can obtain snug fitting frames that do not shift.  Alternately, an elastic strap can be worn on the ear pieces to hold the glasses in place, or contact lenses could be utilized.  The prescription is devoid of any astigmatism, where a slight shift in position would more likely impact the quality of vision or visual comfort.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment services for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that although the patient clearly has anorexia nervosa, the chart notes indicate progress in recovery, with expected weight gain and relative relinquishment of her calorie restriction.  Based on the notes included, there was a clear-cut progression as of her admission, and it appears that she was quite a bit improved. Additionally, some of the subsequent notes also point to the sustainment of this improvement, inclusive of other passes. As such, residential treatment beyond the date in question was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested Flector patches for the treatment of his condition. Findings:  The physician reviewer found that flector patches are topical non-steroidal anti-inflammatories.  They are typically utilized to control acute pain and inflammation associated with minor strains, spasms, and contusions.  These patches are not generally utilized, nor studied for, treatment of chronic pain due to reflex sympathetic dystrophy. Flector patches are not medically indicated for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a FIBROSpect II study for an evaluation of his liver disease. Findings:  Two physician reviewers found that to date, it has not been shown that FIBROSpect II testing is as helpful or accurate as the gold standard in this setting, liver biopsy. No evidence has been presented that the proposed testing will have superior value in the care and management of this patients chronic Hepatitis C. In sum, it has not been established that FIBROSpect II testing will result in a better outcome for this patient than liver biopsy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Avastin therapy for the treatment of his metastatic head and neck cancer. Findings:  Three physician reviewers found that there is insufficient evidence to support the use of Avastin in this setting. It has been approved for use in a few types of cancer and is being actively studied in clinical trials in multiple other tumor types. Based upon the evidence available to date, Avastin remains an unproven therapy in this clinical setting and offers no clear treatment advantage for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The spouse of a 39-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the enrollee was suffering from an acute illness which manifested as a productive cough, fever, and vomiting (1 episode).  The tachycardia and tachypnea are signs of more severe illness due to dehydration or respiratory distress due to infection.  These symptoms were of sufficient severity that a prudent layperson would reasonably seek immediate medical attention for fear of jeopardy to health or bodily function.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient presented to the emergency department due to severe discomfort, difficulty walking, urinary hesitancy and urinary frequency. The differential diagnosis for these symptoms includes bladder infection as well as more serious disorders including pyelonephritis and renal lithiasis.  It was important that she was evaluated and ruled out for any life and/or organ threatening disorders and that she received antibiotic therapy.  If she had gone untreated, her pain would likely have gotten worse, and the infection could have spread to her kidneys and/or bloodstream.  From the patients description, she was suffering pain of sufficient severity that a prudent layperson would have reasonably decided to seek immediate medical attention due to fear for jeopardy to her organs and organ function.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a breast MRI for an evaluation of her medical condition. Findings:  Three physician reviewers found that in this case, the MRI in dispute was not performed for screening purposes, but was diagnostic.  Indeed, had it not been performed the lesion in the right breast would not have been detected.  The MRI was appropriately part of a thorough evaluation in light of an abnormal mammogram and ultrasound which were discrepant.  The suspicious nature of the screening mammogram suggested a high probability of cancer and this, combined with other worrisome findings on the ultrasound, made the MRI diagnostic.  The American Cancer Society endorses breast MRI in this circumstance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested the medication Zyvox for the treatment of her right knee infection. Findings:  The physician reviewer found that the patient could have been treated with a penicillin or cephalosporin, linezolid, tetracycline, trimethoprim-sulfamethoxazole or vancomycin. However, she has a history of anaphylaxis to the penicillin and an allergy to sulfamethoxazole. This means the penicillins, cephalosporins and trimethoprim-sulfamethoxazole cannot be used. The remaining options are vancomycin, tetracyclines and linezolid. Vancomycin is not available except in parenteral formulation.   Because of the patients skin disease, her physicians did not want her to receive parenteral therapy. Tetracyclines (doxycycline) have been used for treatment of community-acquired methicillin-resistant Staphylococcus aureus infection.  These drugs are not usually used in severe infections.  There is a lack of data to justify their use in infected joints.  Thus, due to the organisms resistance pattern, the patients allergies and the presence of skin disease preventing use of intravenous therapy, the only possible drug for her infection was Zyvox.  The Health Plans denial is inappropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Rituxan therapy for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that at this time there is no data indicating that a particular drug is likely to have long-term effectiveness in the treatment of SPMS. While Rituxan is not a conventional treatment in this setting, there have been published studies of its use in RRMS. (Hauser, et al). Rituxan appears to have produced dramatically beneficial results in some patients. Given the limited knowledge available regarding the treatment of SPMS, Rituxan is a medically  appropriate and reasonable treatment option.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested the prescription medication Namenda for the treatment of the enrollees autism. Findings:  Two physician reviewers found that autism is a frequently seen condition without a known etiology. Namenda has been approved by the Food and Drug Administration for treatment of Alzheimers disease. Namenda is not approved for autism treatment. There is literature indicating its potential application in autistic treatment, but at this time the use of Namenda in this clinical setting remains unproven. At this time, there is insufficient data to support the use of Namenda for patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested an MRI of the right breast for the evaluation of her right breast lump. Findings:  Three physician reviewers found that the utility of MRI is limited to problem solving in certain individuals. In a patient with a painful, possibly increasing, palpable mass, excisional biopsy would be indicated regardless of the MRI results. The proposed MRI is not likely to be of any additional clinical value in this setting. An excisional biopsy is the next appropriate step for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested an acellular xenograft (Oasis) for the treatment of his ankle wound. Findings:  Two physician reviewers found that there is no scientific clinical evidence to show the effectiveness of Oasis over standard care. While Oasis might be helpful, there is a lack of data to support its use over alternate standard treatments. The patient might benefit from additional hyperbaric oxygen therapy or a flap as recommended by his physician.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a Vest Airway Clearance System for the treatment of her medical condition. Findings:  Two physician reviewers found that this is a patient with severe progressive lung disease which has been minimally responsive to previous standard therapies (antibiotics and steroids).  Although additional large scale studies need to be done, chest physiotherapy is a standard of care for patients with pulmonary disease.  Unfortunately, this patient is alone and does not have the home support to undergo chest physiotherapy.  A Vest Airway Clearance System is consequently an appropriate therapy option for her.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested a gastric bypass procedure for the treatment of his medical condition. Findings:  The physician reviewer found that before weight loss surgery, it is necessary to ensure that there are no behavioral, dietary, or metabolic barriers to the success of the surgery.  In this case, there is no evidence to remove these barriers. There is no evidence of reasonable dietary attempts, multidisciplinary evaluation or normal TSH level.  Although this patient is morbidly obese and may benefit from weight loss surgery, at this time the medical necessity of this procedure is not substantiated by the record.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented with an acute condition. He had an infected sebaceous cyst that undoubtedly caused him discomfort.  However, neither the pain nor the disorder was of sufficient severity that a prudent layperson would seek immediate emergency medical care.  There was no threat or jeopardy to his life or bodily organ functions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Lyrica for the treatment of his polyneuropathy. Findings:  Two physician reviewers found that Lyrica has been beneficial for this patient. Lyrica is medically appropriate for the treatment of painful diabetic neuropathy. Management of neuropathic pain is usually a clinical extension of what is learned in clinical trials with well-studied neuropathy pain, typically diabetic in origin. There is no evidence that non-diabetic neuropathy pain responds differently than pain from diabetic neuropathy. There is evidence that supports the use of Lyrica in cases with non-diabetic neuropathic pain, including postherpetic neuralgia and fibromyalgia. Lyrica should be approved for this patient. He has already failed gabapentin, and he has had successful response to Lyrica.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested magnetic resonance guidance and MRI scan of the pelvis for the evaluation of her piriformis syndrome. Findings:  Two physician reviewers found that although the magnetic resonance guidance and MRI of the pelvis were not the standard of care for this patient, they were more likely to be of benefit to this particular patient than any other additional imaging modality and intervention. This patient has already undergone spinal surgery with incomplete resolution of symptoms, a postoperative MRI scan including contrast injection and a CT myelogram. Since conventional surgery, imaging studies and routine evaluation have failed to elucidate the etiology of her persistent symptoms, a new technique such as MRI guided neurography and intervention may offer benefit to the patient.  In addition, it would be prudent to exclude other soft tissue diseases such as nerve sheath tumor, myositis, or pelvic side wall masses as the etiology of symptoms. Routine exams of the lumbar spine do not cover the anatomical areas necessary for evaluation outside of the lumbar spine, and there was no real alternative evaluation or treatment offered by any other provider.