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

A 35-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 and has failed five preventive therapies. Beta-blockers are contraindicated given her history of asthma. Botox has been very helpful for her headaches in the past. Botox has been shown in studies in peer-reviewed journals to reduce the frequency and severity of chronic headaches. The patient has a history consistent with disabling chronic migraine. There are no FDA approved treatments for chronic migraine. She has tried and failed standard episodic migraine preventive therapy. Unmanaged, her headaches are severely disabling, and would require ongoing and potentially hazardous daily treatment with narcotics and triptans. Botox has variable, though considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). She has been treated with Botox for multiple cycles with substantial success.  With Botox, she has had a reduction of headaches, improvement in response to acute treatment, and better ability to function. Botox has been more successful than standard preventive treatments for this patient. Prior Botox treatments should be covered by the Health Plan, and Botox should be approved for ongoing headache prevention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested artificial disc replacement surgery for treatment of his degenerative disc disease.  Findings:  Three physician reviewers found that The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Furthermore, there is no evidence supporting the safety and efficacy of a two-level disc replacement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested Serostim for treatment of his HIV-associated wasting syndrome.   Findings:  The physician reviewer found that The study cited by Moyle and others demonstrated that Serostim improved lean body mass, physical performance and quality of life in HIV-infected infected patients receiving highly-active antiviral therapy. This placebo-controlled trial delivered the drug for a period of 12 weeks. While the manufacturers prescribing information does not define an optimal duration of treatment, the research that documented the efficacy of the treatment was a 12-week study. Variable, longer-term regimens of this drug therapy have been suggested, but there are no published, controlled trials demonstrating a benefit with extended use Serostim. There is no evidence that extending this patients treatment with Serostim would be of benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of an 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees substance abuse.   Findings:  The physician reviewer found that According to the ASAM Criteria and the standard of care for the treatment of substance abuse problems in adolescents, the patient did not demonstrate any behaviors that would require a residential treatment setting. There are also some concerns as to the quality of the treatment rendered at this facility based on the lack of medical oversight. The treatment notes were sparse, with only weekly entries. Nonetheless, a complete review of the clinical record does not provide evidence of serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested Humira for treatment of her inflammatory arthritis.  Findings:  The physician reviewer found that Humira is approved for the treatment of Crohns disease and by report, such treatment is  recommended by the patients gastroenterologist due to continuing bowel disease. The patient still has a colostomy and her history makes it clear that her disease is severe, recurrent and damaging. The patient has required multiple surgeries, making inadequate control an unacceptable risk. In addition, it is the opinion of the treating rheumatologist that the associated joint symptoms are also severe, and to a significant degree, part of the patients Crohns disease. A trial of Humira is appropriate for control of the patients bowel disease. This agent will hopefully allow reversal of the patients colostomy, decrease the risk of an exacerbation and control her arthropathy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female enrollee has requested continued partial hospitalization services for treatment of the enrollees autism.  Findings:  The physician reviewer found that the submitted clinical records demonstrate that the patient has progressed with intensive multidisciplinary services. The presence of severe organicity, and a possible seizure disorder with severe stability problems are indications for a multidisciplinary approach coordinated through the Regional Center and through the IEP in her local school district for the present and the future. The psychiatric issues of self-harm or inability to sustain weight due to rejection of food secondary to autism are no longer primary issues. As of the date in question the patient had no psychiatric issues that presented an imminent threat to her well-being. Continuation of treatment for this patients multiple problems will be needed including physical therapy, occupational therapy, speech therapy, and behavioral modification, and should be coordinated through the Regional Center and with the IEP through the local school district.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female enrollee has requested continued partial hospitalization services for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient has neurological findings of hypotonia and possible seizures.  She has developmental delays consistent with mental retardation. She also has pervasive developmental delay and autism. The syndrome of autism requires multidisciplinary treatment coordinated through both the Regional Center and the school district.  Psychiatric issues of self-harm or psychosis can be addressed by mental health professionals. The initial presentation to the PHP included the refusal to eat. This has been corrected and the patients weight is in the ideal range for a three-year-old female. There were no psychiatric problems that were an imminent threat to this patient as of the date in question. Continuation of treatment for this patients multiple problems will be needed including physical therapy, occupational therapy, speech therapy and behavioral modification, and should be coordinated through the Regional Center and with the IEP through the local school district.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested applied behavioral analysis (ABA) therapy (20 to 40 hours per week for treatment of the enrollees Landau-Kleffner Syndrome.  Findings:  Three physician reviewers found that ABA is an experimental and investigational treatment for patients with Landau Kleffner Syndrome. A review of the relevant medical literature failed to yield documentation of controlled trials supporting the efficacy of ABA therapy in the treatment of Landau-Kleffner Syndrome. Additional long-term clinical study is needed before ABA therapy can be recommended for this diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested genetic testing for evaluation of his myotonia congenita.  Findings:  The physician reviewer found that review of the literature indicates that there are over 50 mutations to the gene involved in myotonia congenita. In addition, genetic analysis of patients suspected to have either the dominant or recessive form of the disease is informative in only 50% of patients. Given this, and the fact that no pedigree analysis has been presented in the case, there is no evidence to support genetic testing in this setting. There is a high probability that such testing will be non-informative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested nasal surgery (septoplasty and SMR turbinates for treatment of his chronic nasal congestion.  Findings:  The physician reviewer found that in terms of treatment for chronic nasal airway restriction alone, the patient does not meet the Health Plans stated criteria for septoplasty nor does he have a unilateral nasal airway restriction secondary to severe septal deviation. With regard to the reduction of the inferior turbinates, the most common indication is chronic nasal obstruction with evidence of inferior turbinate hyperplasia on examination that is not responsive to an adequate trial of allergy medications. Although there is a note by the sleep medicine consultant that the patient has inferior turbinate hypertrophy, this finding is not verified by the otolaryngologist on either of his examinations. As such, this patient does not meet customary standards for inferior turbinate reduction either.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an five-year-old female enrollee has requested speech therapy for treatment of the enrollees speech disorder.  Findings:  The physician reviewer found that the enrollees tongue thrust was identified through the observation of the speech therapist and the articulation disorder was objectively evaluated with the Goldman Fristoe Test of Articulation. The therapist also documented that the patient could manage all consistencies of food and liquid despite the tongue thrust. The majority of the literature available regarding tongue thrust describes this condition in regard to articulation deficits. There is limited literature supporting the use of speech therapy in the treatment of a dysfunctional swallowing pattern, and what does exist is inconclusive as to efficacy. This is especially true when all textures of food and liquid are managed. Additionally, there is no medical documentation that the tongue thrust is related to a disease, illness or injury.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of his bipolar disorder and alcohol dependence.  Findings:  The physician reviewer found that according to the documentation, the patient was not faring well on his own and had a significant level of depression and anxiety. No doubt, this was worsened by his drinking, though the cyclic relationship between the problems, with one issue compounding the other, is very complex. To that extent, admission to a PHP program was eminently reasonable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested residential treatment services for treatment of her eating disorder.  Findings:  The physician reviewer found that a retrospective review of the entire medical record supports a conclusion that the patient was able to move to a PHP level of care as of the date in question. An optimal program would offer intensive individual therapy for victims of sexual abuse, family therapy and monitoring of her eating disorder. The last certified date is consistent with the patients readiness to move to a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that this patient has an abdominal pannus with photographic evidence of intertrigo and PCP notes that confirm treatment for chronic infections since 2004.  Her rashes have persisted despite the use of antifungal powders. This patient has a large pannus with recurrent infections.  Her history is confirmed by photographs and PCP notes. Because the patient has persistent infections despite conservative care, the requested panniculectomy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested Focalin XR, at a dosage of 40mg daily for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that the clinical use of Focalin XR for the treatment of ADHD is often off-label with a higher dosage prescribed if the patient is healthy and has no reported cardiovascular or other side effects. In this case, the off-label prescription of Focalin XR was carefully documented and a dosage of 40mg daily was found to be effective. The treatment of ADHD in adolescence is a frequent exception to the FDA guidelines. When all other medications have failed and the patient responds to the higher dosage of Focalin XR without side effects, it is a common practice to prescribe a higher dosage, which appears to be indicated in this instance. When a dosage in excess of 20mg daily is prescribed, blood pressure and pulse should be monitored during each encounter with the prescribing physician and the presence or absence of any potential side effects should be assessed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee, with an extended history of back and cervical pain, has requested authorization for axial decompression therapy with the DRX-9000. Findings:  The physician reviewer found that the transient reduction of disc pressure has never been definitively shown to correlate with long-term relief of low back pain. There is no convincing evidence that this treatment modality is efficacious. Axial decompression therapy is not the standard of care in managing degenerative back discomfort.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee, who underwent a total abdominal hysterectomy, has requested authorization for the medication Lupron. Findings:  The physician reviewer found that the patient has declined treatment with Zoladex because of concern over having a substance implanted subcutaneously and additional concerns that the implanted capsule will cause activation of her numerous hypersensitivities. Lupron is given as a routine intramuscular injection in either the deltoid or gluteal muscles while Zoladex is administered as a subcutaneous implant with a 16-gauge needle in the abdomen. This difference likely accounts for the fact that Lupron is used much more commonly in clinical practice. The patients objection to implantation of the Zoladex capsule is reasonable, and since the medications are equally effective, Lupron treatment should be considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee, with erectile dysfunction, has requested authorization for the medication Viagra.  Findings:  The physician reviewer found that the patient has a several-year history of erectile dysfunction, which has been successfully treated with Viagra. Hyperlipidemia is documented in the patient's laboratory testing. Hyperlipidemia is a condition that is consistent with organic impotence, and in fact, appears to be included as such in the Health Plans coverage criteria. Viagra for treatment of the patients erectile dysfunction is medically appropriate and clinically indicated in this setting and should be authorized by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee, who has a small abdominal pannus and is said to have pruritus and moisture in the pannus fold, has requested authorization for a panniculectomy.  Findings:  The physician reviewer found that physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Surgical intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee, diagnosed with short stature, poor growth rate and low IGF-1 levels, has requested authorization for growth hormone (GH) therapy. Findings:  The physician reviewer found that GH therapy is medically indicated in that the patient exhibits obvious short stature, a decreased annual growth rate and low IGF levels. Authorization of past and present GH therapy should reasonably be conditioned upon a bone age study and clinical documentation of a positive response to the GH therapy that has been provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee, with diagnoses of autism and seizure disorder, has requested authorization for occupational therapy (OT). Findings:  The physician reviewer found that there is insufficient evidence to support sensory integration (SI) OT as a treatment for autism and no convincing outcomes data showing a long-term benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee, with a body mass index of 40.1, has requested authorization for the medication Xenical. Findings:  The physician reviewer found that Pharmacotherapy for weight reduction should be used as an adjunct to significant diet therapy and participation in a weight loss program. The patient should be enrolled in a structured diet program a six-month period prior to consideration of Xenical.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-month-old male enrollee, born prematurely at 33 weeks gestation, has requested authorization for two additional Synagis injections. Findings: The physician reviewer found that according to the American Academy of Pediatrics, palivizumab prophylaxis should continue for the duration of the RSV season, with the first dose typically administered in November and the final dose administered in March to provide coverage into April. Dosing is recommended every 30 days, as the half-life of palivizumab is approximately 24 days. Although the criteria for determining the end of the RSV season is flexible, one of the more strict definitions is a positive testing rate below 10%. Some experts hold that any positive tests in a given area pose a significant risk to susceptible children. While protection through the month of April would have been medically appropriate, there is no clinical benefit in a sixth or seventh dose of palivizumab at the present time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-month-old female enrollee, born prematurely at 33 weeks gestation, has requested authorization for two additional Synagis injections. Findings:  The physician reviewer found that according to the American Academy of Pediatrics, palivizumab prophylaxis should continue for the duration of the RSV season, with the first dose typically administered in November and the final dose administered in March to provide coverage into April. Dosing is recommended every 30 days, as the half-life of palivizumab is approximately 24 days. Although the criteria for determining the end of the RSV season is flexible, one of the more strict definitions is a positive testing rate below 10%. Some experts hold that any positive tests in a given area pose a significant risk to susceptible children. While protection through the month of April would have been medically appropriate, there is no clinical benefit in a sixth or seventh dose of palivizumab at the present time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee, with high-grade endometrial cancer, has requested authorization for a full-body PET scan. Findings:  The physician reviewer found that the previous Centers for Medicare and Medicaid Services (CMS) indications for PET scans did not include uterine cancer. However, the National Oncologic PET Registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and other indications not previously eligible for Medicare reimbursement. The diagnosis, staging, restaging, and monitoring of uterine cancer are now listed as indications for PET scan. The sensitivity and specificity for PET in endometrial cancer are high; 83-100% sensitivity and 78-99% specificity. PET combined with CT or MRI has been shown to be more sensitive than CT or MRI alone in overall lesion detection and in detection of pelvic nodal or extra pelvic metastases.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee, with a six-year history of polysubstance abuse, has requested authorization for residential treatment services. Findings:  The physician reviewer found that there was no evidence of serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. There was no history of a rehabilitation attempt at a lower level of care prior to this admission. An intensive outpatient program along with a twelve-step program and a sober living arrangement would have been medically appropriate in lieu of the residential treatment admission.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee, who underwent left total hip arthroplasty, has requested authorization for a referral to the Texas Nerve and Paralysis Institute or a similarly qualified specialist for nerve decompression consultation and treatment. Findings:  The physician reviewer found that there is no role for operative intervention in the treatment of sciatic nerve injury following total hip arthroplasty. The injury is typically a stretch injury. There is no benefit in a referral to the Texas Nerve and Paralysis Institute or a consultation with a nerve decompression specialist. A plan of conservative treatment, watchful waiting and serial EMGs is consistent with the recognized standard of care for this type of nerve injury.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee, who has been followed for diabetic foot care, has requested authorization for Anodyne therapy. Findings:  Two physician reviewers found that Anodyne therapy is an unproven mode of physical therapy that lacks validation. The efficacy of Anodyne therapy has not been established through significant, case-controlled studies. There is no evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee, with a history of abdominal pain, cramps, nausea, vomiting and constipation, has requested authorization and coverage for colonic irrigation. Findings:  The physician reviewer found that there is no specific literature or evidence in peer-reviewed journals on the efficacy of colonic irrigation in the management of patients with IBS. Thus, at present, the benefits of colonic enema/irrigation remain unproven.