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

A 51-year-old male enrollee has requested for Sonata for treatment of his insomnia. Findings:  The physician reviewer found that its recommended zolpidem tartrate or Lunesta. The patients objections are predominately due to a negative experience with long-acting zolpidem tartrate, and theoretically, due to the duration of action of Lunesta.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins in her right leg.   Findings:  Three physician reviewers found that the appropriate role for sclerotherapy is limited to the treatment of recurrent varicose veins following surgery and thread veins. There is inadequate scientific data establishing the superiority of sclerotherapy in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for residential treatment services for treatment of his alcoholism. Findings:  The physician reviewer found that given the patients prodigious drinking, family history of severe alcohol dependence, having quit his job and being isolated, alongside an inability to really remain sober for any sizable period of time, a more protected and intensive treatment appears to have been in order.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a consultation with a bariatric surgeon for the treatment of her condition. Findings:  The physician reviewer found that this patient is an obese female with a body mass index of 39. She has failed multiple attempts at weight loss surgery. The patient meets nationally accepted criteria for consideration of weight reduction surgery. The requested consultation is medically indicated to help determine if surgery is an appropriate treatment modality for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 28-year-old female enrollee has requested highly specialized surgical services for the treatment of her Barlows disease. Findings:  The physician reviewer found that the patient has severe mitral regurgitation secondary to Barlows disease. She will require complex repair with sliding annuloplasty. This can only be done by a specialist in mitral repair. The requested services are medically indicated and warranted for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested Subutex for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the available evidence indicates that the use of Suboxone is preferred, but not mandated, for unsupervised maintenance. In this case, the patients physician describes the patients headaches and inability to progress to a lower dose as intolerability to Suboxone. That he was able to reduce his intake of Subutex to 2mg per day is an indication that the patient achieved better results with Subutex than Suboxone, and therefore, supports the continued use of Subutex this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a second opinion consultation with an out-of-network ophthalmologist for the evaluation of her condition. Findings:  The physician reviewer found that the optometrist noted best corrected vision of 20/25 and 20/40. He noted ocular pressure of 26 and mild cataracts in each eye. The optometrist did not describe damage to the optic nerve but did say there was early disruption of the left macula. On another visit, the provider noted vision of 20/20 and 20/40 and pressures of 22 and 21. The drawings of the optic nerve were normal, and no mention was made of cataracts or macular degeneration. Visual fields and optical coherence tomography scanning were ordered. The patient did not keep the appointment for these tests. These ordered tests are certainly recommended, as is a second opinion. However, as there are several qualified providers on the staff, an out-of-network referral is not medically warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested removal of bilateral saline-filled breast implants for the treatment of her condition. Findings:  The physician reviewer found that there is insufficient evidence that the proposed procedure is indicated based on general principles of medical necessity. The mammogram reports do not document abnormalities of the implants, leaking implants or capsular contractures or masses. There is no evidence that the etiology of the patients back pain and thoracic cage issues have been evaluated with diagnostic tools, medical evaluation, or been treated with physical therapy. Furthermore, there is a lack of documentation of Baker IV capsular contractures. As such, there is no medical justification for removal of the patients breast implants.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-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 chronic pain and narcotic addiction without any acute disorder. This clinical scenario does not meet the Prudent Layperson Standard for seeking immediate medical attention. The patient had normal vital signs and did not appear to be going through opiate withdrawal. Furthermore, opiate withdrawal is not a life-threatening disorder. It is unclear why the patient chose to go to an emergency department for her prescription refill given that it was a weekday, and she should have been able to reach her primary care physician or pain clinic physician for additional medications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested the use of an ultrasound bone growth stimulator for the treatment of the enrollees left calcaneal stress fracture. Findings:  Three physician reviewers found that the literature fails to support the use of bone stimulators for the treatment of stress fractures. Rue and colleagues studied the use of bone stimulators with tibial stress fractures and found no benefit. The use of the ultrasound bone growth stimulator was not medically warranted for treatment of this patients stress fracture.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a TLSO brace for the treatment of her condition. Findings:  The physician reviewer found that this brace appeared to be reasonable in this setting. In particular, it was not being utilized as a tool to determine the efficacy of fusion, but rather utilized in an effort to offer some degree of better pain relief than the originally prescribed brace and to be considered as a source of postoperative immobilization following this spine surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested functional foot orthoses for the treatment of her foot problems. Findings:  The physician reviewer found that the patient has tried an over-the-counter arch support which did not help her condition. She is attempting to avoid surgery. The patient seemed to have experienced considerable relief of symptomatology with custom made orthotics. The Health Plan states that coverage for custom made orthotics is included once over-the- counter orthotics have failed. The enrollee seems to have fulfilled that requirement. Custom made orthotics are within the spectrum of non-operative treatment for hallux rigidus. The requested medical equipment is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested an ultrasound to be included with her routinely scheduled mammograms for her breast cancer screening. Findings:  The physician reviewer found that yearly mammograms are indicated for all women over the age of 40. Ultrasound of the breast is not a screening exam and is only done to evaluate a palpable mass, a finding detected on the mammogram or as a follow-up of a known lesion.  In this case, it appears the patients prior ultrasound films and reports are not on file. Without having the prior films in hand, or at least a report describing the size, exact location, and sonographic characteristics of a previously detected lesion, the radiologist cannot assess the importance, if any, of the sonographic abnormality. As such, the medical necessity of an ultrasound in conjunction with the patients routinely scheduled mammograms has not been established at this time. If the patients prior breast imaging records or at least her most recent ultrasound report are obtained, then her request for concurrent ultrasound and mammogram should be reconsidered.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the patient was suffering from an acute condition of sufficient severity such that one could reasonably expect the absence of medical attention to result in serious jeopardy to her health or bodily functions. Although she had a history of headaches in the past, this headache was of greater severity and was intractable or unresponsive to treatment with Vicodin, trazodone and Imitrex medications. The patient had no other option but to seek immediate medical attention for relief of her severe headache. In addition, the emergency physician was concerned about the possibility of intracerebral bleeding and mass, as evidenced by ordering the CT scan of the head.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested psychological testing and related services for an evaluation of the enrollees behavioral health problems. Findings:  The physician reviewer found that the standard of clinical practice does not recommend psychological testing prior to the initiation of treatment for an adolescent with a major depressive disorder.  The testing is not consistent with a delay in initiating treatment for either dysthymia or depression, since both of these diagnoses are made based upon a clinical history and interview with the patient. The psychological testing and related services were not medically indicated for this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested wireless capsule endoscopy for an evaluation of her medical condition. Findings:  The physician reviewer found that the proposal is for a wireless capsule endoscopy to visualize the remainder of small bowel. An upper gastrointestinal study (UGI) with a small-bowel follow through (SBFT) was negative. It is of the utmost importance in this case to determine whether the small bowel is significantly involved with Crohns disease. This will impact whether the patient should be placed on 6-mercaptopurine (6-MP) and long-term steroid treatment. Since the proposed procedure is likely to affect treatment decisions made in this case, it is medically reasonable and appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a biologic ankle replacement for the treatment of her left ankle pain. Findings:  Three physician reviewers found that the efficacy of biologic ankle replacement remains unproven at this time. There are no prospective randomized studies to warrant its use other than for investigational purposes. Ankle replacement is performed very sporadically and is prone to high failure rate. This procedure, biologic replacement, has no significant published results to support its use at this time. As such, the requested procedure is not expected to be more beneficial than any other standard treatment in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested reimbursement continued intravenous Rocephin therapy for the treatment of her Lyme disease. Findings:  Three physician reviewers found that the published data does not support treatment of patients until the IgM titer converts to negative. Titers may remain positive indefinitely and are not necessarily markers of disease activity. Further, there is no evidence of harbored Lyme infection with recrudescence over time. The Infectious Disease Society of America (IDSA) guidelines, though under review, are the most complete evidence-based medicine for the treatment of Lyme disease. The therapy at issue was not and is not more beneficial over the standard treatment of one four-week course of antibiotic for the treatment of late-stage Lyme disease. The therapy at issue was not and is not supported in peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a Magnetic Resonance Imaging (MRI) of the breast for the evaluation of her medical condition. Findings:  The physician reviewer found that if indeed there was a palpable abnormality on physical exam, the MRI would not have settled the issue as to whether biopsy was indicated or not.  MRIs are not always positive when a malignancy is present, and they may also yield false positive results as well.  In this patient, an ultrasound would have been indicated.  If there was a cyst or some other clearly benign finding, a biopsy would be avoided.  However, in a patient such as this (where malignancy is obviously of concern), biopsy of a palpable mass, particularly if there is a change noted on physical exam, would have been indicated no matter what the scans may have shown, absent a cyst shown on ultrasound.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested Provigil for the treatment of her depression and anxiety with excessive sleepiness. Findings:  The physician reviewer found that there is very little supporting documentation of how Provigil has necessarily added to the patients welfare. From what little can be discerned, she still appears fatigued and irritable despite taking Paxil and Provigil. The dosage of Paxil was increased.  This does not speak very positively to the ostensible betterment of the patient by virtue of the noted combination. Hence, while there may be merit to it in general terms, there is a lack of support for the benefit of this medication for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Prevacid for the treatment of her acid reflux disease. Findings:  The physician reviewer found that this patient has documented acid reflux. She has taken Prevacid for years, and there was documented failure to Protonix and Prilosec. The patient has had a stable course on Prevacid and has been doing well. The requested medication is medically appropriate and indicated for this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested treatment with a pediatric electrophysiologist for the treatment of the enrollees recurrent supraventricular tachycardia. Findings:  The physician reviewer found that recurrent supraventricular tachycardia at a young age is a potentially curable arrhythmia through ablative therapy. In patients who are refractory to medications and younger patients who would likely have significant morbidity with lifelong medication, ablation therapy is a well-established, clinically acceptable therapy. An adult electrophysiologist will not likely have considerable experience with very young patients, so it would be clinically reasonable to request a pediatric electrophysiology referral. I would therefore recommend overturning the Health Plans decision to deny coverage for a pediatric electrophysiology referral, as the requested services are likely more clinically appropriate than the alternative therapy offered by the Health Plan.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the differential diagnosis of these presenting symptoms includes several potentially life threatening disorders including epiglottitis and peritonsillar abscess. The patient presented to the hospital with fever, chills, and sore throat of sufficient severity that one could reasonably believe failure to obtain immediate medical attention could result in serious jeopardy to health, serious impairment to body functions or serious dysfunction of bodily organs.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 40-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 an acute exacerbation of low back pain that was of sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to their health and/or bodily function. She required immediate evaluation and treatment of her severe pain in order to continue her normal daily activities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested Prilosec 40mg for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis. PPIs continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although inter-patient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic end points or side effects profile. In this case, the patient should be a given a trial of Protonix single and double doses for eight week each. If she fails to respond to these trials, then she should be approved for Prilosec. She has already failed Prevacid, Aciphex, and generic omeprazole.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested participation in a clinical trial, echocardiogram and pulmonary function test, for the treatment of her recurrent metastatic cancer. Findings:  Three physician reviewers found that there is a lack of data to support the efficacy of high dose chemotherapy in the management of metastatic breast cancer. No survival advantage has been demonstrated. Furthermore, the therapy is associated with increased toxicity. Review of the scientific literature reveals that investigations of high dose chemotherapy in this setting showed no better results than standard therapies. In light of the absence of supporting data, the proposed clinical trial is not likely to be superior to standard regimens.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested an out-of-network specialist referral for the treatment of his bilateral lower extremity pain. Findings:  The physician reviewer found that this patient went to his primary care physician with complaints of right foot pain for the prior eight weeks. A tender Achilles tendon insertion was noted, and a diagnosis of Achilles tendonitis was made. An EBoot was dispensed. The boot did not help, and pain was noted in the right and left posterior heels. The patient saw a podiatrist who diagnosed the patient with bursitis ankle/foot, Achilles tendonitis and equinus. The patient was prescribed physical therapy. The patient saw a neurologist for weakness in the legs, and an MRI was ordered. The patient saw another physician, and x-rays revealed tiny spur posterior heel. He reported that Vicodin was not working for the pain. The patient had a neurology follow-up, and foot pain was determined to be unlikely secondary to radiculopathy. The patient had another podiatry visit and an MRI revealed chronic Achilles tendonitis with acute insertional tendonitis. Most, if not all, of the physicians recommend ice, rest, physical therapy, immobilization/stretching boot, orthotics and heel lifts. He has had an MRI and neurology consult. An out-of-network referral is not medically indicated as the patient has had an extensive work-up with concurring recommendations within the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested Lovaza for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that the patient is undergoing risk reduction for coronary artery disease and vascular disease. He will benefit from LDL lowering, which is not the primary action of Lovaza. However, if there is a specific need for lowering of the patients triglycerides, the alternatives offered by the Health Plan are clinically appropriate medications to use and have been shown to decrease arteriosclerotic vascular disease risk.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a home sleep study for the treatment of her sleep apnea. Findings:  The physician reviewer found that the most useful measurement in the sleep study for assessment of severity of a sleep apnea disorder is the apnea hypopnea index (AHI), which is the number of apneas and hypopneas per hour of recorded sleep. During a home study, the actual time of sleep is not documented but is estimated. In regards to home sleep studies, the documentation needed for patient management decisions is not at the level of the standard, generally accepted sleep study.  The services included in a standard sleep study (measurement of stages of sleep, amount of actual sleep, documentation of sleep and position of sleep) are medically necessary for treatment decisions. The absence of these services is a deficiency of the home test that renders this exercise in data collection less useful clinically.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Reclast injections for the treatment of her osteoporosis. Findings:  The physician reviewer found that the patient has failed objective response in her spine to three bisphosphonates. There is no evidence in the literature or current rationale that would suggest she would respond to another bisphosphonate orally (Boniva) or intravenously (Reclast) better than those previously failed. In any case, the bisphosphonates will not work if she is unable to absorb calcium. She appears to be treated with suboptimal doses of vitamin D. She is taking a medication (Cytomel) that is potentially bone toxic. There are two good alternatives (Evista, and Forteo) and one fair to poor alternative (nasal calcitonin). However, they also will not work without adequate intake of calcium with vitamin D. The requested therapy is not medically warranted for treatment of this patient.