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

The parent of a seven-year-old female enrollee has requested speech therapy for the treatment of the enrollees phonological disorder. Findings:  The physician reviewer found that the patients articulation and consonant substitution were significantly below the norms for her age. The etiology of the speech disorder was neurological in that the patient was intellectually normal and had normal motor development and speech acquisition. The difficulty is related to a motor apraxia of the tongue and palate which is a congenital neurological dysfunction. The therapist felt strongly that the disorder was treatable within a finite period. Speech therapy is medically appropriate and indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient presented with acute right lower-quadrant abdominal pain of sufficient severity that a reasonable and prudent layperson would seek immediate medical attention due to fear for jeopardy of her health and/or bodily function.  According to the ER documentation, she appeared ill enough to warrant blood testing as well as a CT scan of the abdomen and pelvis.  The differential diagnosis of her presenting symptoms included several serious disorders including:  Bowel perforation and obstruction, diverticulitis, abdominal abscess and tumor, aortic aneurysm, and other disorders.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested The Vest Airway Clearance System for the treatment of the enrollees chronic pulmonary condition. Findings:  Three physician reviewers found that while it is true that there is little medical literature studying the use of The Vest in this, or in analogous clinical situations, there have been anecdotal reports of benefit in cases such as this. In fact, this patient has received a trial of The Vest with good results. Based on this individual patients positive response to the therapy, and with an intuitive extrapolation of published literature, it is our opinion that use of The Vest in this case is also likely to be more beneficial for this patient than any available standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested microprocessor-controlled lower-limb prosthesis repair for the treatment of her transfemoral amputation. Findings:  Two physician reviewers found that the available scientific studies demonstrates that there is sufficient published evidence that the microprocessor controlled C-leg offers advantages over standard prosthetic devices. For example, a study by Kaufman, et al. found that transfemoral amputees had a significant improvement in balance and gait when using a microprocessor-controlled knee. An article by Orendurff, et al. showed that patients using the C-Leg had greater efficiency at self-selected walking speeds. Furthermore, the study by Seymour, et al. determined that the use of the C-Leg resulted in statistically significant decrease in oxygen consumption, decreased number of steps to complete the same ambulation tasks (i.e., increased functional mobility), and improved quality of life scores compared with non-microprocessor prostheses.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested Nutropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient has constitutionally delayed adolescence with a normal predicted adult height. The patients predicted adult height based upon a delayed bone age (estimated at a 4 year delay at 10 years) appears to lie near the mid parental estimate assuming that he still had a retarded bone age of 3 years (based on the Greulich and Pyle Hand Atlas). As such, the medical necessity of growth hormone for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested Neumega injections for the treatment of his pre-T-Cell Acute Lymphoblastic Leukemia (ALL). Findings:  The physician reviewer found that Neumega is indicated for the prevention of severe neutropenia due to myelosuppressive chemotherapy. Review of the submitted clinical evidence indicates that this patients platelet count has not been at a level that Neumega would be indicated. Appropriate options in this clinical setting include proceeding with chemotherapy or administering platelet transfusions. The use of Neumega is not medically indicated for this patient based upon the information provided at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested acute inpatient hospital services and sub-acute residential services for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient presented as a seriously impaired young woman with a complex group of psychiatric issues who was clearly in need of a comprehensive treatment plan at the time of acute admission. However, her specific need for inpatient treatment from the date in question forward and for residential treatment from the date in question forward has not been established. The patients body weight was stable and in the normal range. She was not psychotic, homicidal or suicidal. She appeared to be, at most, only moderately depressed. Although carefully observed by nursing personnel during her initial hospital days, she was able to go out of the hospital with her mother in a relatively short time. Her need for 24/7 professional monitoring and care is not substantiated by the submitted documentation. All told, the patient could have been safely and effectively treated at less intensive levels of care during the dates in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for the medication Aciphex for treatment of her gastroesophageal reflux disorder (GERD). Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, and they continue to be the standard of therapy for the treatment of gastroesophageal reflux disease. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps, and all PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. There are subtle differences in the adverse reactions of all the PPIs available in the market. The differences in the metabolites of various PPIs explain some differences in adverse reaction among various PPIs. This patient developed rash and difficulty breathing with Nexium, Protonix, Prevacid and omeprazole.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for an abdominoplasty for treatment of her excess skin condition. Findings:  The physician reviewer found that the patient does not have medical record documentation over time of skin infections in the abdominal fold, and photographs documenting cellulitis, ulcerations or rashes have not been submitted. The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for skilled nursing care for treatment of her conditions. Findings:  The physician reviewer found that there are no inherent advantages or improved outcomes with inpatient versus outpatient settings of rehabilitation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested Lap-Band evaluation and procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that a Lap-Band procedure is indicated to facilitate weight loss for this patient. This will allow the patient to reach a weight such that orthopedic intervention will be successful and she will be able to resume an exercise program. The patient has tried supervised weight loss programs without effect. The Lap-Band procedure is the least invasive mechanism for weight loss and is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested for inpatient hospital stay for treatment of his ulcerative colitis. Findings:  The physician reviewer found that there is inadequate evidence to support the contention that the patient required an acute level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for growth hormone therapy with Humatrope for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that GH therapy is indicated for the treatment of idiopathic short stature defined by height standard deviations less than or equal to 2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means.GH therapy is also indicated for the treatment of short stature or growth failure in children with short stature homeobox-containing gene (SHOX) deficiency whose epiphyses are not closed. The endocrinologist does not affirm this diagnosis. The second IGF-1 which is mildly depressed is of no clinical significance in this situation of a normal GH stimulation test.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient was suffering from an acute exacerbation of severe pain (9 on a scale from 1 to 10).  A prudent layperson would reasonably seek immediate medical attention for pain of such severity.  It appears that the patient was suffering from an acute exacerbation of a chronic pain syndrome related to her frozen shoulder and arthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for Extracorporeal Shock Wave Therapy (ESWT) for treatment of her bilateral foot pain.   Findings:  Two physician reviewers found that according to literature and studies, ESWT for the treatment of plantar fasciitis would not be more beneficial than other generally accepted treatment. (Endoscopic plantar fasciotomy, custom orthotics, and physical therapy).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Malarone 100mg for treatment of her condition. Findings:  The physician reviewer found that there was no documentation provided requiring specific medical therapy with Malarone. The review of standard therapy for malaria prophylaxis (prophylaxis of Plasmodium falciparum malaria in areas where chloroquine resistance has been reported) indicates doxycycline is a recommended first-line treatment. The dose for prophylaxis is 100mg per day starting one day prior to travel. It is used daily while in endemic areas and continued for a period of four weeks after travel to the endemic area. The patient has no documented contraindications to doxycycline therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for a 3-D ultrasound for evaluation of her condition.  Findings:  Three physician reviewers found that real-time 3-D and 4-D ultrasound is a technical advancement that involves computer-generated images of the fetus shown in three-dimensions. The resulting picture provides almost life-like images of the fetus. For obvious reasons, this technology is a tremendous patient-pleaser. However, this technology has not been definitely established as superior to conventional 2-D ultrasound in providing the diagnosis of fetal abnormalities. In fact, some studies have even suggested it is inferior to assessing basic cardiac views of the fetal heart. Thus, the clinical application and wide-spread use of 3D ultrasound for the routine assessment of a fetus is unclear.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for Da Vinci robotic-assisted surgery for treatment of her uterine prolapse.   Findings:  Two physician reviewers found that according to this search of the medical literature, there are no peer-reviewed published reports of robotic-assisted laparoscopic sacrocolpopexy in women with an intact uterus, and again none reported for postoperative failures of laparoscopic sacrocolpopexy. As in other gynecologic indications, the use of robotic assistance in the performance of this technique may be proven to have great utility in the future.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a low dose chemotherapy for the treatment of his Hodgkins lymphoma, stage 4. Findings:  Three physician reviewers found that Hodgkins lymphoma is one of the most curable human cancers, and many years of intensive studies have provided the scientific and clinical evidence for the current therapies.  Deviation from the current state of the art recommendations is not within the standard of care. It is well established by multiple clinical studies that deviation from the current state of the art to treat Hodgkins lymphoma is in fact detrimental and clearly not more beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested continued skilled nursing facility services for the treatment of her multiple fractures. Findings:  The physician reviewer found that the patient was benefitting from skilled care. She had just reached minimum/CGA with transfers. The submitted documentation provides no rationale or support for discontinuing daily therapy just two days after the patient reached this level. The patient was clearly making progress and was likely to continue to benefit from therapy. No evidence has been provided that the patient had reached her current maximum potential as of the date in question. In light of the potential for progress, the patient should continue to receive SNF services. A re-evaluation should be performed two-weeks from the date of this decision to determine if the patient is continuing to benefit from the SNF services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested speech therapy for the treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that this nearly four-year-old patient has the classic features of autism. Psychometric testing has indicated severe communication dysfunction, but not severe intellectual impairment, which makes the patient a suitable candidate for speech therapy. Speech therapy notes report slow, but consistent improvement in language function. Failure to make rapid improvements would imply the need for more intensive therapy not discontinuing therapy. Speech therapy has been shown to provide its greatest benefit for autistic children under the age of five.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Increlex for the treatment of the enrollees severe primary IGFD (insulin-like growth factor deficiency). Findings:  The physician reviewer found that it would appear that the L-dopa test was judged to indicate a low GH response on the basis of only one blood level after the initial one test. A second stimulation test was not done. According to the physician, there was no IGF-1 done before GH had been initiated and that level was normal according to the standards that the lab in question had been using. Since there was also no growth response to GH therapy, GH deficiency cannot be substantiated. The diagnosis of IGF-1 deficiency also appears improbable since IGF-1 levels appeared to be normal while on GH therapy yet there was no growth response. Normal to elevated GH levels were not seen. Thus, IGF-1 deficiency was not supported. There was a delayed bone age, however, suggesting a diagnosis of constitutional pubertal delay. However, after IGF-1 therapy was given, there has clearly been a growth response accompanied by an elevated IGF-1 level reported as 732ng/ml (albeit this level might have been affected by IGF-1 antibodies induced by IGF-1 therapy). The case appears most likely to be a question of constitutional delay (not IGF-1 deficiency) which may have been compounded by familial short stature (parental heights were not documented).  Therefore, IGF-1 therapy is not medically necessary in this instance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for Lyrica for treatment of her condition. Findings:  The physician reviewer found that Lyrica has been approved for several neuropathic or chronic widespread pain disorders, including diabetic neuropathy, postherpetic neuralgia and fibromyalgia. Medications are tested on common disorders, but are routinely and appropriately used off-label for related disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for breast thermography for evaluation of her condition.   Findings:  Three physician reviewers found that according to the American Cancer Society (ACS), thermography is not effective as a screening tool for the early detection of breast cancer. The American College of Radiology does not advocate for the use of breast thermography. The gold standard imaging exam for breast cancer screening continues to be mammography. Ultrasound and breast magnetic resonance imaging are useful adjuncts in select patients. There is no scientific evidence to support the use of breast thermography.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for continued Botox injections for treatment of her cervical dystonia. Findings:  The physician reviewer found that Dystonia has been defined as a painful condition in which neck muscles contract involuntarily, causing the head to twist or turn to one side. Sometimes the contractions are sustained and other times the neck muscles spasm, causing a repetitive, jerky movement of the head. Treatment for cervical dystonia usually involves botulinum toxin injections. Therapy may take several cycles to be optimized, usually starting with low dosing and selectively increasing dose, or changing which muscles are treated to fine tune results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for a labial revision procedure for treatment of her labial hypertrophy. Findings:  The physician reviewer found that women who are symptomatic from labial hypertrophy generally get complete relief of their symptoms after reduction in the labial size. They are able to engage in intercourse without the labia getting caught and pulled. All told, patients such as this patient tend to be very pleased with the results of the surgery, in terms of both appearance and function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch for treatment of his morbid obesity. Findings:  The physician reviewer found that there is no scientific evidence which supports the position that patients who have a BMI of less than 50 and have undergone the duodenal switch procedure have done worse than those patients who had a BMI of greater than 50.With the duodenal switch procedure, common and alimentary channel lengths can be tailored for each patient, which in fact makes the procedure more versatile, allowing for greater use of the procedure in a variety of patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested for surgery performed, preoperative studies and postoperative studies for evaluation and treatment of his brain tumor. Findings:  The physician reviewer found that this was not available in the usual neurosurgical setting or standard neurosurgical operating room. An intraoperative MRI scan was utilized. If abnormal tissue had been found, further surgery would have been performed. If an MRI was performed postoperatively and a lesion was identified, the patient would have to be returned for another operation to secure gross total excision of his lesion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for Neupogen (300mcg) injections for treatment of her neutropenia. Findings:  The physician reviewer found that recent guidelines from the American Association for the Study of Liver Diseases concluded that although there were currently insufficient data to recommend the routine use of G-CSF as a means of avoiding reductions in drug dosages, a number of small reports and anecdotal information from doctors treating co-infected individuals and post-transplant patients have suggested that the use of growth factors for neutropenia can be effective and generally well-tolerated. The current recommendation is use Neupogen when the ANC level drops to 750 or less to prevent any super-imposed infection during the course of HCV therapy, and to avoid any dose-reductions in hepatitis-C virus (HCV) therapy in an attempt to offer the patient the best chance to achieve sustained virological response (SVR) at the end of therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in danger without immediate medical attention. This patient was comfortable and sleeping in the emergency department. There is no documentation to support that this patients symptoms were of such severity that a prudent layperson would believe he required immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for continuous monitoring system supplies for treatment of her diabetes.   Findings:  Two physician reviewers found that there is evidence in the literature about the benefits of CGMS in adults and children and the device is accepted in the medical community that specializes in the management of diabetes. This years American Diabetes Associations 2008 Standards of Medical Care in Diabetes states that continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for 4-Aminopyridine, a compounded medication for treatment of her multiple sclerosis.    Findings:  The physician reviewer found that there is literature support for the use of fampridine in this patient population. Fampridine is medically appropriate for this patient in light of her progressive symptoms, which have been refractory to other therapies but showed improvement with fampridine.