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

A 64-year-old female enrollee has requested a PET/CT scan for an evaluation of her adrenal mass. Findings:  Three physician reviewers found that the evaluation of an adrenal lesion is a common clinical scenario. Typical work-up for such a condition would be: 1) thin-section non-contrast CT through the adrenal glands to determine its size, confirm the presence of a nodule, and measure its density or 2) A magnetic resonance imaging (MRI) scan of the adrenal with in phase/out phase scans. If a thin-section non-contrast CT had been performed, it may have confirmed a low density nodule which is benign. Either of the above-mentioned procedures would have been more suitable as a first-step diagnostic test. If either of these procedures were inconclusive, then a PET/CT could have been considered at that time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees unspecified emotional disturbance and concurrent difficulties with sensory integration. Findings:  The physician reviewer found that speech and language therapy with emphasis on pragmatic language and social skills is medically necessary for this patient based on the submitted clinical information. Social communication is essential for development of peer relationships, as well as performance at home, school, and in the workplace. Children with social communication problems have difficulty with interpersonal communication and oral and written communication. Using language in an effective and appropriate manner in social situations requires pragmatic language competency. Increasingly, deficits in this area are linked to child and adolescent disorders. Because of the implications of continued deficits in this area, early intervention is essential. This patient has deficits in pragmatic language. He has difficulties with executive control functions and sensory integration as well. Whether these challenges are due to right hemisphere dysfunction or autism spectrum disorder (as indicated on the ADOS), they represent some type of neurological deficit. Historical and continued speech and language therapy with emphasis on social skills and pragmatic language development is therefore medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested chiropractic care for the treatment of his neck pain. Findings:  The physician reviewer found that this patient presented to his physician with a complaint. It appears as if the patient had sought other treatment with no positive results. Chiropractic practitioners are neuromuscular specialists. X-ray report indicates that there is a subluxation present, in which alignment, movement integrity and physiological function of the spine is altered. Chiropractic care is an appropriate conservative intervention in this clinical setting and is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested bariatric surgery (gastric bypass) for the treatment of his morbid obesity. Findings:  The physician reviewer found that this patient clearly meets the criteria set forth by the National Institutes of Health for surgical treatment of obesity. With a BMI of 49, weight loss surgery is medically indicated and necessary for this patient, as it is not likely that he will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested occupational therapy sessions for the treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is an accepted treatment for children with autism. The Council of Children with Disabilities recommends occupational therapy for autistic children. It has been shown that deficits in neurological processing and sensory integration can be improved with occupational therapy. Based on the clinical evidence provided, the patient is an appropriate candidate for occupational therapy. The requested occupational therapy sessions are medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment center services for the treatment of the enrollees anxiety disorder, not otherwise specified, identity problem and oppositional defiant disorder. Findings:  The physician reviewer found that at the time of admission, the patient did have psychiatric symptoms. However, a need for continued residential care was not established as of the date in question. The patient was not at risk of harm to self or others and did not require 24/7 professional monitoring beyond the last authorized date of service. She was not psychotic, and there was no suggestion that she would decompensate if she was treated at a lesser level of care. Although she had harmed herself in the past, she did not generally appear to be a current risk for such harm. She was described as alert and oriented and denied hallucinations, delusions, and suicidal and homicidal thoughts. The patient was stable for transfer to a less intensive level of care. Thus, she did not require treatment at a residential facility. She could have been safely and effectively treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 34-year-old male enrollee has requested a comprehensive skin biopsy karyotype for an evaluation of his medical condition. Findings:  The physician reviewer found that there are no cures for Down Syndrome, either typical or Mosaic. Therefore, treatment for the condition focuses on controlling symptoms and any medical conditions that may occur as identified. No specific screening is indicated as a consequence of Down Syndrome. Genetic testing and/or providing a definitive diagnosis does not improve the medical management of the patient, nor does it lead to treatment opportunities which would result in improved functionality. Genetic testing to prove or disprove the existence of Mosaic Down Syndrome is thus not medically necessary in this case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had noticed blood on his toilet tissue four days prior. He reported minimal pain. Although the patient states in his letter that he was experiencing large amounts of rectal bleeding, he was not actively bleeding at the time he was evaluated. When he presented to the Emergency Department, the patient was triaged as a level 5, minor illness. There is nothing in the records to substantiate that a layperson with an average knowledge of medicine would assume his health to be at serious risk without immediate attention. He was not actively hemorrhaging. Although his condition may have warranted medical evaluation, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent person with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested continued inpatient mental health treatment for the treatment of his mood disorder, not otherwise specified, anxiety disorder, not otherwise specified and history of bulimia behavior. Findings:  The physician reviewer found that the patient does have a history of serious psychiatric disturbance and in the past has made several suicide attempts. However, shortly after admission, the patient was clearly not psychotic, nor was he suicidal or homicidal. He did not have any particular medical problems, and did not have difficulties adjusting to medications. There was no suggestion that if discharged to a lower level of care he would undergo serious regression. Thus, the patient could have safely and effectively been treated at a lesser level of care. Inpatient treatment during that time was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested bariatric (LapBand) surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 40 and multiple co-morbid conditions. She meets the recommendations set by the National Institutes of Health (NIH) for weight loss surgery. The Swedish obese project study has clearly demonstrated that diet and exercise do not result in sustained weight loss in patients with morbid obesity. This study showed the long-term benefits of weight loss surgery and compared surgical intervention to diet and exercise plans. Furthermore, there is no scientific evidence that pre-operative weight loss results in a better outcome long-term for patients who undergo weight loss surgery. This patient meets the requirements set forth by the NIH for weight loss surgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Avastin for the treatment of her ovarian cancer. Findings:  Three physician reviewers found that it is reasonable to consider alternative biologic therapy such as Avastin to salvage this patients disease. Her current combination of Avastin with oral Cytoxan therapy has been tolerated with documented white blood count of 3,400. Any further cytotoxic regimen would likely result in significant risk of febrile neutropenia.  Therefore, Avastin is expected to be more beneficial than continuation of standard chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy services for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that this patient's deficits negatively impacted his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. It was therefore medically appropriate and necessary to provide speech and language therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an 11-year-old female enrollee have requested an OmniPod insulin pump for the treatment of the enrollees type I diabetes. Findings:  The physician reviewer found that the OmniPod is a desirable alternative since there is no tubing to be concerned with. However, the thickness of the disposable pod does lead to it being dislodged upon heavy contact. One limitation of that system is that the lowest basal insulin increments are only 0.050 units/hour versus 0.025 units/hour (provided from other systems). With the OmniPod, the patient has the ability to operate the pump remotely without exposing the pump to others, which can lead to better compliance and control, especially in light of this patients stated concerns. The OmniPod is a reliable pump approved for clinical use by the FDA. Its features are likely to become standard in updated versions of the competitive systems in due course. In summary, an OmniPod pump is medically appropriate and indicated in this case to improve compliance and control.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested PEG-Intron (pegylated interferon alfa-2b) for the treatment of his hepatitis C. Findings:  Three physician reviewers found that the patient has compensated hepatitis C by biopsy and exam. The standard of care would be to treat the patient. Based on the information provided, the patient is an appropriate candidate for treatment. The laboratory parameters set forth by the Health Plan are too rigid. The articles support treatment with pegylated interferon alfa-2b in this clinical setting. The proposed therapy is likely to be more beneficial in this case than the alternative, which is to provide no treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Cialis 5 mg to be taken daily for the treatment of his erectile dysfunction secondary to prostate cancer. Findings:  The physician reviewer found that the scientific literature reveals no references supporting the medical necessity of a daily dosage of Cialis. The effectiveness of Cialis, Levitra and Viagra are very similar. Results vary from one study to another, but a few have shown better results with Cialis. Daily dosage, however, has not been shown to be medically necessary. The medication enhances a receptor by being a PDE-5 inhibitor. It has not been shown to improve erectile dysfunction if taken on a daily basis. Daily use does allow the patient to take a lower dose and have the receptor inhibitor present on a continuous basis. The article by Wang concludes that further studies are needed to assess the use of Cialis on a daily basis for efficacy in post-radical prostatectomy patients. The medical need for a daily dosage has not been established as concluded in the study by Wang.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraine headaches, there is ample literature supporting its use when more traditional therapies fail.  In this particular case, the patient failed multiple standard first-line therapies for migraine. The evidence further establishes that Botox has in fact been effective for this patient in the past. Given the evidence-based data supporting the benefit of Botox for the treatment of migraines as well as the patients failure of standard preventive agents, Botox is likely to result in a superior clinical outcome in this case and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five year old male enrollee has requested speech and language therapy services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. In the case of this patient, the history of chronic otitis media may have added to his deficits. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. Speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox has been shown in several large, randomized, placebo-controlled studies to result in significant reduction in headache frequency and reduce the need for acute therapy. Given this patients previous response to Botox therapy, the requested therapy is likely be more beneficial for her than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Humira for the treatment of his psoriatic arthritis. Findings:  The physician reviewer found that Humira is Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis and has been associated with dramatic improvement in both skin and joint involvement, as in this patient. There is ample evidence in the medical literature for the therapeutic benefit of this drug in psoriatic arthritis. Fitzgerald writes that, As a result of numerous large, well-conducted, randomized controlled trials, there is now accumulating evidence that anti-TNF treatments are effective in controlling peripheral arthritis symptoms and signs, improving quality of life, and preventing radiologic progression. Overall, the scientific validity of Humira in this setting has been established and its use is consistent with the standard of care in rheumatology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that several interventions are available to improve communication in individuals with autism, and interventions are based on an assessment of needs. A review of the medical documents reveals no previous or current assessment/evaluation of speech and language needs. The progress notes provided are brief, and include limited details regarding the patients deficits and functional status. The documentation indicates that major identified goals have been met. Overall, the documentation submitted does not support medical necessity for speech and language services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested inpatient substance abuse treatment for the treatment of his chemical dependency. Findings:  The physician reviewer found that the patient presented with methamphetamine use 1-2 times per week according to the history provided in the medical records. He denied use of alcohol, marijuana or other substances. He presented with no withdrawal symptoms and with no history of psychiatric co-morbidity or major medical co-morbidity. It was reported that his mood was euthymic, with no suicidal ideation, no psychosis, and his memory was intact.  He was working and was involved with a court program. The medical records indicate he was active in an outpatient treatment program and the progress notes indicated the patient had been clean for 42 days. The level of care provided is consistent with practice guidelines and level of care utilization system guidelines. Given the patients functional status, the absence of significant co-morbidities, and his level of involvement in outpatient treatment, the medical necessity for a higher level of care is not evident in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested electromagnetic navigation bronchoscopy (ENB) for an evaluation of his lungs. Findings:  The physician reviewer found that this patient is at high-risk for any procedure, whether it be a lung biopsy as one physician has apparently suggested or the electromagnetic navigation bronchoscopy (ENB) which another physician has recommended. This patient has already had a pneumothorax with a CT-guided biopsy. An ENB carries the risks of both pneumothorax and the chance that it too would be a non-diagnostic procedure. Thus, the potential clinical value of an ENB in this setting is outweighed by the risk this procedure poses to the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a PET scan for an evaluation of her Parkinsons disease. Findings:  Three physician reviewers found that this patient has been diagnosed with idiopathic Parkinsons disease. The records indicate that she does not respond to L-Dopa and ropinirole. The use of an F-DOPA PET to evaluate this patient is unlikely to alter the usual therapy of a patient with a Parkinsonian syndrome as there is no difference in the treatments, just a difference in the patients response to those treatments. Since the result of such a test would not change treatment, and as the technology remains unproven in this setting, the requested F-DOPA PET is not likely to be superior to other diagnostic modalities in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Procrit for the treatment of her anemia. Findings:  The physician reviewer found that anemia of chronic disease (ACD) is commonly seen in patients with chronic infection, inflammation, or malignancy. It is a mild normocytic normochromic anemia, with low levels of serum iron and transferrin, normal to increased serum levels of ferritin, normal to increased levels of serum erythropoietin (EPO) and a low reticulocyte response for the degree of anemia. Patients with anemia of chronic disease may respond to the administration of recombinant human EPO, with improvement of symptoms which has been demonstrated in several trials. Based on this, an erythropoiesis-stimulating agent (ESA) is commonly used as an off-label indication. However, in view of the recent clinical trials demonstrating that use of ESA is detrimental when the hemoglobin is more than 10 g/dl, the use of the requested ESA (Procrit) should be limited to the times when the patients hemoglobin is below 10 g/dl. Thus, in this patient, it would be deemed medically necessary for use when her anemia is severe with a hemoglobin of less than 10 g/dl (which is consistent with the providers recommended use).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Lyrica (pregabalin) for the treatment of his neck pain. Findings:  The physician reviewer found that Lyrica (pregabalin) is an anticonvulsant which affects the alpha 2-delta N-calcium channels. Its use in neuropathic pain has been established. Current FDA indications include post-herpetic neuralgia, diabetic polyneuropathy and fibromyalgia. In a study by Freynhagen, et al., evidence was presented regarding the analgesic effects of pregabalin in neuropathic pain of peripheral and central origin. Diagnoses included polyneuropathies, chronic radiculopathies, encephalitis disseminata, post-herpetic neuralgia, acute zoster infection, neuropathic cancer pain and complex regional pain syndromes. Pregabalin appeared to be beneficial in patients with neuropathic pain who are difficult to treat because of refractoriness to conventional pain medications, as well as improving sleep impairment and quality of life. A second study by Siddall, et al. suggested that pregabalin may be helpful in managing pain related to spinal cord injury. This double-blind placebo control study showed a statistically significant drop in pain scores at 12 weeks. Efficacy was sometimes seen as early as one week. In fact, this patient has reported good results with a trial of Lyrica. Therefore, the use of Lyrica (pregabalin) in the management of this patients neuropathic pain is supported by the evidence and is medically appropriate and indicated.