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

A 60-year-old male enrollee has requested for a PET scan with CT for attenuation for evaluation of his Merkel cell carcinoma.   Findings:  Two physician reviewers found that a PET scan with CT attenuation was requested to rule out metastatic disease. Merkel cell carcinoma is a rare skin cancer that is often lethal. Because of this, the research for this disease is somewhat limited. A review of the peer-reviewed literature did show that PET scan with CT attenuation can be a useful adjunct in patients with Merkel cell carcinoma to evaluate for metastatic spread. The National Comprehensive Cancer Network indicates that imaging (including PET scan) may be appropriate to assist in the staging of a patient with Merkel cell carcinoma.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for naltrexone 3mg with lactose for treatment of her breast cancer.   Findings:  Three physician reviewers found that there is a lack of peer-reviewed literature indicating a benefit of this drug for this patients condition. This medication is not indicated for the management of breast cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested the prescription medication Elidel 1% cream for the treatment of her skin condition. Findings:  The physician reviewer found that a topical corticosteroid could have been used for this patients contact dermatitis.  There is no literature to suggest that a topical corticosteroid impedes healing more than Elidel. Although Elidel may have addressed the patients condition, a topical corticosteroid would have been considered first line therapy and would have been appropriate for treatment of the patients condition.  In addition, no evidence has been submitted as to why corticosteroids may have been contraindicated in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of an eight-year-old male enrollee has requested an external insulin pump for him for the treatment of the enrollees diabetes. Findings:  The physician reviewer found that management of the enrollee's Type 1 Diabetes cannot be accomplished with insulin syringes.  The external insulin pump is able to provide insulin in 0.05 unit increments.  There is no alternative device available.  It is very important in children to avoid hypoglycemia, as they may not be able to recognize the symptoms of a decreasing blood glucose level.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested a bariatric surgical procedure, laparoscopic gastric banding (lap band) for the treatment of her medical condition.  Findings:  The physician reviewer found that obesity has to be considered a multi-factorial chronic disease which develops from an interaction of genetic and environmental factors. This eventually leads to serious co-morbidities. At the present time, the patients only complaint is lower back pain.  The ASBS Consensus Conference states that class I and II obese individuals treated conservatively can achieve acceptable results in 10-40% of the cases. The degree of success depends greatly on the weight loss program design, which should include proper supervision with intense behavioral modification and exercise along with possible use of medication. Long-term weight loss is very difficult to maintain, and the majority of patients ultimately present as candidates for bariatric surgery.  However, the patient is young and does not have any comorbidities demonstrating the need for surgery. Based upon the information provided, this patient does not meet nationally accepted criteria for consideration of weight loss surgery and should continue attempts at conservative weight loss.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for an emergency room (ER) visit for care of her neck pain. Findings:  The physician reviewer found that the records provided do not support that this patients symptoms meet the prudent layperson definition of an emergency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has multiple obesity-related comorbidities that will be eliminated or ameliorated by bariatric surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested for an MRI of the brain for evaluation of her attention deficit/hyperactivity disorder (ADHD) and bipolar aggressive behavior. Findings:  The physician reviewer found that the accepted uses for MRI include musculoskeletal, cardiovascular, oncological and neurologic imaging.  The accepted neurological uses include acute onset of neurological signs and findings, new transient neurologic signs and findings, headache, seizure, trauma, follow-up of intracranial abscess and primary brain tumor, evaluation  for brain metastases, evaluation of arteriovenous malformation, post intracranial procedure/craniotomy, suspected central nervous system involvement with systemic disease, suspected neurodegenerative disorder, suspected hydrocephalus, non-acute onset mental status changes and macrocephaly and microcephaly.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for an emergency room visit for treatment of her abdominal pain and umbilical infection. Findings:  The physician reviewer found that she did not require any pain control in the emergency department. This patients symptoms were not acute in nature but rather were chronic. There is not evidence to support that an emergency existed in this case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for emergency room services for treatment of his hand injuries. Findings:  The physician reviewer found that a prudent layperson would not have left the emergency department without evaluation and treatment if he believed his health to be in danger. The submitted documentation does not support the argument that an emergency existed in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested for Electron Beam Computed Tomography (EBCT) for evaluation of his coronary condition.   Findings:  Three physician reviewers found that Electron Beam Computerized Tomography (EBCT) is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. The use of this test in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental/investigational application of this technology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for her skilled nursing facility care for treatment of her medical condition.    Findings:  The physician reviewer found that the patient did not receive skilled therapy and did not require skilled nursing services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for reduction mammoplasty for treatment of her neck, shoulder and upper back pain. Findings:  The physician reviewer found that concept supported in the medical literature is that patients who present with the typical symptoms of macromastia and who have a confirmatory exam benefit greatly from breast reduction surgery. As noted by Kerrigan, weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for a CTA coronary artery for evaluation of her coronary disease.   Findings:  Two physician reviewers found that there are guidelines from the American College of Cardiology (ACC) regarding the appropriate use of CTA coronary artery. The use of this diagnostic procedure for strongly positive stress testing for patients with chest pain has an inappropriate recommendation per the ACC guidelines. The patient is at high risk for coronary artery disease given her recent myocardial infarction. Her cardiolite test suggests ischemia.  Normally, the guidelines would suggest traditional cardiac angiography as the next step, and CTA coronary artery as an intermediate step as inappropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for laparoscopic gastric bypass surgery for treatment of her medical condition. Findings:  The physician reviewer found that studies have shown that long-term weight loss in class II is difficult to maintain, especially when physical activity is not possible or significantly limited, as is the case with this patient. It has been documented that there is a direct relationship between increasing BMI and relative risk of death.  There is no conservative method that will adequately treat this patients condition. Continued delay will expose her to grater risk of developing severe comorbidities. The 2004 ASBS Consensus has recommended bariatric surgery to patients who fall into this group who have a condition that can be cured or markedly improved by a substantial and sustained weight loss which can result from the operative procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for the prescription medication Aciphex (20 mg twice daily) for treatment of his acid reflux. Findings:  The physician reviewer found that the patient should attempt appropriate trials of Prevacid, Protonix or Omeprazole prior to consideration of Aciphex.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for the prescription medication Boniva for treatment of his low bone density.    Findings:  The physician reviewer found that although the Food and Drug Administration (FDA) approved indication for Boniva is for postmenopausal osteoporosis, this does not mean that it would be ineffective in treating men with osteoporosis.  Other biphosphates have indications for treatment in both men and women.  There are studies documenting the effective use of Boniva in men as well as women.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for a full body PET/CT scan for evaluation of his multiple myeloma.   Findings:  Two physician reviewers found that the fact of the matter is the initial PET scan now serves as a baseline for tumor involvement, and PET/CT scanning is a reasonable exam to monitor treatment response. A follow-up PET/CT scan is reasonable and indicated in this particular patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a continuous passive motion (CPM) device obtained following knee surgery for post-surgical treatment of his knee. Findings:  The physician reviewer found that the literature does not clearly support the role for CPM after knee trauma surgery. The literature does not clearly demonstrate that CPM improves long-term outcomes when compared to standard postoperative therapy measures. More outcomes data is needed to demonstrate the efficacy of CPM use in cases such as this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for a three week outpatient day treatment program for comprehensive interdisciplinary pain management.  Findings:  The physician reviewer found that the standard of care for long-term management of fibromyalgia remains medications, including analgesics, and skilled outpatient PT graduated to an active, self-directed home exercise program. The medical literature does not yet recognize the efficacy of weeks of outpatient day rehabilitation in the treatment of fibromyalgia.  Also, comprehensive pain management rehabilitation programs have not yet demonstrated better long-term pain and quality of life outcomes than traditional fibromyalgia treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested for right knee surgery for treatment of his right knee pain.    Findings:  The physician reviewer found that the requested procedure is complex and requires special expertise. However, it is appropriate and necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for acute mental health hospitalization services for treatment of her bipolar disorder. Findings:  The physician reviewer found that this patient had recently made a very serious suicide attempt. She was in no condition to be treated in a lesser level of care than in an acute hospital setting. It would not have been safe to discharge this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the procedure is especially useful in the super obese with significant hepatomegaly which makes conventional Roux-en-Y gastric bypass less tenable. The morbidity of the requested procedure is equal or better than Roux-en-Y gastric bypass nationwide.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for a right total ankle replacement for treatment of her polyarticular arthritis.   Findings:  Three physician reviewers found that the results of a total ankle arthroplasty, as stated in the literature, do appear to be similar to those of an ankle fusion.  One must realize that this individual has had an attempted failed fusion already. The right total ankle arthroplasty, at this juncture, would be more beneficial than an attempted repeat fusion. An arthroplasty would allow some remaining motion and would be a reasonable option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for a PET scan for evaluation of her ovarian cancer. Findings:  The physician reviewer found that PET scans for the initial evaluation of recurrent ovarian cancer have not yet been shown to be of more beneficial than standard imaging. As this patient has not had any other imaging to evaluate for recurrent/metastatic disease, a PET scan is not medically indicated for this enrollee at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for stereotactic radiosurgery for treatment of her C2 vertebral body metastasis, new right cerebellar and L5 metastasis.   Findings:  Two physician reviewers found that the only service in question now is treatment of L5. Conventional radiation is customary treatment for this lesion, and it is not followed by severe complications. There is no medical indication to treat this patients current condition with the requested radiosurgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for hyperbaric oxygen treatment for treatment of her squamous cell carcinoma.   Findings:  Two physician reviewers found that a recent Cochrane Database report analyzing all available evidence for hyperbaric oxygen treatment in patients with late radiation tissue injury concluded that this treatment is associated with improved outcomes in patients with late radiation tissue injury of the head and neck.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for insulin potentiation therapy for treatment of her poorly differentiated infiltrating ductal carcinoma of the left breast.   Findings:  Three physician reviewers found that there is no evidence that it provides clinical benefit superior to available standard therapies. There is a lack of peer-reviewed literature to support insulin potentiation therapy for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for Rituxan therapy for treatment of his progressive renal failure. Findings:  The physician reviewer found that there is data to suggest that Rituxan may be effective in membranoproliferative glomerulonephritis associated with Type 2 cryoglobulinemia, which is the predominant type of HCV-related glomerulonephritis. It is medically appropriate and reasonable that a trial of Rituxan be tried in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for residential treatment services for treatment of the enrollees bipolar disorder. Findings:  The physician reviewer found that there appears to be very little to support the patient needing something as intensive as residential placement at any time. The patient was not a particular management problem when in residential placement. She was not suicidal and also was not particularly interested in treatment (exhibited by running away).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for sub-acute inpatient detox services for treatment of his substance abuse. Findings:  The physician reviewer found that the patient had no clinical or behavioral condition that required 24-hour care. Furthermore, there is no documented failure of care at a lower level of professional intervention, such as partial hospitalization or intensive outpatient care, or that there was a contraindication to such care.  There is also no evidence that the patient lacked an appropriate supportive network.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for a laparoscopic adjustable gastric banding for treatment of her morbid obesity.    Findings:  The physician reviewer found that the 2004 Bariatric Surgery Consensus Conference Statement recommends serious consideration of bariatric surgery for obese patients with a BMI 30 to 34.9, especially when a condition exists which can be markedly improved by substantial and sustained weight loss.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for an emergency room for treatment of her severe bloating and diffuse pain. Findings:  The physician reviewer found that a patient must be suffering from symptoms of such severity that a prudent layperson would expect the lack of immediate medical attention to jeopardize her health. This patient admitted that she had suffered similar symptoms in the past related to her gastroesophageal reflux disease. She had stopped taking medication prescribed for her symptoms. Her pain was not severe and had commenced over several hours. Her symptoms do not meet the prudent layperson standard for an emergency.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for a CT coronary calcium study for evaluation of his coronary condition.   Findings:  Three physician reviewers found that CCT is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. CCT is also not a medically acceptable substitute for coronary angiography, as CCT would not be able to accurately confirm or exclude important coronary obstruction. The use of CCT in the diagnosis and prognosis of coronary disease in this subset of patients remains an investigational application of this technology.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested an AutoMed 3400 infusion pump and services related to the initiation and discontinuation of the infusion of 5-FU in the prescribing physicians office for the treatment of his rectal cancer. Findings:  The physician reviewer found that it is medically necessary for this patient to utilize the smaller infusion pump and to have his infusion services at his doctors office.  The requested pump is smaller in all aspects, including needle size, fluid requirements and weight. These factors make it the better medical option for administration of the chemotherapy. It is safer and more effective for this patient than other available infusion pumps. Based upon the patients history and current condition, it is also medically appropriate for the patient to receive these infusion services at his physicians office.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested acupuncture services for the treatment of her endometriosis. Findings:  The physician reviewer found that the patient's primary complaints are chronic endometriosis/abdominal problems, fatigue and back pain.  She is requesting continuation of acupuncture treatment.  The patient has been receiving ongoing acupuncture treatment for her symptoms. On prior progress reports, the pain level, as reported on an analog scale of 0 to 10, was between 3 and 4. It appears that this patient has plateaued, as there has been no significant change/deviation in the level of pain. Accordingly, at this time, the Health Plans denial of authorization for continued acupuncture treatment should be upheld as continued treatment would appear to be maintenance in nature.  Should the patient have an acute/severe exacerbation of symptoms, then further treatment might be considered at that time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested aspirin desensitization treatment for the treatment of his chronic sinusitis. Findings:  The physician reviewer found that the usefulness of aspirin desensitization treatment in this condition has been well-documented to reduce and/or eliminate anaphylaxis with the use of NSAIDs, significantly improve asthma and to reduce the re-growth of polyps and the need for recurrent surgery. This is well-documented in peer-reviewed published studies. Aspirin desensitization can be performed by a trained allergist/immunologist, and this is medically appropriate in this patients case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that this patient had a known history of blood clots in her portal vein. Upon further evaluation, she was found to have an acute blood clot in her heart for which further testing was necessary. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and health would reasonably expect the absence of emergency care to jeopardize their health.