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

A fifty-nine year-old female who has been diagnosed with shingles, lateral epicondylitis and complex regional pain syndrome is requesting authorization of Lyrica.Reviewers Findings:  The reviewing physician found that Lyrica has not been well studied or proven effective for treatment of the patients diagnosed conditions.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-three year-old female with elevated blood pressure, as well as heart palpitations, headache, and nose bleeds is requesting reimbursement for 24-hour ambulatory blood pressure monitoring (ABPM).Reviewers Findings:  The reviewing physician found that ABPM is not recommended as the initial or mandatory first step in the diagnosis of routine systemic hypertension.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year-old female with chronic daily headaches, fibromyalgia, and depression is requesting reimbursement and continued authorization and coverage of Lyrica.Reviewers Findings:  The reviewing physician found that Lyrica has not been well studied or proven effective for the management of chronic daily headaches, fibromyalgia or depression.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-two year-old female with a history of neck pain is requesting reimbursement for an anterior discectomy and fusion.  Reviewers Findings:  The reviewing physician found that there is no objective evidence in the record to indicate that inpatient admission and operative intervention were warranted for the treatment of the patients neck symptoms.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a fifteen year-old female with an eating disorder and bipolar disorder are requesting coverage of psychiatric residential treatment services.Reviewers Findings:  The reviewing physician found that it appears the patient had made sufficient gains that would have allowed segue to a lesser level of care. The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-three year-old obese female is requesting authorization for Xenical.  The patient had previously been treated with Xenical and experienced weight loss.  However, the patient had gained weight since discontinuing the medication.Reviewers Findings:  The reviewing physician found that there is no indication that prescription Xenical at a higher dose is indicated or necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old male with a history of Crohns disease is requesting authorization for a Pro-Predict Metabolites test.  Reviewers Findings:  The reviewing physician found that the Pro-Predict Metabolites test has not been approved by the Food and Drug Administration in clinical testing, as there are no prospective, randomized dose-testing studies to validate the therapeutic benefit of metabolic monitoring.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-eight year-old female who has undergone gastric bypass surgery is requesting authorization of mastopexy, brachioplasty and thigh lift.  Reviewers Findings:  The reviewing physician found that correction of skin laxity following massive weight loss is typically considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative treatment.  The reviewing physician found that the records do not establish that the proposed procedures are medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested radiofrequency turbinate reduction for treatment of his nasal congestion/obstruction.  Findings:  Two physician reviewers found that there is abundant literature on the use of radiofrequency ablation of soft tissue for treatment in the setting of OSA. At this time, the majority of the of the research involves  inferior turbinate reduction for chronic nasal congestion/obstruction that has failed to respond to medical management. This patient is the perfect candidate for radiofrequency reduction and it is medically appropriate in this instance. His underlying medical problems increase the risk of general anesthesia, he has failed medical therapy and he is willing to use the nasal CPAP to treat his OSA.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A seventy year-old male with myelodysplastic syndrome (MDS) with reported pancytopenia is requesting continued authorization and coverage of Neulasta.  Reviewers Findings:  The reviewing physician found that Neulasta is not indicated for on-going maintenance therapy in MDS.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty year-old female diagnosed with breast cancer is requesting authorization of an Oncotype DX assay.Reviewers Findings:  The reviewing physician found that the Oncotype DX tumor assay score quite accurately predicts the risk of recurrence of the cancer within ten years, if the patient is treated with hormonal therapy as the sole systemic treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-two year-old female with irritable bowel syndrome and chronic right buttock and lower extremity pain secondary to persistent sciatica is requesting authorization of Actiq.  Reviewers Findings:  The reviewing physician found that Actiq has not been approved for the management of chronic pain due to non-cancer related syndromes.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old female who was diagnosed with breast cancer is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that without more information, the clinical indication for the PET scan cannot be ascertained.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-three year-old female with chronic myeloproliferative disease is requesting authorization for a trial of low-dose thalidomide.  Reviewers Findings:  The reviewing physician found that thalidomide has anti-angiogenic and immunomodulatory properties; a review of the medical literature revealed many articles and abstracts in support of using low-dose thalidomide in this clinical scenario.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A nineteen year-old male who has a history of recurrent keloids secondary to bilateral ear piercing is requesting authorization for surgery to remove the two keloids.  The patient underwent surgical excision of the keloids, unfortunately, painful keloids recurred.  Reviewers Findings:  The reviewing physician found that treatment of the patients keloids is medically necessary because of functional impairment secondary to pain.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-nine year-old male with symptomatic chest pain is requesting reimbursement for a CT angiography (CTA).  Reviewers Findings:  Two of the three reviewing physician found that the CTA is appropriate for a symptomatic patient when there is an uninterpretable or equivocal stress test. In this instance the patients stress test was equivocal, establishing a valid basis for the application of CTA.  The third physician found that the CTA is considered investigational in most applications and is not a substitute for cardiac catheterization or nuclear SPECT imaging.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A twenty-seven year-old female who has degenerative disc disease is requesting authorization of multi-level artificial disc replacement surgery.  Reviewers Findings:  The three reviewing physicians found that artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty year-old female who has had a history of chronic pelvic pain is seeking reimbursement for the previous physical therapy as well as authorization for additional therapy. Reviewers Findings:  The reviewing physician found that there is adequate scientific evidence demonstrating the benefit of utilizing physical therapy to treat certain types of chronic pelvic pain.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-six year-old female who has breast hypertrophy is requesting authorization of bilateral reduction mammoplasty. Reviewers Findings:  The reviewing physician found that reduction mammoplasty provides the best and perhaps only chance for relief of this patients symptoms.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-eight year-old male with hypertension and chronic cough is requesting reimbursement for a CT scan.  Reviewers Findings:  The reviewing physician found that given the patients history, the CT scan at issue was medically necessary for evaluation of the patients medical condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-four year-old female who is post-menopausal with a history of breast cancer is requesting authorization for a repeat bone density scan.  The patient was being treated with letrozole.Reviewers Findings:  The reviewing physician found that it is standard of care to perform more frequent bone scans in patients such as this patient who was taking letrozole, a drug known to cause significant loss of bone density.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-one year-old obese female with significant comorbid conditions including type 2 diabetes, diabetic neuropathy, asthma, irritable bowel syndrome, hypothyroidism and hypertension is requesting coverage for bariatric surgery.  Reviewers Findings:  The reviewing physician found that the patients preoperative work up is by no means complete. There is no evidence in the record that she has consulted with a surgeon, obtained psychological clearance or obtained clearance from a gastroenterologist.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested an Otto Bock C-leg microprocessor controlled knee for treatment of his above-knee amputation.  Findings:  Two physician reviewers found that this patient is a highly functional ambulator with a prosthesis that is no longer safe for both skin and mobility reasons. The patients mobility needs require varied cadence and stability with stance phase. The proposed microprocessor controlled knee prosthesis is a medically reasonable functional choice for this patient and will best allow him to meet his mobility needs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested CT angiography (CTA for evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found that CTA is still considered investigational in most applications and is not a substitute for cardiac catheterization or nuclear SPECT imaging. In addition, the technology is not fully supported by the AHA and a consensus statement in 2006 confirmed that the test is not ready for widespread use at the time. Inherent limitations include sensitivity and specificity, the need for a low heart rate, the lack of visualization of distal vessels, the use of potentially nephrotoxic dye and radiation exposure. While the noninvasive nature of CTA makes it an attractive test, its exact role in the diagnostic algorithm of coronary artery disease is not fully defined.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a ten year-old female with delayed reading skills and learning disabilities and a diagnosis of a central auditory processing disorder (CAPD) are requesting for authorization and coverage of the recommended speech/auditory therapy.Reviewers Findings:  The reviewing physician found that the current literature suggests that CAPD is an ill-defined diagnosis and that the efficacy of the various treatments available for the disorder has not been established.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A fifty-five year-old female with a history of metastatic breast cancer treated with hormonal therapy and cytotoxic therapy is requesting authorization for authorization for high dose chemotherapy followed by stem cell rescue.  Reviewers Findings:  The three reviewing physicians found that the data in support of high dose chemotherapy followed by autologous stem cell transplant in breast cancer remains inadequate to support its routine use in any breast cancer setting.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-nine year-old female with a history of breast cancer is requesting authorization of an Oncotype DX tumor assay.Reviewers Findings:  The three reviewing physicians found that the Oncotype assay is a validated test published in peer-reviewed journals and presented in various oncological meetings. The test allows the clinician to tailor therapy to the individual patient based on the expression or lack of expression of certain genes.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-nine year-old female with a history of plantar fasciitis is requesting reimbursement for extracorporeal shock wave therapy.  Reviewers Findings:  The three reviewing physicians found that there are no long-term prospective studies of the effectiveness of extracorporeal shock wave therapy for treatment of plantar fasciitis.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-four year-old female with primary progressive multiple sclerosis is requesting reimbursement for a power operated vehicle and related accessories. Reviewers Findings:  The reviewing physician found that the submitted clinical records indicate the patient has an impaired ability to ambulate and is unable to push herself up independently from a chair.  The reviewing physician found that the Health Plan denial should overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-two year-old female who has recurrent substernal chest pain is requesting reimbursement for Enhanced External Counterpulsation (EECP) therapy.  Reviewers Findings:  The reviewing physician found that in this particular case, there does not appear to have been a concerted attempt at medical management.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An eighty year-old male who has chest pain with exertion only is requesting authorization for EECP.  The provider reviewed the role of catheterization with the patient but the patient was reluctant to undergo the procedure.Reviewers Findings:  The reviewing physician found that EECP is not considered a proven substitute for standard medical therapy or revascularization. EECP is instead considered appropriate in those cases where the patient cannot be safely revascularized and medical therapy fails.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old male with a history of major depression and attention deficit hyperactivity disorder is requesting authorization Provigil.  The submitted records do not document a trial of Strattera, Ritalin or amphetamines.Reviewers Findings:  The reviewing physician found that the submitted clinical information does not demonstrate the patient meets medical necessity criteria for Provigil. There are other medications that can be utilized in this case including Ritalin and/or amphetamines.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-five year-old female with hip issues is requesting reimbursement for the CT scans. Reviewers Findings:  The reviewing physician found that CT scans of the pelvis and abdomen were medically necessary in this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested bilateral pulsed radiofrequency ablation of the occipital nerves for treatment of her headache and neck pain.  Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. Available data is sparse and current outcomes do not support the superior efficacy or the lasting benefit of occipital nerve RFA. One of the few, randomized, controlled trials noted initial improvement, however there was no indication it was a better treatment than infiltration of the greater occipital nerve followed by the application of TENS.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested biofeedback therapy for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that biofeedback for incontinence has been studied extensively. Review of the relevant scientific literature fails to show additional benefit or sustained benefit over that obtained with pelvic floor exercises alone. As such, there is inadequate data to warrant the use of biofeedback as an adjuvant to standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-nine year-old female who underwent cochlear implantation is requesting authorization to replace the older speech processor with the Freedom model.  It is documented that the patient continues to receive benefit from the original processor.Reviewers Findings:  The reviewing physician found that the patient currently has a functioning speech processor; the availability of a newer, more advanced model does not indicate a need for replacement of the existing model.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-eight year-old female with a history of cirrhosis, Graves disease, and diabetes mellitus is requesting authorization of Xifaxan (rifaximin).Reviewers Findings:  The reviewing physician found that rifaximin is safe and effective in patients with hepatic encephalopathy, and is considered within the standard of care for the management of patients with this condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a fifteen year-old female with reported depression and suicidal ideation are requesting authorization of ongoing residential treatment.  Reviewers Findings:  The reviewing physician found that in the documentation provided there is nothing to substantiate the claim that the patient warranted continued residential treatment services.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male with a history of expressive and receptive speech delay is requesting reimbursement and on-going authorization for speech therapy.Reviewers Findings:  The reviewing physician found that the clinical records do not indicate the patient will achieve a specific diagnosis-related goal or achieve measurable improvement within a reasonable and predictive amount of time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty year-old female who complains of neck pain is requesting reimbursement for lumbar and cervical MR imaging.Reviewers Findings:  The reviewing physician found that there is no information regarding the duration of the patients symptoms or whether there was a trial of medication and/or physical therapy. Conservative therapy should be attempted before performing an MRI of the lumbar spine.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an eight-month-old male diagnosed with torticollis and plagiocephaly are requesting authorization of cranial orthotic therapy. Reviewers Findings:  The reviewing physician found that the record indicates the parents have attempted repositioning, but there is no evidence physical therapy has been attempted. Therefore, a two-month trial of physical therapy should occur before proceeding to cranial orthotics.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-six year-old female who has undergone gastric bypass surgery is requesting authorization of a mons pubis lift and bilateral brachioplasty.  Reviewers Findings:  The reviewing physician found that the records do not establish that the proposed procedures are medically necessary.  Correction of skin laxity following massive weight loss is typically considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative treatment. The reviewing physician found that the Health Plan denial should be upheld.