Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over several days. Although she was experiencing chest tightness with deep breaths, this was not noted to be severe, nor did she report fever or shortness of breath. The patient had normal vital signs, and the only study obtained in the Emergency Department was a chest x-ray. The patient did not require any oxygen or other medications in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet the criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested hormone replacement therapy (HRT) for the treatment of her postmenopausal osteopenia. Findings:  The physician reviewer found that this patients medical issues are multifactoral and estrogen deficiency is only one of the factors. She has abnormal liver function, possible diabetes, depression, irritable bowel syndrome, and osteoporosis. The patients primary care provider has declined to prescribe HRT as the provider is reasonably concerned with the patients history of smoking and possible related risks for cardiovascular problems and deep vein thrombosis. The provider also addressed the possible risk of ovarian cancer with use of HRT. The records indicate the patient received HRT for more than five years in the past. In the medical literature, although it has been suggested that HRT may protect against some malignancies (i.e., colon cancer) it has been documented to increase the risk of other malignancies. Corbin and colleagues indicate that HRT is contraindicated in active liver disease. This patient has elevated liver enzymes attributed to fatty liver. Furthermore, while it is not clear from the records provided how long the patient has been off of estrogen, there is an increase in cardiovascular disease when initiating HRT later in menopause as noted by Rossouw and colleagues. All told, the risks of HRT outweigh the potential benefits for this patient. As the literature suggests, the use of HRT in this setting is not recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 45.8 and several co-morbid conditions, which makes her an appropriate candidate for surgical intervention. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Furthermore, there is a body of scientific evidence that shows superior short and long-term outcomes with the duodenal switch procedure when compared to the gastric bypass or the lap-band procedure. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. As with any weight loss surgical procedure, the patient should undergo appropriate psychological evaluation prior to surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for Synvisc for treatment of her osteoarthritic changes in her knees. Findings:  The physician reviewer found that Viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. Although the documentation is limited, it appears as if the patient improved with the first course of Synvisc, as the provider noted excellent prolonged improvement. Synvisc is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for the speech generating device DynaVox V for treatment of his dense global aphasia and apraxia and dense hemiparesis. Findings:  The physician reviewer found that this patient faces significant barriers to communicating effectively in educational, social and home situations because of the disabilities resulting from his illness. Technology will allow him to overcome some of these barriers by providing an alternate means of communication. He has demonstrated adequate ability to use an AAC device/SGD. Without such a device, he will not be able to achieve his full potential or maximize his independence. The literature supports the use of such communication devices for individuals such as this patient. In one study, 86% showed gains in speech with AAC intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for a blood glucose monitor for treatment of his pre-diabetic condition.  Findings:  The physician reviewer found that criteria for a diagnosis of diabetes are found in the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) guidelines. A fasting glucose of 112 mg/dl is considered pre-diabetes. However, a two-hour glucose tolerance test is the standard test to determine this diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that it is true that more frequent than annual screening MRI is generally not indicated, even in high-risk patients. However, the MRI requested in this case is for problem solving and monitoring of a specific area seen within the breast that can only be evaluated with a repeat MRI. In this particular setting, physical exam, standard mammography and ultrasound are not sufficient exams to determine if a biopsy is necessary. The dense tissue on mammography and the equivocal findings on ultrasound attest to the limitations of these standard techniques. The lesion in question is best seen on MRI and given the patients strong family history, careful monitoring is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an MRI of the left knee for an evaluation of her osteoarthritis. Findings:  The physician reviewer found that in the peer-reviewed literature there is a lack of support for the use of MRI of the knee in the evaluation of advanced osteoarthritis. The American College of Radiology guidelines do not recommend MRI in patients with documented advanced osteoarthritis on plain radiographs. MRI is sometimes utilized in patients with advanced osteoarthritis for preoperative planning. In patients with advanced osteoarthritis, MRI does not add any further clinical information. MRI of the left knee is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested ultrasound-guided sclerotherapy for the treatment of her varicose veins. Findings:  Three physician reviewers found that generally sclerotherapy is not used as primary treatment for greater saphenous reflux. In the case of this patient, sclerotherapy was used as sole therapy for treatment of the saphenous vein reflux. There is a lack of medical literature supporting the efficacy of sclerotherapy in this setting. There are other minimally-invasive options such as endovenous laser therapy and radiofrequency ablation, which have a lower rate of recurrence as compared to sclerotherapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department with a two-day history of a rash. The patient denied hoarseness or sore throat and was in no acute distress upon examination. The patient reported that he was exposed to poison oak.  The patient had been seen in the Emergency Department the previous day for similar complaints and treated. He was discharged with medications and instructions to return if his condition worsened. There is no documentation in the medical record of facial swelling or angioedema. The patient was discharged in stable condition with a diagnosis of contact dermatitis. The issue in this case is whether a prudent layperson would have sought immediate medical attention for the patients complaints of a skin rash. The patient was not in acute distress, with no difficulty swallowing. There was no documentation in the Emergency Department record of angioedema, hoarseness or stridor. There is no indication in the medical record that the patient was at risk for airway obstruction. All told, there is insufficient documentation in the submitted medical records to support a finding that a prudent layperson would have sought immediate medical attention for this complaint of rash.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a sacroiliac joint injection for the treatment of her back and hip pain. Findings:  Two physician reviewers found that although SI joint injection treatment remains the subject of debate, its use in this particular case was medically appropriate. SI joint injection has been in use for pain for several years as a diagnostic and therapeutic modality. Passar and colleagues in their educational guidelines for interventional spinal procedures recommend that consideration for SI joint injection be given to those patients with pain below the L5 spinal level who have failed to respond to conservative management and have had pain for at least 4 weeks. This patient meets those criteria. An article by McKenzie-Brown and colleagues which evaluated SI joint injection for diagnostic and therapeutic purposes concludes there is a moderate level of data to support the efficacy of SI joint injections. Furthermore a prospective comparative study comparing the effect of periarticular and intraarticular injection of the SI joint revealed that periarticular SI joint injections were effective in providing pain relief for all 25 patients (Murakami and colleagues).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that Byetta is a GLP-1 agonist and Januvia is a DPP-IV inhibitor that will decrease the downgrade of GLP-1, an incretin that stimulates insulin production in relation to a meal. There is a lack of studies to support the safety of their use at the same time and long-term.  In addition, the combined use would be duplication of therapeutic action as they both potentiate the incretin effect. Byetta was not and is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for Avodart 0.5mg for treatment of his benign prostatic hyperplasia. Findings:  The physician reviewer found that Proscar and Avodart are two 5-alpha reductase inhibitors blocking the conversion of testosterone to the active form dihydrotestosterone. This action results in decreased glandular activity. The decreased glandular activity results in decreased prostate volume over many months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for acute inpatient services for treatment of his shortness of breath.  Findings:  The physician reviewer found that the patient was admitted on an episode of shortness of breath. He did not present with symptoms of an acute coronary syndrome. His initial workup did not reveal an abnormal EKG or chest x-ray. However, his Troponin level was minimally elevated and was an indication for further workup. The patients Troponin level did not show further elevation. Since significant cardiac ischemia had been excluded, the patient could have been safely discharged.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that IMRT is an established technique of radiation delivery which potentially affords even more precise radiation dose delivery of escalated doses, in appropriate cases, to targeted tumors, while sparing nearby healthy tissue structures. IMRT has the capability of generating concave dose distribution and tight dose gradients and is felt to be well-suited to the treatment of prostate, to avoid exposure of the rectum, small bowel and bladder. A number of indirect studies exist that describe the dose volume toxicity advantages of IMRT over non-IMRT radiotherapies. Multiple dosimetric and treatment planning comparative studies have favored IMRT over 3D conformal radiation treatment in the treatment of localized prostate cancer. IMRT has demonstrated improved conformality to and homogeneity within the target tissue. It has been hypothesized that IMRT may improve treatment outcomes by permitting escalated tumor doses without increasing normal tissue toxicity. There is evidence from randomized control trials showing a dose response relation above 68 Gy for local and biochemical control of prostate cancer. In addition, dose volume toxicity relations have been established for rectal bleeding and other gastrointestinal and genitourinary toxicity. Veldeman and colleagues concluded that IMRT creates a window for dose escalation with unchanged or lower gastrointestinal and genitourinary toxic effects. Zelefsky and colleagues showed that the use of IMRT reduces risk for grade 2 or greater gastrointestinal toxicities compared with patients treated with 3D conformal radiation treatment from 13% to 5%. Guidelines on prostate cancer treatment from the National Comprehensive Cancer Network were revised in 2008 to add IMRT to 3D conformal radiation treatment throughout the guideline.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for CyberKnife stereotactic radiosurgery (SRS) for treatment of her pancreatic cancer.    Findings:  Three physician reviewers found that according to current National Comprehensive Cancer Network (NCCN) Practice Guidelines for patients with unresectable adenocarcinoma of the pancreas without any evidence of metastasis or jaundice and who have good performance status, treatment options include gemcitabine-based chemotherapy with or without chemoradiation or a clinical trial. Stereotactic radiosurgery, or SRS, is a technique that employs a very high dose of radiation given over few fractions. SRS is not included as a recommended therapy for this indication in the NCCN guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested for Lap Band surgery for treatment of his obesity. Findings:  The physician reviewer found that there is a lack of scientific evidence indicating that pre-operative weight loss improves or predicts outcome. The requirement of participation in a six-month physician-supervised weight management program is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested for ultraviolet A or B phototherapy for treatment of his vitiligo.   Findings:  Three physician reviewers found that there are many therapies for vitiligo including topical corticosteroids, topical immunomodulators, topical calcipotriol ointment, narrowband ultraviolet phototherapy and the Excimer laser. There is no therapy that far exceeds the others in efficacy and most therapies display only mild to moderate improvement in vitiligo. Topical therapies have the benefit of longer usage with few side effects except for cutaneous atrophy with topical steroids.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested Lasik surgery for the treatment of her headaches secondary to vision issues. Findings:  The physician reviewer found that the requested Lasik surgery for correction of refractive error is not medically necessary for this patient. There is no documentation provided that indicates this patients headaches are related to an ocular condition or her glasses. The providers notes state the indication for Lasik in this patient is not the headaches but the refractive error. While the patient states that she cannot wear contact lenses due to the curvature of her cornea, her ophthalmic examination revealed a cornea curvature that should be an easy fit for contact lenses despite her history of dry eyes. There is no documentation to suggest the patients facial pain is due to her glasses and if it is due to her glasses, there is no documentation of an adequate attempt at trying different styles of glasses that were fitted by certified opticians.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the left knee for an evaluation of his left knee pain. Findings:  The physician reviewer found that evidence of instability, effusion or an abnormal x-ray or physical exam is necessary in order for an MRI to be indicated. This patient has no indication for MRI of the knee by any accepted guidelines. A trial of conservative treatment and/or referral to a specialist is the next appropriate step in this setting. An MRI is not medically necessary for evaluation of the patients knee pain without first exhausting conservative treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested the use of a continuous passive motion (CPM) machine for the treatment of her medical condition status post anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the efficacy of the use of a CPM machine following knee surgery remains the subject of debate. The majority of studies do not support the use of CPM as the findings showed no statistical difference associated with the use of a CPM device following knee surgery. The long-term effects of prolonged CPM do not transfer to better functional performance. A recent study by Bruun-Olsen and colleagues concludes that CPM was not found to have an additional short-term effect compared with active physical therapy. This patient was receiving active physical therapy after her knee surgery which, along with home exercises, was all that was needed to improve her range of motion (ROM).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested psychological testing, procedure code 96101 for an evaluation of the enrollees autism. Findings:  The physician reviewer found that psychological testing is considered medically necessary for the purpose of establishing the diagnosis of brain-based disorders and to develop a treatment plan. In the case of this patient, there is no indication in the submitted documentation that the requested testing would alter either the diagnosis or treatment plan. There is a clear and established diagnosis of autism spectrum disorder. In regards to the treatment plan, the patient has been receiving ABA services, speech and occupational therapy and Regional Center services. He is also treated at a private clinic. Possible medication trials have already been recommended. Thus, the submitted documentation does not establish that additional psychological testing would impact this patients existing diagnosis or treatment plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested use of a continuous passive motion (CPM) machine for the treatment of the enrollees medical condition status post anterior cruciate ligament replacement surgery. Findings:  The physician reviewer found that ACL repair surgeries have been performed in the hospital but with shorter hospital stays. The use of a CPM device in the hospital after surgery has become a standard of care. The shorter hospital stays have resulted in utilization of the CPM device in the home in the post-operative period. All of the references suggest that the standard of care post ACL repair for both young and older patients is to use a CPM machine daily for at least two weeks. Thus, the use of the CPM equipment for two weeks following surgery is consistent with the recommendations in the studies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested cortisone injections into the third digit of her right hand for the treatment of her osteoarthritis. Findings:  The physician reviewer found that it is not uncommon in orthopedic clinical practice to give cortisone injections for arthritic pain. Clinically, these injections can be expected to provide relief for three to six months. Cortisone injections do have anti-inflammatory effect, and thus, are most appropriately given in the presence of inflammation. The submitted clinical evidence does not demonstrate the patient is currently experiencing inflammation. Furthermore, there are recognized complications of cortisone injections including tendon weakening, subcutaneous joint atrophy and possible damage to cartilage and surrounding tissues. As such, cortisone injections into joints should be limited to no more than three per year for any indication and should not be provided in the absence of documented inflammation in the affected joint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that this patient was suicidal with plan and was unwilling to contract for safety. Her thinking suggested a possible psychotic element. The patient did improve in hospital, but she contracted for safely slowly and with some reluctance. Additional problems surfaced. An eating disorder with purging and possible drug use was also recognized. Family issues surfaced. The patient had improved somewhat. However, her improvements were not internalized sufficiently to allow her safe treatment at a lesser level of care. The patient continued to need 24/7 professional observation and supervision in the hospital setting. It was not established that her suicidal thinking was fully and safely resolved. Her eating disorder had only begun to be addressed. Her support system was only newly established. Acute inpatient psychiatric treatment provided was medically indicated.  It would have been unsafe and imprudent to discharge the patient earlier.