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

The parent of an eight-year-old male enrollee has requested brain imaging (SPECT scan) for an evaluation of the enrollees Aspergers syndrome. Findings:  Three physician reviewers found that this patient does have a variety of psychiatric symptoms. However, the use of SPECT scan is not an accepted method of evaluation. Imaging techniques of this kind have not been demonstrated to be useful diagnostic tools in the evaluation of mental disorders in children and adolescents. SPECT scan was not more beneficial for evaluation of this patients condition than a standard child psychiatric examination. The use of SPECT scan was investigational and not clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested an ultrasound, foot and ankle strapping, and electrical stimulation for the treatment of her feet. Findings:  The physician reviewer found that the literature demonstrates that there is no evidence to support the efficacy of the modalities used in improving clinical outcomes for this patients diagnoses. The literature noted that these modalities have not demonstrated proven efficacy, while noting that most studies are limited for these modalities. Thus, these modalities are of questionable benefit for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested Provigil for the treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that this patient has a stated diagnosis of narcolepsy with cataplexy, which is a primary indication for Provigil. A multiple sleep latency test is not required to diagnose narcolepsy if the patient has cataplexy. However, no appropriate documentation was submitted to substantiate this diagnosis. Overall, there are no records confirming narcolepsy with cataplexy or shift work sleep disorder to justify coverage for Provigil at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested  for speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees pervasive developmental disorder. Findings:  Two physician reviewers found that ABA therapy, speech therapy and occupational therapy are medically indicated for the treatment of this patient based upon a review of the current literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 74-year-old male enrollee has requested endoscopic third ventriculostomy (ETV) for the treatment of his hydrocephalus. Findings:  Three physician reviewers found that this patient has been diagnosed as having normal-pressure hydrocephalus (NPH) and had temporary improvement with lumbar drainage, which is supportive of that diagnosis. The standard of care at this time is a VP shunt. ETV has gained acceptability as a treatment for obstructive hydrocephalus and research suggests it may be an effective treatment for communicating hydrocephalus. Current literature calls for more clinical studies to explore further the role of this treatment in communicating hydrocephalus therapy. The literature does not support ETV as preferable or superior to a VP shunt.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested osteochondral knee allograft for the treatment of her knee pain. Findings:  The physician reviewer found that the requested osteochondral knee allograft is medically appropriate and reasonable. Given the patients young age and high activity level, arthroplasty should not be considered. Microfracture has also failed. All told, osteochondral knee allograft is likely to be the most efficacious procedure in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested continuation of growth hormone (Genotropin) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the submitted evidence indicates that the patient has responded well to the preparation. Synthetic GH therapy made by a variety of manufacturers appears to be equally effective and without differential immunogenicities. However, immunogenicity has been problematic in certain developmental GH preparations and therefore it is not advisable to switch biological products at this point.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested continued use of any narcotic pain medication for the treatment of her chronic pain. Findings:  The physician reviewer found that treatment of pain in such patients or in those with a history of drug abuse or addiction should include consultation with or referral to an expert who can provide skilled assessment and monitoring. Clinicians must always consider the potential for addiction during the treatment of any patient. The experience of pain management programs further encourages caution in the treatment of patients with idiopathic pain, high levels of psychological distress or disability, previous overuse of medical resources or overuse of prescription or non-prescription drugs. The requested medication is not medically indicated or appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that the National Institutes of Mental Health discovered that among the many methods available for treatment of individuals with autism, ABA has become widely accepted as an effective treatment. Filipek and colleagues indicate that treatment requires a comprehensive multidisciplinary approach that includes speech-language therapists and occupational therapists. Foxx and colleagues note that ABA is a state of the art treatment modality for this medical disorder. ABA utilizes methods derived from scientifically established principles of behavior. Various behavior and analytic methods are employed and individualized for the patients. Whenever possible, treatment should approximate the patients natural environment. ABA therapy is a therapeutic intervention and a health care service and is accepted in the professional standards of practice. The medical records of this patient document the impairments and symptoms that support the need for the requested ABA therapy, speech therapy and occupational therapy. These requested services are medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a custom ACL knee brace for the treatment of her medical condition status post ACL repair surgery. Findings:  The physician reviewer found that while certain physicians use an off-the-shelf anterior cruciate ligament derotation brace postoperatively to try to decrease the risk of recurrent anterior cruciate ligament injury, the indication for a custom brace is a patient who cannot be fit with an off-the-shelf brace for some unusual anatomic reason.  In this case, there is no documentation of an unusual anatomic reason or an apparent trial of an off-the-shelf brace.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested cardiac evaluation and more frequent cardiology evaluations for the treatment of her heart condition. Findings:  The physician reviewer found that studies performed have demonstrated that more effective care is given to patients for the treatment of cardiac disease when performed by a cardiologist compared to care performed by an internist. Thus, annual follow-up visits with a cardiologist are medically necessary, unless recurrent symptoms develop that are of concern for an exacerbation of her underlying heart disease, thereby requiring more frequent evaluation. That said, there is no evidence that the patient needs to continue to be followed by her doctor specifically. A referral to a board certified cardiologist would be medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 17-year-old female enrollee have requested residential level of care for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patient required close RTC level of supervision throughout her stay. Her past history was of severe anorexia with medication complications and this entire level of service should be covered as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a computed tomography (CT) scan of the sinus for an evaluation of her sleep apnea, bruxism and temporomandibular joint (TMJ) dysfunction. Findings:  The physician reviewer found that there is a scarcity of scientific literature supporting the use of static CT scanning as being efficacious in determining treatments and predicting outcomes in patients with OSA.  While real-time nonstatic studies do appear to yield useful information, optical coherence tomography and computer assisted video-endoscopy are still largely investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Daytrana transdermal patch for the treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that the relevant evidence demonstrates that Daytrana transdermal patches are medically necessary for this patient. Adler and colleagues support this finding based on their randomized, double-blind, placebo-controlled, 6-month trial examining the efficacy of the atomoxetine in ameliorating symptoms through the evening hours. Adler and colleagues concluded that in their study of 94 patients randomized to atomoxetine and 112 patients randomized to placebo, the once-daily morning-dosed atomoxetine was efficacious for treating ADHD in adults when measured 10 weeks and 6 months after initiating treatment. Further, Patrick and colleagues state, Concentrations of l-MPH (methylphenidate) typically attain 40-50%...vs. 1-2% following oral MPH and therefore not only address potential swallowing difficulties, but also offers flexible, individualized MPH exposure time in a once-daily regimen. The fact that this patient has shown contraindications to a variety of other oral stimulants and positive response to the requested medication further emphasizes the medical necessity of the Daytrana transdermal patch for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested growth hormone therapy (Genotropin) for the treatment of the enrollees hypopituitarism. Findings:  Three physician reviewers found that there is not enough evidence to support that the patient has pituitary growth hormone deficiency. The documentation provided suggests low IGF-1 deficiency. IGF-1 deficiency can be seen in conditions other than pituitary dysfunction, such as malabsorption and malnutrition, liver disease, and other catabolic states. Additional endocrine evaluation would be needed to establish pituitary growth hormone deficiency. If she indeed has hypothalamic adrenal insufficiency and hypothalamic hypothyroidism, the criteria for treatment under FDA approval will be fulfilled and GH treatment would be indicated. Osteoporosis is associated with GH deficiency but it is not an indication for GH therapy. Most studies that show positive evidence of GH therapy in catabolic states or aging, for example, caution that there are not enough safety studies regarding the doses and effects of GH therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Indium-III Pentetreotide therapy for the treatment of his metastatic carcinoid tumor to the liver. Findings:  Two physician reviewers found that this patient has previously received SIRT twice, and there is concern about radiation dosage to the liver with additional internal radiation therapy. Furthermore, the published studies are Phase I-II studies, and there are no well-designed clinical trials suggesting superior benefits of the proposed treatment. The efficacy of this treatment is yet to be determined. Lastly, this patient has disease not only in the liver but also in the omentum, which probably will not benefit from the requested therapy if given.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested aquatic-based physical therapy (PT) from a non-contracted provider for the treatment of her knee status post total knee arthroplasty. Findings:  The physician reviewer found that although aquatic therapy is certainly a choice of modality for treatment, there is no proven benefit over land-based PT in the treatment of osteoarthritis of the knee/hip. The study by Wyatt and colleagues found that both aquatic and land-based exercise programs were beneficial for osteoarthritis. Bartels and colleagues review of several studies for aquatic exercise for knee and hip osteoarthritis determined that the available studies were not conclusive to recommend aquatic therapy over land-based therapy. This reviewer did not find any published randomized, controlled trials comparing the effects of land-based versus aquatic PT for patients following TKA. Ulrich and colleagues study regarding focused rehabilitation treatment of poorly functioning TKA recommends various rehabilitation techniques, but they do not include aquatic therapy. Based on the totality of the available evidence, aquatic therapy following TKA has no proven benefit over land-based PT. Here, although this patient had improvement in ROM, aquatic therapy is not proven to be superior to traditional (i.e., land-based) physical therapy. The gains may have been made had the patient continued land-based therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections for the treatment of her chronic migraines. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraines, it has been shown to be effective in some patients who suffer from chronic headaches. Studies supporting this are listed above. This particular patient has failed multiple standard treatments for headaches. She has also shown benefit with Botox in the past. Botox therapy is medically reasonable and indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Genotropin for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that growth delay associated with small for gestational age, nutritional growth deficiencies, and idiopathic short stature, are all possible contributing factors to this patients condition. Assuming that he has been adequately treated by a gluten-free diet, then it is likely this patient has a diagnosis of idiopathic short stature, and is likely to be in the category of severity for which the FDA has approved the use of growth hormone (more than 2.25 standard deviations below the mean for age and sex, or the shortest 1.2% of children). All told, there is adequate evidence to justify the use of growth hormone therapy by this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested Mirena Intra-Uterine Device (IUD) for the treatment of her menstrual disorder. Findings:  The physician reviewer found that this patient has not received adequate relief from her dysmenorrhea from oral contraceptive pills, hormonal pens, or narcotics. Her symptoms are severe and quite debilitating. As the above cited studies indicate, intra-uterine devices have been shown to be successful in the treatment of menstrual disorder. These devices can decrease the need for surgeries.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested daily doses of Cialis 5 mg tablets for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that 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. The medication enhances a receptor by being a PDE-5 inhibitor. A daily dosage allows the patient to take a lower dose and have the receptor inhibitor present on a continual basis. The medication has not been shown to improve symptoms of erectile dysfunction if taken on a daily basis. The medical need for the proposed daily dosage has not been documented in peer reviewed literature. In this case a daily dosage of Cialis 5mg tablets has not been shown to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent and conservator of a 40-year-old female enrollee has requested transfer to an out-of-network facility for brain rehabilitation following the enrollees traumatic brain injury. Findings:  The physician reviewer found that there is no evidence that intensive neurological rehabilitation has a role in the care of patients who are unresponsive. The intensity and effective duration of such therapy is debated even for patients less seriously injured. The medical care for patients with severe head injury is a serious and complex matter. The Health Plans recommendations for consultation are appropriate and helpful, but most of the patients needs are custodial in nature, as there is no evidence or expectation that a comprehensive neuro-rehabilitation program will benefit an unresponsive person. There is no defined medical therapy that can be expected to improve outcome although anecdotal reports abound. Unfortunately, these reports do not provide a guide to a coherent systematic approach that can be expected to provide any benefit. At any rate, medical or pharmacological interventions designed to improve cognitive function can be employed at the patients current residence, especially in consultation with specialists as the Health Plan has suggested. There is no medical necessity for a move to a comprehensive center.  Finally, examination of her limbs found she was receiving satisfactory care with splinting, medication, and passive range of motion exercises for joint mobility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a power operated wheelchair for the treatment of his symptoms associated with multiple sclerosis. Findings:  The physician reviewer found that the patient does not have a documented mobility deficit that affects his ability to perform mobility related activities of daily living (ADL) within his home. Although he appears to feel weaker at times, there is no documentation that he is unable to perform normal ADLs within his home at those times. It appears that the patient is requesting a power wheelchair mainly for use outside the home. He does not meet the criteria for a power operated vehicle as he does not have a mobility related deficit that keeps him from performing or completing ADLs within his home. If he does indeed have intermittent mobility related deficits that affect his ability to perform ADLs, there is no documentation that his deficits cannot be ameliorated with the use of a walker or cane. Lastly, there is no documentation that the patient is not able to propel a manual wheelchair. Hence, he does not meet the criteria for a power operated vehicle. If he is at increased morbidity risk due to his mobility deficit, a cane, walker or manual wheelchair must have failed to correct this deficit before guidelines for a power operated vehicle are met.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee is requesting surgical removal of an eye lesion for the treatment of his pterygium. Findings:  The physician reviewer found that surgical removal of pterygium has a significant rate of recurrence. It would be prudent to try conservative therapy and observe the patient for signs of growth. Pterygium is a benign lesion that is very common. In a small number of cases, the growth may approach the pupil and require surgical removal. This does not appear to be happening in this patients case. As such, there is currently no clinical indication for the proposed procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested vertebral axial decompression therapy for the treatment of her cervico-thoracic pain. Findings:  Three physician reviewers found that in the medical literature there is no good scientific evidence to support the use of vertebral axial decompression in the cervical spine over standard therapy. Furthermore, there is no indication from the medical records that the patient underwent and failed standard therapies for her medical condition. Vertebral axial decompression for this patients medical conditions is not generally accepted by the medical community as being a safe or an effective form of treatment and remains investigational and/or experimental.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested left breast ultrasound-localized needle bracketed segmentectomy with sentinel lymph node biopsy and possible lymph node dissection of the left breast and axilla for the treatment of her multi-focal left breast cancer. Findings:  The physician reviewer found that the requested needle bracketed segmentectomy is a standard of care surgical option offered to women with breast cancer. The treatment plan was presented to the patient who is in agreement with the approach. This patients initial core biopsy was performed a few months ago and it would be prudent to proceed with the needle-bracketed approach as quickly as possible.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Cyberknife (stereotactic radiosurgery) for the treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that there is a paucity of available clinical studies on the use of Cyberknife, and those available have primarily involved patients with single or perhaps a few pulmonary metastases whereas this patient has a multitude of metastases. Hof and colleagues indicated that the potential benefits of Cyberknife were demonstrable, but their study included 61 patients with a total of 71 metastases, thereby suggesting that each patient had one or perhaps two metastases in the study. While overall survival and local tumor control rates were measured at 12, 24, and 36 months after therapy with promising results, the use of Cyberknife is still investigational or experimental in the patient subset with many metastases and not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested use of a continuous passive motion machine for the treatment of her medical condition, status post left total knee replacement. Findings:  The physician reviewer found that the benefit of the use of a continuous passive motion machine following total knee replacement has been the subject of debate for many years. While there is some consensus for its usefulness in the early postoperative period, there is little support in the literature for continued employment of the continued passive motion machine for longer periods of time. The use of a home continuous passive motion machine was not indicated for treatment of this patient.