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

A 20-year-old female enrollee has requested residential treatment services for treatment of her eating disorder.   Findings:  The physician reviewer found that according to the admission record, the patient had been binging and purging approximately 20 times per month but had not been drinking for several weeks prior to her admission. She was above her IBW and had no electrolyte, cardiac or other biomedical abnormalities. The patient denied suicidal and homicidal ideation. There is no evidence in the record of a reasonable trial of treatment at a lower level of care prior to her admission to the residential treatment facility.  She did need psychiatric intervention. Her depression had not been evaluated or treated prior to her admission. The opportunity for antidepressant medication and outpatient psychotherapy had not been utilized. The patients alcohol binging, her binging and purging and her depression were likely interrelated no attempt to intervene at a lower level of care is documented. Her binging and purging behaviors were not present during her residential stay. The limited frequency of the patients binge/purge episodes and the lack of electrolyte, orthostatic or cardiac changes argues against the need for residential treatment. An IBW of greater than 100% lends additional support to this conclusion. The patient was admitted to a specialized residential eating disorder program without any attempt to intervene in a less restrictive environment utilizing therapy, medication and guidance. Her admission was not consistent with the guidelines of the American Psychiatric Association for the treatment of an eating disorder.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female with a history of metastatic endometrial (endometroid histology) cancer, metastatic to visceral organs, who is also receiving Topotecan, requests authorization for Herceptin.Reviewers Findings:The three reviewing physicians found that there is insufficient evidence in the relevant medical literature to support the proposed use of Herceptin in this case. The combination of Herceptin and Topotecan has not been explored in the treatment of gynecological (endometrial) cancers. Given that Herceptin has no proven benefit in the situation, and in fact carries some associated risk, its use in this case is not recommended.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested extracorporeal shock wave therapy for treatment of chronic plantar fasciitis.  Findings:  Two physician reviewers found that This patient has undergone numerous standard treatments for plantar fasciitis. The records document eight visits with a physical therapist for ultrasound, iontophoresis, stretching, hydrotherapy and plantar fasciitis night splint. Altogether, conservative care demonstrates an efficacy rate of about 90%. When this fails, standard endoscopic plantar fasciotomy also carries a 90% efficacy rate. Extracorporeal shock wave therapy for treatment of chronic proximal plantar fasciitis, while FDA approved, only carries a 65-80% effective rate depending on the study. There is also literature stating an even lower efficacy rate for the procedure.  The requested extracorporeal shock wave therapy is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male with a history of metastatic colon cancer with progressive liver metastases is requesting authorization for SIRT with Sir Spheres treatment.  Reviewers Findings:Two out of the three physicians have determined that SIRT has shown good responses and outcomes in hepatic metastases in literature. Given the lack of available treatment options in this setting, SIRT is medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested endovenous laser treatment (EVLT) for the treatment of her varicose veins.  Findings:  The physician reviewer found that in recent times there has been an increasing interest in radiofrequency ablation of the greater saphenous vein in combination with stab avulsions. There is a growing body of literature that strongly suggests that radiofrequency ablation is superior to high ligation and greater saphenous vein stripping. It produces the same clinical efficacy, has a shorter recovery time and has greater patient acceptance. There is also significant interest and improving data on endovenous laser therapy (EVLT) as an alternative to ligation and stripping. As yet, there are no randomized clinical trials comparing this approach to standard therapy or to radiofrequency ablation. However, the laser fiber is less expensive than the radiofrequency catheter, the pull back treatment time is shorter and the saphenous obliteration and anti-reflux results appear to be similar in non-randomized trials. The case control literature indicates a recurrence rate of approximately 7% to 10% at 2 years; superior to traditional ligation and stripping. Despite a lack of randomized clinical trials, endovenous laser therapy and radiofrequency ablation are becoming equivalent in clinical practice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old woman at 22 weeks gestation with a twin pregnancy and a beta-thalassemia trait diagnosis requesting authorization for treatment of her anemia with Procrit.   Reviewers Findings:The reviewing physician found there is very little experience reported in the use of recombinant erythropoietin in pregnancy, and even less in its use for the anemia of thalassemias. Clearly the efficacy and safety of recombinant erythropoietin use for thalassemia during pregnancy is not established and cannot be considered medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested authorization and coverage for Lyrica. Reviewer's Finding:The reviewing physician found that while the FDA guidelines support the use of Lyrica for various neuropathic pain syndromes, this patients diagnosis is low back pain. There is no documentation suggesting the proposed treatment is consistent with the FDA-approved indications or the generally accepted off-label use of Lyrica for the treatment of neuropathic pain syndromes
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested Xyrem for the treatment of her fibromyalgia. Findings:  The physician reviewer found that although Xyrem is not a first-line therapy for fibromyalgia, there is medical evidence to suggest that it can be useful in patients with this disorder. In Swicks paper, there was a substantial benefit noted in many modalities for fibromyalgia patients as compared to placebo patients. This was true for pain, fatigue and sleep. Similarly, Scharf et. al. demonstrated that Xryem can reduce symptoms of pain, fatigue and sleep abnormalities in patients with fibromyalgia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested growth hormone therapy (Genotropin injectable) for treatment of her growth hormone (GH) deficiency.  Findings:  The physician reviewer found that AACE Guidelines state that most adults selected for GH therapy should have an easily recognizable cause, clear cut clinical features of the adult syndrome and nonrefutable laboratory evidence of GH deficiency. The guidelines further state that a test using arginine and GH-releasing hormone has been determined to be more stringent than tests using arginine or L-dopa alone. Other studies indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary. In this case, we are told that the IGF-1 was low in 1999, but we are not told what the original IGF-1 level was. Additionally, a non-preferred stimulation test was performed. The clinical notes indicated that L-dopa and arginine were used as stimulation agents, however the laboratory report provided pertains only to L-dopa.Isolated growth hormone deficiency is a rare diagnosis in adults. In this instance we do not have obvious pituitary or hypothalamic disease documented by history, surgery or MRI and there is no evidence of anatomical abnormalities or other hormone deficits. It would seem reasonable at this juncture to perform a preferred stimulation test with arginine/GH releasing hormone while off of GH therapy to document a GH deficiency. At the present time,  the use of Genotropin is not medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a power-operated vehicle (POV) for mobility. Findings:  The physician reviewer found that there is no specific evaluation of the patients upper body strength, range of motion or her ability to propel a manual wheelchair. There is no indication the POV is needed for activities of daily living (ADLs) within the home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female has requested authorization and coverage for occupational therapy with a lymphedema specialist. Reviewer's Findings:The reviewing physician found that lymphedema therapy has been proven beneficial for management of volume and pain.  The patients condition interferes with activities of daily living and treatment is expected to reduce edema to a more manageable level in a reasonable period of time. The patient should receive occupational therapy evaluation and treatments until her edema is back to baseline.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested a CT angiography for evaluation of his chest pain and dyspnea on exertion.  Findings:  Two physician reviewers found that CT coronary angiography is an acceptable alternative to coronary angiography in excluding anomalous coronary origins, and is often performed as a confirmatory test after a non-diagnostic angiography to define the origin and relationship to the great vessels in suspected cases.  According to the 2006 Appropriateness Criteria referenced above, the use of coronary CT angiography for evaluation of suspected coronary anomalies is highly appropriate (highest score 9/9) for this indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested  for acupuncture therapy for treatment of  her elbow and knee pain. Findings:  The physician reviewer found that acupuncture is a modality for the management of chronic pain. It is generally utilized to control or modulate chronic symptoms recalcitrant to more conservative or traditional evidence-based treatment approaches.A cortisone injection might also be considered. There is no evidence to suggest a chronic pain condition requiring acupuncture.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollee's behavioral health problems.   Findings:  The physician reviewer found that based upon the evidence provided, the patient was ready to step down to a less intensive level of care after the date in question. She received an effective clinical intervention at the residential level of care from a specialized eating disorder program.  She reached a weight that was safe for her to be transferred to a less intensive level of care, but continued to demonstrate evidence of a chronic eating disorder with loss of calcium from her bones. As such, an appropriate step-down from the residential treatment eating disorder program was a PHP eating disorder program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A fifty-four year old female who had a subtotal resection of a left frontal grade III anaplastic astrocytoma, followed by radiation therapy and chemotherapy, subsequently developed a progressive gait disturbance and mild right-sided hemiparesis . Contrast MRI and PET/CT could not exclude metastatic tumor. The treating radiation oncologist along with a consensus of Neurosciences Conference physicians recommended MRS of this region to distinguish tumor recurrence from delayed tissue effects of prior irradiation. Reviewers' Finding:Two of the three physician reviewers found MRS is frequently performed to differentiate active tumor from necrotic tissue and that MRS is not considered experimental or investigational in this instance and is superior to other diagnostic modalities in its ability to discern the metabolic pattern of an active tumor.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested pulmonary vein ablation for treatment of atrial fibrillation.  Findings:  Three physician reviewers found that pulmonary vein ablation has become an accepted tool for the management of refractory symptomatic atrial fibrillation. While long-term efficacy data is still evolving, clinical practice supports its use in symptomatic patients that have failed traditional medical therapy. Alternative treatments such as flecainide, amiodarone, diltiazem, digoxin and the mini-maze have already been tried without success.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested Genotropin for treatment of his growth hormone deficiency.  Findings:  The physician reviewer found that growth hormone (GH) guidelines published in Endocrine Practice state `most adults selected for GH therapy should have an easily recognized cause, clear cut clinical features of the adult syndrome and non refutable laboratory evidence of GH deficiency.`  Furthermore, the guidelines state, `a test using arginine and growth-hormone-releasing hormone (GHRH) also has been accepted as more stringent than tests using arginine or levodopa alone, which are considered less stringent. There are other studies that indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female has requested intravenous immune globulin (IVIG) therapy for thre treatment of her asthma, refractory chronic sinus disease and chronic fatigue. Findings:  The physician reviewer found that the practice parameters published jointly by the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), as well as those published by the World Health Organization (WHO) do not recommend IVIG for treatment of individuals with recurrent infections but normal immune systems. As such, IVIG is not deemed medically appropriate and should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for two-level artificial disc replacement for treatment of degenerative disc disease.  Findings:  Three physician reviewers found that The Health Plan is correct that the proposed procedure is experimental. Although the artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine, there is no evidence supporting the safety and efficacy of a two-level disc replacement. Current data for single level disc replacement demonstrates that although many of the procedures may be successful in the short term, the long-term outcomes are unknown and complications may be severe.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested psychiatric treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that in light of the severity of the patients condition, outpatient therapy was not likely to be of significant benefit. The amount of comorbidity of this patients eating disorder, in combination with the confluence of his irritability and defiance, necessitated a higher level of care than outpatient therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested  for bilateral reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the patient has symptoms that are typical for symptomatic macromastia, and all attempts at conservative therapy have failed. This is not surprising, as an outcome study by Collins and others has shown that conservative therapy is generally not effective for the musculoskeletal symptoms associated with macromastia. The Schnur table is a well-accepted guideline for differentiating medically necessary breast reduction from cosmetic mastopexy. Schnur considers reductions below the 5th percentile cosmetic and reductions above the 22nd percentile medically motivated. For reductions falling between the 5th and 22nd percentiles, Schnur essentially states that if the patient is symptomatic and conservative measures have failed, the breast reduction should be covered. In this instance, the planned reduction may be below 22nd percentile weight of 260 grams. However, the record documents the patient has seen two physicians and has tried chiropractic care, analgesics, acupuncture and special bras without symptom relief. According to Schnur, the proposed breast reduction is a functional one and is not cosmetic.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for Celebrex and Lidoderm patches for treatment of her lower back pain.  Findings:  The physician reviewer found that although the has only FDA approved the Lidoderm patch for the treatment of post-herpetic neuralgia, Lidoderm is prescribed by many practitioners for the management of regional pain such as back pain and osteoarthritis of the knee and shoulder. The medication has a good safety profile and two open-label studies support its beneficial effects in the treatment of low back pain. The patient has already tried this medication with good results and continued treatment is medically appropriate. Celebrex is a selective Cox-2 inhibitor used primarily in the management of chronic pain due to osteoarthritis. Its efficacy is comparable to other NSAIDs, but its safety profile is better due to the lack of gastrointestinal side effects. Cardiovascular side effects have been noted in the product literature, however that is likely a class effect found with all NSAIDs. With regard to this particular patient, her MRI is consistent with a diagnosis of lumbar spondylosis, which is a form of osteoarthritis with a degenerative course.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested acute inpatient rehabilitation services for the treatment of the her paraplegia. Findings:  The physician reviewer found that it appears that the patient had a complex inpatient course. At the time of her acute rehabilitation admission the patient had good strength and function in her right upper extremity, but no use of her left upper extremity or her bilateral lower extremities. She also had multiple cognitive issues. An acute-level rehabilitation program was indicated at that time. However, the patient had been thoroughly evaluated and home exercise/stretching programs could have been established. Her equipment needs were identified and a wheelchair had been ordered. It does not appear there were other major goals still outstanding that would require an extension of her acute inpatient rehabilitation stay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested psychiatric residential treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that the patient was viewed as more manageable by the specified date, with a continued course of improvement thereafter. There was no indication that continued residential treatment was medically necessary for treatment of the patients medical condition as of the specified date.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested the compound medication triiodothyronine (T-3) for the treatment of her thyroid condition. Findings:  The physician reviewer found that patients with thyroid disease, or more specifically hypothyroidism, are usually treated with levothyroxine (T4). Various brands of this medication are available.  In some cases, physicians feel that triiodothyronine (T3) is useful along with levothyroxine, although this practice is somewhat controversial. In this case, however, the patients thyroid tests were normal so there is no evidence that thyroid hormone (T3 or T4) is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested psychiatric treatment services she received from a non-plan provider.  Findings:  The physician reviewer found that the patient was hospitalized on a 5150 involuntary hold followed by a 5250 hold due to an altered sense of consciousness and paranoid delusions. Since the police initiated the 5150, and a 5250 was also authorized, the patient had no control over her hospital stay. The difficulty in transporting a paranoid patient on a 5250 to another hospital is significant.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that although the Oncotype DX test is a widely used tool in treatment decision making for women with breast cancer, it has not been studied for women with ductal carcinoma in situ or Stage 0 breast cancers, in which chemotherapy is not typically a consideration. The benefit of the Oncotype DX test for women with non-invasive breast cancer has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female with relapsing-remitting multiple sclerosis (MS) is requesting authorization for Tysabri for the treatment of her condition. Reviewer findings:The reviewing physician found the data in regard to Tysabri shows this therapy is substantially more effective than the current disease-modifying therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested a nephrectomy within the requested timeframe for treatment of renal carcinoma.  Findings:  The physician reviewer found that despite the assertions by the oncologists and the radiologist as to the urgency of this disease, there is absolutely no evidence that delaying the operation will have any adverse affect on either the conduct of the procedure or the cancer outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Avastin (bevacizumab) and Camptosar (irinotecan) for the treatment of her glioblastoma multiforme. Findings:  The physician reviewer found that the data, though preliminary, is promising in support of this novel combination of medications for the treatment of glioblastoma multiforme. A trial of the proposed therapy is medically appropriate at this juncture. The patient is likely to either respond or show evidence of progression within a relatively short period of time.