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

A 51-year-old male has requested a microprocessor controlled lower limb prosthesis for treatment of above knee amputation. Findings:  Two physician reviewers found that use of a microprocessor controlled lower limb prosthesis will increase stability, reduce energy consumption, limit low back pain from biomechanic alterations and reduce skin breakdown. The literature cited by the Health Plan compares amputees using conventional prosthetic knees (i.e., hydraulic) with computer-controlled devices; however, these patients did not suffer from the above mentioned complications. The patient is an active person who would benefit from the increased stability provided by a microprocessor controlled prosthetic lower limb.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech delay. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate speech therapy was or is medically necessary for this patient. No evidence has been presented demonstrating that the etiology of the patients problem related to illness, injury or chronic disease. There is no documentation of a hearing evaluation, tympanometry, or clinical documentation supporting a diagnosis of chronic otitis media with effusion or hearing loss. Furthermore, the speech therapist found no abnormalities on the patients oral peripheral exam. Additionally, it appears the patient had an in-school speech and language evaluation, which concluded that his speech errors were very minor. Finally, there is insufficient objective evidence that the patient benefited from the speech therapy services he received.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested  for Lumigan, 7.0 ml (or 7.5 ml) per month for treatment of the enrollees glaucoma.  Findings:  The physician reviewer found that one 2.5 ml bottle of Lumigan drops will last the typical patient one month, with once-daily usage. If it does not last for an entire month, then one of three conditions is likely to be occurring: The medication is being administered more frequently than prescribed;The medication is being wasted due to improper administration; orThe bottle was not properly filled by the manufacturer.Additionally, with all of the discussion that has ensued over the quantity of medication needed on a monthly basis, it does not appear likely that the patient is using the medication more often than prescribed. Therefore, the most logical explanation is that the patient is having difficulty with administration, and is inadvertently wasting a quantity of the medication each month.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 76-year-old male has requested cryoablation of the prostate for treatment of prostate cancer. Findings:  Two physician reviewers found that it is unlikely that cryoablation will be more successful than conventional treatments such as external beam radiation or brachytherapy. There is no evidence establishing the long-term effectiveness of this procedure in the treatment of prostate cancer, and it has not been shown to be more effective than traditional treatment approaches. Cryoablation is generally more successful as a secondary treatment for prostate cancer that has failed radiation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested prescription medication Lyrica for treatment of small-fiber neuropathy.  Findings:  The physician reviewer found that while Lyrica is specifically approved for diabetic neuropathy, it is also useful for a number of different painful neuropathies. Treatment with Lyrica is commonly prescribed for patients such as this patient, as it is known to be safe and effective.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for the enrollees participation in a wilderness program for treatment of the enrollees behavioral health problems. Findings:  Three physician reviewers found that wilderness programs are considered experimental at this time. There is inadequate evidence documenting their efficacy. There were other available treatments that were likely to be more effective for this patient, including medication.  There is no evidence the patient received an adequate trial of standard therapy prior to entering the wilderness program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for retreatment with Rituxan for treatment of her rheumatoid arthritis. Findings:  Three physician reviewers found that Rituxan is effective in the treatment of rheumatoid arthritis due to the selective depletion of CD-20 positive B-lymphocytes. It is well recognized that those beneficial effects decrease as the B-cell population returns, typically six to 12 months after treatment. Schematically, this is parallel to the action of tumor necrosis factor (TNF) inhibitors. The effects of each agent last for a period of time based on the duration of TNF inhibition by that particular drug. Obviously, retreatment with TNF inhibitors is needed for long-term control of the disease process. Clinical experience demonstrates quite clearly that repeat treatment with Rituxan is also necessary to maintain benefit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested artificial disc replacement for the treatment of his degenerative disc disease at L5-S1. Findings:  Three physician reviewers 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. Though short-term results have been favorable, further studies and results are needed. Thus, the procedure cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for laparoscopic robotic-assisted radical prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that there are several areas in which the laparoscopic and open (standard) radical prostatectomy may be compared. As far as the risk of complications is concerned, there is now enough evidence accumulated over time from multiple sources to be able to conclude that the two types of surgical procedures have comparable complication rates. In addition, there is now adequate evidence to conclude that cure/survival rates of laparoscopic and open radical prostatectomy are comparable. With regard to the technical aspects of the two procedures, the laparoscopic approach is less traumatic to the patient than the open incision approach, often resulting in easier recovery. Given that the robotic-assisted laparoscopic radical prostatectomy is superior in ease of patient recovery following surgery, it has a distinct advantage over the standard surgical approach and as such, is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested treatment with Tykerb and Xeloda for the treatment of her metastatic breast cancer. Findings:  The physician reviewer found that the patient and her treatment team have requested authorization for Tykerb and Xeloda in the setting of first-line therapy for metastatic breast cancer. This combination is indeed an active regimen, but is approved in patients that have been treated with other prior regimens namely anthracyclines, taxanes and Herceptin.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested  for an artificial disc replacement procedure for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that artificial total disc replacement remains an experimental procedure. There is insufficient evidence to demonstrate long-term safety and efficacy. There is also insufficient evidence to demonstrate that disc replacement results in better clinical outcomes than other available treatment. This patient has other standard treatments available to treat her condition that are likely to be more beneficial than artificial disc replacement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of an 11-year-old female is seeking growth hormone therapy for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that it is doubtful that growth hormone therapy would contribute significantly to the patients adult height. Her IGF-1 level was already high before the initiation of growth hormone therapy. Her initial response to growth hormone therapy of 1.5 cm in 4 months has been modest. In the absence of literature to document an increased adult height in such circumstances, growth hormone therapy is not indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old male have requested growth hormone (GH) therapy with Humatrope for treatment of short stature.   Findings:  The physician reviewer found that a diagnosis of GH deficiency appears improbable given his normal IGF-1 levels and his growth at the 20th percentile. The patient would not qualify for GH therapy under the FDA guidelines for idiopathic short stature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee is requesting 16 injections of Imitrex per month for the treatment of her migraine headaches. Findings:  The physician reviewer found that the request for 16 Imitrex injections per month should be authorized since this medication is highly efficacious and has been demonstrated to reliably terminate this patients acute migraines. The requested usage of Imitrex does not represent a concern for medication overuse headaches. Furthermore, based on the information provided, there is no contraindication to the prescribed dosage.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested a brain PET scan for evaluation of cognitive problems.  Findings:  Two physician reviewers found that PET scanning is not the standard of care in this setting as it has not been shown to have established benefit under these circumstances. At this time, there is inadequate data demonstrating that the use of PET in this context is likely to alter the care and management of this patient. The utility of PET as a diagnostic tool for evaluation of cognitive problems remains unproven.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 83-year-old male has requested a power-operated vehicle (POV) for mobility.  Findings:  The physician reviewer found that there is no documentation that the patient has a mobility-related deficit that impairs his ability to perform activities of daily living within his home safely and within a reasonable time. The record does not indicate if the patient uses a cane or a walker for ambulation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female has requested speech therapy for treatment of apraxia and sensory integration dysfunction.  Findings:  The physician reviewer found that the diagnosis of childhood apraxia of speech is controversial, as is its etiology.  There are numerous theories as to the cause of childhood apraxia, but none are established in peer- reviewed journals. The medical necessity of speech and language therapy for childhood apraxia of speech has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male has requested Humatrope for treatment of growth failure.  Findings:  The physician reviewer found that based on the reported results of the patients bone age study, he falls within the 2003 Food and Drug Administration guidelines for growth hormone therapy for idiopathic short stature. Growth hormone therapy in this instance is clinically indicated to promote growth velocity and increased final adult height. The information provided demonstrates the patient is likely to experience positive results from growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested for the Fluency Master for treatment of his speech pathology. Findings:  Three physician reviewers found that the Fluency Master is an electronic device that uses a technology called altered auditory feedback (AAF). According to the manufacturer, the device fosters better hearing of the natural vocal tone associated with speaking. In 2002, the National Stuttering Association conducted a survey of its membership. One of the questions asked was about experiences with an AAF device, including the Fluency Master. 38% of the respondents categorized  their experience with this type of device as not at all successful, 44% said their experience was somewhat successful, and 18% reported their experience was very successful. Bothe, et al. conducted a systematic review of the evidence for behavioral, cognitive, and related treatments for stuttering and concluded that research utilizing a rigorous experimental design was lacking. Although the Fluency Master may be helpful in some circumstances, there are no long-term, randomized, controlled studies demonstrating efficacy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that review of the relevant medical literature regarding the etiology, symptoms, ages and treatment of childhood dysfluency revealed no evidence of a medical cause for the etiology of childhood stuttering. The available evidence suggests the average age of children with childhood dysfluency is three to five years old.  In 60-80% of these children, the dysfluency resolves spontaneously. The use of speech therapy in the treatment of speech dysfluency is not within the standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male has requested gastric bypass surgery without a 10% preoperative weight loss for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 77.3 and severe comorbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% preoperative weight loss, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality in this population.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested skilled nursing facility services for the skilled rehabilitation/treatment of her multiple medical problems. Findings:  The physician reviewer found that the patient did not progress with OT or PT. Her participation was limited in the last three days of therapy and she had not shown the ability to progress beyond the stand-by assistance and minimal assistance levels. Despite her serious diagnoses, the patient did not require daily skilled nursing intervention due to a changing medical condition, wounds, or injections. Monitoring of coagulation status during Coumadin therapy is a standard outpatient procedure and did not require inpatient care. The patients subsequent acute illness was not evident in the days preceding it. The patient had no daily skilled nursing needs and she had reached the maximum functional level attainable through skilled PT and OT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech and language delays. Findings:  The physician reviewer found that there is no suggestion that speech therapy is required due to a medical condition or to restore the patients speech to a previously attained skill level. While speech therapy may be appropriate to treat his developmental speech delays, this type of intervention is not medically indicated. Speech therapy is available to the patient through his school district.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has chronic neuropathic pain with post-laminectomy syndrome, and has needed invasive treatment as well as oral agents for management. He is taking Duragesic, Norco, Neurontin, Lyrica, and Cymbalta. A trial of Lyrica has been beneficial, and when discontinued, led to functional decline. The Health Plan has denied coverage for Lyrica as not medically necessary, and states that the FDA has only approved the drug for post herpetic neuralgia (PHN), diabetic neuropathy pain, and epilepsy. PHN and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain due to their relatively high prevalence and thus ease of study.  Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy as well as the patients own experience with treatment on a trial basis. Standard treatments for neuropathic pain have been tried and have provided inadequate relief. Lyrica has been beneficial, and therefore should be continued.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female has requested sclerotherapy for treatment of the varicose veins.  Findings:  Two physician reviewers found that sclerotherapy is a reasonable alternative to correct the patient's condition. There is sufficient data supporting the safety and efficacy of this approach for patients such as this one. Sclerotherapy is likely to provide the patient with significant pain relief.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female has requested the extended use of a continuous passive motion (CPM) machine for post-operative rehabilitation.  Findings:  The physician reviewer found that generally accepted standards recommend that the use of CPM devices is limited to approximately three weeks following surgery to allow scar tissue to be stretched out.  Review of the peer-reviewed literature does not demonstrate that the use of a CPM device beyond 21 days results in significant benefit beyond that which can be achieved with therapy alone.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested continued physical therapy for treatment of carpel tunnel syndrome and fibromyalgia.  Findings:  The physician reviewer found that the patient received sufficient physical therapy services as of the specified date to be able to establish a home program. Continued physical therapy beyond that date would be for purposes of maintenance. Additional therapy is unlikely to be clinically effective in restoring function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested  for child/adolescent-focused cognitive behavioral therapy with exposure and response prevention (E-RP) for treatment of the enrollees obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the therapy was successful, resulting in a full recovery without the use of medications. This particular specialized treatment program was on target for the needs of the patient and eliminated her symptoms of OCD and improved her quality of life in a brief period of time. The therapy was medically indicated and resulted in a dramatic improvement in the condition of the patient. It is also reasonable for the therapist that conducted the cognitive behavioral therapy to see the patient periodically to make sure that she does not move from the new baseline that has been established without the use of medication. Follow-up with this provider at three-month intervals for one year is clinically appropriate for reinforcement and monitoring.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a CT angiography (CTA) for evaluation of coronary artery disease (CAD).  Findings:  Two physician reviewers found that CT angiography is not, thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography cannot accurately confirm or exclude important coronary artery obstructions. The use of CTA in the diagnosis and prognosis of coronary disease in this subset of patients remains an experimental/investigational application of this technology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of articulation disorder.  Findings:  The physician reviewer found that there is no documentation outlining the specific criteria necessary to classify developmental speech apraxia as a disease and there is no documentation in this case that identifies a medical condition related to the speech apraxia. As a result, the speech delays are considered developmental in nature, and there is no medical indication for speech therapy. The treatment of developmental speech apraxia would typically fall under the auspices of the school system through an Individual Education Plan (IEP).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested lumbar epidural neuroplasty and neurolysis as needed for treatment of lumbar neuralgia.  Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. There continues to be conflicting views on the safety and efficacy of neuroplasty and neurolysis and these procedures are not generally accepted or widely employed interventions. Credible evidence showing the clinical value of these modalities for the management of post-polio syndrome or degenerative disc disease is lacking and the treatment is experimental for patients such as this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male has requested the Novolog Flexpen Syringe/Lantus (prefilled insulin syringe/cartridge) for treatment of type I diabetes mellitus.  Findings:  The physician reviewer found that this prefilled insulin syringe/cartridge is clearly a convenience item in this instance. There is no indication the patient has a disability or physical impairment that would prevent him from learning to accurately draw his insulin dosage from a multi-dose vial or to securely store the medication and syringes.