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

A 24-year-old female enrollee has requested for Nexavar (sorafenib) for treatment of her glioblastoma multiforme.   Findings:  Three physician reviewers found that there are no clinical trials which have determined the utility of the combination of sorafenib and Temodar in this setting. It is not FDA-approved, compendium listed, or supported by expert consensus guidelines for this indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a thirteen-year-old female enrollee has requested for residential psychiatric care  for treatment of the enrollees condition. Findings:  The physician reviewer found that there is no documentation pertaining to an imminent perceived return to drug use.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the prudent layperson standard applies to distress that reasonably requires urgent medical therapy or diagnosis. The patient in this case, who was pregnant, was in sufficient distress to seek medical attention. Given the lack of alternative options, it was reasonable for her to seek treatment at a local hospital. Pruritis, as with pain, is a subjective matter and cannot be readily quantified. As such, its severity, as interpreted by the patient cannot be discounted as non-urgent just because no life threat was indentified. Additionally, there are a number of potentially severe medical conditions that can present with itch  with or without apparent rash. Pregnancy can also complicate matters by broadening the diagnostic considerations (e.g., cholestasis of pregnancy). Likewise, pregnancy can complicate therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old female enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that speech therapy is, in fact, serving as treatment for this patients congenital condition. The enrollee's therapist has set forth expected goals and a plan to reach those goals. Whats presented here does fulfill the need for speech therapy as a medical necessity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested IVIG therapy for the treatment of his condition. Findings:  The physician reviewer found that the stated need for IVIG is based upon borderline low levels of IGG and a host of other studies. These latter studies do not represent the standard evaluation of chronic fatigue/chronic infection and are not well-accepted by practicing allergists/immunologists. There is no documentation of a sinus CT to document a sinus infection. The submitted documentation does not support the need for IVIG therapy for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Botox injections for the treatment of her condition. Findings:  Two physician reviewers found that Botox therapy is helpful for torticollis, but it is not generally used for muscle spasms/myofascial type pain. The patient did have a 50% decrease in symptoms with Botox therapy, although it is unclear exactly where Botox was given. The patient has not tried migraine specific medications. The physician did start Topamax, but the patients response is not documented. The patient has many options for medication trials prior to considering Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 21-month-old male enrollee have requested a Dynamic Orthotic Cranioplasty for the treatment of the enrollees positional plagiocephaly. Findings:  The physician reviewer found that although a Dynamic Orthotic Cranioplasty was recommended, there is no hard, scientific data to support its use. The patient had normal facial features and milestones. The use of this device is only for cosmetic purposes.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for Thalomid for treatment of her condition.   Findings:  Two physician reviewers found that there is no standard therapy for metastatic islet cell cancer. A phase II study of the combination of thalidomide and temzolomide revealed a very promising degree of clinical activity. For this disease with no standard treatment options, this combination is promising.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested for skilled nursing facility services for treatment of his condition. Findings:  The physician reviewer found that the patient needs to do daily exercise to maintain or improve his current level, but this does not require daily physical therapy and occupational therapy. It does require a daily exercise regimen. He does not have daily skilled nursing needs.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested bariatric surgery (duodenal switch) for the treatment of her obesity. Findings:  The physician reviewer found that the requested bariatric surgery is medically necessary for treatment of this patient. The Health Plans denial is not medically appropriate. However, if the gastric outlet is blocked, a more appropriate procedure would be a Roux-en-Y gastric bypass.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested wireless capsule endoscopy for an evaluation of his abdominal pain. Findings:  The physician reviewer found that this patient suffers from vague abdominal pain with a rather unremarkable EGD and Colonoscopy. Based on information provided, the diagnosis of possible Crohns disease in this patient is not supportable. Thus, the need for a wireless capsule endoscopy is not supported by the record at this time.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that an emergency room is necessary where there is a sudden onset of symptoms of such severity that a prudent layperson would believe their health to be in jeopardy without immediate medical attention. This patient did not experience the sudden onset of symptoms. Although she was experiencing pain, her pain had begun at least a week prior. She specifically denied any chest pain or other acute symptoms. She had previously been evaluated, diagnosed, and treated for the same condition. According to the documentation, this patients symptoms do not meet the definition of a medical emergency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested partial hospitalization program services for the treatment of her condition. Findings:  The physician reviewer found that the patient's need for this care was apparent. She was clearly unable to make progress at a lesser level of care; her psychopathology is documented in the statement submitted by her providers and her treatment plan clearly met her needs. Her time in RTC was lengthy, but she was deeply impaired. I believe her RTC treatment was medically indicated and appropriate. The patients subsequent treatment in two PHPs, as well as her current and future treatment in IOP is most appropriate, clinically indicated, and medically necessary. She is being stepped down in a manner consistent with her complex psychiatric and medical conditions. She remains fragile and to step her down any more aggressively is to risk regression and dissipation of the gains she so painfully achieved. Her treatment has been difficult but well managed by her providers. I recommend that all denials of the patients PHP treatment be reversed. Further, I believe her IOP treatment is medically appropriate and indicated. Any denials for these services should also be reversed. I also endorse the plan to transition the patient to outpatient psychotherapy in the reasonable future.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 16-year-old female enrollee has requested for residential treatment for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the patient is now responding to treatment, but is not currently capable of care in a modality less restrictive than residential.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 73-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his lung cancer.   Findings:  Three physician reviewers found that the standard of care in this situation is normally surgical intervention. However, this patient is a high risk for surgery. The alternative curative treatment is stereotactic body radiation therapy (SBRT). Although there are no randomized trials available, there is sufficient evidence in peer-reviewed medical literature to support the efficacy of SBRT.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for radiofrequency ablation procedure for treatment her condition.   Findings:  Two physician reviewers found that There is no recent PET/CT scan available for status of the disease. If a repeat PET/CT confirmed that there are no other metastases, radiofrequency ablation would be likely to be of benefit. However, if there is evidence of other metastases, then it would not be likely to be of benefit. Absent this information, the medical indication for the requested procedure cannot be established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Avastin and Ixempra combination chemotherapy for treatment of her metastatic breast cancer.   Findings:  Three physician reviewers found that Ixempra (ixabepilone) is a new drug that has recently been approved for use in metastatic breast cancer in patients whose cancer appears to be refractory to taxanes, anthracyclines, and Xeloda. This patient falls into that category. Avastin (bevacizumab) has been approved for use in first line treatment for metastatic breast cancer, when used with taxol. There is no real data as to whether it is of any use when given later in the course of the disease, nor whether it should be used after the disease has progressed while on the drug. In the absence of such data, the continued use of Avastin in this situation must be considered investigational, and of no proven clinical benefit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a PET scan for evaluation of her condition.   Findings:  Two physician reviewers found that a review of the peer-reviewed literature, including the National Cancer Institute and American Society of Clinical Oncology and National Comprehensive Cancer Network, showed no medical evidence to support the use of PET imaging in patients with a diagnosis of cholangiocarcinoma. The standard imaging studies that are routinely utilized in the staging and restaging of cholangiocarcinoma include CT and MRI. There is a lack of evidence to support the use of PET scan over standard imaging studies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for CyberKnife Therapy (CyberKnife Stereotactic Radiation or CyberKnife Robotic Surgery) for treatment of his Primitive Neuroectodermal Tumor (PNET) with metastatic growth.   Findings:  Three physician reviewers found that Cyberknife treatment is an emerging modality which has been used for cancer of the prostate, lung, liver, etc. There is no data in the literature suggesting superior outcomes using Cyberknife for PNET. The patient has a very large tumor measuring approximately 12x10 cm. With preoperative treatment utilizing radiation, a very large area has to be treated with moderate doses of radiation. I do not see any benefit of Cyberknife in this situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested an MRI of both wrists/hands for the evaluation of her synovitis. Findings:  Three physician reviewers found that the use of MRI in patients with tenosynovial diseases is well-established and not at all experimental.  The evaluation of the flexor retinaculum for suspected carpal tunnel syndrome is well established.  In addition, since there is a question concerning the extensor tendons of the hand, an MRI would be the procedure of choice for imaging of such a structure.  The use of intravenous contrast will address the active synovial inflammatory nature of rheumatoid arthritis, and the MRI scan will also address the integrity of the flexor and extensor tendons of the hands and wrists.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested proton pump inhibitor Aciphex for the treatment of his condition. Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion.  While interpatient variability of the efficacy has been seen with PPIs, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effects profile.  In this case, it is medically reasonable to require that the patient undergo a trial with Prevacid, single and double dose, for eight weeks each. If he fails to respond, he should be approved for Aciphex. Protonix made his symptoms worse, and therefore, would be inappropriate to use.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested emergency services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient was suffering pain of a sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to his health and/or bodily function.  This case is complicated by the fact that the patient had recently been treated with an antibiotic and yet had an acute exacerbation of ear pain due to infection.   It was appropriate that he was re-examined to determine the cause of his acute pain as well as rule out several other serious disorders including tympanic membrane perforation, mastoiditis, and others.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Provigil for the treatment of her chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that there have been no large scale studies evaluating the use of Provigil in CIDP. However, it has been shown to have a positive effect in patients with Charcot-Marie-Tooth neuropathies and fatigue in other subsets of patients. Provigil is a medically reasonable treatment option for this patients overall symptoms given her current medical conditions. This patient has responded well to this medication in the past, and it is medically appropriate to continue her with this medication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her condition. Findings:  The physician reviewer found that the enrollee's symptoms warrant evaluation with MRI of the lumbar spine. The referring physician, the patients treating surgeon, has detailed knowledge of the anatomy and neuroanatomy of concern. An MRI of the lumbar spine is medically indicated for evaluation of this patient. Referral from a primary care physician or orthopedic surgeon is not medically warranted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested Botox injections for the treatment of her migraine. Findings:  Two physician reviewers found that this patient has a history consistent with disabling chronic migraine and has tried and failed standard episodic migraine preventative therapy. There are no FDA-approved treatments for chronic migraine. Botox has variable, though considerable data consistent with a positive benefit as a migraine preventative, especially where the frequency of attack is high (chronically). Thus, Botox should be approved in this case as a trial for her headache symptoms.  Baseline headache frequency, severity, and disability should be recorded, and if Botox is ineffective after 2 cycles, then it should not be continued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested the use of a CPM machine for the treatment of her condition. Findings:  The physician reviewer found that there is no medical necessity for the use of CPM after total knee surgery. There is no class one study that demonstrates improved long-term outcomes with the use of CPM after routine total knee surgery. More quality outcomes data is needed to support the indications for CPM use after total knee surgery. It is not the standard of care at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested cognitive rehabilitation/speech therapy for the treatment of his traumatic brain injury. Findings:  Three physician reviewers found that the patient suffered a very severe traumatic brain injury and as a result he has significant cognitive deficits including word retrieval, processing, attention, and memory. Cognitive remediation by a speech therapist is standard therapy at most, if not all acute rehabilitation facilities including outpatient brain injury programs. Research data is generally supportive of cognitive rehabilitation in the young, awake, and brain-injured patient. There are no alternatives to this standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested Neulasta injections for the treatment of her medical condition. Findings:  The physician reviewer found that the use of pegfilgrastim (Neulasta) to prevent febrile neutropenia following TAC chemotherapy is justified under both the National Comprehensive Cancer Network (NCCN) guidelines and the American Society of Clinical Oncology (ASCO) guidelines. The FDA approval label for the drug states that it is approved for the prevention of febrile neutropenia in patients treated with cytotoxic chemotherapy from which a high incidence of febrile neutropenia is expected.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old female enrollee has requested Strattera for the treatment of the enrollees condition. Findings:  The physician reviewer found that an exception for the off-label use of a medication for this patient of 5 years of age would be appropriate if the proposed use is consistent with guidelines provided by national academies (such as the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry). These two academies indicate that a non-stimulant medication should not be used until traditional medications have been attempted and failed. The potential problems with a non-stimulant medication are felt to be increased compare to a stimulant medication. If the patient is placed on other medications and fails or has significant side-effects, then the off-label use of Strattera may be considered. The documentation provided does not support the use of Strattera at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested a microprocessor controlled prosthesis knee-leg (C-Leg) for the treatment of her condition. Findings:  Two physician reviewers found that the requested device is not medically indicated for this patient. The patient should be fitted for a new prosthesis, as the current one is poorly fitting. There is no substantial evidence that the microprocessor controlled prosthesis knee-leg is clinically superior to a traditional prosthesis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a consultation with a bariatric surgeon for the treatment of the enrollees obesity. Findings:  The physician reviewer found that this patient has obesity-related comorbidities that will be ameliorated or eliminated by bariatric surgery. She is requesting a lap band which requires far more compliance than gastric bypass.  Although she has listed the diets which she tried and failed, we do not have dates, length of success, and degree of physician supervision. Gastric banding requires an understanding of the eating behaviors that will lead to failure. The patient carries a diagnosis of depression, yet the submitted documentation does not include a psychiatric evaluation or evidence that she is being treated. This patient would benefit from a multidisciplinary approach, including physician supervised diet, behavioral counseling, and attendance at support groups. The requested service is not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patient presented with a bruise/hematoma on the back of her left thigh. Although this was an acute condition, she was not suffering pain nor was there concern that her life or well-being was possibly in jeopardy. A prudent layperson would not reasonably seek immediate emergency medical attention for such an ailment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 74-year-old female enrollee has requested Procrit for the treatment of her anemia secondary to diabetes mellitus. Findings:  The physician reviewer found that since the cause of the anemia has not been medically evaluated for possible causes, such as chronic renal failure with loss of endogenous erythropoietin, underlying cancer, or other marrow disorders, it is not possible to conclude that the Procrit is medically necessary for this patient. It seems clear that were a cause of the anemia identified by proper medical evaluation, it is likely that the cause would support the continued use of Procrit. However, the possibility remains that the medical evaluation might uncover a cause of anemia that should be treated by other therapy than Procrit. Thus, at this time, without further medical evaluation of the cause of this anemia, this medication cannot be supported as being medically necessary.