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

A 50-year-old male enrollee has requested Viagra (sildenafil) 100mg daily for the treatment of his pulmonary hypertension. Findings:  The physician reviewer found that this patient does have moderate to severe pulmonary hypertension, but it is on the basis of his mitral regurgitation and left ventricular dysfunction and not on the basis of any documented intrinsic pulmonary pathology. This is confirmed by the right heart catheterization results demonstrating severely elevated mean pulmonary capillary wedge pressure (41 mmHg) with very large V wave and no transpulmonary gradient. In this circumstance, specific pulmonary vasodilators, including sildenafil, are not indicated and are not considered standard of care in the medical community. Current practice guidelines that are endorsed by several national organizations do not recommend specific pulmonary vasodilator therapy for treatment of pulmonary hypertension secondary to left heart pathology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for an evaluation of her breast cancer. Findings:  The physician reviewer found that the recent peer-reviewed literature revealed no evidence to support screening breast MRI in patients with a personal history of breast cancer. In a study published in December 2007, Willey and Cocilovo state, Patients with an elevated risk, but not in the very high risk category, are those with a family history of breast cancer, personal history of breast cancer, significantly dense breast tissue.  Breast MRIs as a screening tool for patients at an elevated risk has not been scientifically proven to be of value. According to the American College of Radiology (ACR) guidelines as revised in 2008, there is insufficient evidence to support the use of screening breast MRI in patients with dense breast tissue and in those patients with a personal history of breast cancer. ACR guidelines state Breast MRI may be useful in women with a prior history of breast cancer and suspicion of recurrence when clinical, mammographic, and/or sonographic findings are inconclusive. This patient does not have any clinical or mammographic evidence of recurrent breast cancer. There is no family or personal history of BRCA gene mutation and there is no history of radiation to the chest as a child. Thus, the patient did not meet generally accepted criteria for a screening or diagnostic breast MRI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested a referral to a physical medicine and rehabilitation and pain management physician for the treatment of his lower back pain. Findings:  The physician reviewer found that diagnostic medial branch blocks under fluoroscopic guidance have been validated as sensitive and specific for the diagnosis of facet generated pain. In the setting of a positive response to a medial branch block, radiofrequency neurotomy can be considered for long-term pain relief. Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. While this patients physical exam may suggest facetogenic pain, the studies demonstrate no particular set of signs or symptoms as typical for this condition. All told, the planned course of action appears medically appropriate and indicated. Furthermore, given the location of the tertiary center, the referral recommended by the Health Plan is contraindicated as it is likely to result in increased back pain associated with travel to and from the facility.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested  for IV therapy from an out-of-network provider for treatment of the enrollees pulmonary hypertension. Findings:  The physician reviewer found that this patient should be started on IV therapy as soon as possible. She needs to be managed by a pulmonary hypertension center experienced with its use.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patient does not meet the criteria set forth by the National Institutes of Health (NIH) for weight loss surgery.the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. This is particularly true for this patient, as an active infection such as MRSA is generally a contraindication to placing an implantable device.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for computed tomography perfusion and carotid angioplasty and stenting for treatment of her severe bilateral supraclinoid internal carotid artery stenosis. Findings:  Three physician reviewers found that there is a lack of large, scientific studies on intracranial stenosis and its treatment by angioplasty and stenting that shows evidence of its safety and efficacy. The studies address symptomatic disease. This patient does not have symptomatic cranial disease. Her symptoms have been deemed non-focal by her neurologist. At this time, there is a lack of supportive literature regarding computed tomography perfusion imaging, and there is inadequate published evidence showing that it improves outcome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for chemoembolization of liver metastasis for treatment of his metastatic colon cancer.   Findings:  Three physician reviewers found that the scientific evidence suggests that chemoembolization of liver metastasis greater than 5 cm is investigational in nature. Furthermore, there is no peer-reviewed literature demonstrating that chemoembolization confers additional benefit over standard therapy in patients with metastatic colon cancer. Given the paucity of data regarding the use of chemoembolization in this particular setting, its superiority remains unproven.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested for magnetic resonance spectroscopy (MRS) for evaluation of the enrollees microcephaly, developmental disorder and possible metabolic disorder. Findings:  Two physician reviewers found that performing a MRS is a reasonable diagnostic test, in keeping with best medical practices, in order to rule in or out this condition.  There are a number of well-recognized biochemical abnormalities that can arise from impaired mitochondrial metabolism in the central nervous system.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for robotic-assisted colon surgery for treatment of his colon cancer.   Findings:  Two physician reviewers found that the Clinical Outcomes of Surgical Therapy Study Group (COST) study demonstrated the equivalency of open and laparoscopic surgery in the treatment of colon cancer. There may be short-term benefits to laparoscopic surgery (less blood loss, shorter hospitalization, less pain) and the technique does not compromise oncologic outcomes. Robotic-assisted surgery is a further technologic modification of traditional laparoscopic surgery, though whether the use of a robot further improves (or compromises) outcomes is unclear. It is unlikely that a trial will be performed comparing robotic-assisted colon surgery to traditional laparoscopic surgery, and therefore case series with historical (or concurrent) series comparison will be the only evidence to support this technique. While the early reports demonstrate acceptable and comparable outcomes to laparoscopic surgery, there are currently few data of this type. All told, there is insufficient evidence available to date that robotic-assisted surgery is more beneficial to the patient than options such as traditional laparoscopic colectomy or an open colectomy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that Lobular carcinoma in situ (LCIS) is a very well known entity which when present, even when treated, places the patient in a high risk category. There is no known increased risk for LCIS concerning a specific lesion, however, there is clear evidence that the breast parenchyma is at increased risk for the development of invasive cancer. It is well established that lobular carcinoma is usually difficult to see with conventional imaging studies such as mammography and ultrasound. In this case, since there is difficulty in reproducing the findings seen on prior MRI with a follow-up ultrasound, it is medically reasonable and prudent to re-evaluate the patient with MRI. Ultrasound or mammographic guided biopsy is not possible since the lesions of concern could not be seen on the follow-up ultrasound.  Thus, in this case due to the higher risk of breast cancer based upon the history of LCIS and the equivocal ultrasound exams, it is necessary to rule out breast cancer and the best procedure to perform at this point would be the MRI.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for a magnetoencephalography (MEG) for evaluation of the enrollees medically refractory seizures.   Findings:  Two physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the patient was in no acute distress on examination. The patients vital signs were completely normal. He did not exhibit any signs of respiratory failure, and he did not require any treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for Treximet for treatment of her migraine. Findings:  The physician reviewer found that the literature indicates that the pharmacokinetics of sumatriptan and naproxen in Treximet are not identical to that of the individual components. There is also literature support for clinical superiority for Treximet over its components, with lesser headache recurrence rates noted.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a positron emission tomography (PET) scan of the brain for evaluation her mediastinal mass.  Findings:  Two physician reviewers found that regardless of the PET results, this patient needs a tissue diagnosis to guide her care. Following a tissue diagnosis, a PET scan can be ordered for staging if appropriate. If the patient has a tissue diagnosis of malignancy, then PET would be an appropriate way to stage this patient and monitor her response to chemotherapy. If biopsy reveals infection or other benign findings, additional work-up may be required.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the parent states that the patient was experiencing fever and shortness of breath. However, this is not documented in the physicians records. The patient was described as comfortable and without respiratory distress. His nose was congested, but lung sounds and oxygen saturation were normal. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy services for treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that Morgan and Vogel noted the success of intervention for severe motor apraxia, and the same principles apply to less involved children who should have even greater success rates.  A significant number of children with untreated articulation disorders will retain their articulation defects throughout elementary school without spontaneous remission.  Articulation phonological dysfunction is due to the delayed maturation of the motor development of speech.  It is a congenital disorder of brain function.  It can usually be significantly improved by speech therapy, which can hasten the establishment of normal speech.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for implantation of an auditory osseointegrated implant system for treatment of his acoustic neuroma. Findings:  The physician reviewer found that the patient is an excellent candidate for the BAHA procedure and does appear to meet the criteria set, as he is five years of age or older with unilateral single-sided deafness with hearing in the contralateral ear that meets the stated definition for normal. The fact that he is nearly deaf in the right ear is not a contraindication to the implantation procedure and in fact makes him a qualified candidate for a BAHA device.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested for extracorporeal shock wave therapy for treatment of his plantar fasciitis.  Findings:  Two physician reviewers found that there is adequate outcome data to support the use of ESWT for the treatment of plantar fasciitis that has failed to respond to conservative treatment. ESWT is performed more commonly for plantar fasciitis than open surgical treatment and is much safer than open surgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for a sacroiliac joint injection for treatment of her low back pain.  Findings:  Three physician reviewers found that the use of fluoroscopic guidance is appropriate as noted by Slipman and colleagues in their publication. The therapy was significantly more beneficial to her than alternative therapies
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested a computed tomography (CT) heart scan for an evaluation of his medical condition. Findings:  Three physician reviewers found that this patient is a relatively young male who has no cardiac symptoms and only one documented cardiac risk factor of modest hyperlipidemia (LDL less than 160). In this setting, the patients 10-year risk for developing significant coronary stenosis is low based on Framingham scoring. In this low risk circumstance, guidelines for evaluation and management of hyperlipidemia have been developed, endorsed by several national organizations, and do not include routine screening with coronary calcium scoring using CT. In addition, appropriateness guidelines for coronary CT imaging have also been developed, endorsed by several national organizations, and do not consider quantification of coronary calcium appropriate in a general population of asymptomatic individuals with low coronary heart disease risk. There is no study to support that a change in treatment based on results of coronary calcium quantification in this group of patients leads to an incremental outcome improvement above that obtainable by treatment based on standard risk factor profiling.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a follow-up visit to an endocrinologist for the treatment of her medical condition. Findings:  The physician reviewer found that there is emerging evidence that keeping the TSH level to less than 2.5 in women with hypothyroidism who are pregnant or pursuing pregnancy is indicated. There are thoughts that a TSH level of greater than 2.5 may be associated with fetal loss. Certainly, TSH should be kept in the normal range and levels of 6 and 10 are above normal. The UpToDate article entitled Overview of thyroid disease in pregnancy notes that during pregnancy women with hypothyroidism need more thyroid hormone and are unable to increase thyroidal T4 and T3 secretion. The goal of therapy is to normalize the mothers serum TSH concentration. Thus, it is clear that Synthroid doses need to be increased during pregnancy. In this particular clinical situation, with the patients past history of miscarriages and her previously high TSH levels, it seems medically reasonable and appropriate that this patients needs would be better met with a follow-up visit with the endocrinologist she saw rather than her primary care physician.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested acute inpatient detoxification for the treatment of the enrollees chemical dependency. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that upon admission the patient was detoxing from opiates with no life-threatening withdrawal signs or symptoms. There is no evidence that the patient was experiencing benzodiazepine withdrawal during the period at issue. Thus, per American Psychiatric Association and American Society of Addiction Medicine (ASAM) criteria, the patient could have been safely detoxed in an outpatient setting and did not require a 24-hour detoxification program for her withdrawal.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of her risk of breast cancer. Findings:  The physician reviewer found that a study by McPherson and colleagues noted that florid epithelial hyperplasia is a benign finding that carries a slightly higher risk of breast cancer, estimated at 1-2 fold over normal. This risk is higher with the presence of atypia, but there is no evidence suggesting that this breast pathology shows a high prevalence of BRCA1 or BRCA2 mutation. Additionally, epithelial hyperplasia does not warrant consideration of chemoprevention. There are specific guidelines that direct genetic testing for BRCA1 and BRCA2. A single first degree relative with breast cancer does not suggest a BRCA mutation in the family, especially in an individual with non-Ashkenazi family history. The Health Plans finding that it is not medically necessary to test this patient is consistent with the guidelines published by the U.S. Preventive Services Task Force.
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 migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraine headache there is literature supporting its use for patients with refractory headaches.  In this particular case, the patient has showed a documented response to occipital blocks and Verapamil. The available evidence does not demonstrate that Botox is likely to confer additional benefit over the response the patient has had to occipital blocks and Verapamil.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech disorder secondary to apraxia and dysarthria. Findings:  The physician reviewer found that this patient is a young child with speech disorder, apraxia, and dysarthria, whose skills fall below those of other children his age. These deficits negatively impact his ability to communicate effectively. However, he has demonstrated improvement with speech and language services. Studies have shown that speech therapy can result in significant improvement in such patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested Lidoderm patches for the treatment of her chronic pain. Findings:  The physician reviewer found that while there is no evidence of controlled trials of Lidoderm patches in the treatment of fibromyalgia, a study of pain relief in myofascial pain syndrome (a related chronic pain syndrome) showed significant improvement in pain control and somatic pain thresholds with lidocaine (Lidoderm) patches compared to placebo (see Affaitati and colleagues). This patient was reported to have tried and failed Prozac, Flexeril, Ultram and Motrin. The patients treating rheumatologist documented improvement in the patients pain after the use of Lidoderm patches, which the patient finds preferable to Lyrica since there is no side effect of sedation. This patient has failed multiple treatments for her pain, and is deriving benefit from Lidoderm patches. As such, it is medically appropriate to continue her on Lidoderm patches for pain management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Cialis for the treatment of his prostate cancer, status-post prostatectomy. Findings:  The physician reviewer found that Cialis is a 5-phosphodiesterase inhibitor which helps with the recovery of erectile dysfunction associated with radical prostatectomy. The recovery of erectile dysfunction following surgery is variable and depends on a number of factors including preoperative function, and the ability to avoid damage to the nerves at the time of surgery. It is clearly documented that the use of medication such as Cialis improves sexual performance and satisfaction over the use of placebo alone and there are several studies which demonstrate this fact. However, the number of pills required, the length of time the medication is needed, and whether the medication should be used nightly or simply on demand is unknown. Studies have not shown any particular program to be superior, including daily use versus on-demand use (see Montorsi and colleagues, 2008). Generally, medications such as Cialis are prescribed by urologists to be used several times per week in the hope that increased blood flow to the corpeal bodies of the penis will speed spontaneous recovery of erections. The number of pills (12 per month) requested for this patient is without scientific basis. The length of time the medication should be taken for maximum effect post-prostatectomy is similarly not established in the medical literature. Thus, at this time, without more studies to show the advantage of the proposed medication schedule and quantity, the medical necessity of the request has not been established.