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

The parent of a 15-year-old male enrollee has requested for Focalin 25mg for treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that Focalin XR contains both an immediate release as well as delayed release of Dexmethylphenidate, thus making twice daily dosing not medically necessary.  Although an increase of the medication beyond the recommended maximum of 20mg may be considered for a patient, the increase ought to be on the order of 5 to 10mg.  There is no pharmacologic merit in transitioning from 20mg per day to more that double the dosage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Imitrex 100mg for treatment of her migraines and skull-based tumor. Findings:  The physician reviewer found that Imitrex is not for frequent, daily headaches.  As of 2006, the patient was also on Imitrex and Amerge. The patient is at high risk for rebound headaches.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for pudendal nerve injections and pelvic physical therapy (PT)  for treatment of her pelvic pain.    Findings:  The physician reviewer found that this patient has completed an extensive pelvic floor PT program and should be independent with her home exercise program (HEP) at this point.  On-going skilled pelvic PT has limited additional value beyond compliance with the HEP.  Occasional pudendal nerve injections for intermittent severe, sharp neuropathic symptoms may be medically justified, but not until chronic medication management has been optimized with use of pain medications for breakthrough pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for right ankle replacement surgery for treatment of her arthritic ankle. Findings:  Two physician reviewers found that the FDA approved the Agility total ankle prosthesis in 2002.  The intention of this procedure is to give the patient limited mobility by reducing pain, restoring alignment and replacing flexion and extension movement of the ankle joint.  Early studies were not encouraging, but intermediate term results were somewhat better.  Considering the evidence of this particular patients clinical condition and information currently available in the literature, total ankle replacement may be a better procedure for her.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested for Actiq for treatment of his Crohns disease. Findings:  The physician reviewer found that Actiq is approved by the FDA for use in cancer pain patients, and the original package insert specifically states its use is to be limited to cancer pain only. There are no randomized controlled trials of this medication in non-malignant pain patients. Rather, there are several case series and individual case reports in the literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested  for minimally invasive interbody fusion at L5-S1 using the Dynesys Spinal System for treatment of his low back pain. Findings:  Three physician reviewers found that the Dynesys system is not currently accepted as standard of care for spinal surgery.  This is a non-fusion, pedicle screw stabilization system using flexible materials intended to stabilize the affected lumbar region while preserving the natural anatomy of the spine. The system was developed in an attempt to overcome the disadvantages of rigid instrumentation and fusion. This system remains investigational and requires additional long-term studies to conclusively establish efficacy greater than standard methods of treatment. Additionally, there is no documentation that this individual underwent discography to determine if this was, if fact, the painful level.  Prior to undertaking any type of fusion surgery, all pain generators should be identified.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for his acute inpatient care for treatment of his bipolar disorder.    Findings:  The physician reviewer found that the patient has major mental illness.  He persisted in having intent and plan to kill himself and his parents, as well as his uncle and aunt.  The patient had paranoid ideations and aggressive outbursts.  Additionally, he had on-going conflict and distrust with his parents.  Although his symptoms and behavior improved during his inpatient stay, he still presented a substantial risk of harm to himself and his family.  Discharge would have been unsafe.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for scanning laser ophthalmoscopy with retinal nerve fiber layer analysis for treatment of her eye condition. Findings:  Three physician reviewers found that there are no other glaucoma risk factors present.  Optic nerve status can be adequately and appropriately monitored with serial optic disc photographs.  The requested testing is not needed for this purpose.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a ten-year-old male enrollee has requested for circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that an adequate course of topical corticosteroid therapy would be most appropriate before subjecting him to a surgical procedure that is not without its own morbidity. Re-evaluation of the request for circumcision would then be appropriate if corticosteroid therapy fails.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for psychiatric residential treatment for treatment of the enrollees major depression, polysubstance dependency, conduct disorder and attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that there was no indication of suicidal or homicidal thinking, and he was not psychotic. In the residential facility, he initially appeared reasonably cooperative, but did apparently continue some use of drugs.It would not have been reasonable to manage this patient in a lesser level of care. The patient did require the structure and the 24-hour professional observation imparted in a residential facility.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for physical therapy (PT) for treatment of her knee and back pain. Findings:  The physician reviewer found that the records show some limited improvement in the patients tolerance of PROM, which was not clearly documented or quantified. It does not appear there were any significant changes in the patients symptoms, range of motion, or exercise program.The patient could have reasonably continued with the exercise program at home. There is no documentation that the modalities used provided any temporary or permanent reduction in the patients pain or facilitated the patients exercise program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested for long-term acute care for treatment of his herpes simplex 1 viral encephalitis. Findings:  The physician reviewer found that patient was medically stable, and he was able to go up and down stairs (20 steps) with the use of handrail. The patient was naming tasks with 55% accuracy, and he followed written directions with 100% accuracy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for artificial disc replacement for treatment of her degenerative disc disease.   Findings:  Two physician reviewers found that Tthere is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. The potential problems that may occur with longer follow-up have not been fully documented. Zigler et al, recently completed a randomized, prospective, multicenter study of the ProDisc-L versus circumferential fusion for low back pain. This study identified a reasonable cohort, subscribed the sample in a short time period, and demonstrated minimal attrition. Total disc replacements should still be considered an investigational procedure without long-term follow-up and should only be used within the context of strict clinical trials.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested for growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the growth rate increased from 6 cm per year to 9.6 cm per year. the patient has a combination of genetic short stature and constitutional delayed maturation, and she is predicted to achieve an adult stature inside of the FDA guidelines for GH therapy for idiopathic short stature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee have requested for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the reports of the child clearly establish and reinforce a diagnosis of autistic spectrum. The etiology of autism has not been clearly delineated, but the consensus is that it is a congenital disorder. The highlight of dysfunction in autism is a communication defect. Consistent speech therapy on a one-to-one basis is the only known method of improving communications in an autistic child.The speech therapy reports have clearly defined goals on each visit. Generally, the trend is consistent improvement in these goals. The variation in the sub-tests of the psychometric testing is consistent with a child with autism, despite the childs improvement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her foot pain.    Findings:  The physician reviewer found that Lyrica is generally used for treatment of neuropathic pain syndromes associated with diabetes, as well as post-herpetic neuralgia, and fibromyalgia. Lyrica is not a common medication for central nervous system neuropathic pain syndromes such as MS, nor is it FDA approved for this indication. In addition, it appears that this patient has not had a trial of formulary neuropathic pain medications. Such a trial would be appropriate prior to off-label utilization of Lyrica.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for a referral to an out-of-network provider for endoscopy and dilation for treatment of her anastomotic stricture. Findings:  The physician reviewer found that Endoscopic or fluoroscopic dilation of a stricture is a fairly common procedure and can be accomplished by virtually any gastroenterologist.  There is no medical reason to go out-of-network.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested Fentora 800mcg or Actiq 1600mcg for the treatment of his intractable abdominal pain. Findings:  The physician reviewer found that Actiq and Fentora are approved by the FDA for use in cancer pain patients, and the original package insert specifically states its use is to be limited to cancer pain only. There are no randomized, controlled trials of this medication in non-malignant pain patients. There are a number of other medications on the formulary that are not documented as having been tried. There is no documentation of diagnostic nerve blocks (celiac or superior hypogastric). Additionally, the case series submitted in support of the appeal do not pertain to chronic abdominal pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for an electric scooter for treatment of her post-polio syndrome. Findings:  The physician reviewer found that the patient does have a mobility impairment. During her in- home PT evaluation, she demonstrated the ability to compensate for this by walking 50 feet twice with a single point cane and independence with her activities of daily living.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for a pneumatic compression unit with hot/cold contrast for treatment of his post right unicondylar knee replacement. Findings:  Three physician reviewers found that a continuous passive motion machine in combination with a pneumatic compression unit with hot/cold contrast was prescribed for postoperative use. To date, there is no randomized, controlled data supporting the benefit of this equipment over more conventional postoperative treatment modalities. As such, the unit cannot be recommended as either reasonable or medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested continued eating disorder residential treatment for the treatment of her anorexia nervosa. Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines for eating disorders specifically state, The decision about whether a patient should be hospitalized on a psychiatric versus a general medical or adolescent unit should be made based on the patients general medical and psychiatric status Further, the guidelines clearly indicate that every attempt should be made to prevent physiological instability, as it may be associated with sudden and catastrophic cardiac consequences. The criteria provided by the American Academy of Pediatrics (AAP) are quite similar. This is a very seriously ill individual with a body weight at a dangerously low level. She was not gaining weight and her condition was becoming a more serious safety risk. This patient required admission to an acute inpatient treatment program. She requires on-going inpatient medical care until she is physiologically stabilized. After stabilization, treatment in a residential facility would likely be appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested upper and lower blepharoplasty for the treatment of her chronic blepharochalasis. Findings: The physician reviewer found that blepharoplasty procedures and repair of blepharoptosis are considered functional/reconstructive surgeries when implemented to correct visual impairment due to dermatochalasis, blepharochalasis, or blepharoptosis, symptomatic redundant skin weighing down upper lashes, chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin and prosthesis difficulties in an anophthalmic socket, according to the American Academy of Ophthalmology (AAO). Documented patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. Photographs should demonstrate that the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex, the upper eyelid skin rests on the eyelashes, the upper eyelid indicates the presence of dermatitis or the upper eyelid position contributes to difficulty tolerating prosthesis in an anophthalmic socket. This patients photos do not show significant dermatochalasis, and the records do not describe a functional impairment due to upper and lower lid skin excess. In addition, visual field studies are not provided for review. The AAO guidelines are not met.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for emergency services for treatment of her abdominal pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. Based on the available medical records it appears that the patients pain had abruptly worsened that day. A prudent layperson with an average knowledge of medicine and acute onset of 6/10 abdominal pain would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested for Hyzaar 100/25 for treatment of his hypertension. Findings:  The physician reviewer found that this medication is indicated and medically appropriate. Per Milliman Care Guidelines, Hyzaar is indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has for referral to a pediatric gynecologist for treatment of her vaginal bleeding. Findings:  The physician reviewer found that trauma and infection, two common reasons for prepubertal vaginal bleeding, have been ruled out.  A pediatric endocrinologist was consulted and concluded the patient does not have precocious puberty.  There is no medical necessity for a pediatric gynecologist, as this is a not a widely-recognized specialty.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of her type 1 diabetes mellitus.  Findings:  Two physician reviewers found that the CGMS is FDA approved for patients with diabetes mellitus and problems with hypoglycemia and wide fluctuations in blood glucose levels. The scientific evidence supports a decrease in the time spent in hypoglycemic range and probable improvement in Hgb A1c values. The patient already has complications related to her diabetes and the CGMS will enable her to have better glycemic control.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for an MRI of the leg, bilateral for evaluation of her left lower extremity pain and swelling. Findings:  The physician reviewer found that the medical records indicate that the patient has cord-like varices of the left lower extremity.  She has complaints of a swollen left knee.  MRI is not medically indicated under these circumstances.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for emergency services for treatment of his ear pain.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and 8/10 ear pain for two days, similar to previous episodes of ear wax blockage, would not reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an eight-year-old female enrollee have requested for Nutropin therapy for treatment of the enrollees growth failure/short stature. Findings:  The physician reviewer found that the patient does have a subnormal growth rate and if the subnormal growth rate continues this estimate may need to be revised downwards. However, based upon the available information this patient has a predicted adult height outside of the Food and Drug Administration (FDA) guidelines for growth hormone therapy for treatment of idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for extracorporeal shock wave therapy (ESWT) for treatment of his plantar fasciitis. Findings:  Two physician reviewers found that the literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of the treatment effect or any long-term adverse effects. In addition, there have been some conflicting results among the randomized controlled studies; a recent randomized, placebo-controlled, double-blinded, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested for participation in a Level 3 Chronic Pain Management Program for treatment of his chronic pain.  Findings:  The physician reviewer found that it is currently reasonable for him to enter a Level 2 Pain Program first, since he has not attended such program. His need for additional treatment, including a Level 3 Pain Program, should be assessed upon completion of such treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested for CyberKnife radiosurgery for treatment of his prostate cancer. Findings:  Two physician reviewers found that a short course of high-fraction radiation treatments that will deliver the biological equivalent to 40 IMRT treatments is well advised considering the radiobiology of prostate cancer. Participation in the CyberKnife clinical trial for the treatment of prostate cancer would be considered optimal treatment according to NCCN guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for hepatitis A vaccination.  Findings:  The physician reviewer found that the patient is not in a category for which vaccination for hepatitis A is recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested for partial hospitalization treatment services for treatment of her eating disorder. Findings:  The physician reviewer found that the patient was slowly improving. The magnitude of improvement did not justify a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for endoscopic removal of a pituitary tumor for treatment of her pituitary adenoma. Findings:  The physician reviewer found that Standard transsphenoidal surgery does not provide access or visualization of the cavernous sinus. Endoscopic surgery provides much better visualization to determine if the tumor has extended.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested for acute inpatient substance abuse detoxification and treatment services for treatment of his cocaine dependence. Findings:  The physician reviewer found that there were no acute withdrawal symptoms noted in the records available for review and no evidence of vital sign instability.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for sclerotherapy for treatment of her lower extremity varicosities.  Findings:  Two physician reviewers found that the saphenous veins were not removed, and she now has symptoms related to the remaining saphenous veins and varicosities. Given the presence of bilateral reflux, it is reasonable to treat the residual saphenous veins and branches.