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

A 42-year-old female enrollee has requested for Provigil for treatment of her excessive daytime fatigue and hypersomnolence. Findings:  The physician reviewer found that obstructive sleep apnea refractory to CPAP is an approved indication for Provigil. In this case, the patients obstructive sleep apnea is refractory to CPAP secondary to claustrophobia. Thus, CPAP therapy is not a viable alternative to control the patients daytime somnolence. A medical condition may be refractory to therapy for numerous reasons, including as this case illustrates, psychological limitation, mainly claustrophobia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a continuous glucose monitoring system (CGMS) and related supplies for the treatment of his type I diabetes. Findings:  Two physician reviewers found that there is no information provided documenting that the patient had a wide variability in his finger stick blood sugar results, frequent irreversible lows or significant complications prior to the use of the CGMS. In addition, it appears the patients diet may be a contributing factor to his reported poor control. There is no indication the patient has seen a dietician to evaluate his meal plan or eating patterns. As such, there is inadequate evidence to support this patients use of a CGMS.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 19-year-old male enrollee has requested the medication Xolair for the treatment of the enrollees allergies. Findings:  Two physician reviewers found that the submitted records do not establish the medical necessity of treatment with Xolair for this patient.  The records provided do not document a diagnosis of moderate to severe persistent asthma with symptoms that are inadequately controlled with standard therapy. There is no documentation of wheezing, coughing, shortness of breath, etc.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Botox injections for the treatment of her muscle spasm and dystonia. Findings:  Two physician reviewers found that the clinical data submitted for review is consistent with a complex regional pain syndrome. There is no documentation of cervical dystonia and the original Botox therapy was for pain in the right axilla. There are multiple standard therapies that have not been explored, including desipramine, Lamictal, Keppra, and Tegretol.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested continued growth hormone (GH) therapy for the treatment of the enrollees pituitary dwarfism. Findings:  The physician reviewer found that the patient has a clear medical need for GH therapy together with replacement of other pituitary hormone deficiencies. His excellent response to GH therapy is not an appropriate basis for discontinuing the treatment. The patients prospects for reaching his mid-parental height of 65.5 are good with continued GH supplementation. GH therapy should continue until the patient has had epiphyseal closure and growth arrest.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested a PET scan for an evaluation of his renal carcinoma and melanoma. Findings:  Three physician reviewers found that the use of F-18-FDG PET scan in this clinical setting is recognized as in accordance with generally accepted medical standards of practice. It is safe and effective and provides high sensitivity for assisting in proper treatment decisions. The clinical utility of PET scan in these circumstances is well-established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested an adjustable oral appliance (SomnoMed) for the treatment of her obstructive sleep apnea (OSA). Findings:  The physician reviewer found that sleep apnea, if left untreated, can lead to serious cardiac and gastrointestinal disorders. This  patient cannot tolerate CPAP, but had moderate success with a fixed, non-adjustable appliance. Assuming that the symptoms only occurred in the right TMJ as reported, it is consistent with therapeutic guidelines to assume that a different oral appliance could work. Certainly, with any orthotic trials of different types may be needed to find the one that is most effective. The same is true for oral appliances. The SomnoMed device is totally different than the TAP-2 appliance and a trial of the device is reasonable. There are limited treatment alternatives at this juncture, and severe sleep apnea should not go untreated.
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 the patients predicted adult height does not warrant GH therapy on the basis of idiopathic short stature, according to the 2003 FDA guidelines. Additionally, the patient had a normal IGF-1 level and the reports for GH stimulation testing are incomplete. Although the patient may have had growth-retarding therapy for his ADHD and gastrointestinal problems, the medical indication for GH therapy has not been adequately documented. The patients bone age and history of linear growth are unknown and laboratory testing is non-confirming.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested growth hormone (GH) therapy with Humatropey for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that this patient has profound short stature, disordered growth velocity, and some psychosocial issues. GH therapy is appropriate in this instance. However, both Nutropin and Humatrope are FDA approved and known to be safe and effective for treatment of idiopathic short stature over the long term. Nutropin is therapeutically equivalent to pituitary-derived human GH. In vivo and in vitro pre-clinical and clinical testing of Nutropin in pediatric patients with GH deficiency, chronic renal insufficiency and Turners syndrome showed an increase in growth rate and an increase in IGF-1 levels. Nutropin is a formulary medication and no compelling reason for choosing Humatrope over Nutropin has been identified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 10-year-old male have requested growth hormone (GH) therapy with Humatrope for treatment of idiopathic short stature.    Findings:  The physician reviewer found that it would appear from the information included in the record the patient will have a delayed adolescence but will eventually reach a normal adult height. His adult height prediction excludes him from coverage for GH therapy on the basis of idiopathic short stature according to the July 2003 FDA guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother for a five-year-old male has requested continued follow up care with an orthopedic surgeon specializing in oncology for treatment following surgery for Ewings sarcoma.  Findings:  The physician reviewer found that the care of this child can be broken down into two components; (1) treatment of his Ewings sarcoma and (2) his recovery from his limb-sparing surgery. As to the first, the treating oncologist is still in-Plan and will likely continue to treat the patient with chemotherapy as well as provide the majority of his long-term follow-up. As to the second consideration, the patient is recovering well from the limb-sparing surgery and it would be anticipated that the orthopedic surgeons involvement in the care of the patient will decrease. Any issues that might develop would be within the spectrum of care of other (pediatric) orthopedic surgeons, including those offered as in-Plan alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested annual DEXA scans for the evaluation of osteopenia.  Findings:  The physician reviewer found that it is generally recognized that DEXA measurements to ascertain the response to therapy for osteopenia or osteoporosis should not be done before completing two years of treatment, due to regression to the mean. Markers of bone resorption may be useful after three months of treatment. In this instance, the patient will not benefit from DEXA scanning at an interval of less than two years.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Supartz injections for the treatment of his arthritis. Findings:  Two physician reviewers found that at this time, Supartz is only FDA approved for use in the knee. Other joints, including the shoulder, have been tried with limited success. There is no evidence in the peer reviewed scientific literature that supports the use of viscosupplementation in the shoulder. Thus, Supartz injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for the prescription medication Vyvanse for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that no untoward side effects were reported after a one-month trial of this medication and it was clearly beneficial. The prescribed dosage is within recommended guidelines. Continued treatment with Vyvanse is clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male has requested Provigil for treatment of bipolar disorder.  Findings:  The physician reviewer found that the progress notes submitted for review do not clearly outline the progression of the patients symptoms or his response to treatment. It does not appear that mental status examinations were conducted at regular intervals and there is no clinical support for the addition of Provigil to the patients medication regimen.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female has requested on-going physical therapy (PT) for treatment of a frozen shoulder.  Findings:  The physician reviewer found that the clinical record indicates the patient improved with therapy, but had eventually plateaued. Her shoulder ROM was not within normal range, but was fairly functional. The patients pain did not resolve. It is not likely that additional PT would be of significant benefit at this stage. Continued use of the HEP will help to maintain the gains the patient has achieved and may also facilitate slow improvement in ROM. PT has not alleviated the patients pain and alternative modalities should be explored.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the patients symptoms are attributable to nerve damage and he has been diagnosed with chronic neuropathic pain of the neck, upper thoracic spine and upper extremities. He has shown consistent response to Lyrica for the past 18 months. This medication is being used for its antineuropathic effects, which have been validated for conditions such as diabetic polyneuropathy and post herpetic neuralgia. Off-label use of Lyrica for other types of neuropathic pain is common within the Neurological and Pain Management communities. Lyrica is an appropriate treatment for this patient due to its profile of minimal side effects and broad efficacy in the management of neuropathic pain. Additionally, it would not be in the patients best interest to discontinue this particular drug considering his response.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested the Oncotype DX tumor assay for an evaluation of her breast cancer. Findings:  The physician reviewer found that the greatest utility of the Oncotype DX is in determining whether an individual patient falls into the low risk category, for which hormone therapy alone may be sufficient, or the high-risk category, for which chemotherapy followed by hormone therapy is probably indicated. There is not unanimity of opinion among medical experts on whether the Oncotype DX assay should be routinely applied. The NCCN is split in their opinion about Oncotype testing. ASCO has approved the use of the Oncotype assay in early-stage breast cancer patients for decisions regarding chemotherapy. The TAILORX trial is a large cooperative group trial, currently investigating the benefit of chemotherapy in patients with an intermediate recurrence score with the Oncotype DX assay. Subjects with high and low recurrence scores were not randomized. This trial demonstrates the validity of the Oncotype DX tumor assay and the applicability of the results in patients with low recurrence and high recurrence scores, which constitutes approximately 70% of all results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested rhinoplasty to be performed in conjunction with septoplasty (and turbinate reduction) for the treatment of his chronic nasal obstruction. Findings:  The physician reviewer found that the description of the patients nasal septal deviation as being off of the nasal spine along with a mid-third nasal dorsal deviation strongly suggests that the mid-third dorsal deviation is secondary to the dorsal septal deviation. An open rhinoplastic approach  would facilitate complete correction. It is unlikely there would be an optimal result in terms of the patients nasal airway, with a septoplasty and turbinate reduction done by a simple endo-nasal approach. Septorhinoplasty should be performed as a single procedure for this patient, both to facilitate correction of the nasal airway and to avoid two anesthesias. It is probable that full correction of the septum will correct the dorsal deformity as well and therefore no aspect of the surgery what would be considered cosmetic. If it is determined during the procedure that correction of the septal dorsum does not completely alleviate the nasal dorsal deformity, further correction would be considered cosmetic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested bilateral thigh skin excision for the treatment of her excess skin. Findings:  The physician reviewer found that due to the absence of any office notes documenting infections, the patients history of uncontrollable and recurrent intertrigo cannot be verified. Either the patients rashes have not been severe enough to require medical treatment or the appropriate treatment notes have not been submitted. The patients condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care. Surgical dermatolipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested surgical excision of a sebaceous (inclusion) cyst for the treatment of her skin condition.  Findings:  The physician reviewer found that based on the medical record, the patients inclusion cyst was not causing any health problems. The indication for removal was the patients desire to have it removed rather than to maintain or improve her health. According to the H&P, the cyst was not bothersome. The records do not document any recent change in size or a concern that the mass might be malignant. The cyst was removed for a cosmetic reason, rather than a medically necessary indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested continued diabetes care management for the treatment of his diabetes. Findings:  The physician reviewer found that the patients diabetes is under good control. At this point, he does not meet the criteria to enroll in the diabetes care program. Further involvement would not provide additional benefit. The patient should follow-up with his PCP and endocrinologist for further assistance if necessary.
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 problems. Findings:  The physician reviewer found that the medical records do not indicate that the patients expressive delay is related to an injury, illness or other medical condition. Rather, this appears to be a developmental speech delay. At age 312 it is not clear whether the problem is simply a delay or an actual speech impairment. In either case, the deficits are educational in nature, and as such, speech therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-month-old male enrollee has requested Elidel 1% cream for the treatment of the enrollees atopic dermatitis. Findings:  The physician reviewer found that records indicate that this young patient with documented atopic dermatitis, food and inhalant allergies and asthma has experienced inadequate response to the standard therapies provided for his significant atopic dermatitis.  These include topical steroids. Standard medical care for atopic dermatitis is to induce a remission with topical steroids, but to limit their use to avoid systemic absorption. If the skin is widely involved, as in this patient, too much steroid is absorbed. It is especially important to infants to avoid systemic absorption of steroids. Elidel is medically necessary and more clinically appropriate for inducing and maintaining remission of atopic dermatitis in this patient as a steroid-sparing therapy.  The use of Elidel for treatment of atopic dermatitis in infants and children is the standard of care in the medical community at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Lamisil for the treatment of his nail fungus. Findings:  The physician reviewer found that the submitted clinical information is unclear in whether this patient has a fungus infection of his nails. There is mention of scrapings being sent for a fungus culture, but no results have been provided. Lifting and separation of the nails can occur in many conditions, only one of which is onychomycosis. The primary care physician did not document a physical exam of the skin and nails in the records provided. In light of the evidence provided, it appears evaluation by a dermatologist would be appropriate. There is not sufficient evidence of a fungal infection to support the use of Lamisil at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested physical therapy (PT) for her rehabilitation. Findings:  The physician reviewer found that the PT provided actually addressed several different therapy goals. Initially treatment focused on the patients right shoulder. She demonstrated progress, but could have continued with strengthening through a home exercise program. However, the patient was also given a prescription for physical therapy for her right ankle. There was limited documentation in this regard, and extension of treatment would have been sufficient. The patient received her leg braces and additional PT for gait training was indicated. She progressed at which time she walked 18 five times. Her walking distance declined after that date, probably due to an exacerbation of her chronic right shoulder problems. The progress note indicates the patient had scheduled surgery for rotator cuff repair. The patient had plateaued with ambulation and there was limited potential for additional gains due to the rotator cuff problems; PT should have been discontinued.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested Alimta (pemetrexed) for the treatment of her ovarian cancer.  Findings:  Two physician reviewers found that patients with chemotherapy-resistant ovarian cancer rarely experience a clinical response with any of the known drugs used for treatment of this disease. This is especially true with the administration of seven chemotherapy regimens as was described in regard to this patient. However, she was able to achieve a clinical response with the administration of Alimta in combination with Tarceva. The fact that the patient progressed on Tarceva alone would indicate that Alimta was the active agent in this combination. The FDA granted approval for the use of Alimta in mesothelioma and lung cancer, giving some assurance of safety.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his prostate cancer. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has localized prostate cancer, which is highly curable using different radiation techniques. Although CyberKnife treatment is a relatively new treatment, this technique is more conformal in terms of dose delivery than any other available method of delivery. The use of CyberKnife is medically appropriate and indicated in this case and should be authorized
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested proton beam radiation therapy for the treatment of his pre-sacral chordoma. Findings:  The physician reviewer found that this patient appears to have a locally aggressive pre-sacral chordoma. The Health Plan offered a team of oncologic surgeons, including orthopedic, spine and general, to perform the second surgical procedure. The outcome of that surgery is not known. The patients needs in regard to post-operative radiation therapy are dependent upon the surgical  result. If the surgical excision was not complete and there is discernible residual tumor, the precision of proton beam radiation therapy is clinically indicated. However, if there is no discernable residual tumor, IMRT is appropriate for post-operative radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested the medication Hyalgan for treatment of knee pain.  Findings:  The physician reviewer found that there is no documentation of other therapies, such as a trial of corticosteroid injections. Hyalgan injections are indicated for treatment of arthritic knee conditions when other measures have been unsuccessful. As corticosteroid injections have not been attempted, Hyalgan is not yet indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested the medication Zylet for treatment of teary eyes.    Findings:  The physician reviewer found that there is no evidence in the record of trials of other antibiotic/steroid combination medications. There is no specific infection being treated that requires Tobramycin. Nor is there any reason identified for choosing one type of steroid over another. There are other antibiotic-steroid combination medications available. As such, the medical necessity of Zylet has not been established.