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

A 32-year-old female enrollee has requested medication Lexapro for treatment of depression.  Findings:  The physician reviewer found that there is no evidence that the patient has ever received a trial of any other antidepressant. Based on the information provided, there is no reason to believe that she would not respond as favorably to any other SSRI, such as Celexa. Thus, it has not been established that Lexapro is superior to other SSRIs for treatment of this patients depression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of speech and language deficits.  Findings:  The physician reviewer found that if the patients speech deficits are a part of an autism spectrum disorder, speech therapy would be an integral part of a comprehensive treatment plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested physical therapy (PT) including soft tissue therapy, therapeutic exercise/activities and hand therapy for treatment of status post stem cell transplant and graft versus host disease (GVHD).  Findings:  The physician reviewer found that the various therapies cannot be considered medically necessary, as there were no documented goals and therefore no documentation of progress toward achieving the designated goals.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a Roll-A-Bout walker to help his mobility. Findings:  The physician reviewer found that the patient has a prior history of shoulder surgeries and right-sided carpel tunnel surgeries. The record includes documentation from his orthopedic surgeon stating he should not bear weight with his shoulders and therefore should not utilize crutches or a standard walker. Given this set of circumstances, the Roll-A-Bout walker was the appropriate equipment for the enrollees mobility following surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested the medication Invega for the treatment of the enrollees Tourette Syndrome and Attention Deficit Hyperactivity Disorder (ADHD). Findings:  The physician reviewer found that the safety and efficacy of Invega in children and adolescents has not been studied nor established. Invega is not the standard of care for adult patients with either Attention Deficit Hyperactivity Disorder or Tourette Syndrome.  The off label use of Invega for Attention Deficit Hyperactivity Disorder and/or Tourette Syndrome is at present considered investigational. The use of Invega by a nine-year-old patient is also considered investigational and not the standard of care for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested the prescription medication Celebrex for the treatment of his osteoarthritis of the lumbar spine. Findings:  The physician reviewer found that the Health Plans denial of  authorization for Celebrex for the treatment of the patients degenerative joint disease of the lumbar spine is not correct given his history of ITP. Immune ITP is a recognized, though rare, complication arising from the use of naproxen and certain other NSAIDs. The patient has successfully used Celebrex for several years and has not had platelet problems. He has an osteoarthritic condition and it is not reasonable to require a trial of four NSAIDs in this instance
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested a DEXA scan for the evaluation of her osteoporosis. Findings:  The physician reviewer found that DEXA scans at two-year intervals are satisfactory in following progress even taking into account this patients higher risk based on her mothers osteoporosis as well as the patients history of radiation and chemotherapy to treat her breast cancer. There is no data supporting yearly DEXA scans in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested prescription medication Lyrica for treatment of left arm pain.  Findings:  The physician reviewer found that there are many standard therapies available for the treatment of cervical radiculopathy including physical therapy, narcotic pain medications, oral steroids, epidural steroids, and a variety of medications for neuropathic pain. Lyrica is not generally a first or second-line agent for radicular pain,  and there are no studies supporting its use in this instance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested  for Avastin and irinotecan therapy for treatment of the enrollees astrocytoma. Findings:  Two physician reviewers found that Although available data are modest for irinotecan plus Avastin, there are several studies underway and the results are very encouraging. There are no high-activity treatments available for first-degree gliomas following the development of TMZ resistance. Few treatment options exist for this young patient with recurrent disease. Irinotecan-Avastin therapy is more promising than the standard treatment alternatives that are no longer effective.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested reimbursement for Botox injections. The Health Plan has denied this request indicating that the Botox injections at issue are considered experimental for treatment of the enrollees lateral pterygoid muscle dystonia. Findings:  Two physician reviewers found that the medical record indicates the patient has responded to Botox for this disorder.  Dystonia, including oral-buccal dystonia, typically does not respond to medication. There is data to support Botox for treatment of this patients condition. It is unlikely that any other available treatments will benefit the patients condition than Botox.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 82-year-old male is seeking testosterone compound for treatment of hormone deficiency.  Findings:  The physician reviewer found that Testosterone is available as a gel.  However, it is not known if the requested compounded product has the same absorption as the approved and studied version of this drug.  The requested compounded product is not an approved product.  Although other products are available for testosterone replacement, use of testosterone replacement in this patients clinical circumstances is not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested the medication Botox for treatment of myofascial pain syndrome and muscle spasm.  Findings:  Three physician reviewers found that Botox injections are not FDA approved for chronic muscle or myofascial pain.  Botox injections are not a generally accepted intervention for chronic muscle/myofascial pain as there is inadequate/insufficient evidence to support the use of Botox injections in the treatment of chronic myofascial muscle pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male have requested a speech evaluation and speech therapy for treatment of speech disorder.  Findings:  The physician reviewer found that recent studies from peer reviewed journals show no association, to a very small negative association, between OME and the childs later speech and language development. These studies concluded that attempts at early detection of OME in the asymmetric child to prevent delayed language development were not warranted. The studies also found that any association between early OME and language development found at the pre-school age, was no longer present by school age. Based on the inconsistent recommendations, the presence of normal hearing and the peer-reviewed evidence, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient fulfils the Food and Drug Administration criteria for GH therapy for the treatment of idiopathic short stature. He is abnormally short and has a projected adult height of 63 to 64 that is well below his mid-parental target of 70. The patient has had a positive response to GH therapy, further supporting the recommendation for continued treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the lack of delayed bone age and thus his low adult height prediction, he is clearly an appropriate candidate GH therapy. He has a diagnosis of idiopathic short stature and fulfils the criteria of the FDA ruling of 2003 for treatment with GH therapy. GH therapy is clinically indicated in this instance to promote increased growth velocity and maximize final adult height.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested treatment at a non-Plan comprehensive cancer center for the treatment of her pancreatic cancer. Findings:  The physician reviewer found that based on a prior diagnosis of adenocarcinoma, a marked elevation of CA19-9 and only mild elevations of gastrin and chromogranin (which often occur in benign conditions or due to PPI use), the diagnosis of pancreatic neuroendocrine tumor is not justified in the opinion of this reviewer. In summary, it appears that the patient has persistent and progressive pancreatic adenocarcinoma (based on CA19-9 levels). She was  treated with several regimens that have known efficacy in this disease (gemcitabine, Tarceva, Xeloda and platinum). At this point, no other treatment has proven efficacy. A regimen of 5-FU/oxaliplatin is of questionable benefit, but nonetheless could be provided within the Health Plan. If the patient has sufficient performance status, she could be considered for a clinical trial or a repeat challenge of Tarceva, or best supportive care; all managed through the Health Plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a CT angiography for the evaluation of his potential coronary artery disease. Findings:  Three physician reviewers found that contrast enhanced CT coronary angiographies have been evaluated for a variety of coronary artery clinical problems. Advantages include its ability to depict the vessel wall and to characterize plaque. It is considered as sensitive as invasive angiography for evaluation of the left main coronary artery and the proximal left anterior descending artery. However, its sensitivity and specificity falls off for more distal vessels as well as the right coronary and circumflex arteries. Many of the studies reporting its usage present data on sensitivity and specificity only for vessels that were analyzable and not for all vessels studied. Other proposed usages include evaluation of bypass grafts, serial follow-up of invasive angiography, and evaluation of stents. CT coronary angiography may have problems identifying highly stenotic lesions. An area where it has shown promise is the identification of coronary artery anomalies.  In summary, while the noninvasive nature of CT coronary angiography makes it an attractive test, its exact role in the diagnostic algorithm of CAD remains to be undefined.
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 for the treatment of the enrollees short stature. Findings:  The physician reviewer found that a normal IGF-1 level argues against a diagnosis of GH deficiency. The record indicates that the height of the patient was 52.75 yielding an adult height prediction of 66 to 67.4 by the Greulich and Pyle Atlas tables for (bone age) retarded boys. From the clinical information provided, a diagnosis of constitutional delay appears probable and the adult height prediction is within the normal range.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female has requested a magnetoencephalograpy (MEG) and magnetic source imaging (MSI) for the evaluation of epilepsy.  Findings:  Two physician reviewers found that MEG and MSI is indicated in sorting out and mapping different types of functional cortex and can be helpful in determining viability of surgical resection of malignant brain tissue and epilepotenic tissue from surrounding normal functioning cortex. It is particularly helpful in establishing interictal epileptic spike activity and has demonstrated superiority compared to other invasive and noninvasive approaches and provides superior data compared to MRI, PET or SPECT scanning
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male has requested a continuous glucose monitoring system (CGMS) for type I diabetes.  Findings:  Three physician reviewers found that although there are no substantial studies to demonstrate the utility of continuous glucose monitoring in preventing severe hypoglycemia, clearly the warning system would be helpful during the patients hypoglycemic or hyperglycemic episodes. Frequent finger-stick blood glucose monitoring cannot be performed at sufficient intervals to avoid severe hypoglycemia, particularly at night. Given the patients clinical history, it was determined that the requested equipment is likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested sub acute residential detoxification services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the specific need for sub acute detoxification is not clearly shown in the medical record; there was no detoxification - treatment plan found. That patients progress is described in physician notes, but it is unclear what protocol, if any, he was following. The information provided does not demonstrate that at the time of transfer to subacute care the patient had any mental status abnormality of documented withdrawal symptoms. Although psychiatric consultations were obtained, there is no specific indication that the patients condition required treatment beyond that of an outpatient program. She was not psychotic, suicidal or homicidal. The patient was treated with acupuncture, massage and various medications, but it is unclear what the specific goals of the subacute detoxification actually entailed.The record does not demonstrate the patients potential for clinically significant withdrawal requiring 24 hour medical intervention. Active withdrawal symptoms are not described. In addition, the patients associated psychiatric condition does not require inpatient care. While medications were ordered there was no specific medication management of withdrawal symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested growth hormone (GH) therapy for treatment of idiopathic short stature.  Findings:  The physician reviewer found that the patient clearly has marked growth deficiency and warrants a trial of GH therapy under the FDA guidelines of 2003 for idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) vertebral assessment scan for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is no data indicating that a BMD by DEXA with or without vertebral fracture assessment has any role in the evaluation of the patients neck and head pain. In addition, there is no data indicating that a BMD by DEXA more frequently than every two years (except for specific diseases which the patient is not reported to have) is useful. Therefore, there is no evidence to support the medical indication for the diagnostic procedure at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested for bilateral knee MRI for evaluation of her knee pain.   Findings:  The physician reviewer found that x-ray evaluation was essentially normal and there is no history of instability of the knee joints. A trial of viscosupplementation has not been attempted and a medication history is not provided. In sum, MRI is not appropriate at this juncture.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a four-year-old female enrollee have requested a consultation and treatment with a pediatrician specializing in integrative medicine for treatment of possible autism/developmental delay.  Findings:  The physician reviewer found that the benefit of consultation and treatment with an integrative medicine physician is not clear from the documents provided for review. The physician identified by the family does not list credentials that would qualify him to treat a child with a developmental disability or a child with an autistic spectrum disorder. There are two other reports from qualified professionals that indicate an intent follow the patient and to make the needed treatment recommendations. The record also indicates there is a pediatrician currently involved in the patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested continued treatment with testosterone pellet implantation for the treatment of her menopausal symptoms. Findings:  Two physician reviewers found that over the recent years, there is increasing evidence-based data and empirical experience by physicians and patients that androgen insufficiency is a real entity in women, particularly during the menopausal time period. Treatment with testosterone/androgen therapy, by various routes, can result in a substantial decrease in troublesome symptoms. Studies involving non-oral testosterone products are on-going, but here are currently no products with FDA approval for use in women. The use of testosterone patches and creams is not an FDA-approved alternative to testosterone pellet implantation. Nonetheless, non-oral testosterone formulations are widely used in the United States and internationally to treat androgen-deficiency syndromes in women, with excellent results and apparent safety. The current therapy has clearly provided a benefit for this patient and continued treatment is consistent with the standard of care within the gynecological community.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested sound sensitivity treatment and other services included in the treatment plan offered by Developmental Spectrums (e.g. laboratory testing, dietary supplements and medications) for the treatment of the enrollees autism and central auditory processing disorder. Findings:  The physician reviewer found that there is no evidentiary basis for the application of sensory integration therapy, auditory integration therapy or sound sensitivity treatment in the treatment of autism according to a current review of autism published in the peer-reviewed literature. With regard to the other treatment modalities offered by the Autism Spectrums clinic, these interventions are not evidence-based and are far less likely to have a positive impact on the patients behavior and level of functioning than the more standard approach outlined following the patients multidisciplinary evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested reimbursement for enhanced external counterpulsation (EECP) therapy for treatment of coronary artery disease.  Findings:  Three physician reviewers found that the use of external enhanced counterpulsation therapy (EECP) in the treatment of chronic stable angina, refractory to medical and not amenable to revascularization procedures has been a well accepted, non-experimental use of this technology in selected anginal patient subsets. The use of EECP in the treatment of heart failure - although early trials show promise - has not yet shown benefit in this patient subset. There are patients who present with crossover symptoms such as dyspnea which may be an anginal equivalent in patients who are not amenable to revascularization procedures; however this patient from review would be a suitable candidate for repeat revascularization procedures if recurrent ischemia is a concern.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a five-week-old male enrollee has requested for transfer to an out-of-network Level 4 Neonatal Intensive Care Unit (NICU) for treatment of the enrollees multiple medical problems secondary to severe prematurity. Findings:  The physician reviewer found that although pediatricians provide good coverage, it is standard of care for neonatologists to attend a triplet delivery and to cover high acuity patients. For such a patient, neonatology coverage should be available on site, on a 24-hour basis. A patient such as this one should be managed in a level 4 NICU with sub-specialty coverage and high acuity equipment such as high frequency ventilators and ECHMO available. In general, the transfer of a five-week old premature infant is feasible if the receiving facility has accepted the patient, the proper equipment and medical coverage are available at the receiving facility and the patient is stable for transport.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer.  Findings:  The physician reviewer found that the patient has a very localized tumor with Partins tables suggesting a 99% likelihood of containment within the volume of the prostate. The side effects of all forms of radiation therapy are relatively low. This is especially true with IMRT, which is a form of treatment available to the patient. He appears to have a good understanding of the various modalities and is aware and assured that the local control and overall cure rate are the same for both proton beam and IMRT. As the side effects are minimal and manageable for both forms of treatment, I see no medical indication for proton beam radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female is seeking reimbursement for a liposuction procedure for treatment of lipomas of the arms.  Findings:  The physician reviewer found that there are no photographs to support the patients complaints. Nor, has a pathology report been submitted to support the patients complaints. There are no radiologic studies documenting soft tissue tumors. There is no mention of cancer concerns, rapid growth of lesions with pain, or any other symptoms that would arouse tumor concerns. Furthermore, there is no evidence of a fine needle or core biopsy for diagnosis of a medical condition requiring treatment. All told, there is inadequate data to establish that the procedure at issue was medically necessary for treatment of the patients medical condition.