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

A 49-year-old female enrollee has requested  for long-term physical therapy for treatment of his knee and shoulder pain. Findings:  The physician reviewer found that long-term physical therapy will not be of benefit to this patient. She has numerous subjective pain complaints along with degenerative changes of the knees and limited shoulder motion. The patient has been provided an extensive course of therapy to date. There is no appreciable improvement documented for the hand, knees or shoulder. At this juncture, based on her failure to improve, any further therapy would be maintenance with little to no expectation for significant gains in terms of pain relief or functional restoration. Therapy intervention should be structured and goal-driven.  Continued physical therapy will offer no benefit beyond that of a compliant home exercise program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for DRX 9000 spinal decompression for treatment of her sciatic pain. Findings:  Three physician reviewers found that non-surgical decompression systems such as the DRX 9000 are promoted as replacing traditional spinal procedures (discectomy, decompression, and fusion). However, although initial results are encouraging, there have not been studies of this treatment that control for placebo effect or spontaneous recovery in the results. At this time, DRX 9000s clinical efficacy is unproven.  Also, in this particular patient, there was no medical indication for the proposed non-surgical spinal decompression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has authorization and coverage for a knee brace for treatment of the enrollee, who is status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the request for an off-the-shelf de-rotation/ACL brace is reasonable and necessary.  The literature is mixed as to the efficacy of prophylactic bracing, but it is reasonable to recognize that in the case of an ACL reconstruction the graft will not regain its full strength for at least six to nine months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for venous ligation and division for treatment of his varicose veins. Findings:  The physician reviewer found that it does not appear the patient has undergone the appropriate work-up for consideration of vein stripping. This would typically include a consultation with a vascular specialist and a duplex ultrasound. The medical records provided do not support the need for vein stripping.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for pulmonary vein isolation/catheter ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that most cases of atrial fibrillation can be managed effectively with rate control and anticoagulation, or with pharmacologic antiarrhythmic suppression and anticoagulation. However, rare patients,  remain very symptomatic even with the best medical management strategies. Ablation procedures are appropriate, even though they may require repeated ablation attempts, in this particular subset of patients.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for emergency services for treatment of his leg pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a history of diabetes, hypertension and high cholesterol and posterior leg pain that was acutely worsening after three days, would reasonably expect the absence of emergency care to jeopardize their health. DVT was high on the list of possible causes for the patients symptoms and physical exam findings. Patients with DVT are in immediate jeopardy of pulmonary embolism and a prompt diagnosis is paramount.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Hyalgan injections for treatment of her bilateral knee osteoarthritis.   Findings:  Three physician reviewers found that this patient has undergone intraarticular cortisone injections. These were helpful initially, but lost their effectiveness. The patient has also had Synvisc and Hyalgan injection series with a reaction to the Synvisc. There are no studies demonstrating the efficacy of repetitive use of viscosupplementation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for a pelvic MRI to rule out adenomyosis. Findings:  The physician reviewer found that the MRI was ordered after an ultrasound of the uterus (during an IVF procedure) showed findings that were suspicious for the diagnosis of adenomyosis. The MRI was ordered to resolve the suspicious finding. An MRI is medically necessary to assist in the diagnosis of adenomyosis. It can be a more sensitive imaging modality than ultrasound. Additionally, an MRI can help avoid a tissue biopsy of the area, which is the gold standard for diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested the prescription medication Sonata for the treatment of her insomnia. Findings:  The physician reviewer found that this patient has sleep maintenance insomnia, not sleep initiation insomnia. Out of the three benzodiazepines on the market, Sonata (zaleplon) is the best option for this type of insomnia. It has the shortest half life and a decreased the risk of hangover effect. Other agents such as benzodiazepine agonist or hypnotics are not appropriate given the prolonged half-lives. Treatment with Ambien or Lunesta is not equivalent to or exchangeable for treatment with Sonata in this instance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested continued acute rehabilitation services for the treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that this patient is demonstrating continued progress in acute rehabilitation and has potential for additional improvement. Appropriate rehabilitation goals are identified and include hygiene, grooming and self-care skills. Acute rehabilitation services should continue for an additional four weeks.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested participation in a phase II clinical trial for the treatment of her systemic scleroderma. Findings:  Three physician reviewers found that this patients pulmonary fibrosis has progressed to where her chest x-ray has a ground glass appearance, her diffusion capacity has deteriorated, and she has worsening dyspnea despite supplemental oxygen. It is felt the patient has derived maximal benefit from past and current conventional therapies. Her records indicate she is a viable candidate for ASCT, which represents the best treatment alternative given this clinical scenario. Clearly, there are risks associated with participation in the clinical trial, but early data shows promising results.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain. Findings:  Three physician reviewers found that artificial disc replacement is a unique technique for the surgical treatment of discogenic back pain. However, there is a paucity of controlled studies and clinical trials showing the safety and efficacy of this procedure, particularly as compared to interbody fusion surgery.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested emergency services for the treatment of her head pain. Findings:  The physician reviewer found that the patient complained of being unable to sleep due to a frontal headache. Two days earlier, she woke up with a bump on her head and a severe headache. The patients symptoms met prudent layperson criteria for emergency care. Although she had been evaluated by Plan providers two days earlier, there is evidence in the medical record that her headache pain worsened. A prudent layperson with an average knowledge of medicine, a history of previous hemorrhagic stroke and severe headache two days after being evaluated for head trauma, would reasonably expect the absence of emergency care to seriously jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested chiropractic services for the treatment of her neck and back pain. Findings:  The physician reviewer found that the medical records lack specificity as to progression of care, diagnosis, clinical impressions and management.  There is evidence of x-rays, but no documentation of the impressions of those studies.  The records do not indicate functional gain, consistency of progression, percent of recovery or return to normal function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Epivir-HBV for the treatment of his hepatitis B. Findings:  The physician reviewer found that there is no one standard therapy for hepatitis B. There are multiple medications available and many studies evaluating their effectiveness. It is not clear this patient needs to be treated based on laboratory results. However, if treatment is deemed essential, Epivir-HBV offers no added benefit over the formulary medications. A trial of the formulary medications is reasonable prior to treatment with Epivir-HBV.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Dynesys Spinal System surgery for the treatment of the enrollees degenerative disk disease and stenosis, L3 to S1.   Findings:  Three physician reviewers found that the patient has multilevel degenerative disc disease and stenosis.  The Dynesys Spinal System is still unproven in the medical literature. While, in theory, it may offer relief of pain with maintenance of motion, there is no long-term, peer-reviewed literature that supports its efficacy or superiority over traditional treatment modalities for overall health benefits.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested emergency services for the treatment of her postoperative complications (shoulder). Findings:  The physician reviewer found that the patient had arthroscopic surgery two days prior. She was concerned about bleeding and complained of pain that was moderate in nature.The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and pain and bleeding after attempting to remove a catheter placed during shoulder surgery two days earlier would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested refractive laser surgery on the right eye for the treatment of his acquired astigmatism. Findings:  Three physician reviewers found that this patient has had a very serious condition requiring a corneal transplant many years ago. No one knows how long corneal transplants will last. Refractive laser surgery is reported to help with correction of large degrees of anisometropia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested Bicillin LA injections for the treatment of his chronic group B streptococcus infection.  Findings:  The physician reviewer found that there is a lack of evidence that group B streptococcal infection has been effectively prevented with antibiotics in non-pregnant adults. However, it is notable that Bicillin LA is not used for this purpose. This drug achieves relatively low levels in the blood, and group B streptococci are relatively resistant to penicillin. Doses several times higher than those recommended for group A streptococcal infection are recommended. Penicillin G or ampicillin is recommended by the CDC for prophylaxis. It is also unlikely the patient would still be carrying this organism after more than four years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 13-month-old female enrollee have requested a Dynamic Orthotic Cranioplasty (DOC) banding for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that this child had plagiocephaly significant enough to warrant an external prosthesis. There is growing evidence that correction of this head deformity improves long-term outcome related to the temporal bone, ear, orbit and jaw. The family started with Hanger Cranial band and the problem worsened. They then chose to go with the DOC band. As pointed out by Cranial Technologies, there is a significant difference between the two procedures. The Hanger cranial band has not been shown to be as effective, and it passed FDA standards only by being similar to the DOC band. Correction of this deformity was in the patients best medical interest.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested emergency services for the treatment of her itchy eyes. Findings:  The physician reviewer found that for the previous week her eyes had been extremely itchy and somewhat red. She came to the ED because she could no longer tolerate the itchiness. However, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a history of Sjogrens syndrome with a five-day history of itchy eyes would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Botox injections for the treatment of her chronic daily headaches. Findings:  The physician reviewer found that this patient has received multiple treatments including analgesics, muscle relaxers and antineuropathic medications, with no pain relief. The patient underwent Botox injections to the cervical paraspinal musculature. This therapy did improve the patients head and neck symptoms. Because standard therapies have failed and Botox therapy has been effective for this patient, the patient should continue with Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plans criteria for this medication requires that the patient is between the ages of 6 and 12 years, has had an unsatisfactory response to a medication in the amphetamine and methylphenidate class and treatment does not exceed 70mg per day. The patient meets the latter two criteria but is 16 years old. The Health Plan reports that Vyvanse is not FDA approved for the treatment of children over age 12.The patient does have ADHD, and he has responded favorably to treatment with Vyvanse 70mg daily. Vyvanse is approved by the FDA for the treatment of this condition, and that approval was based upon clinical data in children from 6 to 12 years of age. FDA approval defines the marketing claims a manufacturer of a medication may make. Practitioners may prescribe a medication for indications that are not specifically approved in the product label, and they may likewise prescribe a product outside the age range in which the product was studied. The age difference of 12 versus 16 years does not appear to be clinically relevant. To suggest that the patients medication be changed simply because he is 4 years beyond the age of 12 is not clinically appropriate and may not be safe.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Erwinia L-asparaginase for the treatment of his acute lymphocytic leukemia (ALL). Findings:  Three physician reviewers found that Asparaginase therapy is a very important part of ALL therapy, particularly T-cell ALL. In the presence of a hypersensitivity reaction to PEG-asparaginase, the only alternative is Erwinia L-asparaginase. This is not yet FDA-approved. The International Acute Lymphoblastic Leukemia Working Group study in 2006 supports this use. The standard of care in pediatric oncology is to use Erwinia L-asparaginase in this situation. Pediatric oncologists do not consider this experimental, although not yet FDA approved.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Erbitux therapy for the treatment of her lung cancer. Findings:  Three physician reviewers found that Erbitux is FDA approved for colorectal and head and neck cancer. It is not compendium listed or included in the recommended treatment options under the NCCN consensus panel recommendations for non-small cell lung cancer. There are no randomized, controlled trials showing that the addition of Erbitux to Alimta will lead to an improvement in outcome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Abraxane chemotherapy for the treatment of his metastatic melanoma. Findings:  Three physician reviewers found that Abraxane is an albumin-bound form of Taxol. It is approved for use in metastatic breast cancer and is being actively studied in many other tumor types, including melanoma. There is one published abstract submitted with the appeal. There were partial responses noted, particularly in patients that were previously untreated with chemotherapy. As far as can be determined, there is nothing beyond an abstract published as yet. The data for the use of Abraxane in melanoma is therefore quite minimal, and the evidence in terms of survival benefit is lacking.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested artificial cervical disc replacement surgery at spinal levels C4-5 and C6-7 for the treatment of her neck and arm symptoms. Findings:  Three physician reviewers found that although total artificial disc implantation is a novel technique to replace standard anterior cervical discectomy and fusion (ACDF) surgery, there is insufficient peer-reviewed evidence demonstrating its long-term safety, efficacy and adjacent level disease prevention. At this time, artificial disc replacement does not appear better than traditional ACDF for treatment of cervical disc disease and herniated cervical disc with radiculopathy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested emergency services for the treatment of the enrollees abdominal pain and headache.  Findings:  The physician reviewer found that the patient had a high fever to 104.4 and she has a history of urinary tract infection. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with the combined symptoms of high fever, headache, and photophobia, in association with altered level of consciousness, would reasonably expect the absence of emergency care to jeopardize their childs health. These symptoms were very concerning and suspicious for meningitis or encephalitis. Abdominal pain raises the possibility of an intra-abdominal infection such as appendicitis or pyelonephritis, particularly given the history of urinary tract infection.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested emergency services for the treatment of his abdominal pain. Findings:  The physician reviewer found that the patient had a history of chronic left lower quadrant abdominal pain that was exacerbated over the previous three weeks. He rated the pain level in the ED as 7/10. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and chronic abdominal pain increasing to a level of 7/10 over a three-week period, without any other associated symptoms, would not reasonably expect the absence of emergency care to jeopardize their health. Although this patient states in his appeal letter that his pain had become unbearable on that day, the medical record is not consistent with that claim and described moderate pain, chronic in nature. Based on the patients symptoms as described in the medical record, his evaluation could have safely occurred on a non-emergent basis.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested emergency services for the treatment of his abdominal pain. Findings:  The physician reviewer found that the patient complained of generalized abdominal pain since 12 noon, rated as 8/10, and associated with nausea, diarrhea and myalgias. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and the sudden onset of severe abdominal symptoms would reasonably expect the absence of emergency care to jeopardize their health. Although the medical record does not support the patients claim that he was having chest pain and arm numbness, the severity of his abdominal complaint is evident.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested  for continued follow-up with a pediatric cardiologist for treatment of his tetralogy of Fallot. Findings:  The physician reviewer found that adult physicians have not been educated about the complexity of the adult with a congenitally malformed heart. In a field which is so rapidly changing, it is crucial that cardiologists treating adult patients not only have special training, but deal with these complexities on a daily basis to keep abreast of advances in the field. For this patient, the best option may be to eventually transition to such a center. In the interim, or in the absence of an adult congenital cardiologist, it is imperative that this patient with complex heart disease who has had numerous surgeries continue his care with a pediatric cardiologist if an adult congenital cardiologist is not available to him. To require him to see an adult cardiologist who is not specially trained in congenital defects violates the current standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested for the Paradigm Real-Time continuous glucose monitoring system (CGMS) for treatment of the enrollees persistent hyperinsulinemic hypoglycemia of infancy (PHHI).  Findings:  Three physician reviewers found that the management of PHHI is difficult and these children are at risk for brain damage from repeated hypoglycemias. Persistently their high insulin levels may also inhibit alternative brain energy substrates such as ketones. Prevention of seizure requires numerous blood glucose measurements throughout the day and the night. The patient could be monitored more closely and be spared frequent finger-stick blood sampling through the use of a CGMS.