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

A 23-year-old male enrollee has requested eating disorder partial hospitalization program services (PHP) for the treatment of his condition. Findings:  The physician reviewer found that the APA guidelines state that outcomes from partial hospitalization programs that specialize in eating disorders are highly correlated with treatment intensity. The more successful programs involve patients in treatment at least 5 days per week for 8 hours per day. Thus, it is recommended that partial hospitalization programs be structured to provide at least this level of care. The aims of treatment for patients with bulimia nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical complications of bulimia nervosa; 3) enhance patients motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. For this patient the PHP program was effective in reducing purging, but did not eliminate such.  There were no significant clinical complications.  Cooperation and motivation improved, and education was provided.  The core problems include a personality disorder that will be difficult to change.  The psychiatric comorbid conditions are being treated with a need to re-evaluate psychopharmacological intervention.  The family is now actively involved to reduce the symbiosis that they have with their son.  Relapse prevention can be addressed at a lesser level of care after the patient is stabilized at the PHP and seen an average of 5 days per week over the above stated period of time.  Admitting the patient for a 7 days per week program initially with reduction as stated offers the intensive treatment that is suggested in the APA guidelines.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for an emergency room visit for treatment of her severe abdominal pain. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with are consistent with a variety of diseases and disorders including appendicitis, cholecystitis/cholelithiasis, pyelonephritis/urinary tract infection, gastrointestinal bleeding, pelvic infection, and other potentially life-threatening illnesses. The patient presented for evaluation of acute abdominal pain of sufficient severity that a prudent layperson would be concerned enough to seek emergency medical evaluation immediately.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested for cognitive rehabilitation services for treatment of his residual impairments from a stroke. Findings:  The physician reviewer found that benefit from comprehensive, community-based, cognitive rehabilitation when compared with traditional rehabilitation programs is not established and does not have support in the literature. The cognitive rehabilitation program is not superior or necessary when compared to the usual alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for a bunionectomy and custom-made foot orthotics for treatment of her hallux valgus condition. Findings:  The physician reviewer found that there is no documented physician-directed, non-operative treatment. In addition, custom made foot orthotics would not be indicated in the absence of trial and failure of more conservative measures, such as the use of shoe modifications, which have not been documented.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for radiofrequency neurotomy of the cervical spine for treatment of her post-herpetic occipital neuralgia. Findings:  Two physician reviewers found that there is not sufficient evidence in the scientific literature to show that the procedure is effective in the long-term. More peer-reviewed outcomes data is needed to establish the safety and efficacy of this procedure in the long-term.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested a DexCom STS Continuous Glucose Monitoring System for the treatment of the enrollees Type I diabetes. Findings:  The physician reviewer found that there is no data on the use of this continuous glucose monitoring system (CGMS) in children around her age. The child has low variability in the day-to-day variation of her blood sugars. Her A1C is very good (6-6.5%). The patients pediatric endocrinologist specifically notes that she does not have hypoglycemia unawareness or nocturnal hypoglycemia. Acetaminophen (Tylenol) interferes with the CGMS function and remains a very important medication for treating fever in her age group which cannot use aspirin.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for a knee scooter for treatment of his mobility needs. Findings:  The physician reviewer found that there is nothing in the record to indicate that the patient had formal training by a physical therapist for ambulation to determine what type of walking assist device would best accommodate the non-weight-bearing status of his left lower extremity. The standard options are crutches, walker or a wheelchair. An assessment by a home health care professional would also be helpful to help facilitate his convalescence.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 17-year-old female enrollee has requested for residential treatment for treatment of her major depression. Findings:  The physician reviewer found that the patient has clearly struggled with a mood disorder that heretofore has been considered that of major depression, and for which residential treatment was deemed necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for residential treatment services for treatment of the enrollees attention-deficit/hyperactivity disorder, oppositional defiant disorder and marijuana abuse. Findings:  The physician reviewer found that there is no indication that the patient demonstrated much beyond a personality construct of significant narcissism, with relatively minor outward behavioral manifestations at that.As such, there are no medical grounds for continued residential treatment beyond this point.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for Actiq 1600mcg for treatment of her cervical pain. Findings:  The physician reviewer found that there is more experience with the use of opioids in the cancer population, and the long-term use and continuous efficacy of these medications in the non-malignant pain population is still a matter of debate. Even though the etiology of pain in these two separate populations seems to be fairly distinct, the actual experience of pain itself cannot be clearly separated. Moreover, long acting opioids seem to be a more reasonable alternative than around-the- clock short acting preparations.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested for early childhood partial hospitalization program services for treatment of the enrollees autism. Findings:  The physician reviewer found that Applied Behavioral Analysis (ABA) in the home and parent education would seem to be a more suitable an approach to this childs problems. The hospitalization and its duration (far longer than a typical period of observation) appear to be of doubtful long-term benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a replacement continuous positive airway pressure (CPAP) machine and related supplies for treatment of her medical condition.    Findings:  The physician reviewer found that there is no evidence explaining why the patient requires a replacement CPAP machine.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested the prescription medication Solodyn (90 mg) for the treatment of his skin condition. Findings:  The physician reviewer found that minocycline is commonly used in rosacea treatment.  Brand name extended release minocycline (Solodyn) is clinically known to have fewer associated side effects than generic formulations.  For this reason, Solodyn is usually prescribed for patients intolerant of or unresponsive to generic minocycline.  This particular patient presents with both intolerance and unresponsiveness to generic minocycline.  As generic minocycline has been tried and has failed in this case, Solodyn is the next indicated and appropriate clinical treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested testosterone therapy (at standard doses) for the treatment of his stated hypogonadism. Findings:  The physician reviewer found that in order to preserve future fertility, the patient should slowly taper and retest his hypothalamic-pituitary-testicular axis. Body builders who take too much testosterone turn off their ability to make their own testosterone as well as sperm.  The former is what the patient, did as evidenced by his very high levels of testosterone and suppressed levels of LH, the usual testicle testosterone stimulator. The requested therapy is not medically appropriate or indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Reclast infusion for the treatment of her osteopenia. Findings:  The physician reviewer found that the patient began taking Fosamax in addition to calcium and vitamin D to protect from osteoporosis. According to a note, there was some apparently minor discomfort with ingestion. The patient is interested in yearly Reclast infusion as an alternative. Her last DEXA scan done noted normal femoral neck density and modest osteopenia of the L-spine with T-score of 1.5. This is very mild compared with age matched controls. The Health Plans criteria are appropriate. Reclast infusion is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old male enrollee has requested irritable bowel disease serology marker testing for an evaluation of the enrollees abdominal complaints. Findings:  Two physician reviewers found that the patient has a history of abdominal complaints consisting of pain with a change in bowel habits over a 10 to 12 month period. He did not have any alarm symptoms that would have prompted a colonoscopy at the time, and a decision to order an IBD serology was made. When the IBD serology came back positive, a colonoscopy was performed. The colonoscopy revealed aphtoid ulcerations in the patients left and right colon extending into the terminal ileum with a serpiginous ulcer seen there. Biopsies of these lesions showed some cryptitis, but were not diagnostic of IBD. Putting together the symptoms, endoscopic findings and the serology have helped confirmed the patients diagnosis. Although not performed in the traditional order of a colonoscopy preceding the IBD serology, in this case, an IBD serology would not only have been helpful to confirm the diagnosis, but also led the gastroenterologist to the right test, i.e. the colonoscopy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested osteochondral allograft surgery on the left knee for the treatment of his osteoarthritis and bone destruction of the left knee. Findings:  Two physician reviewers found that this patient's provider has recommended that he undergo an allograft procedure. The patient underwent knee arthroscopy with little relief of pain. At surgery it was noticed the patient had a large lesion of chondromalacia. Because of these findings, allograft surgery was recommended. Allograft surgery is not considered investigational for treatment of this patients condition. There is sufficient data to support the procedure as appropriate and indicated for treatment of this patients condition. Furthermore, the patient has limited treatment options and allograft is likely to be the most beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the child was profoundly language-delayed by the age of two. Speech pathology evaluation was clearly one of the mandatory primary evaluations. The licensed speech pathologist found a near absence of developed language. Childhood speech delay has many possible etiologies. This child was considered intellectually normal, had no obvious genetic or familial disorder, and the language delay was diagnosed as being due to a neurological dysfunction of the childs expressive language cerebral center. Labeling the childs language delay as apraxia was an unusual diagnosis, as apraxia is a motor malfunction of the oral-facial musculature and is generally utilized in adult neurology to describe damage from small strokes. A more meaningful diagnosis would be developmental expressive aphasia. The childs language delay is clearly neurological due to failure of his cerebral speech development, and the referral was appropriate. The treatment was medically indicated and appropriate for the child to develop speech by school age.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a breast MRI study for an evaluation of her breasts. Findings:  Three physician reviewers found that the standard evaluation for breast symptoms is diagnostic mammogram and breast ultrasound. This is true for patients with or without a history of breast cancer. Breast MRI is a useful adjunct to mammogram/ultrasound in select patient populations including those patients with new diagnosis of breast cancer. The use of breast MRI for screening purposes in patients with personal history of breast cancer continues to be controversial. At this time, breast MRI for screening purposes is limited to patients with BRCA mutation or strong family history of breast cancer. Breast MRI is not meant to replace mammography/breast ultrasound. In regard to this patient, breast MRI is not medically indicated at this time and would not be considered more beneficial than other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for a positron emission tomography (PET) study for evaluation of her brain.   Findings:  Two physician reviewers found that there is data to support the use of PET scanning to assist in this patients diagnosis and the results of a PET scan will most likely significantly assist in directing the patients treatment plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The family of a four-year-old female enrollee has requested speech therapy (Tomatis technique) for the treatment of the enrollees autism and speech-language disorder. Findings:  Three physician reviewers found that this autistic child also has a history of recurrent otitis media and a chronic auditory problem. Both problems are recognized as benefiting from speech therapy. This patient received therapy through the Tomatis technique. The Health Plan considers the Tomatis technique investigational and has denied reimbursement for the therapy at issue. There is no definitive proof that the Tomatis technique method is more effective than standard speech treatment. The Tomatis technique is more than 40 years old, and there are no controlled studies demonstrating its effectiveness. In contrast, standard speech therapy is known to be beneficial for treatment of patients with autism.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for Avastin/Ixempra combination therapy for treatment of her metastatic breast cancer.   Findings:  Two physician reviewers found that Avastin is a humanized monoclonal antibody targeting VEGF. It is approved in colon, lung, and breast cancers. In breast cancer it is specifically approved for front line use with Paclitaxil, although it has been studied in other settings. Many questions remain regarding the optimal use of Avastin, including optimal duration of therapy and multiple lines of therapy. These questions will likely never be answered by Phase III clinical trials. The treatment with the highest probability of efficacy would be an Avastin-containing regimen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for inpatient hospital services for treatment of her bipolar disorder. Findings:  The physician reviewer found that the time of admission there was uncertainty regarding whether the patients diagnosis was unipolar versus bipolar, and the patient had placed a bag over her head the previous night. There was also a past history of another suicide attempt, and ongoing outpatient treatment was no longer effective in dealing with her depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested an anterior cervical discectomy with artificial intervertebral disc replacement for the treatment of his cervical myelopathy and disc herniation at C4-5. Findings:  Two physician reviewers found that although cervical disc replacement surgery with artificial disc prosthesis is a novel approach to management of cervical myelopathy due to a herniated disc, there is currently insufficient peer-reviewed literature reporting on its safety and efficacy long-term. Furthermore, there is no peer-reviewed evidence directly comparing cervical artificial disc replacement surgery to an anterior cervical discectomy and fusion. Anterior cervical discectomy and fusion remain the standard of care for treatment of this patients condition. In addition, considering this patients myelopathy and progressive neurological deficit, anterior cervical discectomy and fusion would be the optimal treatment choice for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested pulsed radiofrequency neurolysis for the treatment of his primary supraorbital and primary trochlear headaches. Findings:  Three physician reviewers found that radiofrequency nerve blocks are considered investigational treatment for headaches, and this form of treatment is not standard of care. There is no evidence to support radiofrequency nerve blocks as medically necessary or effective for treatment of this patients condition. Furthermore, there is no clinical evidence that this patient has exhausted available standard treatment options. Even if the patient has exhausted standard treatment options, radiofrequency nerve blocks would not be considered appropriate for treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested X-Stop spinal surgery for the treatment of his back problems. Findings:  Three physician reviewers found that the X-Stop procedure is not the best procedure available for the described pathology in this patient.  Additionally, there is presently only short-term data on the safety and efficacy of the X-Stop device.  There is some concern for subsidence of the implant over time and loss of initial distracting effect on the osteoporotic spinous processes, and this patient would present significant concern for osteoporotic bone.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested a percutaneous disc decompression (PDD) procedure for the treatment of her back pain. Findings:  Three physician reviewers found that the requested procedure does not appear to be indicated in this case. The MRI study does not reveal a large right or left side disc herniation, and the patient does not appear to have radicular complaints. The patients chronic pain is not an indication for surgery. Furthermore, there is no evidence demonstrating that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than other available procedures.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested a PET/CT scan for an evaluation of hiss cholangiocarcinoma. Findings:  Two physician reviewers found that the patient has been treated with radiation and chemotherapy.  His referring physician requests a PET/CT scan for restaging.  Renal insufficiency precludes intravenous contrast administration for MRI or CT scanning, thus limiting the usefulness of each modality for the detection of recurrent or metastatic tumor. The Health Plan does not include cholangiocarcinoma as a covered indication for PET/CT scans. The Health Plan has denied coverage for the PET/CT scan. Of note in this case is the unusual situation in which the patients elevated serum creatinine precludes intravenous contrast administration for MRI and CT scans, which in turn compromises each modality in the search for a soft tissue tumor. The PET Oncology Registry has recommended PET scanning in the staging of all tumors and is awaiting a ruling from CMS on this recommendation sometime in 2008.  PET/CT could be of use, particularly in light of the contraindication to IV contrast. The diagnostic procedure is likely to be more efficacious for evaluation of this patients condition than alternate diagnostic methods.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested revisional gastric bypass surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that there is no mechanical problem that would justify revisional surgery. Although the patients limb may have been short, this is not definitive and would not mandate the need for surgical revision.  Furthermore, as set forth above, UGI and EGD do not demonstrate pouch enlargement or fistula. The documentation provided demonstrates that the patients weight regain is most likely related to noncompliance. At this time there is no medical justification for the requested procedure. Although this patient may be an appropriate candidate for further surgery in the future, at this time revisional surgery is not medically justified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested the medication Vyvanse for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plan requires that the patient show a documented failure in both the amphetamine class and the methylphenidate class. Although the patient has documented failure on Adderall XR, there is no documented failure of any medication in the methylphenidate class. Vyvanse is not medically indicated for treatment of this patient. The Health Plans requirements are reasonable and appropriate.