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

The parent of a 16-year-old male enrollee has requested jaw reconstruction surgery with dental implants for treatment of ectodermal dysplasia.Findings:  The physician reviewer found that the proposed reconstructive surgery is designed to restore defects, both functional and morphogenic, that are due directly to the congenitally inherited disease of ectodermal dysplasia. This intervention is not designed to restore structure or function that was lost due to dental disease, dental caries or periodontal disease. Therefore, bone augmentation and placement of dental implants is medically reasonable and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested a PET/CT scan for the evaluation of his gastrointestinal stromal tumor (GIST).Findings:  The physician reviewer found that research indicates PET/CT allows an early evaluation of the patients response to treatment with imatinib, is a valuable tool in patients with gastrointestinal stromal tumors and improves staging (and) accurately separates responders from non-responders in an early phase, and is helpful during follow-up. PET/CT is superior to CT in evaluating the response to treatment, and is particularly effective for patients treated with imatinib mesylate therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested acute inpatient rehabilitation for treatment of status post hip fracture.Findings:  The physician reviewer found that rehabilitation goals were limited to transfers and power-chair mobility. This would not require a three-hour per day acute rehabilitation program and the documentation indicates the patient would not have tolerated this intensity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested physical therapy including biofeedback for the treatment of her vulvodynia. Findings:  Two physician reviewers found that physical therapy with biofeedback for treatment of vulvodynia is not the standard of care and remains experimental/investigational. There is insufficient scientific evidence demonstrating the therapy at issue is efficacious in this clinical setting. The evidence in support of the therapy is primarily anecdotal and is not adequate to support its use for the treatment of vulvodynia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested liposuction of fatty tissue for treatment of her lipodystrophy. Findings:  The physician reviewer found that lipodystrophy of the posterior neck is a well-recognized complication of HIV and anti-viral therapy. The medical literature confirms that patients with neck lipodystrophy often experience pain and difficulty breathing. The submitted letter from the patient and an office note from her infectious disease specialist describe neck discomfort, breathing problems and difficulty sleeping due to airway obstruction when lying flat in bed. According to Wolfort, et. al., suction-assisted lipectomy to remove HIV protease-inhibitor associated fat deposition is an effective procedure, which eliminates the functional disability and pain associated with the buffalo hump. Other investigators confirm these findings, indicating that liposuction is effective in the treatment of medication-induced buffalo hump. The request for liposuction is appropriate and medically necessary to correct a deformity and improve the patients ability to function (obtain restful sleep).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested a consultation with a clinical audiologist for the evaluation of the enrollee for possible central auditory processing disorder (CAPD). Findings:  The physician reviewer found that in order to determine if the patient does have an auditory processing disorder, she will need to be evaluated by a licensed clinical audiologist with expertise in auditory processing evaluations and treatment.  These evaluations are exclusively within the scope of practice of clinical audiologists and no other clinical professional.  Because central auditory processing disorders represent a medical and not an educational condition, the evaluations are medically necessary. Clinical audiologists are licensed clinicians who are trained to conduct medically necessary evaluations to diagnose impairments of the auditory and vestibular systems. Auditory processing disorders represent a dysfunction of neural processing within the central auditory pathway. Because auditory processing disorders typically fall into one or more of four classifications, the recommended therapy and treatment are individualistic and not universally applied. Until this patient is evaluated and diagnosed positively or negatively with an auditory processing disorder, the appropriate therapeutic and/or educational goals will be incomplete.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested a motorized wheelchair and portable oxygen device for treatment of numerous medical conditions, including minor immobility and respiratory diseases.   Findings:  The physician reviewer found that the submitted medical records from the patients treating provider document significant functional impairment secondary to his multiple medical problems. In addition, he also has severe PAH with pressures up to 75 mm Hg. This would explain his dyspnea, edema and generalized poor exercise tolerance. The treatment of PAH includes supplemental oxygen, ideally 24 hours a day along with various vasodilators.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a continuous passive motion (CPM) device for treatment of her left knee pain.   Findings:  The physician reviewer found that the utilization of a CPM device status post arthroscopy for lateral meniscal tear and chrondomalacia has not been proven to improve functional outcomes in the rehabilitation of the knee following surgery. There is insufficient peer-reviewed literature supporting the use of the CPM device in this group of patients. As such, there is inadequate evidence to warrant the use of the CPM device in the patients post-operative recovery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Forteo for treatment of her osteoporosis.   Findings:  The physician reviewer found that while the patient does have osteoporosis, she has not been tried on a bisphosphonate. Her previous tibial fracture was a traumatic fracture, not a fragility fracture. Forteo is generally not a first-line treatment. It is typically reserved for (1) patients with severe osteoporosis as measured by a T-score of -3.5 or below without fracture or -2.5 or below with a fragility fracture; (2) patients who not able to tolerate bisphosphonates or have relative contraindications to this therapy; or (3) patients who fail other osteoporosis therapies as indicated by fracture and loss of bone mineral density (BMD) in spite of compliance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for psychiatric residential treatment services for treatment of the enrollee behavioral health problems. Findings:  The physician reviewer found that there is nothing to indicate that the patient warranted continued residential treatment services. He had been taken off of self-harm precautions, was no longer considered a threat to others and his medications were stable. The patients clinical progress from the time he was initially admitted was significant. His need for 24-hour monitoring had ceased and his dangerous and aggressive behaviors had substantially improved. The patient could have been safely treated in a less restrictive setting by that time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for a continuous passive motion (CPM) machine for treatment of the enrollee post knee surgery. Findings:  Two physician reviewers found that the use of the CPM machine is considered controversial. It is not indicated for home use following surgery for osteochondritis of the knee. There is no evidence supporting this approach over standard modalities including physical therapy and range of motion (ROM) exercises. These alternatives are readily available in the outpatient setting and are appropriate for this patient following surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for Xenicalfor treatment of her obesity. Findings:  The physician reviewer found that Xenical is approved by the FDA at the prescribed dosage for obese patients with a BMI greater than 30. Xenical has been found to contribute significantly to successful weight loss when compared to the results achieved with diet and exercise alone. The Xenical studies did not include a weight loss of 10% as a pre-condition for enrollment and there is no clear medical indication for such a requirement. The patient has a BMI greater than 30 with significant co-morbidities and treatment with Xenical is consistent with the FDA guidelines. Although the benefits of Xenical for a patient such as this one are clear, there are a number of precautions related to its use and reports on the benefits do not extend beyond two years of therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for Botox injectionsfor treatment of her piriformis syndrome. Findings:  Three physician reviewers found that a review of the medical literature and the materials provided does not confirm the efficacy of Botox for the treatment of piriformis syndrome. Overall, scientific studies fail to document the efficacy of Botox in musculoskeletal chronic pain disorders. Thus, Botox remains an unproven therapy for the purpose of treating buttock pain in the setting of piriformis syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested for Omacor for treatment of her hyperlipidemia.  Findings:  The physician reviewer found that there are other available therapies that are likely to be effective for treatment of the patients elevated triglycerides.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for Xifaxan for treatment of his Crohns disease.  Findings:  The physician reviewer found that although Xifaxan is not FDA approved for the treatment of Crohns disease, a review of the literature indicates it can be useful for patients with this condition. It is thought that bacterial overgrowth contributes to exacerbations of Crohns disease. Like metronidazole, Xifaxan is believed to control bacterial overgrowth and reduce acute symptoms. At this stage of his disease, it appears the more standard treatments are not effective for this patient. Xifaxan has proven to be beneficial and  continued treatment is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.  Findings:  The physician reviewer found that the best measure of good diabetic control is currently a hemoglobin A1C of less than 6.5%. When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta; suggesting his glycemic control is dependent on other factors such as diet and exercise. Research has not yet determined the incremental benefit of improving postprandial blood glucose levels when the hemoglobin A1C is already at over below goal.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for residential treatment services for treatment of her alcohol and opiate dependence. Findings:  The physician reviewer found that it appears from the record the patient made good progress towards recovery during her inpatient stay. She could have been treated at a lesser level of care as she no longer required 24-hour supervision to remain sober and to prevent relapse. By that point in her recovery, the patient could have been appropriately treated on an outpatient basis along with a community 12-step program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested  for a panniculectomy for treatment of her redundant skin condition.  Findings:  The physician reviewer found that the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that (1) are plainly related to the excess skin (2) are health threatening or cause significant functional disability and (3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. The proposed procedure does not meet this standard as there is no documentation over time of skin infections in the abdominal folds (e.g., series of office notes, dermatology consultations, or prescription records) and no photographs documenting cellulitis, ulcerations or rashes were submitted. Additionally, the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss has not been satisfied as  the records do not document panniculitis or the failure of medically supervised conservative therapy to control intertrigo. A panniculectomy may be desirable for aesthetic reasons, but it is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for MRIs of the abdomen and pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that a pelvic MRI was also felt not to be medically necessary based on InterQual criteria as there were no pelvic masses or suspicion of cancer.  However, InterQual guidelines do recommend pelvic MRI for the diagnosis of endometriosis and this would apply to the case of this patient who had had a history of endometriosis for which she underwent a hysterectomy. Although uncommon, it is possible for endometriosis to recur particularly in patients who are on estrogen replacement as is the case with this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for radiofrequency ablation for treatment of his lung metastases. Findings:  Three physician reviewers found that there are several reports of the safety of RFA of pulmonary neoplasms, with most of these in patients with lung cancer who are medically unfit for surgery. Additional reports are also published regarding the treatment of pulmonary metastases for control of symptoms. However, there is no data on the efficacy of RFA in prolonging disease survival in either lung cancer or metastatic disease. In this patient, who is asymptomatic and has multiple, bilateral pulmonary metastases, and in whom the largest two lesions are not amenable to either re-section (due to multiple prior surgeries) or even RFA (due to the location of the left lesion adjacent to the mediastinum and the right lesion adjacent to the diaphragm), the denial of RFA should be upheld. Given the multiple lesions, there is no value in treating one asymptomatic lesion, as this offers no palliation (the patient is without symptoms).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested  for gynecomastia surgery for treatment of his gynecomastia.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS) Position Paper Gynecomastia, the recommended coverage criteria for adults are as follows:1. Breast biopsy is indicated when malignancy is suspected 2. Unilateral or bilateral grade III or IV gynecomastia present (per modified       McKinney and Simon, Hoffman and Kohn scales) thatPersists more than three to four months after pathological causes are ruled out  Persists after three to four months of unsuccessful medical treatment for pathological gynecomastia 3. Pain and discomfort due to the distention and tightness from the hypertrophied      breastThe records provided do not document a concern regarding malignancy, a work-up for pathologic causes or significant pain requiring analgesics. A note from the patients provider indicates that the left breast was only mildly tender. Photographs documenting grade III or IV gynecomastia have not been submitted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for Aredia for treatment of her osteoporosis. Findings:  The physician reviewer found that there is no evidence that Aredia is a better choice for the treatment of osteoporosis than Boniva, although both medications might be considered second choices. Forteo is often the best choice for preventing fragility fractures. The use of Forteo was originally rejected by the patients provider due to fear of reactivating the patients breast cancer. There is no known clinical basis for that fear. Although Arimidex may have been the appropriate choice at that time, this medication has been shown to increase fracture rates. If it can be demonstrated that the patient is now postmenopausal, a switch to tamoxifen might be considered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that educational programs generally provide autistic children with speech/language therapy as part of a comprehensive program. On-going goals for this patient can be appropriately addressed through an individualized education plan (IEP).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Zofran 8mg for treatment of post-chemotherapy nausea.   Findings:  The physician reviewer found that optimal management of chemotherapy induced nausea and vomiting involves assessment of risk, use of an appropriate prophylactic regimen, and management of breakthrough symptoms. She has received a very good prophylactic regimen. Given that she has had delayed emesis despite this regimen, it is reasonable to add a prepitant such as Zofran to her prophylactic regimen.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested reimbursement for air ambulance services for treatment of her pneumonia.  Findings:  The physician reviewer found that a progressive multilobar pneumonia with a failure to establish a diagnosis and/or prognosis constitutes a medical emergency. A diagnosed bacterial pneumonia in a community-acquired setting has approximately a 5% mortality rate. For hospitalized patient, the mortality is increased to 15%. The general expectation is that an otherwise healthy individual should improve within one to three days of treatment. That did not occur in this instance, nor was a reasonable diagnosis established. In fact, the treating physician stated a need for air transport due to his concerns regarding the infectious and potentially contagious nature of the patients condition. The inability of the treating facility to provide a diagnosis and/or prognosis along with apparent radiographic and clinical evidence of the patients failure to improve, constituted a medical emergency situation and a need for medical transport. Land travel would not have been appropriate for a patient with a progressive lobar pneumonia, given the distance. There was no reasonable alternative mode of evacuation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee has requested occupational therapy (OT) for treatment of the enrollees developmental coordination disorder.  Findings:  The physician reviewer found that based on the information provided, there is no documented illness, injury or congenital deformity associated with the delayed motor skills. The goals as listed cannot be achieved in a reasonable amount of time and there is no end date to the therapy. In addition, the majority of the goals are educationally-based and are not medical goals. The goals listed that are not educationally-based are primarily therapeutic exercises (sustain supine flexion, perform jumping jacks, hit a balloon with a racquet, perform two pull-ups) that do not require the expertise of a licensed therapist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a colonoscopy for evaluation of her polyps.  Findings:  The physician reviewer found that it is medically reasonable and appropriate for the patient to undergo a colonoscopy at this point in time. The patient has a family history of cancer and a family history of polyps, both in a first degree relative. As such, a colonoscopy is medically prudent and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested the prescription medication Provigil for her multiple sclerosis (MS).  Findings:  The physician reviewer found that there have been multiple open-label studies supporting the use of Provigil in the treatment of MS-related fatigue. Although one moderately-sized, placebo-controlled, double-blinded study found no statistically significant difference as compared with placebo, there is obvious benefit for this patient. Provigil is widely prescribed by neurologists to treat MS-related fatigue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested laparoscopic cryoablation for his renal cell carcinoma. Findings:  Two physician reviewers found that laparoscopic cryoablation is generally utilized for smaller tumors such as the tumor involved in this case. Patients are usually able to tolerate the procedure well. The results for selected patients have been comparable to other procedures such as surgery. Furthermore, cryoablation is a less invasive treatment option for this patient. Overall, the body of literature regarding cryoablation is adequate to support its use in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested a colonoscopy for screening of colon cancer. Findings:  The physician reviewer found that the patient is at average risk for developing cancer and, as such, a colonoscopy every 10 years is medically appropriate as long as he is asymptomatic.