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

The parent of a 21-year-old male enrollee has requested a mandibular positioning device and related medical services for the treatment of the enrollees sleep apnea. Findings:  The physician reviewer found that the central problem with determining medical necessity in this case is that the patient has not had a sleep study using the oral/dental positioning device to determine if it is effective in reducing the episodes of obstructive sleep apnea (OSA). The Practice Parameters referenced above indicate that `Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild to moderate OSA who prefer OAs (oral appliances) to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep position change.` The Parameters state, however, that `Because of the inability to predict success reliably, when OAs are selected, follow-up testing should be obtained to ensure treatment effectiveness.` The patient travels frequently and therefore CPAP may be difficult at those times. As such, an oral positioning device might be a reasonable alternative. However, the patient has not had follow-up testing to demonstrate effectiveness. The device cannot be considered medically necessary if it has not been demonstrated to be effective in treating the patients sleep apnea.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for a full-body MRI, DEXA scan, mammogram and a thyroid evaluation for treatment of her multiple medical conditions. Findings:  The physician reviewer found that the patient has no clinical indication for a full body MRI. There is no indication in the literature for the use of full body scanning in the screening of patients who do not have symptoms suggestive of a disease due to the low rate of finding disease, and the inconclusiveness of the cause of the abnormality seen. The current literature does not establish a clear benefit to whole body CT or MRI for health screening. The reviewed documentation established no clinical evidence for the requested MRI scan.Moreover, the patient does not meet the clinical criteria per accepted standards of medical practice for the requested procedures: full-body MRI, DEXA scan, mammogram, and thyroid evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Euflexxa injections to her right knee for treatment of her medical condition. Findings:  The physician reviewer found that Euflexxa (or visco-supplementation) injections are used in patients who have degenerative arthritic changes and have failed conservative care with activity modification, home exercise, anti-inflammatory medication, and a possible cortisone injection.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for inpatient care for treatment of her detoxification. Findings:  The physician reviewer found that the patient showed no signs of imminent withdrawal requiring a detoxification inpatient program. Though she was considered to have evidence of benzodiazepine dependency and withdrawal, no chart evidence or objective data to support this view has been provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) bone density scan for evaluation of her  osteopenia.  Findings:  The physician reviewer found that the T scores  were consistent with mild osteopenia that can occur in patients who have been on treatment with Depo-Provera. These changes resolve without specific treatment other than discontinuing the Depo-Provera therapy. The patient was treated by discontinuance of the Depo-Provera, followed by estrogen supplements and subsequent oral combination contraceptives. The DEXA scans which showed progressive improvement, and there was no other identified medical condition that would warrant continued testing since the Depo-Provera had been discontinued.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.  Partial hospitalization allows for close monitoring of medication while adjustments occur, and it also allows for intense interventions for impulsivity and aggression and abnormal involuntary movements by a multi-disciplinary team.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for Humira for treatment of her arthritis. Findings:  The physician reviewer found that there is a lack of support for the use of Humira for the treatment of systemic lupus erythematosus-related arthritis. .
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for continued physical therapy for treatment of her chronic lower back pain.  Findings:  The physician reviewer found that there is no documentation of any new injury or condition necessitating additional physical therapy. Continued physical therapy at this time would be maintenance in nature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for selective internal radiation therapy (SIRT) for treatment of her breast, bone and liver cancer.  Findings:  Two physician reviewers found that there is a growing body of literature to support the use of SIR-spheres for liver metastases. There are at least 2 randomized studies supporting the use of SIR-Spheres for liver metastases from primary colorectal cancer (references no. 5 and no. 6 cited above). There are also innumerable other prospective and retrospective studies.  The FDA has in fact approved the use of SIR-spheres for this indication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for a PET/CT scan for evaluation of her endometrial cancer.   Findings:  Two physician reviewers found that in peer-reviewed literature, PET/CT scans have been shown to be clinically pertinent in evaluation of patients with uterine cancer. The outcome of PET scans in patients with uterine cancer affected patient management in one-third of the cases according to Pandit-Tasker. Furthermore, the National Comprehensive Cancer Network (NCCN) recommends radiologic imaging for patients with incomplete surgical staging, as is the case with this patient.  PET/CT scans provide functional information in regards to metastatic disease involvement within lymph nodes. CT and MRI cannot provide functional information; they provide anatomical information only. The outcome of the PET/CT scan in this case will determine the proper radiation therapy for this patient. The proper radiation therapy treatment plan will affect the outcome of the patients known malignancy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested for Crestor 10mg for treatment of her hyperlipidemia. Findings:  The physician reviewer found that there is no evidence that Crestor is likely to be specifically indicated over these alternatives, Zocor, Pravachol and Mevacor.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for a new prosthesis for treatment of his left leg below the knee amputation. Findings:  The physician reviewer found that , it is clear that this patient requires replacement of the left lower limb prosthesis. He has lost at least 17 pounds, and this would definitely cause poor fit of the prosthetic socket. This patients prosthetic foot/ankle component is worn out.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech, occupational and physical therapy for treatment of the enrollees severe articulation disorder, expressive/receptive language disorder and coordination delays. Findings:  The physician reviewer found that the patients therapist recommended a number of goals and made a strong recommendation for a highly experienced craniofacial speech therapist for a minimum of two hours per week. The patient began to receive therapy at a hospital with a very small pediatric facility, and he failed to make progress in speech or occupational therapy. This was felt to be due to his lack of attention and developmental delay. The patients physician recommended speech therapy, and he was reported as motivated and making progress after two months of hourly weekly sessions. Speech therapy is medically necessary for a minimum of two hours per week, and occupational and physical therapies are medically indicated for this patient. Therapy at a public school setting is insufficient for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for Celebrex 200mg for treatment of her osteoarthritis. Findings:  The physician reviewer found that this patient has failed two NSAIDs, and it is medically reasonable to require that the patient try at least two other NSAIDs prior to coverage for Celebrex.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a low intensity pulsed ultrasound device (LIPU) bone growth stimulator for treatment of her left foot fifth metatarsal fracture.   Findings:  The physician reviewer found that the literature in the past has recommended, in very athletic individuals who truly have a defined Jones fracture (fracture of the diaphysis of the fifth metatarsal), that these fractures should be treated surgically. Other fractures of the fifth metatarsal should heal in due time. The definition of a delayed/non-union is: no progression of clinical signs of healing or radiographic signs of healing. For these signs to occur, one has to wait at least 6-8 weeks or even longer. Thus, a fracture of the metaphyseal/diaphyseal juncture of the fifth metatarsal should heal in due time. It may take 2-3 months indeed to heal, but closed treatment, without bone growth stimulation and/or surgery, is appropriate and most often sufficient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for Solodyn for treatment of her cystic acne.  Findings:  The physician reviewer found that the patient does not provide any documentation of a trial of doxycycline, such as providing records from her prior physicians. If documentation were provided of a prior trial of doxycycline, then medical necessity from Solodyn would be established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female is requesting for cervical artificial disc surgery for treatment of her neck pain. Findings:  Three physician reviewers found that there are insufficient well-designed clinical trials showing superior long-term results of artificial cervical disc surgery over cervical fusion. The requested procedure remains of unproven efficacy at this time, as additional studies demonstrating long-term safety and benefit are needed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a percutaneous discectomy/decompression for treatment of his low back pain. Findings:  Three physician reviewers found that there are numerous treatments for back pain aimed at removing nuclear material and lowering intradiscal pressure through devices inserted percutaneously into intervertebral discs. Various techniques are utilized in managing discogenic pain, with or without disc herniation. The indications for percutaneous lumbar disc decompression include low back pain and lower extremity pain caused by a symptomatic disc. Cohen and colleagues demonstrated that nucleoplasty is not an effective long-term treatment for lumbar radiculopathy, either alone or with IDET. Endoscopic percutaneous discectomy/nucleoplasty is an experimental procedure without established clinical efficacy. Percutaneous discectomy via endoscopic procedure is not a proven therapy for the treatment of the patients condition, and there is no medical indication for the percutaneous discectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for revision of bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the long-term outcome of gastric bypass offers only a 55% excess body weight loss at best. Therefore, some patients will have inadequate weight loss, or even weight regain, without having any anatomical explanation for it.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee have requested for speech therapy four times per week for nine months for treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy is a recommended treatment for autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for Xolair injections for treatment of her asthma. Findings:  The physician reviewer found that her nocturnal symptoms, she would be classified as having severe persistent asthma. She had nocturnal symptoms nightly and she received monthly steroid injections (which could be considered equivalent to oral), and discontinuation of steroids allowed progression of symptoms and decreased activity level. The requested medication is medically indicated for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees growth failure. Findings:  The physician reviewer found that the FDA approval for GH use in idiopathic short stature is restricted to patients who are more than 2.25 standard deviations from the mean in terms of their height.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for FES bike therapy for treatment of his spinal cord injury with paraplegia. Findings:  The physician reviewer found that the FES bike has been shown to reduce spasticity, prevent atrophy, improve cardiovascular conditioning and perhaps stimulate some neurological recovery
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee have requested for 35 hours per week of behavior modification for treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA therapy has been well-established as the most effective therapy for developing interpersonal and communicative skills in autistic children.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested intravenous immunoglobulin (IVIG) infusions for the treatment of her elevated natural killer cells during pregnancy. Findings:  Three physician reviewers found that IVIG therapy for recurrent pregnancy loss is not an accepted therapy. There is much more data to support anticoagulant therapy for thrombophilia related losses (which is the case with this patient) or immunosuppression in patients with overt autoimmune disease. Neither testing for natural killer activity nor treating increased activity with IVIG therapy has been proven to be effective.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a three-year-old male enrollee have requested for ABA therapy for treatment of his global developmental delays. Findings:  The physician reviewer found that the present treatment of choice and the only well-documented successful therapy for autism is ABA therapy. This treatment has been shown to result both in gains in IQ scores as well as improvements in functioning across language, social and behavioral adaptive domains. The studies by Sallows et al. and Howard demonstrated improvements in IQ scores following ABA treatment as compared with age and IQ matched controls. Although progress may be slower in patients with lower initial IQs, studies have shown improvements with ABA across a range of initial IQ scores, and there is no cut off point for pre-treatment IQ below which ABA has not been shown to be beneficial. This patient has made limited but definite progress with the intensive ABA home program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for a PET/CT fusion scan for evaluation of her primary peritoneal cancer.   Findings:  Two physician reviewers found that there is no data to support the notion that recurrent disease detected earlier improves overall survival unless perhaps an isolated mass is noted, which can be diagnosed with CT. Additionally, other modalities such as CT or MRI or tumor markers have utility in monitoring patients with ovarian or peritoneal cancer. In this case, the patients tumor markers are in the single digits. Unless her CA-125 is not instrumental in following her disease (i.e., never elevated at presentation) there is no benefit to performing a PET/CT scan. There are other markers that can be followed depending on the original histological subtype (i.e., mucinous including CA 19-9). Additionally, PET scans have poor resolution in tumor sizes less than 7mm.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for Orthovisc injections for treatment of her bilateral chondromalacia patella. Findings:  The physician reviewer found that this patient does not meet the criteria under the plan guidelines for visco-supplementation inasmuch as there has not been documented failure of Tylenol, there has not been documented failure of four full-dose anti-inflammatories, and there has not been documented failure of at least one intra-articular corticosteroid injection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for a CT to detect coronary artery calcification (CT coronary calcium scoring) for evaluation of his high cholesterol. Findings:  Two physician reviewers found that according to the NCEP-ATP II Guidelines cited above, treatment is targeted at risk-factor management. These guidelines do not incorporate or recommend screening with CT coronary calcium scoring. No incremental outcomes benefit has been shown with CT coronary calcium scoring in a setting such as this, beyond that attainable by management based on clinical-risk profiling.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) for treatment of her obesity and degenerative joint disease. Findings:  The physician reviewer found that weight loss is probably slightly greater and the risk of missing a gastric cancer is eliminated with the BPD/DS procedure. While morbidity from both procedures is considerable; it is arguably greater with Roux-en-Y. A particular point is that nutritional differences are common and potentially severe with both operations. Furthermore, the results achieved with gastric banding are not likely to be sufficient in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Confidential Confidential
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a PET scan for evaluation of her breast cancer. Findings:  The physician reviewer found that there are multiple studies in the peer-reviewed literature have shown that PET/CT scans are clinically effective in monitoring response to chemotherapy in those patients with metastatic breast cancer. Schwarz and colleagues found that PET scans could predict response to treatment following the first cycle of chemotherapy. Rosen and colleagues reported that PET/CT is particularly useful in determining response to therapy. Smith and colleagues found that PET imaging can predict response of metastatic breast cancer to chemotherapy, and Couturier and colleagues found that PET studies done after three cycles of chemotherapy are useful for monitoring response to chemotherapy in metastatic breast cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for partial breast irradiation therapy for treatment of her obstructive Grade I infiltrating ductal carcinoma. Findings:  The physician reviewer found that there is no documentation that the patient has ever been seen by a hematologist or has had any specific workup for her low WBC counts to determine if there are other causes for the condition. In terms of treatment for her current tumor, usually only the breast is irradiated in patients with DCIS with the sternum receiving little radiation.  In estimating the risk of radiation induced leucopenia for the whole breast irradiation, the marrow in the sternum constitutes 3.1% of total marrow and the bone marrow in all ribs is 16.4% of the total marrow mass. Less than 10% of the ribs would be in the radiation field. Thus, less than 5% of the patients bone marrow would be involved, even in the unlikely event of the sternum being partially irradiated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for helical tomotherapy intensity modulated radiation therapy for treatment of his stage IIIB non-small-cell lung cancer of the left lung. Findings:  Two physician reviewers found that pre-clinical dosimetry studies have not demonstrated that IMRT increases the lung volume. A recent study by Sura and colleagues confirms the efficacy and tolerability of IMRT with lung cancer. Indications for IMRT include unfavorable tumor geometry, proximity of the tumor to critical organs and/or small lung volumes. This patient has tumors in close proximity to critical organs and arguably the total extent of the tumor (large cranial-caudal extent) represents unfavorable geometry. Tomotherapy is well-suited for this particular case since the patient has a large extent of disease in the cranial-caudal direction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee has requested for high-dose chemotherapy with stem cell support (HDCSCS) triple-tandem transplant utilizing the TICE regimen (paclitaxel and ifosfamide followed by carboplatin and etoposide) for treatment of his testicular germ cell tumor.   Findings:  Three physician reviewers found that there is no established standard of care for relapsed germ cell tumors. Based on a thorough review of the available medical literature and historical data, tandem cell autologous transplantation appears to be superior to standard chemotherapy or single autologous stem cell transplantation. The above-cited literature demonstrates adequate support for a tandem transplant procedure for this patient. With regard to the requested triple-tandem transplant, the procedure has not been sufficiently studied to date to recommend its use over a tandem transplant procedure in this case.