Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested Avastin for the treatment of her breast cancer. Findings:  Three physician reviewers found that the scientific data reveals that the single-agent activity of Avastin is very poor. Other more standard agents like Navelbine and Gemcitabine have not been tried. They do not have proven superior activity in combination with Avastin. Thus, the use of Avastin alone or in combination with standard agents is not likely to be more efficacious for this patient than available standard agents in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested hyperbaric oxygen treatment for the treatment of her soft tissue radiation necrosis of the brain. Findings:  Two physician reviewers found that although there is a theoretical risk of worsening a tumor with HBO and/or inducing seizures, there are numerous case studies and reports to show adjunctive benefit in reducing complications from late central nervous system (CNS) effects of radiation. Some conflicting reports indicate there may be no benefit. However, there is sufficient evidence to suggest this patient may benefit from HBO considering that her providers have weighed other first-line options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested a referral to a gastroenterologist for treatment of his ulcerative colitis. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has a long-standing history of ulcerative colitis. Generally, primary care physicians do not have the training, experience, and expertise necessary to provide long-term care for patients with ulcerative colitis. Even though his colitis is in remission, the patient should be under the care of a gastroenterologist who has expertise and experience in providing ongoing management of such patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Intravenous Immune Globulin Therapy for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has a history consistent with relapsing remitting multiple sclerosis (RRMS), now progressive. Prior treatments with Betaseron, Cellcept and methotrexate have not been effective. Novantrone has not been considered a clinically appropriate option for this patient. IVIG treatments have been successful for over 2 years and are accepted as a second line therapy for multiple sclerosis. IVIG should be continued as treatment for this patients multiple sclerosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of the enrollees type 1 diabetes. Findings:  Three physician reviewers found that the patients family and treating physician have been diligent in their efforts to improve diabetes control and to prevent hypoglycemic episodes, especially during the night. The device appears clinically appropriate and indicated in this setting. The large numbers of data points (5 minute intervals throughout the day and night) will help the physician and family to gain new insights that will allow for insulin adjustments to minimize the current large glucose fluctuations. Such insights often cannot be deduced from the usual 3-5 point blood glucose levels in a 24-hour period that are traditionally taken. The alarm system on the device will also let the family know when hypoglycemia occurs so that adjustments can be made in a timely manner to minimize glucose rebound.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that Byetta is used with insulin in the endocrine community for management of patients such as this patient. It is likely the manufacturer will soon have FDA approval for concomitant use of Byetta with insulin as well. The proposed use of Byetta is medical reasonable and appropriate in these circumstances and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a panniculectomy for the treatment of her excess abdominal skin and back pain. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patients lower back and leg pain is caused by piriformis syndrome and is unrelated to her excess abdominal skin. There is no documentation in the medical record of skin irritations, infections, or pigment changes related to the abdominal pannus. Thus, no medical indication for panniculectomy has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested an uvulopalatopharyngoplasty (UPPP) for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient follows the textbook diagnosis of Upper Airway Resistance Syndrome. He has symptoms similar to those associated with obstructive sleep apnea and an elevated arousal index. However, he has an AHI of less than 5. Therefore, he does not meet current standard of care surgical indication guidelines for UPPP. As such, current medical necessity criteria have not been met.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Provigil for treatment of her major depressive disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that while it is true that the FDA has not approved Provigil for the treatment of major depressive disorder, adequate medical literature is available to demonstrate the utility of the drug for the treatment of this condition. Review of the relevant medical literature reveals three open-label trials suggesting modafinil's efficacy as an augmentation to antidepressants (DeBattista et al. 2001; Menza et al. 2000; Ninan et al. 2004) or as a way to help ameliorate the sedation caused by antidepressants (Schwartz et al. 2004). A small, preliminary controlled trial (DeBattista et al. 2003) found modafinil effective for the fatigue associated with depression. Each of these references comes from established journals that are accepted by practicing psychiatrists. It is a relatively frequent and accepted practice to augment antidepressants with stimulants such as Provigil.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested the medication Fentora for the treatment of her brachial plexopathy.    Findings:  The physician reviewer found that Fentora is approved by the Food and Drug Administration for use in cancer pain patients.  The original package insert specifically states that its use is to be limited to cancer pain.  There are several case series and individual case reports in the literature, but no randomized controlled trials of this medication in non-malignant pain patients. Fentoras effectiveness in nonmalignant pain is unproven. It is noted that there are agents (OxyIR and OxyFast) that are on the Health Plans formulary, but are not specifically listed as having been tried in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 2-year-old male enrollee has requested Synagis for the treatment of the enrollees current chronic lung disease and bronchomalacia. Findings:  Two physician reviewers found that RSV is a common cause of bronchiolitis and pneumonia in young children infecting almost all children at least once by two years of age. Infection does not provide life-long immunity and re-infection throughout life is therefore quite common. It is not practical or medically indicated to attempt to prevent RSV infection for children without significant underlying cardiopulmonary disease or in children past two years of age. The provided article by N. Sigurs indicating an increased risk of asthma and allergy following RSV infection involves infants, all less than one year of age, who were hospitalized due to severe RSV. This data does not apply to the patient who is already two+ years of age. There is not published medical literature that supports the use of Synagis in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breast for an evaluation of her breast condition. Findings:  The physician reviewer found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative extent of residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. Based on her family and medical history, this patient is at high risk for breast cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 91-year-old female enrollee has requested skilled nursing facility services for the treatment of the enrollees fractured pelvis. Findings:  The physician reviewer found that this patient had a minimal fracture and needed custodial care and pain relief during the period in question. Her severity of illness did not meet skilled nursing facility level of care. Her therapy did not require a skilled level of nursing or rehabilitative care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested continued speech therapy for the treatment of the enrollees congenital muscular dystrophy. Findings:  The physician reviewer found that the patients speech issues result from a congenital abnormality, as she has been diagnosed with congenital muscular dystrophy with dysarthria. The patients dysfunction is not self correcting. Based on the documentation provided, speech therapy has resulted in practical improvement within a reasonable time. The patient is likely to benefit from continued therapy and meets criterion for medical necessity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested IVIG therapy for the treatment of his Easton-Lambert Syndrome. Findings:  The physician reviewer found that this patient has a history consistent with progressive autoimmune cerebellar ataxia. Prior treatment with Rituxan and steroids have not been effective. There are no FDA approved treatments for autoimmune cerebellar ataxia. IVIG is accepted as a clinically appropriate therapy for a variety of neurologic autoimmune disorders. The clinical evidence provided shows that IVIG treatments have been successful for this patient for over two years. IVIG is medically appropriate in this setting and should be continued as treatment for this patients cerebellar ataxia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested ABS disc decompression for the treatment of her back pain. Findings:  Three physician reviewers found that chiropractic vertebral disc decompression is generally considered an investigational/experimental treatment modality for disorders of the lumbar spine. There is little and insufficient peer-reviewed literature and no randomized controlled trials reporting on the safety and efficacy of vertebral disc decompression therapy compared to standard medical and surgical management options. Vertebral disc decompression therapy is not likely to be more beneficial than standard management options in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a four-wheeled walker with a seat because she has multiple sclerosis. Findings:  The physician reviewer found that the patients medical condition is complicated, but pertinent to this discussion are her multiple sclerosis, cervical stenosis and compression fracture. Her neurosurgical evaluation describes her difficulty with gait and balance. The patient does have a mobility deficit that impairs her ability to perform mobility-related activities of daily living. The requested four-wheeled walker with a seat is medically reasonable to accommodate her mobility limitations and fall risk.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested skilled nursing facility services for the treatment of her fractured fibula. Findings:  The physician reviewer found that this patient received restorative assistance for therapeutic exercise and slide board transfers, but not on a daily basis. The patient was generally stable and was appropriate for a less intense level of care
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Byetta for treatment of the enrollees diabetes. Findings:  The physician reviewer found that Byetta is a drug that has been added to diabetic regimens for weight loss. This patients blood sugar continues to be well controlled on Byetta, diet and exercise. Although it is not known why Avandia was discontinued in this case, the medication was halted in many patients following the release of a meta-analysis in the New England Journal of Medicine that raised the specter of increased myocardial ischemia in Avandia trials. In any event, given the good results this patient has experienced from the use of Byetta, continued use of this medication is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Increlex therapy for the treatment of the enrollees IGF-1 deficiency and short stature. Findings:  The physician reviewer found that the patients mid-parental height is 67.5. Given the patients height of 55 at a bone age between 11 and 1112 years, his predicted adult height should be 67.2 to 68.4 as assessed by the G & P Hand Atlas for average boys. Thus, with his delay in sexual maturation, he should attain his target height without intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a Dynesys surgical procedure for the treatment of her lumbar stenosis and grade 1 spondylolisthesis. Findings:  Three physician reviewers found that the literature does not support the use of the Dynesys device for grade I spondylolisthesis. At this time, there is no long-term outcome data that exists to support its safety and efficacy. Further studies are needed to establish that the Dynesys device is appropriate and efficacious for this indication.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested artificial disc replacement for treatment of her degenerative disk disease. Findings:  Three physician reviewers found that cervical artificial disc replacement has only recently been FDA approved and the procedure is of unproven efficacy. Long-term results are unknown and the long-term risks, viability, and complications are unclear. Though short-term results have been favorable, further studies and results are needed. Thus, the procedure cannot be recommended at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested total ankle arthroplasty for treatment of her severe post-traumatic arthritis/degenerative joint disease.   Findings:  Two physician reviewers found that unfortunately, this young patient has developed endstage ankle arthritis. Conservative care has been most thorough including viscosupplementation, activity modification and traditional injections. Despite these treatments, the patients symptoms and findings persist. Total ankle arthroplasty has been recommended. The ODG guidelines indicate that earlier studies of ankle arthroplasty in the 1970s and 1980s had high long-term failure rates. Clearly, total ankle arthroplasty has continued to evolve and improve. Surgical techniques have improved. Per the ODG guidelines, the main alternative for total ankle replacement is arthrodesis. At issue in this case is whether total ankle arthroplasty is likely to be more beneficial than available standard therapy which would refer to arthrodesis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested a second series of Hyalgan injections for the treatment of his osteoarthritis of the shoulders. Findings:  Two physician reviewers found that Hyalgan injections have not been approved by the FDA for joints other than the knee. There is insufficient evidence in the medical literature supporting the use of Hyalgan or any other form of viscosupplementation for the shoulder. Based upon the evidence available to date, the patient should achieve better results with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 79-year-old male enrollee has requested Sonata (zaleplon)for the treatment of his insomnia. Findings:  The physician reviewer found that the concerns expressed regarding the safety of zolpidem are not supported in the literature. Both zaleplon and zolpidem are FDA approved and have an identical mechanism of action. These medications have a similar side effect profile, including amnesia and sporadic reports of parasomnias. There is nothing in the report of zolpidem-related car accidents to suggest that the drivers did not take the medication and operate a motor vehicle purposefully. Furthermore, as zolpidem is more commonly prescribed than zaleplon, there is selection bias in side-effect reporting. In summary, both zaleplon and zolpidem are likely to be effective in treating this patients symptoms, and there is no convincing argument that zaleplon is safer than zolpidem. The Health Plans requirement that the patient undergo a trial of zolpidem prior to authorization of zaleplon is not unreasonable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested sclerotherapy injections for the treatment of her varicose veins. Findings:  The physician reviewer found that the Cochrane Database Systemic Review strongly suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of recurrent varicose veins following surgery and thread veins, which was not the case with this patient. Furthermore, the submitted information does not demonstrate that the patients varicosities were or are of a level of severity that necessitates treatment from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested substance abuse residential treatment services for the treatment of her pain medication addiction and chronic pain. Findings:  The physician reviewer found that the patient suffers from multiple diagnoses, and has had a rapidly shifting approach to her various medications. Unquestionably, she had a chronic pain syndrome, though the multitude of her somatic complaints is such that it is surprising that she was not also considered to be experiencing Somatization Disorder. However, to the extent that she was consistently cited in the submitted treatment notes as better, there appears to be nothing to support the notion of her warranting services as intensive as residential treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male has requested PET/CT scans for evaluation of esophageal cancer.  Findings:  Three physician reviewers found that PET/CT scans have proven value in the initial staging and restaging of esophageal cancer. For this patient, a PET/CT scan following completion of radiation and chemotherapy will assist in treatment planning. If the repeat PET/CT scan shows no metastatic disease, the patient would be a candidate for surgical removal of the esophageal cancer. If the patient continues to have metastatic lymph nodes, surgery may not be appropriate. Medicare coverage criteria allow for staging and restaging PET/CT scans for patients with esophageal cancer. The previous PET/CT scan and the proposed scan are essential studies and medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Femara for treatment of endometrial cancer.  Findings:  The physician reviewer found that the utility of hormone therapy in the adjuvant setting for endometrial cancer is unclear. This would also apply to the adjuvant use of Femara for advanced endometrial cancer. Investigation is underway, and Novartis has a phase II study (NCT00171808) for ER/PR positive patients who have measurable disease. Femara is not included in the Health Plans formulary for the treatment of endometrial cancer. As there is no clear evidence that Femara is superior to other hormonal agents, or to no hormonal therapy, it cannot be considered an essential component of the patients treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested revision of gastric bypass for treatment of morbid obesity.  Findings:  The physician reviewer found that data exists to show re-operative intervention can yield results similar to the initial surgery. Clinically, this patient meets medical necessity criteria for weight loss surgery. She once again has the same comorbidities that prompted the first operation and stands to benefit significantly from revision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested breast reduction surgery for treatment of back pain.  Findings:  The physician reviewer found that there is no photographic evidence of shoulder grooving or skin changes related to the patients large breasts. There is very limited documentation of conservative treatment of the patients back pain such as non-steroidal anti-inflammatory drugs, physical therapy, support garments or medically supervised weight loss attempts.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of diabetes.  Findings:  Three physician reviewers found that current scientific evidence makes clear that a CGMS will help to decrease the time spent in hypoglycemic range. This device has also been shown to improve HgA1c with extended use. This device improves net health outcomes in a patient such as this patient who is having severe hypoglycemic reactions and needs to avoid low blood sugars. The CGMS is FDA approved for use in diabetics. The REAL-Time CGMS in combination with the Medtronic insulin pump is a better option for this patient than the alternative of finger-stick glucose monitoring.