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

The parents of a sixteen year-old male with bipolar disorder are requesting authorization of psychiatric residential treatment services.  Reviewers Findings:  The reviewing physician found that the submitted clinical information indicates the patient has a number of diagnoses and whether the patient was most affected by bipolarity or pervasive developmental disorder, one or both clearly affected the patient quite adversely.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is an accepted treatment for various types of headaches for patients who have failed standard therapies. A trial of Botox is usually appropriate after having tried and failed three to four prophylactic agents and various abortive medications. The evidence in this case indicates the patient failed to respond to trials of several abortive and prophylactic medications. As such, Botox therapy was medically indicated and has been shown to be effective for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested sensory integration therapy for treatment of the enrollees sensory processing dysfunction.  Findings:  Three physician reviewers found that sensory integration therapy has been proposed for many years. To date, there is no scientific basis to support its use. It is not a medical therapy, but a psycho-educational one and is considered experimental. There is no evidence to support such therapy as beneficial for this patient. It is highly likely the patient will benefit from some therapy and from assistance from her family and teachers; however, there is no basis for sensory integration therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-four year-old male with a medical history of migraine headaches, chronic low back pain, anxiety and insomnia is requesting authorization and coverage for Norvasc.Reviewers Findings:  The reviewing physician found that there is sufficient evidence to conclude that Norvasc 15 mg per day is necessary for treatment of this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-five year-old obese female is requesting authorization of requested gastric bypass surgery.  The patient has no documented life threatening comorbidities. Reviewers Findings:  The reviewing physician found that the patients current level of minimal obesity with minimal comorbidities, the requested surgery is not medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male with alcohol and cocaine dependence is requesting coverage for residential treatment.Reviewers Findings:  The reviewing physician found that the medical records provided shows that the patient did not meet accepted criteria for admission to the residential level of care for adult substance abuse. There are no notes in the chart that indicate that the patient was attended to by a physician during this stay.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of is a four-year-old male who was diagnosed with hypotonicity and motor apraxia is requesting reimbursement for occupational therapy (OT) services.  Reviewers Findings:  The reviewing physician found that the OT services were not medically necessary or reasonable because the foundational program could have been accomplished in a home setting without expert OT supervision or oversight.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested hyperbaric oxygen therapy (HBO) for treatment of the enrollees autism.  Findings:  Three physician reviewers found that a review of the published literature indicates that HBO therapy is a controversial treatment for autism and speech delay and of questionable efficacy. There are no valid, controlled, double-blind, reproducible studies showing that HBO therapy results in measurable improvement. This treatment is not the standard of care for the management of autism and is clearly investigational at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-six year-old female who contracted Lyme disease is requesting authorization and coverage for intravenous antibiotic therapy.Reviewers Findings:  The reviewing physician found that the evidence provided does not demonstrate a diagnosis of Lyme disease. There is no clinical documentation of arthritis or other physical findings consistent with the diagnosis.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-eight year-old female with excessive daytime sleepiness is requesting reimbursement for twice per day Provigil and prospective authorization and coverage for three times per day Provigil.  Reviewers Findings:  The reviewing physician found that the patient should be reimbursed for her out of pocket expense for the purchase of Provigil.  There is no support in the record for an increase in the dosage to three times per day.  The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-one year-old male with Peyronies disease is requesting authorization for verapamil.  Reviewers Findings:  The reviewing physician found that the peer-reviewed literature does not document the efficacy of topical therapy with verapamil.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-one year-old female diagnosed with stage IV non-small cell lung cancer is requesting reimbursement for intensity modulated radiation therapy (IMRT).Reviewers Findings:  The reviewing physician found that there is no evidence IMRT was likely to be any more efficacious for this patient than standard radiation therapy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-eight year-old male with degenerative disc disease of the lumbar spine with radiculopathy is requesting authorization for IDET at the C3-4 and C4-5 levels.Reviewers Findings:  The three reviewing physicians found that although some of the early results with IDET are promising, it is not yet a reasonable alternative to conventional treatment such as fusion.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an eleven-year-old male with type-1 diabetes are requesting authorization of a Medtronic MiniMed Paradigm insulin pump.  The patients parents have been endeavoring to keep the patient's blood glucose levels in tight control, which generally the patient has achieved by taking several injections of insulin and having frequent blood glucose monitoring.Reviewers Findings:  The reviewing physician found that there is sufficient evidence to conclude that an insulin pump is necessary for treatment of this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-four year-old male with a diagnosis of multiple sclerosis is requesting coverage of IVIG therapy.  Reviewers Findings:  The reviewing physician found that there is no convincing evidence that there is efficacy of IVIG therapy in terms of disability status reduction under these clinical circumstances.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty year-old female with breast asymmetry is requesting coverage of a breast augmentation mammoplasty and bilateral periareola mastopexy.Reviewers Findings:  The reviewing physician found that the asymmetry was not of such a level that surgical correction was clinically indicated.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year-old female with chronic daily headaches characterized as migraine is requesting authorization of Amerge tablets.  The patient has been taking daily Amerge as well as Zomig and Relpax for breakthrough pain.Reviewers Findings:  The reviewing physician found that there is no clinical indication for daily long-acting triptans such as Amerge to be taken in combination with other triptans.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old male with bipolar disorder and anxiety is seeking authorization for Cymbalta 60mg twice a day.Reviewers Findings:  The reviewing physician found that Cymbalta in a dose greater than 60mg per day is not FDA approved.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-six year-old female with multiple sclerosis and quadriplegia with severe spasticity is requesting reimbursement for the equipment for an Apex Lift.  Reviewers Findings:  The reviewing physician found that the Apex electric lift with sling is not a convenience item; it is clinically indicated to maintain the patients ability to transfer with assistance.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-seven year-old male with type 2 diabetes mellitus is requesting authorization of Byetta. The provider submitted a request for authorization of Byetta two weeks later noting that the patient had taken Glucophage, Actos and glyburide with poor results.Reviewers Findings:  The reviewing physician found that had glyburide been discontinued without starting Byetta, the patient might still have lost weight and maintained good blood glucose control on Actos and metformin alone.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-nine year-old male with benign seborrheic keratoses is requesting authorization of surgical excision.Reviewers Findings:  The reviewing physician found that in cases where a possible skin cancer is identified, surgical excision is medically appropriate and within the standard of care.  The reviewing physician found that the Health Plan denials should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty year-old male who had bariatric surgery has chronic pain in his neck, upper extremities, mid back and upper back is requesting authorization of breast reduction surgery.Reviewers Findings:  The reviewing physician found that breast reduction surgery is not a cure for degenerative disc problems and other conservative or neurosurgical treatment modalities should be considered to address the etiologies of this pain.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested a lower extremity prosthesis with a microprocessor-controlled knee for treatment of his above the knee amputation.  Findings:  Two physician reviewers found that the requested microprocessor-controlled knee prosthesis has not become the generally accepted prosthesis even for a patient who is high functioning. There has not been sufficient study of this prosthesis. According to the peer-reviewed literature, it has not yet been demonstrated that the C-Leg microprocessor controlled prosthesis provides improved functionality and fall prevention when compared with a standard prosthesis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old male who was diagnosed with a T1c, Gleason 3+3=6, PSA 6.08 adenocarcinoma of the prostate is requesting reimbursement of proton beam radiation therapy.  Reviewers Findings:  The reviewing physician found that following national guidelines, proton beam radiation is not superior to photon beam radiation. IMRT and 3D conformal radiation are standard options that appeared to have been available from the Health Plan.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested psychiatric residential treatment services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that based on the submitted clinical documentation, it appears this patient was admitted to a residential level of care primarily to avoid incarceration at the juvenile hall. Preceding this admission, the patient had had three consecutive residential treatment admissions for a combined stay of 24 months without benefit. There is no evidence that her most recent admission was likely to have therapeutic benefit. Furthermore, the records provided from the most recent admission include no evidence of psychotic behavior or suicidal ideation requiring a 24-hour structured setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for surgical removal of excess skin for treatment of her excess abdominal, back and leg skin.  Findings:  The physician reviewer found that the patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. She has not required hospitalization or treatment with IV or oral antifungal or antibiotic medications. Her excess skin has not jeopardized her health. She does have intermittent, bothersome infections that affect her quality of life, but it is not clear that they significantly compromise her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for the medication Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that per the submitted medical history, the patient has pain due to fibromyalgia and rheumatoid arthritis. She does not have neuropathic pain or diabetes. Lyrica has not been well-studied or proven effective or medically appropriate for fibromyalgia and rheumatoid arthritis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-four year-old female with injury to the low back is requesting reimbursement for the chiropractic services and prospective authorization for additional chiropractic treatments.Reviewers Findings:  The reviewing physician found that the record indicate that the patient improved with one treating session and the provider has requested only two additional treatments for this condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a six-year-old male who has consistently grown below the 1.2 percentile are requesting authorization of growth hormone (GH) therapy.Reviewers Findings:  The reviewing physician found that given the patients poor growth, the lack of delayed bone age and thus the patients low adult height prediction, the patient is clearly an appropriate candidate GH therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-two year-old male who underwent a right shoulder rotator cuff repair, acromioplasty, resection of the coracoacromial ligament and partial bursectomy is requesting reimbursement for the rental cost of electronic-controlled thermal therapy device.Reviewers Findings:  The reviewing physician found that date there is no evidence in peer reviewed literature establishing the clinical benefit of an electronic-controlled thermal therapy device over the application of an ice bag and compression with an elastic bandage.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-five year-old female who has undergone cosmetic breast augmentation surgery is requesting authorization and coverage for the medication Accolate to prevent recurrent capsular contraction.Reviewers Findings:  The reviewing physician found that Accolate is not FDA approved for the treatment of capsular contracture and is not necessary to maintain or improve the patients health.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-four year-old male with a history of cervical spondylosis, headaches and low back pain is requesting reimbursement for epidural injections.Reviewers Findings:  The reviewing physician found that the submitted medical records do not establish that the epidural steroid injection the patient received were medically necessary for treatment of the patients chronic pain.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old female with insulin dependent diabetes is requesting reimbursement for a bedside commode and coverage for a motorized wheelchair.  Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude that a motorized wheelchair and a bedside commode are necessary for this patient. There is no documentation indicating the patient is bed or chair confined or cannot access the bathroom.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of a four-year-old male enrollee have requested an intrapulmonary percussive ventilation (IPV) system for treatment of the enrollees spinal muscular atrophy (SMA).  Findings:  Two physician reviewers found that although the IPV system has been FDA approved since 1993, a survey of the peer-reviewed literature reveals only a few studies; most with small sample sizes and dealing with the use of IPV for cystic fibrosis. Cystic fibrosis is not a neuromuscular disease and is a very different entity than spinal muscle atrophy (SMA), Type II. The studies that did show a significant positive effect often involved a subject who was refractory to the standard modalities of chest physiotherapy. In general, there is a paucity of IPV studies in the pediatric and neurological literature. While IPV is thought to be of some benefit in this instance, the patient already has a therapy vest and a cough-assist device and manual chest physiotherapy is also an effective method of airway clearance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty year-old female with multiple sclerosis is requesting coverage of a TriLite ultra light manual wheelchair.Reviewers Findings:  The reviewing physician found that the patient is unable to adequately maneuver the power-operated wheelchair through the doors and around the furniture in the home; the patient requires a manual wheelchair for mobility within the patients home.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested extracorporeal shockwave therapy (ESWT) for treatment of his plantar fasciitis. Findings:  Three physician reviewers found that to date, there are no long-term prospective studies of the effectiveness of extracorporeal shock wave therapy for treatment of plantar fasciitis. Additionally, the current scientific literature does not adequately document the associated complications or risks of ESWT. ESWT has been approved by the Food and Drug Administration and demonstrates about a 70-85% cure rate. This rate, however, does not exceed the 90% cure rate demonstrated with a minor surgical approach such as endoscopic plantar fasciotomy. Thus, the current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than minimally invasive surgical treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that the patient had no signs of withdrawal when he was admitted to the residential treatment facility. There were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. Although he had a significant history of alcohol and marijuana dependence, there is no evidence he required residential treatment. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested Lyrica for treatment of his autonomic dysfunction/ chronic regional pain syndrome of the lower extremities. Findings:  The physician reviewer found that the patient has CRPS with constant moderate to severe pain. He has failed all of the usual treatment modalities and the usual medications which have included tricyclic antidepressants and anticonvulsants. Lyrica has reportedly given him symptom relief over the past five to six months. The safety of Lyrica has been sufficiently tested in other clinical applications and this medication has become a standard of care in the management of  dozens of neuropathic pain syndromes outside of the indicated post herpetic neuralgia and diabetic neuropathy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female enrollee has requested speech therapy for treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that a thorough review of the literature reveals there are no outcome studies or randomized, controlled studies demonstrating that individual speech therapy improves pragmatic speech and communication in patients with autism. Furthermore, the majority of the goals outlined for this patient are educationally based, such as improved receptive vocabulary, expressive vocabulary and expressive communication. While pragmatic goals are also identified, the patient has not shown significant gains in these areas and such goals could appropriately be incorporated into an individualized education plan (IEP) and addressed through the school system.