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

A 51-year-old female enrollee has requested for an osseointegrated auditory implant for treatment of her sensorineural hearing loss. Findings:  The physician reviewer found that an osseointegrated implant is indicated for use in patients with hearing loss who cannot tolerate the use of conventional amplification. In the past, this has frequently been interpreted to mean patients with hearing loss that have external or middle ear disease that precludes the use of traditional hearing aids. Over the years, the application of this device has been expanded to assist patients with severe unilateral sensorineural hearing loss. Given the current literature and standard of care, this patient does meet medical necessity criteria for this device. With the severity of her hearing loss, conventional amplification would not be useful.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for nutritional consultation for treatment of his postoperative weight loss. Findings:  The physician reviewer found that this is not a routine situation where a cancer patient has been referred for cancer-related weight loss. This patient receives his nutrition from a gastrostomy tube (GT). Calculating the patients caloric needs and identifying the best nutritional product and feeding regimen to meet those needs is a complex and challenging task. A registered dietician generally has expertise in this area and such consultation should be approved to maximize the patients quality of life and optimize his healing. This patient would truly  benefit from on-going consultation with a knowledgeable nutritional specialist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for computed tomography angiography (CTA) of the coronary arteries for evaluation of her chest pain. Findings:  Two physician reviewers found that the patient has little cardiac risk and presents with atypical chest discomfort.  Although there were very mild non-diagnostic ECG changes on the stress test, the more accurate nuclear perfusion images were reported as entirely normal.  Therefore, the test should not be considered equivocal or non-diagnostic, but rather negative.  In this circumstance, no additional cardiac testing for coronary ischemia is medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 17-year-old enrollee has requested for residential treatment services for treatment of the enrollees oppositional defiant disorder and depression. Findings:  The physician reviewer found that the medical records submitted do not support the medical necessity of nearly four months of acute residential treatment.  The available records do not contain an intake evaluation, or a treatment plan.  The notes provided do not contain clinical detail or provide any description as to why the patient required such services or how such services were effective and beneficial for treatment of the patients condition.  Without such objective evidence there is no information to support this patients admission and continued stay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  for occupational therapy (OT) for treatment of the enrollees sensory processing deficits.  Findings:  The physician reviewer found that the documentation provided for review fails to show the patient has a medical condition or functional deficits that interfere with age-appropriate activities of daily living. There is no clinical basis for the assumption that his motor skills will not improve with maturity. The evidence does not support the premise that OT intervention has improved, or will improve, this childs level of daily functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for surgical scar revision for treatment of her right buttock. Findings:  The physician reviewer found that the patient had an unaesthetic buttock depression and scar following a steroid injection. The plastic surgeons notes do not describe any functional limitations or discomfort related to the scar. The operative note indicates that scar excision and intermediate closure were performed. The records do not provide compelling evidence that the patients scar was painful or was causing significant functional problems. Moreover, the photographs show a simple scar depression that would not be expected to cause a functional problem.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for emergency services for treatment of her foot pain. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. An emergency is generally defined as the sudden onset of symptoms, including pain, of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient was diagnosed with an acute flare of gout. He had no history of gout, so likely did not know the reason for his symptoms. Although acute gout is not life or limb-threatening, it is extremely painful. The patient required an IM injection for pain relief.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for gall bladder surgery for treatment of her gall bladder condition and liver hemangioma.   Findings:  The physician reviewer found that although the liver hemangioma is not close to the gall bladder fossa, and the chance of the spontaneous rupture is less than 1%, it nonetheless presents a surgical risk.  Technical expertise certainly would reduce that risk.  The availability of vascular back up during surgery is medically reasonable and appropriate to address this risk.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for Vyvanse for treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).   Findings:  Two physician reviewers found that the patient has a confirmed diagnosis of ADHD and responded favorably to treatment with Vyvanse, 70 mg per day. Vyvanse is approved by the FDA for the treatment of ADHD. That approval was based upon a clinical trial with children from six to 12 years of age. FDA approval, among other things, limits the marketing claims a drug manufacturer may make. Practitioners may prescribe a medication for indications that are not specifically stated in the product label and may likewise prescribe a product outside the age range in which the product was studied. The age difference in this instance does not appear to be clinically significant. Treatment with Vyvanse, 70 mg daily, is clinically indicated for treatment of the patients ADHD. He has not had a satisfactory response to other medications and, most importantly, he is currently benefiting from this treatment. To convert him to formulary drug at this juncture would be medically inappropriate and create an unnecessary medical risk, which is never in the patients best interest.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for IVIG therapy for treatment of her hypogammaglobulinemia. Findings:  The physician reviewer found that the patient does not meet standard criteria for treatment with IVIG therapy. Although she has documented low levels of IgG, she has not been diagnosed with a specific immunodeficiency. IVIG therapy is not indicated for all causes of hypogammaglobulinemia. Laboratory testing did not demonstrate an inability to respond with IgG antibody production after antigenic challenge against Diphtheria, Tetanus toxoid or pneumococcal vaccine. The testing was initiated, but no post-antigenic values were reported prior to treatment with IVIG.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for vagus nerve stimulation (VNS) therapy for treatment of her major depression. Findings:  The physician reviewer found that there has apparently not been a trial of ECT and there are no MAOIs in her past or present list of medications. Nor is it entirely clear that the patients primary diagnosis is treatment-resistant depression. It appears she may have a mixed mental disorder and there are no double-blinded studies in the medical literature suggesting that VNS therapy would be effective in that context.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested for emergency services for treatment of his toe pain. Findings:  The physician reviewer found that the patients primary care physician had sprayed the wart with nitrogen the day before. He reported that the area had become larger, darker and painful to touch. Swelling to the whole toe with redness and 6/10 pain was noted The patient reported lancing the lesion at home with bloody discharge and no pus. On physical exam, there was a 1cm hematoma on the great toe with no active discharge, some distal swelling and mild erythema. The patient was given the diagnosis of warts, status post removal and prescribed an antibiotic and a narcotic based pain medication.The evidence in the case shows that within 24 hours following treatment with liquid nitrogen, there were sufficiently severe symptoms (pain, swelling, necrotic-appearing lesions) such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize their health. A progressive infection could have been life/limb threatening without immediate intervention.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for emergency services for treatment of his dental pain. Findings:  The physician reviewer found that the patients pain had been present for five days and was rated as 6/10. He denied fever, chills, facial swelling or any other associated symptoms. On exam, the patient had poor dentition, caries on the right lower and upper incisors with mild soft tissue swelling at the gingival/buccal mucosa margin and tenderness to light palpation. He was diagnosed with dental caries with gingivitis and possible early dental abscess and prescribed an oral antibiotic.A prudent layperson with an average knowledge of medicine and 6/10 dental pain without other associated symptoms would not expect the absence of immediate emergency care to jeopardize his health. This patient could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for Xolair for treatment of her asthma. Findings:  The physician reviewer found that the FDA approved indications for Xolair include moderate to severe persistent asthma in patients who have a positive skin test or in-vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and a pre-treatment total IgE level of 30 or greater.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for emergency services for treatment of his toe pain. Findings:  The physician reviewer found that the patient complained of right great toe pain after a vase fell on her foot. She had tenderness and a subungual hematoma on physical exam. While in the emergency department, her toe was x-rayed and her toenail trephinated (a hole placed to drain the blood). She was given oral narcotic analgesics for pain control. The patient had a subungual hematoma that required trephination for drainage. She also required evaluation for possible fracture. Had there been a fracture present, the patient would have required antibiotics for prophylaxis against infection as it would have been an open fracture after the trephination.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for liposuction excision for treatment of his lipoma. Findings:  The physician reviewer found that the medical necessity for liposuction excision of the lipoma is not established. The records do not document a concern over malignancy or any functional problems related to the lipoma. The patient indicates in his appeal letter that the lipoma was painful, but the records do not include any preoperative physician documentation indicating the lipoma was symptomatic. Although liposuction is an effective method for removal of lipomas, the medical records do not document any health-related problems secondary to this lipoma.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that the condition of the patients knee has changed since she last had viscosupplementation. She remains symptomatic, requiring narcotic analgesics. Cortisone injections have been minimally successful, and she is young for knee replacement. A series of Synvisc injections is clinically reasonable in this setting. Past treatment with Synvisc does not preclude additional benefit from this therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for two series of hyaluronan injections (Euflexxa) for treatment of her osteoarthritis.  Findings:  The physician reviewer found that this patient was a reasonable candidate for Euflexxa and the therapy was provided at reasonable intervals. She has documented evidence of arthritis and has undergone an unsuccessful trial of conservative treatments including rest, medication, analgesic, creams, braces and physical therapy. MRI studies revealed significant arthritis with associated meniscal tearing. The benefits of Euflexxa for the treatment of osteoarthritis are well documented. There have been several studies suggesting that arthroscopy and debridement for arthritic knees are not helpful, leaving the patient with very few treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for a VPAP (variable positive airway pressure) device for treatment of his sleep apnea (OSA). Findings:  The physician reviewer found that while the patient does have OSA and also had central apneas with the use of BiPAP, a thorough review of current literature does not support the use of VPAP as standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested reimbursement for total ankle arthroplasty for treatment of his right ankle arthritis.   Findings:  Two physician reviewers found that the only alternative to total ankle arthroplasty would have been ankle arthrodesis, which would have adversely affected the biomechanics of the adjacent joints, particularly the compromised knee. Over time, ankle arthrodesis often leads to significant secondary arthritis of the adjacent joints. Ankle replacement gave this patient the best chance of preserving joint mechanics and gait pattern and resuming an active lifestyle.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested for occupational therapy (OT), speech therapy (ST) and physical therapy (PT) for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and executive dysfunction. Findings:  The physician reviewer found that there are no medical indications for OT, PT or ST. The Fast ForWord Program is an educational program (software) that helps with processing for improving reading, understanding, etc., and may be beneficial for the patient. This program is usually provided in the school setting and does not require administration by a speech therapist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for acute inpatient psychiatric services for treatment of the her depression and substance abuse.   Findings:  The physician reviewer found that the patient told her outpatient psychiatrist that she was suicidal and restated that she was suicidal and told of a plan to overdose on aspirin the previous night, while in the ED. She was abusing cocaine at the time, and may have had depression secondary to her substance abuse. Withdrawal from cocaine does often cause or exacerbate depression. The patients inpatient evaluation appropriately included a substance abuse consultation with a recommendation to attend a CD IOP.  Step down to a CD IOP was appropriate at that point in time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested temperature gradient studies and surface electromyography for an evaluation of his back and leg pain. Findings:  Three physician reviewers found that temperature gradient studies and surface EMG are not recognized or generally accepted by the medical community as diagnostic technologies for this type of case. There are no objective studies demonstrating their effectiveness in evaluating this patients condition. The patient could have received an appropriate evaluation through standard tests and physical examination.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested skilled nursing facility services to treat her after being in a motor vehicle accident. Findings:  The physician reviewer found that this patient was unable to progress with PT and OT for two weeks and had made very modest gains before that. She was, for example, two person maximum assist for sliding board transfers when initially evaluated, and she did not progress beyond that level.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The mother of a 15-year-old female enrollee has requested a continuous glucose monitoring system (CGM) for the treatment of the enrollees diabetes. Findings:  Two physician reviewers found that this patient already monitors her blood sugars at an increased frequency of 10-12 times daily.  However, this is still leaving unattended gaps of unpredictable blood glucose excursions that disturb her quality of life and performance and increase her chances of developing diabetes-related complications.  The FDA has approved the system in dispute for children as young as age seven.  The medical literature supports the value of real-time glucose monitoring in improving diabetic control in both adults and children.  A CGM will allow this brittle patient to ultimately improve her blood glucose values and HgbA1c.  More importantly, CGM will increase her chances for preventing and surviving unpredictable or asymptomatic hypoglycemic events.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a musculoskeletal ultrasound, spinal echography, and nerve conduction study for the treatment of his sciatica. Findings:  The physician reviewer found that there is presently insufficient peer reviewed literature to support the diagnostic role of musculoskeletal ultrasound, spinal echography, and lumbar distribution sensory nerve conduction studies for low back pain and sciatica.  These tests are not widely accepted diagnostic modalities nor are they supported for diagnostic use in the spine.  These techniques are generally unproven in the diagnosis of lumbar spinal etiologies and sciatica.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested ambulance transport for the treatment of her ear pain. Findings:  The physician reviewer found that a prudent layperson with an average knowledge of medicine would not have sought ambulance transport for treatment of her ear pain. Although this patient was having severe pain for which she reasonably sought medical care, there is no evidence that she could not have been driven by taxi, taken public transportation or been driven by private vehicle to the hospital. The patient was not noted to be unsteady on her feet, confused, or having any of the usual types of medical conditions (chest pain, acute trauma, stroke, confusion) that a prudent layperson would reasonably expect to require ambulance transport. It appears the ambulance was utilized for transport only, and the patient did not require any of the expertise or emergency equipment available on the ambulance to ensure safe transport.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested emergency services for the treatment of her migraine headache. Findings:  The physician reviewer found that the patients symptoms met the prudent layperson criteria for emergency care. She had severe headache, vomiting and blurry vision of acute onset. A prudent layperson with these symptoms and an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize their health. In addition, the patient had an abnormal vital sign (significant tachycardia), a red flag for potentially serious or life-threatening conditions.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested emergency services for the treatment of her groin pain. Findings:  The physician reviewer found that the patients symptoms did not meet the prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and intermittent, moderate groin pain for two weeks would not reasonably expect the absence of emergency care to jeopardize their health. The medical documentation does not support the patients assertion that she could not bear weight on her leg without screaming.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 39 and comorbid conditions this patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed articles demonstrate superior weight loss and maintenance of weight loss over the long term with BPD/DS as compared to other surgical procedures. The published data also demonstrates that the Roux-en-Y procedure offers no advantage in regard to protein calorie malnutrition and may even have more severe consequences. This patient has significant metabolic syndrome, and BPD/DS is the treatment of choice for her obesity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested gastric bypass surgery for the treatment of his obesity. Findings:  The physician reviewer found that this patient is morbidly obese with multiple significant co-morbid conditions that are clearly aggravated by his obesity.  These will likely improve with significant weight loss, and the patient has tried and failed multiple non-surgical ways to lose weight. He meets nationally accepted criteria for consideration of bariatric surgery and is an appropriate candidate for treatment by bariatric surgery.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested emergency services for the treatment of her body aches. Findings:  The physician reviewer found that records from the ED note patient complaints of generalized body ache, low grade fever and mild headache for the previous three days. She had a past medical history remarkable for insulin dependent diabetes, hypertension and high cholesterol. The patient also complained of numbness to the legs and left face. Her pain level on presentation was 5/10.