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

A 54-year-old female enrollee has requested Botox injections for the treatment of her post herpetic neuralgia. Findings:  The physician reviewer found that there are a variety of treatments for PHN.  As there is no documentation or evidence that the patient has tried gabapentin or pregabalin, both of which are standard non-opiate treatments for PHN, I cannot say that this patients PHN is refractory.  Botox may be beneficial in treating this patients PHN, and may be appropriate if her PHN becomes refractory, but there is no evidence that the patient has tried other standard therapies for PHN.  With the available records, and the limited amount of documentation of treatments actually tried and failed by the patient, Botox is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested an ultra lightweight wheelchair for the treatment of her bilateral leg weakness secondary to brain trauma. Findings:  The physician reviewer found that the patient's energy expenditure of ambulation and activities of daily living with bilateral knee-ankle-foot orthoses is extremely high. Fatigue is an expected consequence, and the patient does require a wheelchair in this situation to optimize function. Thus, a wheelchair is medically necessary and indicated to allow continued ambulation and performance of activities of daily living. However, there is a lack of support for the medical necessity of an ultra lightweight wheelchair. The medical notes do not indicate a reason as to why an ultra lightweight wheelchair is needed, as a standard wheelchair would suffice. Thus, while a wheelchair is medically necessary for this patient, the ultra lightweight wheelchair is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested continued physical therapy services for the treatment of her medical condition status post right proximal humerus fracture with displacement and malunion. Findings:  The physician reviewer found that another session of 8-12 visits of skilled PT are medically necessary for this patient, as there is reasonable expectation of improvement with skilled PT. The patient did make some gains with range of motion with prior PT sessions.  A study by Mao and colleagues showed that continued physical therapy beyond the initial 2-3 month period resulted in additional benefit. The authors reported that there was a subgroup of patients that showed slow improvement over time. Considering that the alternative for this patient is repeat surgery, it is medically prudent and necessary to extend the period of physical therapy in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested partial hospitalization eating disorder program services for treatment of her eating disorder. Findings:  The physician reviewer found that the patient did not respond to intensive outpatient treatment and was admitted to the partial hospitalization program for this reason. She was experiencing relatively serious medical complications and required emergency treatment for significant bradycardia. Although she was not overtly suicidal, homicidal, aggressive or psychotic, it would not have been appropriate for her to return to an outpatient program since she had previously failed to respond to such a program. The patient did require treatment in a partial hospitalization eating disorder program. She was not progressing satisfactorily during the relatively short time she was in this program. It would be unsafe and not prudent to recommend a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested a 24-hour ambulatory blood pressure monitor for an evaluation of his hypertension. Findings:  Two physician reviewers found that ABPM provides a large number of measurements over time (usually 24 hours), which can be plotted to give a profile of blood pressure. Although in practice the average daytime blood pressure is used to govern decisions, the clinical use of ABPM has allowed a number of phenomena in hypertension to be identified that would otherwise not have been. ABPM is of benefit in excluding white coat hypertension and in helping establish the diagnosis of patients with borderline hypertension. In terms of white coat hypertension, patients with normal blood pressure may have higher daytime ambulatory pressures than blood pressure measured conventionally. But in those with hypertension, daytime blood pressure is usually substantially, but unpredictably lower than blood pressure measured conventionally. For patients whose blood pressures are borderline, they may benefit from ABPM by avoiding drug therapy, and in establishing the diagnosis of hypertension.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested an MRI of the brain with anesthesia for an evaluation of the enrollees autism and/or minor seizures. Findings:  The physician reviewer found that the patients primary doctor in her letter reports minor seizures five months after the neurologists evaluation. However, since there are no records nor any documented history confirming the presence of epilepsy or seizures, the MRI is not medically necessary. Although a MRI is sometimes obtained in children with autism, autistic patients have a high incidence of epilepsy (approximately 50%). In epileptic patients, a cerebral imaging study (preferably a MRI) is indicated. However, since the submitted medical records state there is no evidence of seizures or convulsions in this case, the proposed MRI is not indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for Avastin infusion treatments for treatment of his metastatic Ewings Sarcoma.  Findings:  The physician reviewer found that Avastin in the Phase I setting, and found the dose that they wished to move forward in Phase II trials. The Phase I trial had 5/18 patients who were evaluable and 3 of them had Ewings (out of a total of 5 patients with Ewings enrolled).  The drug was able to provide them longer periods than predicted to progression, but did not show shrinkage of the tumor. The Phase II trial uses this agent in combination with chemotherapy and is ongoing.  There is not sufficient information at this time to recommend the use of Avastin for this indication outside of a clinical trial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his prostate cancer. Findings:  Three physician reviewers found that the guidelines are developed through an explicit review of the evidence integrated with expert medical judgment by multidisciplinary panels from NCCN member institutions. Treatment recommendations are specific and are implemented through performance measurement. In reviewing current NCCN guidelines, this patient would be deemed a low recurrence risk.  Based on a life expectancy of greater than ten years, options regarding initial therapy would be active surveillance, radiation therapy or radical prostatectomy.  Additionally, these guidelines state that 3D conformal or IMRT technique should be employed.  Doses of 70 to 79 Gy in 35 to 41 fractions to the prostate appear to be appropriate for patients with low risk cancer, such as this patient.  Alternatively, this patients radiation oncologist has recommended 38 Gy delivered in four fractions.  This dose fractionation is not compatible with the NCCN guidelines. We do not have long-term data regarding this dose fractionation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested continuous azithromycin (Zithromax) for the treatment of her bronchiolitis obliterans/constrictive bronchiolitis. Findings:  The physician reviewer found that there are significant long-term complications of chronic steroids, and other anti-inflammatory agents should be tried. As macrolide antibiotics such as Zithromax have been shown to be helpful in eosinophilic bronchiolitis, a six-month trial of Zithromax is medically appropriate. As discussed in review papers, the macrolides have been shown to have significant anti-inflammatory effects. These have had demonstrated efficacy in panbronchiolitis and other chronic inflammatory conditions of the lungs. Given this patient's clinical condition as well as her lack of adequate response to steroid treatment, an additional six-month trial of Zithromax is medically necessary and indicated at this time, and is supported by the literature for this use. If after the six-month trial period, there is documentation of improvement in FVC-FEV1 and/or FRC, the medication should be continued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested mastopexy and augmentation mammoplasty for the treatment of her breast deflation due to Graves disease.   Findings:  The physician reviewer found that the augmentation mammoplasty and mastopexy are not medically necessary for this patient. The condition does not constitute an abnormal structure of the body. There is no loss of functioning documented in the records. There is no abnormal structure or abnormally functioning structure of the body due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The patients breast atrophy is likely a combination of factors including weight loss and aging, as well as some effect from Graves disease. However, the patients breasts are not structured abnormally or deformed. Nor is there a functional impairment that would be improved by the proposed procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested bilateral knee Hyalgan injections for the treatment of his chondromalacia and osteoarthritis. Findings:  The physician reviewer found that this patient has not tried a number of medications which might be helpful. In addition, the patient has not tried topical modalities. The Health Plan's requirement for a trial of intra-articular steroids is not unreasonable, as these may be effective. Given that there are a number of alternatives, the use of Hyalgan is not medically necessary at this time for the patients bilateral knee condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested artificial cervical disc replacement for the treatment of her degenerative cervical disc disease and neck pain status. Findings:  Three physician reviewers found that the patient has no radicular nor myelopathic symptoms. She has no neurologic abnormalities nor symptoms nor findings on exam.  She has axial neck pain, which is a contra-indication for cervical disc arthroplasty, as addressed by the above referenced author, and discussed in much of the available medical literature. Furthermore, her pain has been in her lower neck, yet surgery has been proposed on her upper/mid neck. Thus, based on this patients clinical findings, there is inadequate evidence that artificial disc replacement is likely to be efficacious.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 78-year-old male enrollee has requested skilled nursing facility (SNF) services for the treatment of his multiple injuries. Findings:  The physician reviewer found that the patients condition does not respond to therapeutic pharmaceuticals. Brain healing determines progress. The submitted documentation reveals that continued PT showed a decline from the peak. The patient was progressing with OT, but the rate and area of progression indicate limited capacity to regain function. As discussed in the paper by Gordon et al., the progress for recovery following traumatic brain injury can continue for extended periods of time, but the extent of brain injury and the rate of brain injury determine the rate of functional recovery. Continued PT and OT cannot hasten functional recovery in the absence of brain recovery, nor do they promote brain recovery. Because the patient was progressing and did progress, the Health Plans denial should be overturned for the first round of therapy and upheld for the second round.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested the Saunders Home Lumbar Traction Device for the treatment of his low back pain. Findings:  Two physician reviewers found that the requested Saunders Home Lumbar Traction Device is not likely to be more beneficial than other available standard therapies such as home exercises and over-the-counter medication. While this patient has ongoing back complaints, the medical record does not document objective abnormal physical findings. While the concept of traction to unload the spine sounds appealing, there are no good studies documenting the efficacy of a home traction device to achieve those goals. It takes a tremendous amount of force to distract or unload a lumbar spine, and that amount is clearly greater than can be obtained by a home traction unit. There is a lack of documented studies revealing the efficacy of this type of treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested inpatient substance abuse rehabilitation services for the treatment of her opiate and alcohol dependence. Findings:  The physician reviewer found that the patient could have been safely and effectively treated at a lesser level of care during the dates of service at issue. A methodology for the selection of the appropriate rehabilitation setting for patients with dual diagnoses (substance abuse and psychiatric comorbidities) is outlined in the American Society of Addiction Medicine (ASAM) criteria. This patient went through the detoxification process as an inpatient and was medically stable from that standpoint, having been started on Subutex. Although she had a diagnosis of depression, she was not suicidal and had been started on treatment. She was compliant with treatments. As such, she did not have any indication for continued acute hospitalization. While she still required treatment of her condition, there were no documented circumstances that would indicate that this could not be safely and effectively undertaken at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested MRI (magnetic resonance imaging) scans of the cervical and thoracic spine for an evaluation of his back and chest pain. Findings:  The physician reviewer found that this patient had back pain that started rather abruptly. It has continued despite physical therapy and anti-inflammatories. The pain is currently being managed with a combination of medication. MRI or CT studies should be considered in patients with worsening neurologic deficits or a suspected systemic cause of back pain, such as infection or neoplasm. Worrisome signs or symptoms that would warrant investigation with an MRI include fever, focal or progressive neurologic findings on physical exam, history of trauma, systemic symptoms, weight loss, history of cancer, chronic steroid use or drug/alcohol use, history of HIV or TB, and suspected ankylosing spondylitis. These imaging studies may also be appropriate when referral for surgery is a possibility. There is no documented evidence of radiculopathy or myelopathy on physical exam, or any of the aforementioned risk factors. MRI scans of the back will often identify incidental findings such as a bulging disc, but these may not in fact be the cause of the pain. Early or frequent use of scanning is not recommended. In one study (Gilbert, et al.), 782 patients were randomly assigned to early or delayed selective imaging. Early use of imaging did not affect overall treatment. In another randomized study (Modic, et al.), 246 patients with low back pain underwent early MR imaging; patients were randomly assigned to a group who were informed of MR findings, or a group in which patient and physician were blinded to the MR results. MR imaging had no measurable value in designing a program of conservative care. Patient knowledge of the MR findings did not improve outcome and was associated with increased anxiety and pain. All told, MRI of the cervical and thoracic spine is not likely to be of clinical value in this setting, and thus, is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Botox (type A) injections for the treatment of her muscle spasticity (left upper extremity and left foot). Findings:  The physician reviewer found that Botox is effective for spasticity, and is widely approved for this use. There has been efficacy demonstrated in one or more studies for spasticity related to cerebral palsy, post stroke spasticity, and paresis due to spinal cord injury and even painful spasms of the hand due to overuse (`writer's cramp`). However, not all patients with these conditions respond to Botox. As of yet, there are no known patient specific characteristics that have been identified that predict which patients will respond to treatment. Given the patient's degree of symptoms causing difficulty with performing her job and ambulating, and the fact that she has failed treatment with standard oral antispasmodic medications, the use of Botox is medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for continued residential eating disorder treatment for treatment of her condition. Findings:  The physician reviewer found that this patient required a RTC level of care, and will continue to require a RTC level of care for at least an additional 30 days (subject to reassessment at that time).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested 72 weeks of pegylated interferon (Pegasys) for the treatment of the enrollees hepatitis C. Findings:  Two physician reviewers found that genotype 7 has been recently discovered as a distinct genetic make-up, and the response to standard combination therapy has not been established for genotype 7. Although some studies claim this duration of time to be typically adequate, other trials have demonstrated that longer courses of treatment have lower relapse rates. Infection with hepatitis C virus (HCV) genotypes 46 is distributed and studied less widely than genotypes 13. However, genotypes 46 are very common in geographic areas where chronic hepatitis C is highly prevalent. Response to treatment in patients with HCV genotype 6 may be at an intermediate level between that seen with genotype 1 and genotype 2 or 3. The optimal duration of treatment (24 versus 48 weeks) for HCV genotype 6 is unclear and currently under investigation. Although a couple of published studies by Yuen and colleagues and Hui and colleagues showed better sustained virological response in genotype 6-7 patients than genotype 1, the duration of therapy in these genotypes remains controversial and uncertain at this point. In this patients case, Pegasys treatment should be given for 48 weeks. This is likely to be more efficacious for treatment of this patient than the Health Plans proposed 24 weeks of Pegasys therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested an EBCT coronary artery scan for an evaluation of his cardiovascular risk. Findings:  Three physician reviewers found that the medical records provided indicate that the patient has high cholesterol. The patient is reportedly under stress and has a family history of heart disease, although the age of onset is not provided. At this time, none of the available literature states that EBCT coronary artery scan is superior to standard testing, namely nuclear stress testing. Rather, this is an additional testing option. Although EBCT for evaluation of coronary artery disease is becoming a more frequently used modality, it was not likely to be superior to alternative methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested a vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Three physician reviewers found that the literature lacks significant peer-reviewed papers reporting results on long-term randomized studies comparing sleeve gastrectomy to other procedures. Lap-band is universally accepted as the safest surgical procedure for morbid obesity, with studies showing excellent long-term results. Lap-band allows for the stomach to remain intact and the band pressure can be adjusted as needed without operative procedure. The 2007 American Society for Metabolic and Bariatric Surgery (ASMBS) statement reviewed sleeve gastrectomy results by many authors, but the follow-up up data are limited to three years. Lap-band has shorter operative time, less morbidity, less severe complications, shorter hospital stay and longer follow-up data available.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested surgery to re-innervate the abdominal wall musculature for the treatment of her chronic left flank pain and bulging, status post left 12th rib resection. Findings:  The physician reviewer found that several evaluations by in-network surgeons did not find any apparent anatomic problem (i.e., a hernia). It was suspected that a nerve injury had occurred from the rib resection or subsequent hernia repair, resulting in denervation of the muscle with atrophy. While the patient has a contour deformity, it does not appear that the condition sustained as a result of the rib resection has resulted in a significant functional impairment that is not amenable to conservative management. This case does not qualify as reconstructive surgery since the condition does not rise to the level of an abnormal structure of the body.  While there is a slight irregularity, surgical correction will not result in more than a minimal improvement in the patients appearance, and is therefore cosmetic rather than reconstructive in nature. While the patient reports experiencing some residual pain, there is no documentation of a trial of gabapentin, lidoderm patch, and Botox or steroid local injections into the scar as proposed by the Plan. The recommendations of the in-plan physicians for conservative management are medically appropriate. Surgical intervention is only indicated for patients that have failed optimal medical management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested lap band surgery for the treatment of her obesity. Findings:  The physician reviewer found that the NIH (National Institutes of Health) guidelines for obesity surgery that are recognized by all of the major specialty societies are that the surgery is indicated for the treatment of morbid obesity in patients with a BMI greater than 40; or in patients with a BMI between 35 and 40 if they also have co-morbid conditions such as hypertension, type 2 diabetes, sleep apnea, etc. This patient is not morbidly obese. The patient has a calculated BMI of 30. This puts her in the `obese` category, but not in the morbidly obese category. In any case, even at her current weight, bariatric surgery is not medically necessary for the treatment of her obesity.