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

A 66-year-old male enrollee has requested for intravenous immunoglobulin (IVIG) therapy for treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP).       Findings:  The physician reviewer found that the use of IVIG in this instance was clinically appropriate. Although CIDP is often difficult to diagnose, the clinical picture and electro-diagnostic features of this patients history are indicative of this disorder. In addition, the laboratory testing was suggestive of an anti-MAG variant of this disease in which IVIG is one of the few studied therapies. It should also be noted that one of the standard therapies for CIDP, steroids, may not have been appropriate given the possibility of early diabetes.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested  for a Morcher iris implant for treatment of her cataract. Findings:  Three physician reviewers found that the Morcher iris implant has a good safety record and success rate in other countries. The compassionate use protocol through UCLA is an appropriate approach in this clinical setting. The patients visual potential with cataract surgery is quite good. However, any improvement will be mitigated by the glare and brightness that will result following cataract extraction if the large iris defect is not addressed. Though still in its early stages, the Morcher iris implant procedure is reasonable and indicated given the patients exceptional circumstance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for the growth hormone therapy (Nutropin AQ) for treatment of the enrollees short stature.       Findings:  The physician reviewer found that given that the patient is not short, and that he does not appear destined to become a short adult, there appears to be no medical indication for GH therapy in this instance. However, the crossing of percentiles in linear growth does indicate a need for further observation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee has requested for deep brain stimulation for treatment of his Parkinsons disease. Findings:  Two physician reviewers found that deep brain stimulation has widespread acceptance as being effective in treating severe Parkinsonian tremor, essential tremor and late motor manifestations of Parkinsons disease.  Parkinsons tremor is notoriously unresponsive to medical therapy. This patient has exhausted all reasonable medical options other than deep brain stimulation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a deceased 65-year-old female enrollee has requested reimbursement for skilled nursing facility (SNF) services the enrollee received for the enrollee who had lung cancer. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient had severe cognitive impairment and altered consciousness while at the SNF facility. She was unable to participate in therapy. She did not have symptoms that required daily skilled nursing management. Hospice care would have been appropriate during the period in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested for laparoscopic surgery for treatment of her pelvic pain. Findings:  The physician reviewer found that the patient had two prior procedures that could lead to significant adhesions and possibly cause pelvic pain. The apparent posterior cul de sac pseudocyst raised the question of possible dense adhesions. In this setting, laparoscopic surgery including lysis of adhesions, partial excision of the left ovary for ovarian cystectomy and dilation and curettage was medically appropriate. However, there is insufficient evidence that the hysteroscopy was clinically indicated. The patient had a normal endometrium on MRI. There is no documentation of a need for hysteroscopy or attempted medical management of heavy periods.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for a positional MRI for evaluation of her back pain. Findings:  Three physician reviewers found that there is no peer-reviewed literature supporting the use of positional MRI over conventional MRI for low back pain. Positional MRI produces motion artifacts resulting in image irregularity. The diagnostic procedure at issue remains investigational in nature at this time and there is no evidence its use results in improved clinical outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested artificial disc replacement for treatment of degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement is not yet a mainstream operative procedure. While  a recent study published this year in Spine (Zigler, et al) indicates some improvement in patient outcomes with disc replacement surgery versus single-level fusion many of the findings are based on subjective reports of improvement. It was obviously not a blinded study. This study also reports maintenance of motion at the level of surgery with disc replacement but does not indicate how that changes or improves long term outcomes. The two year study did not provide conclusions in regard to long-term efficacy. Overall, it is still not clear whether artificial disc replacement is superior to fusion for the treatment of a patient such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Myobloc (botulinum toxin type B) injections for the treatment of his cervical dystonia. Findings:  Two physician reviewers found that cervical dystonia is well treated with botulinum toxin injections. This therapy is FDA approved for the treatment of cervical dystonia and has been effective for this patient. Other interventions would not be expected to provide the same level of symptom relief.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested Botox injections for treatment of migraine headaches.  Findings:  Two physician reviewers found that the results achieved with Botox are variable, but there is considerable data suggesting its efficacy as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). The patients headaches are refractory to standard preventives and there is a likelihood of success with Botox therapy. If not completely effective, Botox may still reduce the intensity and the frequency of the patients headaches.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested acute inpatient and residential psychiatric services for the treatment of his bipolar disorder. Findings:  The physician reviewer found that he had, had previous acute psychiatric hospitalizations and was receiving pharmacotherapy. His acute stay also appears to have been extended for several days while waiting for residential placement at his facility of choice. A less intensive level of care would have been more appropriate than acute inpatient care. The clinical evidence indicates he was still psychiatrically ill at that time and medication adjustments were on going. In addition, once the final regimen of Lamictal, Neurontin, Klonopin, and Thorazine was established, close supervision for a reasonable length of time was warranted. The transition to residential treatment was clinically reasonable and coverage should be provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for Cyberknife stereotactic radiosurgery for treatment of her metastatic non-small cell lung cancer. Findings:  Two physician reviewers found that the patient has stage IV lung cancer that was treated aggressively with resection of brain metastatic disease followed by Cyberknife radiosurgery. She then received aggressive treatment for lung primary cancer and further treatment with Cyberknife. The patient presented with stage IV lung cancer and despite aggressive chemoradiation and further systemic treatment with Tarceva, she still has persistent systemic disease. Conventional palliative radiotherapy is appropriate in this setting. There is no data to suggest that Cyberknife treatment is likely to be superior to standard radiotherapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested a repeat series of Hyalgan injections for the treatment of osteoarthritis.  Findings:  Two physician reviewers found that conservative treatment has not been effective for this patient. A repeat series of Hyalgan injections is the best treatment alternative at this time. This therapy can reasonably be expected to decrease her pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This 32-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her lower lumbar pain. Findings:  The physician reviewer found that this patient does not meet the established guidelines for MR imaging of the lumbar spine. A physical examination revealed negative straight leg raises, normal strength bilaterally, normal deep tendon reflexes bilaterally and normal gait. The patient did report a dullness in sedation on the left lateral leg. At this juncture, there are no significant neurological deficits and x-rays show only scoliosis. The patient has not yet had a complete trial of physical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female has requested hyperbaric oxygen therapy in advance of a tooth extraction.  Findings:  Two physician reviewers found that HBO for osteoradionecrosis (ORN) prophylaxis is still considered standard of care in the radiation oncology and maxillofacial communities. It is the only treatment option for prophylaxis and active management of ORN. Surgery is an option, but related to high morbidity. Antibiotics are not superior.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a four-year-old female enrollee has for continued occupational therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that autism is a disorder of communication, socialization and behavior. It is usually addressed by an interdisciplinary team focusing on psychoeducational issues. There are no specific medical treatments for autism.  Occupational therapy is not considered clinically indicated for treatment of patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested acute inpatient psychiatric services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient was hospitalized for a relatively short time given the severity of her symptoms upon admission. While on the unit, she continued with suicidal threats and stated a plan for carrying out these threats. The patient often required unscheduled medications. Her behavior was generally manipulative, demanding and attention seeking and she was unable to contract for safety up until discharge. While the patients symptoms suggest a behavioral disorder as well as a mood disorder, her condition was severe enough to require inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested Lyrica 150mg twice daily for treatment of fibromyalgia and depression. Findings:  The physician reviewer found that since fibromyalgia is now an FDA approved indication for Lyrica, and given that this patient has already been receiving Lyrica with significant benefit, continued use of the medication at standard doses (which typically range from 300mg to 450mg daily) is medically appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male has requested a PET/CT scan for evaluation of pancreatic cancer.  Findings:  The physician reviewer found that PET/CT has been shown to have a higher diagnostic accuracy in pancreatic cancer than CT alone; 95% versus 77%. PET/CT is also superior to CT in the detection of liver metastases. The literature indicates PET/CT can reliably differentiate between tumor and inflammatory or scar tissue and can detect unsuspected metastases in the liver. PET/CT has been shown to be sufficiently sensitive in evaluating patients with pancreatic cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Lipitor 10mg twice daily for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation provided necessitating twice daily Lipitor at the requested dosage. Statins are best prescribed to be taken once a day in the evening. This is the time of greatest cholesterol synthesis. There is no evidence in the medical literature supporting twice daily statin dosing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested gastric bypass revision for the treatment of her obesity. Findings:  The physician reviewer found that upon review of the submitted clinical information, there is no evidence of any technical failure of the original gastric bypass operation. Inadequate weight loss is not an uncommon finding after a gastric bypass procedure. A revision of gastric bypass in this setting will involve creation of a smaller stomach pouch and/or reducing the size of the gastrojejunostomy anastomosis. Both of these operative steps will result in worsening of the patients reflux. Further, in the absence of any technical complications such as a gastro-gastric fistula there is no scientific evidence as to the long-term success of a second gastric bypass in a patient for whom the first operation has not been successful.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that with a BMI of 36.7 and no significant comorbidities, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested for eating disorder residential treatment for treatment of his eating disorder. Findings:  The physician reviewer found that he had been quite meaningfully engaged in the treatment program and no longer exhibited symptoms of depression. The patients treatment could have reasonably transitioned to a partial hospitalization program at that time; residential treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A 19-year-old male enrollee has requested for reinduction chemotherapy and haplo-compatible T-cell-depleted transplant with multiple post-transplant donor lymphocyte infusions for treatment of his acute myelogenous leukemia (AML). Findings:  The physician reviewer found that there is extensive research in this area at the present time, and the results are promising. For a patient such as this patient, transplant with multiple DLIs is the only potentially curative treatment alternative, and may be effective even in the face of aggressive AML.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested  for custom orthotics for treatment of the enrollees flat feet. Findings:  The physician reviewer found that it is a well accepted theory that pathomechanics of the foot can cause knee and low back pain. It is also well accepted and proven that orthotics can control abnormal motion of the foot.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 72-year-old female enrollee has requested for acute rehabilitation services for treatment of the enrollee following a cerebral vascular accident. Findings:  The physician reviewer found that there was no indication for transfer to acute rehabilitation as the patient was making steady progress, as expected, at the SNF level of care. Transfer from SNF rehabilitation to acute rehabilitation in this setting is not consistent with current national standards because there is no expectation of clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that with a body mass index of 41.5 and comorbid conditions including diabetes mellitus, this patient meets medical necessity criteria for weight loss surgery. The rationale for requiring psychological evaluation prior to weight loss surgery is to identify a possible eating disorder that may have contributed to the patients obesity.  There is no scientific data to support that patients with bipolar disorder do any better or worse after weight loss surgery than a patient who is not diagnosed with this condition. The patients obesity and its related co-morbidities require surgical treatment; her psychiatric conditions should not prevent her from receiving appropriate treatment for her medical problems.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The representative of a 49-year-old male has requested neurological rehabilitation for treatment of a ruptured aneurysm.  Findings:  Three physician reviewers found that neurological rehabilitation therapy is customary treatment for brain injured patients with residual cognitive deficits. Rehabilitation specialists do not consider the therapy experimental or investigational and current research supports its efficacy.  The therapy requested by the patient is reasonable and consistent with the standard of care for treatment of traumatic brain injury.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a Lymphopress pump for the treatment of her lymphedema. Findings:  The physician reviewer found that the patient has no documented history of chronic venous insufficiency. There is no evidence of venous stasis, diabetic or arterial ulcers not clinically amenable to revascularization or other surgical intervention. In addition, no history of claudication pain is noted. Lastly, the patient had a positive response to lower extremity elevation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Cialis for the treatment of his erectile dysfunction.  Findings:  The physician reviewer found that it is well documented that 33% of men in their 50s and 50% of men in their 60s have some degree of failure to obtain or maintain an erection. This is thought to be due to early atherosclerotic changes that develop in the small arterioles before lesions are demonstrated in the larger vessels, which are easier to document. Those who are partially impaired are most likely to get an excellent clinical response with Cialis or one of the other 5 PDE inhibitors. In this case, the patient reports his best response is to Cialis. The use of Cialis in this setting is very appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested for a robotic-assisted radical prostatectomy for treatment of his prostate cancer.      Findings:  The physician reviewer found that laparoscopic radical prostatectomy has advantages over conventional radical prostatectomy and has become the preferred surgical option. Laparoscopic radical prostatectomy can be performed with or without robotic assistance. There are no documented advantages to robotic-assisted laparoscopic prostatectomy versus conventional laparoscopic prostatectomy with appropriate experience and training.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer. Findings:  The physician reviewer found that the use of Avastin and Xeloda did not yield encouraging results. The original trial revealed an increase in response rate with the combination of Xeloda and Avastin, but did not show a prolongation of time to progression. Furthermore, no survival advantage has been noted. Moreover, Avastin may result in significant side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for the medication Lamisil for treatment of his onychomycosis.  Findings:  The physician reviewer found that there are other treatments and medications available that should resolve his asymptomatic infection.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested  for Hyalgan injections for treatment of her osteoarthritis and chondral tear.       Findings:  The physician reviewer found that this patient does not require treatment with Hyalgan injections at this time.  She should undergo a documented trial of at least two different non-steroidal anti-inflammatory drugs before pursuing Hyalgan injections. The submitted clinical evidence does not establish that treatment with Hyalgan is clinically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested bilateral breast implant removal and bilateral reduction mammoplasty for treatment of macromastia and scoliosis.  Findings:  The physician reviewer found that The ASPS has developed guidelines for determining the medical necessity of reoperation for women with implants originally placed for cosmetic augmentation. Medically necessary conditions for such surgery include: broken or failed implant; infection; implant extrusion; siliconoma or granuloma; and interference with the diagnosis or treatment of breast cancer. This patient does not meet any of these guidelines, and no peer-reviewed studies or case reports have been identified that show breast implants cause symptomatic macromastia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her back pain. Findings:  The physician reviewer found that the clinical documentation provided for review is limited, and does not include a neurological examination. There is no indication of a recent trial of conservative therapy or referral to a neurologist or orthopedic or neurological surgeon. The need for MR imaging of the lumbar spine is not apparent from the evidence submitted.