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

The parent of a six-year-old male enrollee has requested for speech therapy for treatment of his speech and language delays. Findings:  The physician reviewer found that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. In this particular childs case, entry into elementary school has been delayed because of his speech and language difficulties. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for cervical artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that there is no evidence to support multi-level disc replacement. Although disc replacement may some day be proven more beneficial than fusion, there is still insufficient evidence to support the long-term safety and efficacy. Total disc replacements have not been tested in truly blinded studies and there is no long-term data on the superior efficacy of this procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a nine-year-old male enrollee have requested for comprehensive computerized motion analysis testing and electromyography testing for treatment of the enrollees gait disorder. Findings:  Three physician reviewers found that pre-surgical assessment of the deformity requires three-dimensional motion, force and electromyographic analysis of the patients gait. This allows accurate measurements of the many gait parameters required for precise correction of gait problems at multiple levels. Various clinical studies and publications have shown computerized gait analysis to be far more accurate and precise than visual assessment. It gives three-dimensional views at multiple joints and planes and allows for multiple level surgical interventions in one operation. The older method is a trial and error approach, resulting in over-and under-corrections and often requiring multiple surgeries to correct problems at a single level.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for bilateral reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the constant pull of heavy breasts against the upper torso is a mechanical problem, and conservative treatments have been shown to be ineffective for symptomatic macromastia. .  Non-operative treatments were unlikely to improve her pain, and surgery provided the only real chance for symptomatic relief. Weight loss generally does not improve the symptoms of macromastia. In fact, breast reduction is proven to facilitate weight loss because the postoperative breast reduction patient is better able to exercise. The concept supported in the medical literature is that patients who present with the typical symptoms of macromastia and who have a confirmatory exam benefit greatly from breast reduction surgery. As noted by Kerrigan, weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms were unlikely to improve unless she had a breast reduction.  The reduction was above the amount recommended in the literature for a reduction to be considered medically necessary. The peer-reviewed literature strongly indicates that this patients breast reduction was medically necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for urgent care services for treatment of her sore throat.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for urgent or emergent care. A prudent layperson with an average knowledge of medicine and two days of sore throat, cough and nasal congestion would not reasonably expect the absence of immediate care to jeopardize their health. This patient could have been safely evaluated on a non-urgent/emergent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for bilateral breast MRI for breast cancer screening. Findings:  The physician reviewer found that there is no evidence the patient has a significantly increased risk of breast cancer; this recommendation is medically appropriate and consistent with current guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested a knee brace for the treatment of his knee following right anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the patient has undergone multiple surgeries on his right knee and even though some repairs have been done, this is an on-going risk of instability in the knee due to the deficiency of the ACL and meniscus. As such, he is likely to be at risk of right knee instability on a long-term basis, especially during high demand activities such as running, jumping or stair climbing. A correct fitting right knee stabilization brace was medically indicated for this patient and the need is likely to continue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested orthognathic surgery for the treatment of her mandibular hypoplasia. Findings:  The physician reviewer found that the patient has a significant deformity. Furthermore, she has related difficulty with mastication and orthodontic treatment has been unsuccessful. Correction of this patients deformity is necessary to prevent progression of her condition. The requested procedure is considered standard of care to correct the deformity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for pulmonary vein ablation for treatment of her atrial fibrillation. Findings:  Three physician reviewers found that while pulmonary vein ablation overall may not be a more effective treatment than standard medications, this patient has already failed medical therapy and continues to have limiting symptoms. Treatment with pulmonary vein ablation at this juncture is consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 76-year-old male enrollee has requested for Lyrica for treatment of his back pain. Findings:  The physician reviewer found that Lyrica is a calcium-channel modulator which has been approved for the management of neuropathic pain due to diabetic neuropathy, post-herpetic neuralgia and fibromyalgia. It has been used off-label for many other neuropathic pain conditions, including post-laminectomy pain syndrome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for signal-averaged electrocardiography (SAECG) for evaluation of her heart palpitations.   Findings:  Three physician reviewers found that the use of signal-averaged ECG has essentially been eliminated from clinical practice for the stratification of arrhythmia risk. There may still be some usefulness of this technique in experimental subsets of patients with prior infarction. However, the data have been unsupportive of its general use, even in this subset.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for MRI of the thoracic and cervical spine for evaluation of her back pain. Findings:  The physician reviewer found that while the MRI of the lumbar spine was reasonable based on the severity of the patients pain and positive SLR, there were no findings that warranted cervical or thoracic MRI. Further, the MRI of the brain that is said to have diagnosed MS was done several months after the thoracic and cervical MRIs indicating these studies were not performed to look for evidence of spinal involvement of MS.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for emergency services for treatment of her migraine headache.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine, a history of migraine and 5/10 headache pain for one month, would not reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms as documented on the medical record were not of acute onset or sufficient severity to warrant emergency evaluation. The patient could have been safely evaluated on a non-emergency basis.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for emergency services provided at Sonoma Valley Hospital for treatment of his sciatica pain.  Findings:  The physician reviewer found that The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine, severe back and leg pain, and difficulty walking, would reasonably expect the absence of emergency care to jeopardize their health. Therefore, I have determined the services at issue were emergent in nature and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for an integrated weight change program for treatment of his morbid obesity. Findings:  The physician reviewer found that morbid obesity is widely recognized as a disease process with significant comorbidities. Treatment for this condition is clinically indicated and participation in the integrated weight change program is a reasonable alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. Studies have shown that speech and language therapy can result in significant improvement in children with speech and language deficits. Improved play skills, social skills and self-esteem have also been demonstrated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for cervical artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that the peer reviewed literature to date fails to establish with any certainty that the artificial disc is more effective than standard methods of treatment. Disc implants have not become the standard of care nationwide. Although they are approved for use at this time, the FDA has also determined that further study is needed. The long-term viability of these disc implants is not known. Their superiority to more traditional surgical techniques has not been conclusively established. In this specific case, the use of the artificial disc has been recommended at the two junctional levels (C4-5 and C6-7) with fusion of the middle segment (C5-6). This type of surgery has had even less study and is outside of the FDA approved indications for the use of the Prestige disc.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for a coronary CT angiogram for evaluation of her chest pain.   Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography does not accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental/investigational application of this technology.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 79-year-old male enrollee has requested radiofrequency ablation for the treatment of his renal cell cancer.  Findings:  Three physician reviewers found that the patient is a 79-year-old male with responding advanced prostate cancer. He has a growing kidney lesion suspicious for cancer and is not a good operative candidate. Research data for radiofrequency ablation (RFA) is not likely to ever be at the level required for widespread acceptance or FDA approval. However, carefully selected patients in experienced hands should have similar outcomes at lower risk than with laparoscopic partial or open nephrectomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for Lyrica for treatment of his tarsal tunnel syndrome. Findings:  The physician reviewer found that Lyrica is not FDA approved for tarsal tunnel syndrome, which is a mono-peripheral neuropathy entrapment syndrome. Lyrica is utilized and FDA approved for postherpetic neuralgia, epilepsy/seizures and some neuropathic syndromes that have failed other conservative options. Furthermore, Lyrica has been approved for use in fibromyalgia, but not for widespread pain of unclear etiology that does not meet fibromyalgia diagnostic criteria.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for use of a continuous passive motion machine for treatment of her post total knee replacement. Findings:  The physician reviewer found that postoperative progress notes do not include any documentation of problems with range of motion. Additionally, physical therapy postoperative records do not document the patients full functional ability. The physical therapy records document her pain complaints, yet do not document her strength or motion ability.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for a panniculectomy for treatment of her back pain. Findings:  The physician reviewer found that Panniculectomy does not represent the standard of care for the treatment of back pain. Abdominal wall reconstruction using the techniques described by Toranto or Ramirez should certainly be considered as a last resort type of procedure for patients that have undergone a thorough evaluation to rule out other causes for back pain and have failed a regimen of more standard conservative treatments for their symptoms.  This does not appear to be the case for this particular patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for emergency services for treatment of her abdominal pain.  Findings:  The physician reviewer found that the symptoms  did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and mild crampy abdominal pain of several months duration, anxiety, depression and flatulence would not reasonably expect the absence of emergency care to jeopardize their health. This patients symptoms could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested for Crestor for treatment of his hyperlipidemia. Findings:  The physician reviewer found that a lipid-lowering agent should be discontinued if there is significant intolerability, either in the form of patient side effects or abnormal laboratory data. Therefore, it is medically appropriate for the patient to continue on Crestor. The use of this lipid-lowering medication is supported by the American College of Cardiology (ACC) guidelines for patients with dysplipidemia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for artificial disc replacement at C5-6 and C6-7 for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that Artificial disc replacement is a new technique for management of cervical disc disease and is FDA approved. However, the long-term efficacy of this procedure is still unknown. The medical data regarding artificial disc replacement is not sufficient to promote it over standard spinal fusion.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of her diabetes. Findings:  Three physician reviewers found that the CGMS is FDA approved and the benefits for patients with DM and problems with hypoglycemia have been validated in many studies. The scientific evidence is clear that this device will help to lower the time spent in hypoglycemic range. In addition, the Hgb A1c is often improved while using a glucose sensor. As such, there is evidence that this device improves net health outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested acute inpatient hospital services for the treatment of his medical condition. Findings:  The physician reviewer found that this patient was admitted with chest pain. After ruling out MI, he underwent an adenosine cardiolite stress test. As such, there is no evidence that the patient could not have been safely discharged home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for Humatrope therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the patients mid-parental height calculated from the endocrinologists initial visit note approximates 53.5, while his predicted adult height was estimated at 53. His hypercholesterolemia has been improved with Vytorin. The patient had a low level of IGF-1, but normal growth hormone (GH) provocative tests.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for a wireless capsule endoscopy for evaluation of her abdominal pain.  Findings:  The physician reviewer found that wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. WCE offers the following potential advantages over other more broadly used imaging techniques, Iit offers the potential to directly visualize the entire mucosal surface of the  small bowel. It has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. It is less invasive than conventional endoscopy. It does not require sedation or anesthesia. It is well accepted by patients. WCE is approved for the evaluation of patients with obscure GI bleeding, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease or other small bowel diseases with a negative small bowel series.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for laboratory testing for evaluation of his risk of cardiovascular disease.   Findings:  Three physician reviewers found that current guidelines still do not support routine measurement of inflammatory markers for the purpose of modifying LDL goals in primary prevention. Routine screening for homocysteine also remains controversial. Although routine screening for elevated homocysteine is not yet recommended, it may be advisable for individuals who manifest atherothrombotic disease that is out of proportion to their traditional risk factors or who have a family history of premature atherosclerotic disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of his type 1 diabetes mellitus.  Findings:  Two physician reviewers found that real time glucose sensors are FDA approved and have been validated in many studies as having benefits for patients with DM and problems with hypoglycemia. The scientific evidence is clear that this device will help to lower the time spent in hypoglycemic range. In addition, the Hgb A1c is often improved while using a sensor. As such, there is evidence that this device improves net health outcomes in someone who is purported to be having hypoglycemic reactions and needs to avoid low blood sugars. The Deiss study involved one arm of study patients using the sensor for an extended timeframe, and they realized improved A1c values. In this instance, we are not really given any actual blood glucose data to show that the patient had hypoglycemia and hypoglycemic unawareness. The record states that he had this problem and he very likely did. However, one would need to see blood glucose data from before the patient began using the Dexcom system to be assured that this device is the best treatment option available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for a home cervical traction unit (Saunders Home Tract) for treatment of her cervicalgia. Findings:  The physician reviewer found that the over-the-door unit produces pressure on the temporomandibular joint (TMJ) and her providers clearly indicated the patient cannot tolerate this type of pressure. The Saunders cervical traction unit is a medically reasonable alternative due to the patients TMJ.