Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee, with painful varicose veins of the labial area, has requested authorization for sclerotherapy. Findings:  Three physician reviewers found that Sclerotherapy has higher primary failure and recurrence rates than other available treatment modalities. As in this instance, when the goal of treatment is saphenous closure,  radiofrequency ablation or endovenous laser therapy, or even stripping, have consistently greater efficacy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee, with Hypersomnia, has requested authorization and coverage for Provigil. Findings:  The physician reviewer found that Provigil has been used successfully to treat this disorder. Its properties include the ability to promote wakefulness. This makes Provigil a potentially important tool for treating the excessive diurnal somnolence that can accompany sleep disorders.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee, who underwent a nondivided Roux-en-Y gastric bypass, has requested authorization for gastric bypass revision.Findings:  The physician reviewer found that clinical evidence suggests this is a case of noncompliance with the patients post-surgical dietary regimen. The fact that the patient never lost more than 30 pounds, even early on when the pouch had not yet stretched, suggests maladaptive eating behaviors. Evidence suggests no anatomic reason for the patients regain and many clinicians leave pouches larger than 30ml with good results.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee, who has degenerative disc disease at L5-S1, has requested authorization for artificial disc replacement surgery.Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee, with a prior history of coronary artery disease (CAD), has requested authorization for a CT angiography.Findings:  Two physician reviewers found that although significant coronary disease was found in this patient, CT angiography is not indicated or proven to change outcomes by large randomized clinical trials. Currently, CT angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. Additionally, the test is not supported by the American Heart Association (AHA).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee, with short stature, has requested authorization for growth hormone therapy.Findings:  The physician reviewer found that the patient appears to be having a delayed adolescence and should become an adult with normal height without additional growth hormone intervention. Should the growth chart show a falling off from previous percentiles and the IGF-1 fail to increase (or fall further) as pubertal development ensues, the request for growth hormone therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee,  with chronic wrist pain, has requested authorization for a contrast enhanced MRI of the left wrist.  Findings:  The physician reviewer found that an MRI revealed a 4x7mm lesion, which could be a cyst or a pseudoaneurysm of the ulnar artery. A new study with contrast as proposed by the radiologist is clinically indicated and necessary to more precisely study the lesion, particularly, if surgery is contemplated to treat the lesion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested authorization and coverage for removal of a growth on his finger for treatment of his neurofibroma. Findings:  The physician reviewer found that excision of the patients neurofibroma is not medically indicated because it is benign, is asymptomatic and does not interfere with normal functioning. A 5 x 5 mm nodule is not deforming.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested authorization and coverage for orthognathic surgery for treatment of her skeletal jaw deformity.  Findings:  The physician reviewer found that surgical correction of the patients skeletal deformities is required to provide for adequate mastication and to prevent further injury to the temporomandibular joints. These problems cannot be resolved with orthodontic or other dental treatments alone. Pre-operative orthodontic treatment is essential to level and align the dental arches for an optimal surgical result. It is immediately obvious that mandibular osteotomies will be necessary to correct the patients mandibular prognathism. The provider is correct in that a decision regarding the need for maxillary osteotomies, or their configuration, cannot be made until pre-operative orthodontic treatment is completed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested authorization and coverage for obstetrical delivery of twins at a hospital with a neonatal unit for treatment of her high-risk pregnancy.  Findings:  The physician reviewer found that twin gestations are at risk for preterm delivery. It is not within standard of care to plan delivery of a premature neonate with neonatal transfer post partum. Premature neonates should be delivered at a hospital with a NICU or an appropriate level nursery. Outcome for the neonate is improved if delivery occurs at a tertiary care center versus transporting newborns with complications (i.e., prematurity) to a tertiary care center. Therefore, if this patient delivers preterm, she should deliver at a hospital with a NICU. If she makes it to term without complications, delivery at a hospital with a regular nursery is appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her cancer.  Findings:  Three physician reviewers found that Oncotype DX tumor assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. It has become very important, particularly in this group of breast cancer patients in which it is very difficult to make recommendations about adding adjuvant chemotherapy.  Based on the accumulating data suggesting its validity in predicting risk, the Oncotype DX tumor assay has found its way into the clinic and more oncologists are relying on the recurrence score to make adjuvant treatment recommendations as to who should get and (more importantly) who may not need chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for a CT scan of the pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that  the Health Plans guideline requiring a pelvic ultrasound for evaluation of pelvic pain prior to CT scan unless extenuating circumstances are present is a reasonable approach. In fact, the American College of Radiology rates ultrasound as slightly more appropriate than CT scan for evaluating pelvic pain, except in obese patients. The American Academy of Obstetrics and Gynecology recommends the use of ultrasound in the evaluation of pelvic pain and endorses CT only when ultrasound findings are abnormal.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested authorization for chemical dependency residential treatment services for treatment of his chemical dependency.  Findings:  The physician reviewer found that according to ASAM Adult Patient Placement Criteria, the patient does not meet criteria for RTC admission. The submitted clinical information demonstrates that upon admission to both facilities the patient was at no risk of withdrawal, there were no concomitant biomedical conditions and/or complications, and there were no emotional/behavioral/cognitive conditions requiring a 24-hour structured setting. Furthermore, the records provided show the patients readiness to change is high, he is able to control his use of alcohol, is not in danger of relapse without 24-hour monitoring and his recovery environment is not high risk.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested authorization and coverage for Comprehensive Gait Analysis Testing (computerized gait analysis) for evaluation of the enrollees mobility. Findings:  Three physician reviewers found that computerized gait analysis is commonly used in the pre and postoperative assessment of children with cerebral palsy. It is not an investigational or experimental modality. It is a standard tool for evaluation of mobility and there is a wealth of literature supporting its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee, with a history of chronic allergic asthma since childhood and continuing exacerbations, has requested authorization for Xolair.  Findings:  The physician reviewer found that the patient has been followed for a diagnosis of severe allergic asthma that appears poorly controlled despite optimal medical treatment. The patient has received optimal medical care, has adhered to treatment plans, and her condition has failed to respond adequately. The patients quality of life is severely impaired by her condition. Furthermore, there is concern regarding the continued use of steroids.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee, with painful peripheral neuropathy, has requested authorization for the medication Lyrica. Findings:  The physician reviewer found that painful diabetic neuropathy is a surrogate for small fiber neuropathies; medications that help pain for one are invariably effective for the other. The patient has found Lyrica 300mg twice daily to be substantially more effective than previous therapies in controlling his pain. As such, continued use of Lyrica is medically appropriate and clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee, with a history of hearing loss who uses endaural hearing aids, has requested authorization for transcutaneous electrical nerve stimulation (TENS) related to the fabrication of a dental orthotic.  Findings:  Three physician reviewers found that the use of TENS to facilitate the fabrication of the orthotic is not standard of care. An orthotic can be fabricated by using time-honored bite construction techniques which are commonly utilized with great success. There is no consensus among practitioners that TENS therapy will yield a better bite construction technique than the standard modalities used in the fabrication of dental orthotics
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee, diagnosed with osteoarthritis of both knees, has requested authorization for repeat Hyalgan injections. Findings:  The physician reviewer found that patients who are treated with this type of injection often find the therapy becomes less effective after six to twelve months at which time it is medically reasonable to repeat the injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee, with a long-term history of migraine headaches, has requested authorization for the prescription medication Zomig. Findings:  The physician reviewer found that Maxalt is likely to be as effective in treating this patients migraines without untoward side effects, as Zomig has been. It is not clinically unreasonable for the Health Plan to request a trial and failure of Maxalt prior to authorization of Zomig.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee, with a history of diabetes mellitus, has requested authorization for a continuous glucose monitoring system (Dexcom) and related supplies.  Findings:  The physician reviewer found that real time glucose monitoring systems such as Dexcom system alarm the patient if blood glucose values rise too high or drop too low. It has been shown that these meters also improve overall glucose control. These devices permit patients to evaluate their carbohydrate counting and boluses. They allow for early intervention to prevent rapid rises or drops.  Every sudden change in blood glucose values has to be confirmed by a fingerstick.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee, with worsening anxiety, has requested authorization for psychiatric residential treatment services. Findings:  The physician reviewer found that the range of psychotherapies offered could have been provided via another level of care such as partial hospitalization. The patient was able to avail herself of psychotherapy, and though she was rather wary of medical treatment, pharmacologic agents could have been provided on an outpatient basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee, with idiopathic short stature, has requested authorization for growth hormone therapy. Findings:  The physician reviewer found that the patients growth rate dramatically accelerated after GH therapy was initiated at Tanner stage 2 of his development. His growth response is recorded at 13.6cm/yr when 14.5 years of age.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee, with hypertension, has requested authorization for the prescription medication Diovan HCT (ARB therapy). Findings:  The physician reviewer found that ACE inhibitor therapy has been more extensively studied than ARB therapy and there is no overwhelming evidence in the literature to suggest ARB therapy is superior to ACE inhibitor therapy in this setting. ARB therapy is generally considered a second-line treatment after a trial of ACE inhibitor therapy, which is commonly a first-line treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee, with spinal stenosis, has requested authorization for an X-stop decompression procedure.  Findings:  Two physician reviewers found that there is no data demonstrating that X-Stop implantation is superior to traditional decompression in the surgical management of spinal stenosis. Lumbar laminectomy provides more direct and effective decompression and remains the standard of care for surgical treatment of spinal stenosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.Findings:  Two physician reviewers found that the use of PET scans in the evaluation of large-cell lymphoma is endorsed by National Comprehensive Cancer Network (NCCN) guidelines and by the International Working Group (IWG). PET scans are recommended as baseline evaluations. If they are positive at baseline, they should be performed in follow-up. According to the IWG, PET is essential for post treatment follow-up of diffuse large B-cell lymphoma. PET scans are considered standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee, who had a cerclage placed for cervical incompetence, has requested authorization for obstetrical services.Findings:  The physician reviewer found that this patient presumably had cervical incompetence. However, in the absence of evidence of any other pregnancy complications, the BPP, fetal doppler velocimetry ratios and expanded office visit were not medically necessary. The fetal growth was documented as normal with appropriate interval growth.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee, who was diagnosed with high-grade transitional cell carcinoma of the bladder and had a cystoprostatectomy with an ileal loop, has requested authorization for PET/CT imaging. Findings:  The physician reviewer found that there is little data available regarding PET scans and transitional cell carcinoma. PET imaging should be interpreted with caution in patients who have received prior chemotherapy and its overall usefulness in bladder cancer is still under investigation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee, who has a history of gastroesophageal reflux disease (GERD), has requested authorization for the medication Nexium.Findings:  The physician reviewer found that the superiority of Nexium over other PPIs for patients such as this patient has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee, with secondary progressive multiple sclerosis (MS) with relapses, has requested authorization for intravenous immunoglobin (IVIG) therapy.Findings:  The physician reviewer found that while IVIG has been used for the treatment of MS, in the United States it is generally reserved for treatment of severe exacerbations resulting in significant disability or hospitalizations. Based upon the documentation provided, the patients condition had not reached a level of severity sufficient to warrant the use of IVIG.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested extracorporeal shockwave therapy for treatment of his Achilles tendonitis and right ankle bone spur.  Findings:  Three medical professional reviewers found that although ESWT has been shown to be effective for treatment of lateral epicondylitis of the elbow and plantar fasciitis, it remains investigational for treatment of the patients condition. There are no documented studies showing ESWT has long-term effectiveness for Achilles tendonitis. Furthermore, there are other available modalities such as physical therapy that are likely to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee, who has bilateral silicone breast implants, has requested authorization for a breast ultrasound.Findings:  The physician reviewer found that a Mammography is the only proven screening test for breast cancer. Breast ultrasound is currently under clinical investigation as a screening modality. The indications for breast ultrasound include further evaluation of abnormalities detected either clinically or by mammography, guidance for interventional procedures, and evaluation of problems associated with breast implants. Ultrasound is appropriate as an adjunct exam, but not in lieu of a mammogram.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested the medication Penlac for treatment of her nail fungus.  Findings:  The physician reviewer found that the patient has a painful infection of her toenails that interferes with her ability to function. However, the submitted clinical information does not provide objective evidence that Lamisil is contraindicated. As such, referral to an internist for evaluation would be appropriate. Liver function tests should be performed. If the internist determines that Lamisil is contraindicated, then Penlac would be medically necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested an extrapleural pneumonectomy for treatment of her non-small cell lung cancer.  Findings:  The physician reviewer found that there is simply no efficacy data on the treatment of patients with T4 NSCLC (malignant pleural effusion) with extrapleural pneumonectomy. Traditionally, these patients do poorly with development of metastatic disease; surgery has no role in the local/regional therapy of patients who present with malignant pleural effusion. Although this procedure has been advocated for mesothelioma, it had not been studied in MSCLC because of the anticipated prognosis of these patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a PET scan for evaluation of her breast cancer.  Findings:  The physician reviewer found that the submitted clinical documentation does not include a valid basis for a PET scan at this time. There is no evidence of metastatic disease.  The CMS indications for PET scan in breast cancer patients are treatment, monitoring and restaging in cases of suspected recurrence. Since none of these indications are present in this case, I have determined the requested PET scan is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested intravenous immune globulin therapy (IVIG) for treatment of her inflammatory sensory polyneuropathy.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates the patient has chronic inflammatory demyelinating polyneuropathy (CIDP) rather than idiopathic peripheral neuropathy. There are adequate studies documenting the efficacy of IVIG in CIDP such that its use in this patient is medically reasonable and appropriate. In fact, the patient has benefited from an ongoing trial of IVIG. Based upon the clinical evidence provided, the patient is an appropriate candidate for IVIG and is likely to continue to benefit from its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested laparoscopic gastric bypass surgery for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 43.4 and comorbid conditions such as degenerative joint disease and obstructive sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that laparoscopic gastric bypass surgery will be beneficial for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Avastin for treatment of her ovarian cancer.  Findings:  Two physician reviewers found that Avastin in combination with Taxol has demonstrated safety and efficacy. Clinical trials in the treatment of breast and lung cancer have yielded positive results in terms of progression-free and overall survival when Avastin is added to Taxol chemotherapy. Both Avastin and Taxol have activity in refractory ovarian cancer.