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

The parent of a three-year-old male enrollee has requested authorization and coverage for at-home applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that although review of the literature reveals no citations evaluating the differences between in-home ABA and clinically based ABA, most ABA programs provided today have at least some component of in-home treatment. The ultimate goal of any ABA program is to have the patient functioning independently in the community.  Independent functioning must begin in the home with self-help skills and family communications.  All the social/play and perspective taking skills as well as the self-help skills (especially continence) should take place in the home. The patient will have a need for future self-help skill goals as he becomes developmentally age-appropriate. It is often difficult to have these skills carry over into the home if taught in an outside environment. All behavioral programs should involve training of the parents/caregivers to allow for carry-over from the behavioral sessions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male with a history of expressive and receptive speech delays is requesting speech therapy.  Additional information in the form of an Individual Education Plan (IEP) has been submitted documenting the educational need for speech therapy.Reviewers Findings:  The reviewing physician found that the IEP documentation provides no further evidence that the speech delays are the product of a disease, injury, congenital anomaly or prior therapeutic intervention.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested authorization for acute inpatient psychiatric services for treatment of her amphetamine dependence and psychosis.  Findings:  The physician reviewer found that the clinical record does not support the need for continued acute inpatient psychiatric care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-five year-old male with a diagnosis of bilateral knee degenerative change is requesting reimbursement for bilateral Supartz injections.Reviewers Findings:  The reviewing physician found that this is reasonable and appropriate treatment for a diagnosis of degenerative joint disease. There is nothing in the submitted records to indicate the patient was not an appropriate candidate for the injections.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a sixteen year-old male who had an episode of syncope are requesting authorization of a CT angiography (CTA) to exclude a congenital coronary anomaly.  Reviewers Findings:  The three reviewing physicians found that CTA is the best test available and is superior to traditional angiography in determining and excluding anomalous coronary anatomy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male has requested gastric bypass surgery for treatment of his morbid obesity.  Findings:  The physician reviewer found that the patient does not meet the weight loss surgery guidelines set forth by the National Institutes of Health (NIH) consensus meeting. The basis for the NIH guidelines is a collective risk evaluation. In this patients case, at a BMI of 34, even with his comorbidities, the operative risks outweigh the potential benefits of the surgery. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old female who has low back pain is requesting an MRI of the lumbar.Reviewers Findings:  The reviewing physician found that the clinical record submitted for review does not include a recent history and physical with a neurological examination or a review of the patients medications. As such, there is no clear indication for an MRI.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old obese female with significant comorbid conditions is requesting reimbursement for a duodenal switch procedure.Reviewers Findings:  The reviewing physician found that this patient clearly met the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbid conditions.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A thirty-seven year-old male who had polysubstance abuse, sexual disorder/fetishism and personality disorder is requesting reimbursement for inpatient rehabilitation services.Reviewers Findings:  The reviewing physician found that the patient did not meet established criteria for admission to an acute inpatient drug rehabilitation program.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested artificial intervertebral disc replacement for treatment of her lumbar pain.  Findings:  Three physician reviewers found that the proposed artificial lumbar disc replacement is an experimental procedure without established safety and efficacy. There is no Class I long-term data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is unknown and complications may be severe.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old male with renal cell carcinoma is requesting reimbursement for laparoscopic cryoablation.Reviewers Findings:  The reviewing physician found that thermal ablative techniques of cryoablation and radiofrequency ablation have major limitations including uncertain tumor destruction and inadequate documentation of long-term cancer control.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a seventeen year-old female with a history of an eating disorder are requesting reimbursement for the residential treatment services.Reviewers Findings:  The reviewing physician found that due to the patients complexity and underlying problems and an inability to control binging and purging behaviors, the need for residential treatment rather than partial hospitalization program is readily apparent.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Xolair for treatment of her chronic urticaria. Findings:  Three physician reviewers found that the FDA-approved indication for Xolair is moderate to severe, persistent asthma in patients who have a positive skin test or invitro reactivity to a perennial aeroallergen, symptoms that are inadequately controlled with inhaled corticosteroids and a pre-treatment total IgE level of 30 or greater. Omalizumab is not medically indicated for this patient in accordance with these guidelines. There are no records of persistent asthma or laboratory confirmation of perennial aeroallergen symptoms or reversible airway disease. Coverage for Xolair is being requested for off-label treatment of the patients urticaria. Although there are published case reports of its use for the treatment of IgE-related urticaria and there have been positive results for this patient, its use remains experimental for this diagnosis. Further clinical trials are necessary for evaluation of omalizumab in the treatment of urticaria and the therapy cannot be supported at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-eight year-old female with fecal incontinence is requesting reimbursement for a SECCA radiofrequency procedure.  Reviewers Findings:  The reviewing physician found that the SECCA radiofrequency procedure has been shown to be beneficial for patients such as this one and the literature supports the use of this modality in the treatment of fecal incontinence.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested bilateral L4-5 and L5-S1 facet blocks and, if successful, possible facet rhizotomy for treatment of her back pain. Findings:  Two physician reviewers found that the therapeutic value of facet joint injections is unproven, as there is no class I data to support the use of facet joint injection in cases of back pain and facet arthrosis. Facet nerve blocks are not the community or national standard of care for treatment of patients such as this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a sixteen year-old female who has suicidal ideation with a severe oppositional defiant disorder are requesting reimbursement for residential treatment services.Reviewers Findings:  The reviewing physician found that according to the ASAM Adolescent Criteria and the standard of care for the treatment of substance abuse problems in adolescents, the patient did not demonstrate any behaviors that would require a residential treatment setting.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Synvisc injections for treatment of her osteoarthritis. Findings:  Three physician reviewers found that while Synvisc injections have been approved for osteoarthritis of the knee, there is no scientific literature supporting the use of Synvisc for hip arthrosis.  The patient does not meet the standard guidelines for Synvisc injections based on her diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-six year-old female who had ACL reconstruction and partial lateral meniscectomy is requesting reimbursement for use of a CPM device.Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude that utilization of a CPM device following the type of surgery this patient underwent results in outcomes which are superior to those obtained with standard post-operative care and management without utilization of a CPM device.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested repeat Synvisc injections for treatment of her knee pain.  Findings:  Two physician reviewers found that the submitted clinical information indicates the patient received an initial course of Synvisc with relief for one year. Repeat treatment with Synvisc may be indicated for patients with continued pain in the knee due to osteoarthritis if relief of pain was obtained from a previous treatment course of Synvisc and at least six months have elapsed since previous injections. Based on the evidence provided, the patient met criteria for repeat Synvisc injections.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested bilateral reduction mammoplasty and abdominoplasty for treatment of her back, neck and shoulder pain. Findings:  The physician reviewer found that the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative therapy.  A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy.  The submitted records do not establish medical necessity for the proposed abdominoplasty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested once weekly acupuncture for treatment of his neck and back pain.  Findings:  The acupuncture reviewer found that the submitted information did not include clinical records documenting the patients prior course of acupuncture. Thus, there was no objective evidence that the patient previously responded to acupuncture.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested authorization for IBD First Step testing for evaluation of his irritable bowel disease (IBD). Findings:  The physician reviewer found that the gold standard for determining the specific diagnosis for a patient with irritable bowel disease is colonoscopy and biopsy. The use of IBD testing is not the standard of care. Recent literature suggests that standard testing has a higher positive predictive value and is more sensitive and  more specific.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested authorization for Orthovisc injections for treatment of her degenerative joint disease.  Findings:  Three physician reviewers found that repeat series of viscosupplementation (Orthovisc) have been found to be moderately efficacious in those patients who previously had a favorable response to this treatment. The available literature supports repeat injections as long as benefit is achieved. Alternative treatment for end-stage osteoarthritis in the knee would be total joint replacement, which is a significant surgery, not without its own limitations and complications including possible revision and replacement surgery especially in a young patient such as this patient. As long as benefit is being realized from the Orthovisc injections, continuation of yearly injections is appropriate as a stop-gap measure to delay total knee replacement surgery as long as possible.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested authorization for inpatient psychiatric treatment services for treatment of her polysubstance abuse and eating disorder.  Findings:  The physician reviewer found that the appropriate level of care would have been outpatient therapy with nutritional consultation. The admission to the eating disorder program at the residential level of care was not clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty year-old male who has been diagnosed with prostate cancer is requesting authorization of proton beam radiation therapy through the non-Plan provider.Reviewers Findings:  The reviewing physician found that because the patients cancer volume is small, research indicates all forms of radiation therapy would be equally effective in irradiating the cancer and would have similar side effects. There is no evidence that proton beam therapy would be more beneficial for this patient than the treatments offered by the Health Plan.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-five year-old male who was diagnosed with left renal transitional cell carcinoma with lymph node metastases is requesting authorization of a PET/CT scan.Reviewers Findings:  The reviewing physician found that usefulness of PET/CT scans in urinary tract malignancies is currently unclear.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that a review of the recent peer-reviewed literature indicates that MEG and magnetic source imaging can play an important role in epilepsy mapping. While the procedures are not widely used, their use in select patients with intractable seizure activity has allowed physicians to determine if a patient is appropriate for epilepsy surgery and to provide detailed mapping for pre-surgical planning. In the past, the gold standard for epilepsy mapping was the use of intracranial electrodes. There is risk associated with any surgical procedure and  particularly with brain surgery. MEG is a safer, non-invasive means of obtaining the same information as would be obtained from intracranial EEG (ICEEG).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A nineteen year-old male with type 1 diabetes mellitus is requesting authorization of an insulin pump.Reviewers Findings:  The reviewing physician found that the patient had become less compliant with dietary guidelines and self monitoring of blood glucose levels. As such, the patient does not meet the Health Plans criteria for authorization of an insulin pump.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old female who was diagnosed with infiltrating ductal carcinoma of the left breast; stage IIA, grade 2, ER/PR positive is requesting reimbursement for BRCA1 and BRCA2 genetic testing.  The patients family history is significant for an identical twin who was diagnosed with breast cancer.  Reviewers Findings:  The reviewing physician found that the American College of Medical Genetics guidelines do not specifically address the patients unique situation of an identical twin diagnosed with breast cancer. However, it can be deduced that identical genetic material imparts equal risk.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-one year-old female with a diagnoses of fibromyalgia and left L5/S1 radiculopathy is requesting authorization of Lyrica.Reviewers Findings:  The reviewing physician found that because of recognized success with the use of Neurontin in many patients with fibromyalgia or neurogenic pain, this patients physician appropriately treated her with Neurontin. This proved to be inadequate, and Lyrica was an appropriate next choice.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-six year-old female with a history of multiple neck fusions with resultant cervical pain and possible fibromyalgia is requesting authorization for Botox therapy.Reviewers Findings:  The reviewing physician found that no Class I data exists to support the role of Botox injections for the treatment of chronic neck pain. In addition, there is no evidence to support Botox as effective in the treatment of fibromyalgia.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a ten year-old male with short stature are requesting reimbursement for previous Growth hormone (GH) therapy and authorization for continued treatment with GH therapy.Reviewers Findings:  The reviewing physician found that it would seem probable that the patient has a constitutional delay in growth and is likely to gain a normal height without assistance.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested artificial disc replacement surgery for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-eight year-old male who is status post right total hip replacement is requesting reimbursement for a fully-electric hospital bed.  Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude a fully-electric hospital bed was necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-four year-old female diagnosed with bilateral osteoarthritis and internal derangement in both knees is requesting reimbursement and prospective authorization for a series of Synvisc injections for the left knee.   Reviewers Findings:  The reviewing physician found that the patient has derived a benefit from previous Synvisc therapy, a repeat series of injections for the left knee should be authorized at this time.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A thirty-six year-old male with metastatic gastric cancer is requesting authorization for bevacizumab plus 5-FU.  Reviewers Findings:  The reviewing physicians found that bevacizumab still has unproven efficacy for this disease, and it is not possible to conclude that it is likely to be superior to standard chemotherapy in this setting.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-three year-old female with metastatic melanoma to the lungs is requesting authorization to be treated with Sutent (sunitinib).  Reviewers Findings:  The reviewing physician found that there is no evidence to support the use of sunitinib in the treatment of melanoma.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A thirty year-old female with locally advanced colon cancer is requesting coverage for bevacizumab and trastuzumab.  Reviewers Findings:  The three reviewing physicians found that the addition of bevacizumab in the adjuvant setting is not yet proven to be effective or within the standard of care. Furthermore, there is no evidence supporting the addition of trastuzumab in any setting for colon cancer and its addition to this particular regimen is entirely unproven.  The reviewing physicians found that the Health Plan denial should be upheld.