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

A 51-year-old female enrollee has requested brachytherapy with Mammosite RTS for the treatment of her left breast ductal carcinoma in situ. Findings:  Two physician reviewers found that accelerated partial irradiation (APBI) has been used as part of breast conserving treatment for early stage breast cancer for approximately twenty years using brachytherapy catheters. The Mammosite balloon has been used for only eight years, although the radiation physics are very similar to that of brachytherapy. There are several reports of the efficacy of APBI using the Mammosite balloon with five-year outcomes demonstrating efficacy and comparable outcomes to traditional whole-breast irradiation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for a panniculectomy for treatment of her excessive abdominal skin. Findings:  The physician reviewer found that weight loss and dermatology consultation are the safest initial treatments for this patient. In the absence of such interventions, however, a panniculectomy is not a medically necessary procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain.    Findings:  The physician reviewer found that there is no scientific evidence to support the medical necessity or effectiveness or safety of long-term Synvisc therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested The Vest Airway Clearance System (Vest) for the treatment of her bronchiectasis. Findings:  Three physician reviewers found that the patient is a 58-year-old female with a diagnosis of bronchiectasis confirmed by CT scan. Her pulmonary function is well-preserved. However, the patient has recurrent respiratory infections and has trouble raising secretions. Oscillatory devices have not worked. The patient has established bronchiectasis, and she needs additional help to clear secretions. The Vest Airway Clearance System does help patients with bronchiectasis and is medically indicated and appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a neurosurgical referral for the treatment of her migraines/chronic headaches. Findings:  The physician reviewer found that the requested neurological consultation is not medically indicated for the patients medical condition. Conservative treatment, such as medications, physical therapy and weight reduction, are successful treatment modalities for this patients condition. A neurosurgery consultation is not medically appropriate in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested breast specific gamma imaging (BSGI) test for an evaluation of her to rule out in situ cancer.  Findings:  Two physician reviewers found that BSGI is a relatively new imaging modality for breast imaging. It has been compared in small studies to mammography and MRI. Its sensitivity and specificity have compared favorably with MRI and mammography. BSGI is not an appropriate imaging modality for routine screening. In this case, it was not used for routine screening, but to follow up on suspicious findings. This diagnostic test was clearly more accurate than mammography or MRI in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested the prescription medication Actiq for the treatment of her chronic pain. Findings:  The physician reviewer found that Actiq is FDA approved explicitly for use in cancer pain patients only.  Although there are some cases series and individual case reports in the literature, there are no randomized controlled trials of this medication in non-malignant pain patients.  Actiqs effectiveness in non-malignant pain is unproven.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested physical therapy services for the treatment of his post-surgical back pain. Findings:  The physician reviewer found that the patient had sufficient physical therapy sessions to establish a home therapeutic exercise program. The physical therapy notes are consistent with a maintenance program rather than a restorative program. Additional physical therapy was not medically indicated, and the patient had plateaued by this time.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested an emergency room visit for the treatment of her fever, cough and myalgias. Findings:  The physician reviewer found that the symptoms and signs that this patient presented with are consistent with a potentially serious disease. Many life-threatening and potentially lethal infections begin with vague and nonspecific symptoms, including myalgias and fever. Without timely medical evaluation and treatment, these infections can lead to rapid deterioration. Although the patient had been sick for four days, her symptoms worsened. Being concerned regarding her medical condition, the patients only source of urgent medical evaluation was at an urgent care or emergency facility.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested emergency services for the treatment of her panic attack. Findings:  The physician reviewer found that the patient is a 19-year-old female with diagnosed bipolar disorder, OCD, and a history of anxiety who presented to an emergency department. She presented to the emergency department because she was worried about running out of her previously prescribed medications.  She also felt panic-stricken that particular day. She was told of an easier manner in which to get her refills taken care of and then left the emergency department.  Although the patient was rather anxious, there is no evidence that there was anything emergent in nature related to her seeking refills for her prescription medications such that she would need to use an emergency department for prescription refills.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested extracorporeal shock wave therapy (ESWT) for the treatment of her foot pain. Findings:  Two physician reviewers found that ESWT is an FDA approved treatment for chronic proximal plantar fasciitis.  Most, if not all, studies demonstrate efficacy as compared to placebo.  Review of the literature reveals an efficacy rate of between 50-75%.  However, standard minimally invasive endoscopic plantar fasciotomy demonstrates an effective rate of 90%.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for a breast MRI for evaluation of her HER2-positive, high-risk, primary left breast cancer.   Findings:  Three physician reviewers found that the treating oncologist has requested MRI imaging of the left breast for current follow-up and clinical decision-making. There is tissue induration at the surgical site on palpation, and the breast implant left in place interferes with the proper mammographic visualization of the left breast tissue. Thus, physical exam and standard mammography are clearly compromised in this setting and have impaired diagnostic specificity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a spinal cord stimulator (SCS) implantation for the treatment of her lower extremity pain. Findings:  Three physician reviewers found that the most common FDA approved indication for spinal cord stimulation in the United States is post-laminectomy syndrome with neuropathic pain. There are many well-designed studies documenting its efficacy in this clinical scenario. In this patients case, the use of the spinal cord stimulator was within acceptable parameters and should not be considered experimental.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The husband of a deceased female enrollee has requested stereotactic surgery for the treatment of the enrollees metastatic breast cancer. Findings:  Two physician reviewers found that this patient had metastatic cancer of the breast with pulmonary metastases, and she had few treatment options available to her when her middle bronchus was completely occluded with breast cancer. Conventional radiation therapy was not possible due to her previous chest wall irradiation for her primary breast cancer. Stereotactic surgery could overcome the previous chest wall, which was irradiated anteriorly. In addition, it could minimize the radiation to her esophagus. Stereotactic surgery was her best choice and also the only choice.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested a percutaneous intradiscal electrothermal (IDET) procedure for the treatment of her back pain. Findings:  Three physician reviewers found that there is a lack of well-documented evidence from well-designed studies to confirm the safety, efficacy, and long-term results for IDET. It is experimental at this time and unsupported by clear scientific data. Furthermore, there are other standard treatments available to this patient that are likely to be more beneficial than IDET.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for a cervical MRI  for evaluation of his neck pain. Findings:  The physician reviewer found that the American College of Radiology, an MRI of the cervical spine is indicated in patients with neurological findings and neck pain. This is true if the radiographs demonstrated spondylosis or were normal. The outcome of the MRI study will assist the physician with appropriate treatment planning.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that Botox is a well-accepted and standard of care medication amongst headache specialists for patients failing multiple medications in multiple classes of prophylactic drugs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for a pneumatic compression boot for treatment of her edema. Findings:  The physician reviewer found that this patients workup is incomplete. New onset lymphedema requires a venous duplex for reflux and obstruction and a CT scan of the pelvis. The primary care physician should also review/adjust medication and eliminate any that may cause lymphedema. Once this is complete, management for lymphedema begins with leg elevation, weight loss, external compression garments and manual lymphatic drainage. Only after these are attempted should pneumatic compression garments (not boots) be utilized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for a CT of the heart for evaluation of his chest pain. Findings:  The physician reviewer found that The presence of coronary calcification is a well-accepted, clinically relevant risk factor for the development of future atheromatous coronary artery disease. In patients with minimal risk factors and high calcification scores, aggressive lipid therapy with interventions to lower LDL cholesterol is recommended. The requested diagnostic procedure has been shown to be a clinically useful, non-experimental application of this technology in this patient subset.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested an emergency room visit for the treatment of her vomiting and nausea. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe lack of immediate medical attention would seriously endanger her health. This patient reported diarrhea on the day of her visit, but her other symptoms of dizziness and weakness had been present for one week. Further, she had already been evaluated for those symptoms the day prior. Since the patients symptoms were not acute in onset, and she denied any life-threatening symptoms such as chest pain or shortness of breath, her symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for removal of orthopedic rods and screws for treatment of her post-surgical pain. Findings:  The physician reviewer found that it does not appear that there has been hardware failure, and there is no documentation that the hardware is producing pain.  There are simply no good indications for the proposed hardware removal outlined in the records available.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested osteochondral allografting for the treatment of her left knee problems. Findings:  Two physician reviewers found that in this instance, osteochondral allografting of the medial femoral condyle is preferable to knee replacement given the patients young age and her high activity level.  Other compartments are relatively spared and asymptomatic.  Additionally, she has normal alignment and an intact medial meniscus and no evidence of inflammatory disease.  She is a good candidate for osteochondral allografting of the medial femoral condyle.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an osteochondral allograft for the treatment of her focal osteochondral lesion in the left knee.  Findings:  Two physician reviewers found that the patient is a 54-year-old female who seeks coverage for an osteochondral allograft of medial femoral condyle for suspected osteonecrosis. There is significant involvement of entire medial compartment of the knee. Allograft would not address involvement of medial tibial plateau. She is not an ideal candidate for an osteochondral allograft given her age and the tibial involvement. However, she is a good candidate for unicompartmental replacement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested intensive outpatient services for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient was indeed experiencing significant eating disorder issues in the recent past. Before starting intensive outpatient treatment, she was in a residential facility. The current program appears to be a follow-up of her residential care. However, the specific clinical information provided in the record reviewed is vague and does not demonstrate a clear and unambiguous need for intensive outpatient services. The patients clinical needs could have been safely and satisfactorily met by outpatient treatment, and she did not require intensive outpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 17-year-old female enrollee has requested continued care at a residential treatment center for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that on admission to the RTC, the patient was almost 100% of ideal body weight.  There were no medical issues, no suicidal ideation, no homicidal ideation, or psychosis.  She was cooperative and progressed well in treatment. There is no clinical evidence that the patient continued to require the intensity of RTC services. At that time the medical records demonstrate the patient was appropriate for a less intense level of care.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for an emergency room visit for treatment of her diarrhea, vomiting and abdominal pain. Findings:  The physician reviewer found that the patient was not dehydrated, and her blood pressure was stable. There was no blood. This is an example of acute gastrointestinal syndrome in an otherwise healthy female. This is a problem usually evaluated in a physicians office or urgent care center. It does not rise to the level requiring emergency care. There was no imminent threat to body, the pain was moderate, and the patient did not have a fever.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Botox injections for the treatment of his lower back pain. Findings:  The physician reviewer found that there is a lack of evidence of effectiveness of Botox in chronic axial back pain. The clinical practice guidelines for chronic non-malignant pain syndrome do not support the use of Botox in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for allergen-specific IgG testing for evaluation of her constipation and fatigue. Findings:  Three physician reviewers found that the proposed indication for the allergen testing is fatigue and constipation. The symptoms are non-specific and cannot be attributed to an allergy. Food allergies as a basis for non-specific symptoms as described above have not been reliably established as causative agents. There is a lack of human trials that establish food allergy as causative of fatigue and constipation. The investigation proposed is experimental and has no consistent support in the medical literature. Because the symptom of fatigue is non-specific, there is no specific treatment for it. The patient has no other symptoms of food allergy. Treatment of constipation does not require treatment for food allergy. The experimental investigation will not produce findings that will produce, better, more specific therapy than is available with standard evaluation of the complaints.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a four-year-old female enrollee have requested for speech therapy (ST) and occupational therapy (OT) for treatment of the enrollees articulation disorder. Findings:  Two physician reviewers found that standardized assessment for preschoolers was conducted and the patient was recommended direct, individual occupational therapy (OT) services once a week to be reevaluated in 6 months. The patient is not receiving sensory integration therapy. She has speech delay and needs ST and is the appropriate standard of care. The referral for OT evaluation was also appropriate in light of the speech therapists assessment. Combining OT and ST together is very essential for quicker and effective results. Research studies have shown improvement in well-being and self confidence in children receiving these therapies. Remediation of speech delays in the preschool years is important for kindergarten readiness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 14-year-old male enrollee have requested for Genotropin growth hormone therapy for treatment of his idiopathic short stature. Findings:  The physician reviewer found that the patient meets the FDA criteria of 2003 for growth hormone therapy. Because the patient has idiopathic short stature coupled with a gratifying growth response from growth hormone therapy, continued growth hormone therapy must be judged as a medical necessity in this instance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for Lyrica for treatment of his seizure disorder. Findings:  The physician reviewer found that Lyrica is approved for adjunctive treatment of partial onset seizures. Evidence has not been provided to support the position that Lyrica is preferable to gabapentin due to greater safety, tolerability or efficacy. Due to the absence of data to support this claim, a trial of gabapentin would be reasonable.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested an emergency room visit for the treatment of her cough and fever. Findings:  The physician reviewer found that the patient had symptoms for six days and had no flare or complication of the symptoms. The need for emergent care is not supported in the medical record, as symptoms were not severe and remained unchanged for several days. The non-participating facility is reported to have urged emergent care based on a report of dizziness while waiting for the father to receive treatment. This was not substantiated in the records. Without more information, the dizziness can not be an indication for emergency treatment. A short episode of dizziness after six days of flu is not an indication for emergency care.  The symptoms did not rise to a level that indicated emergent care for a prudent layperson.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested Genotropin growth hormone therapy for the treatment of the enrollees Turners syndrome. Findings:  The physician reviewer found that the patients diagnosis is FDA approved for growth hormone therapy, and the literature is replete with trials indicating the benefits in adult height which otherwise end up around the 4.5 feet range. Growth hormone therapy is medically indicated. The accompanied letter of appeal from the Pfizer Bridge program adequately hits the relevant points and references.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested disc nucleoplasty surgery for the treatment of her chronic low back and leg pain. Findings:  The physician reviewer found that among the therapeutic options to emerge for the treatment of back pain and radiculopathy are a plethora of minimally invasive treatments aimed at removing nuclear material and lowering intradiscal pressure through devices inserted percutaneously into intervertebral discs.  Various techniques are utilized in managing discogenic pain, with or without disc herniation.  Percutaneous techniques are touted to replace traditional open surgery in operations requiring discectomy, decompression, and fusion. Percutaneous access to the disc was developed in the 1970's.  Technical advances in the use of intradiscal therapies led to the development of intradiscal electrothermal therapy (IDET), DISC Nucleoplasty, and DeKompressor, along with laser-assisted, endoscopic, and Nucleotome disc decompressions.  The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Despite advances in such treatments there remains insufficient scientific data demonstrating that nucleoplasty decompression is an effective long-term alternative to other standard therapies such as open surgery. In fact, there is no evidence to support nucleoplasty decompression as more clinically efficacious than surgery. Based upon the lack of data to support the efficacy of nucleoplasty decompression, it cannot be considered medically necessary for this patient.