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

A 21-year-old female enrollee has requested residential eating disorder treatment for the treatment of her eating disorder. Findings:  The physician reviewer found that this patients eating disorder was significant, both in terms of her preoccupation with body image (weighing herself twice a day) and frequency of binging and purging. She also has noted social impairment, having missed semesters in college due to the eating disorder.  As well, she continued to suffer from the eating disorder despite a prior 16 week IOP course.  As such, a more restrictive and therapeutically intensive approach would be the next step, one in which residential treatment would be indicated.  Overall, I find that there was medical indication for residential treatment and recommend reversing the Health Plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for physical and occupational therapy for treatment of his syringomyelia and syringobulbia. Findings:  The physician reviewer found that the patient was at his neurologic baseline, his functional status at the time of discharge was not clear. However, physical therapy and occupational therapy were primarily directed towards endurance. This does not require daily skilled therapy. The therapists did need to assess him, define his capacity and design a restorative program.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a wearable cardioverter defibrillator vest for the treatment of her peripartum cardiomyopathy. Findings:  Two physician reviewers found that the cardioverter defibrillator vest is a device approved by the Food and Drug Administration (FDA) with significant documentation and data supporting its use.  It is particularly effective in younger patients and in situations in which the use of a defibrillator is likely to be temporary.  The disadvantage of the device is principally seen in older patients since it does not have pacing capabilities and bradycardia may follow the delivery of a shock to correct ventricular fibrillation. Based upon the information submitted, it is the best treatment option for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Avastin therapy for the treatment of her recurrent poorly differentiated fallopian tube carcinoma. Findings:  Two physician reviewers found that Bevacizumab (Avastin) is an active agent for platinum-refractory epithelial ovarian cancer, both alone and in combination with cytotoxic chemotherapy. It has been studied in several phase II studies and has shown clinical benefit in relapsed ovarian carcinoma. It is currently included in the NCCN consensus opinion as one of the recommended treatment options for recurrent ovarian cancer. In this patient who has exhausted other available treatment options, the benefits with the use of bevacizumab with chemotherapy would outweigh the risks associated with its use. In view of the available peer-reviewed medical data demonstrating its clinical benefit and support by national expert consensus panel recommendations, it would be considered medically necessary and not experimental/investigational.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested Femara therapy for the treatment of the enrollees short stature. Findings:  Two physician reviewers found that the patients provider has submitted very substantial recent studies confirming this treatment as successful. These studies suggest that this is no longer experimental treatment. The requested therapy is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested radiofrequency ablation (RFA) for the treatment of her Chronic Regional Pain Syndrome (CRPS). Findings:  Two physician reviewers found that the National Guidelines Clearinghouse addresses the issue of sympathectomy and states that published data suggest that sympathectomy in properly selected RSD/CRPS patients may provide one of the most effective treatments for RSD/CRPS. The selection criteria for sympathectomy are critical in achieving long-term success. This applies to this patient who underwent successful anesthetic blocks and good long-lasting pain relief with radiofrequency treatments. Although the patients pain returned after several months, this is usually the case in chronic pain management due to its complex mechanisms and pathophysiology. Several months of good pain relief is a success and not a failure. The requested procedure has demonstrated efficacy for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested biofeedback services for the treatment of the enrollees Aspergers syndrome, oppositional defiant disorder and mixed-receptive-expressive language disorder. Findings:  Three physician reviewers found that currently there is support in various peer-reviewed medical journals for the efficacy of biofeedback treatment for adult and pediatric migraines and tension cephalgia. Less supported in the literature and still investigational include the use of biofeedback for anxiety, hypertension and urinary incontinence. Currently, there is no indication in the medical literature that biofeedback is a proven, medically accepted, standard and current treatment in use in the medical and psychiatric communities for the treatment of Aspergers syndrome, oppositional defiant disorder and mixed receptive-language-disorder. Biofeedback is considered to be no better than standard treatment for this patients condition and is an investigational treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that although this patient could benefit from bariatric surgery, because she continues to smoke, the requested surgery should not be authorized. If and when the patient is able to establish that she has ceased smoking, the requested surgery should be considered by the Health Plan. However, at this time the surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested continued skilled nursing services for the treatment of his condition. Findings:  The physician reviewer found that this patient did indeed have recurrent C. difficile colitis causing diarrhea and one episode of fecal incontinence. The patient does not appear to have had any further documented fecal incontinence nor did he receive any bowel training from skilled nursing. He was receiving oral medications and was not receiving any skilled wound care. The patient did have loose stools due to C. difficile colitis requiring new treatment with vancomycin, but he did not require skilled nursing care for parenteral medications or bowel training or skilled observation (no physician order for any of these). He required custodial care only.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested acute psychiatric hospitalization services for the treatment of her bipolar disorder. Findings:  The physician reviewer found that the Interdisciplinary Progress Notes report that the patient felt good and had no thoughts or feelings of hurting herself.  The patient was reported as being in very good spirits and was ready to go home.  These notes also state the patient was eating well and smoking and getting along well with peers and staff.  The patient was no longer suicidal or a danger others.  There were no acute psychotic symptoms.  There was no grave disability, and there was no self-injury or uncontrolled risk-taking behaviors.  The patient had reached the maximum benefit from acute inpatient care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested Increlex therapy for the treatment of the enrollees stated severe primary IGF-1 deficiency. Findings:  The physician reviewer found that the patient has delayed puberty and should achieve a normal adult height without intervention. IGF-1 deficiency is unlikely in this case. Growth hormone dependent IGF-1 and IGFBP-3 levels were normal. The low normal level of IGF-1 is often seen in delayed puberty prior to the adolescent growth spurt.  The requested therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested a partial hospitalization program stay at Puente de Vida for the treatment of her eating disorder and co-occurring depression and alcohol dependence. Findings:  The physician reviewer found that the patient had improved from the time of admission to the period in question. Her degree of impairment required therapy but was not such that it mandated treatment in a partial hospital program. Her functioning was not deteriorating. Her mood was slowly improving, and her weight was relatively stable. The significant neurological side effects are not clearly delineated by the psychiatrist in the psychiatric progress notes, and the need to manage this in a partial hospital program was not demonstrated. Further, the patients condition at the time in question did not require the structure, monitoring and medical psychological intervention as found in a partial hospital program. The patients treatment needs could have been met in a less restrictive form of treatment than a partial program during the period in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a six-year-old male enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient will not achieve a normal adult height without growth hormone therapy.  There is about a 10% incidence of children with IUGR who fail to show catch-up growth by age two years.  The medical literature is replete with references documenting the benefits of growth hormone therapy in such children.  Based upon this patients history and current condition, growth hormone therapy is considered standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested out-of-network psychological evaluation and intensive outpatient psychotherapy (IOP) for the treatment of his obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the Health Plan recommended pharmacotherapy, individual psychotherapy and OCD group therapy. The care recommended by the Health Plan is consistent with practice guidelines for treatment of patients with OCD as specified by the American Psychiatric Association. It incorporated appropriate pharmacotherapy as well as individual psychotherapy and OCD group therapy. Accordingly, the recommendation made by the Health Plan was appropriate to meet the patients treatment needs.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 65-year-old male enrollee has requested continued rehabilitation services (physical and occupational therapy) at a skilled nursing facility for the treatment of the enrollee, who is status post CVA. Findings:  The physician reviewer found that the rationale for the denial appears to be related to social resources. The patient was denied continued rehabilitation because he would remain in a skilled nursing facility and require 24 hour supervision. The rationale is independent of the clinical progress he was making, albeit slowly. On 5/29/08, the patient required moderate assistance with bed mobility and moderate/minimal assistance with transfers. Two weeks prior, he was moderate/maximum to maximum assist in these modalities. He showed similar progress with occupational therapy. His progress precludes predicting what his precise functional gain will be. There are no clinical algorithms or other predictive tables that permit such a prediction. He is unlikely to gain neurologic recovery, and his progress with rehabilitation is slow, but the standard for stopping rehabilitation is that the patient has reached a functional plateau and is not expected to benefit from additional intensive rehabilitation, as opposed to range of motion or exercise.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Botox therapy for the treatment of her cervical dystonia. Findings:  The physician reviewer found that there is documented scientific evidence demonstrating that Botox is an effective and appropriate procedure for the treatment of cervical dystonia. Available evidence demonstrates that approximately 75% of patients with cervical dystonia respond quickly to Botox therapy with sustained relief. This patient has an established diagnosis of cervical dystonia. Botox therapy is indicated and will likely provide significant benefit for her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested reduction mammoplasty surgery for the treatment of her neck, shoulder and upper back pain. Findings:  The physician reviewer found that although this patient appears to be an appropriate candidate for reduction mammoplasty, there is no evidence that she has been evaluated by a plastic surgeon. A plastic surgeon should evaluate this patient to determine if she is an appropriate candidate for breast reduction surgery. If the plastic surgeon determines the patient is an appropriate candidate for reduction mammoplasty, the surgery should be authorized. However, at this time, without a plastic surgery evaluation, it cannot be determined that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested physical therapy for the treatment of her thoracic outlet syndrome, degenerative cervical disc disease and fibromyalgia. Findings:  The physician reviewer found that with respect to thoracic outlet syndrome, if an individual has thoracic outlet syndrome, the initial conservative approach is a course of therapy for periscapular stretching, strengthening, and shoulder stabilization. After four to six weeks an individual should be advanced to a home exercise program. For cervical degenerative disc disease as well as fibromyalgia, both of which could result in ongoing subjective complaints of pain, an individual could be treated with a four to six week course of therapy with advancement to a home exercise program. A four to six week course of therapy for the various diagnoses would have been appropriate, after which an individual should be advanced to a home exercise program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested interferential therapy for the treatment of her thoracic outlet syndrome, degenerative cervical disc disease and fibromyalgia. Findings:  Three physician reviewers found that interferential therapy to reduce pain from all causes is experimental at this time. Its effectiveness has not been demonstrated in the peer-reviewed literature. Studies showing health outcomes with interferential therapy over conventional therapy do not exist. The treatment remains experimental for chronic pain due to fibromyalgia, cervical degenerative disk disease and thoracic outlet syndrome. Its use in this case is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a clinical trial and the associated tests/services including PET scan, CT scan, blood tests and a CTC for the treatment of her breast cancer. Findings:  Three physician reviewers found that high-dose chemotherapy and autologous stem cell transplant has not been shown, in randomized trials, to offer any survival advantage to women with metastatic breast cancer. As such, this treatment is considered investigational, at best, and of no proven benefit nor medical necessity. Any follow-up tests required by participation in the clinical trial (above and beyond what might be considered routine tests for the follow-up of metastatic breast cancer) are likewise to be considered investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a three week outpatient day treatment program for comprehensive interdisciplinary pain management for the treatment of her medical condition. Findings:  The physician reviewer found that at this time, the standard of care for long-term management of fibromyalgia remains medications, including analgesics, and skilled outpatient PT graduated to an active, self-directed home exercise program. The medical literature does not yet recognize the efficacy of weeks of outpatient day rehabilitation in the treatment of fibromyalgia.  Also, comprehensive pain management rehabilitation programs have not yet demonstrated better long-term pain and quality of life outcomes than traditional fibromyalgia treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a mastopexy procedure for the treatment of her breasts. Findings:  The physician reviewer found that a mastopexy is rarely reconstructive in nature. In this instance, the patient was appropriately treated with reduction mammoplasty. The mastopexy would not lead to improved function. In addition, the mastopexy would not provide more than a minimal improvement in the patients appearance. Mastopexy in this case would not be considered a reconstructive procedure under Californias reconstructive surgery law. Furthermore, there was no medical indication of need for the mastopexy at issue. The mastopexy was a cosmetic procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for Avastin therapy for treatment of his colon cancer metastatic to liver.   Findings:  Two physician reviewers found that there is no data to suggest that the continued use of this current regimen, in whole or in part, is of any clinical benefit. All one could expect from such an approach would be continued risk of toxicity and no benefit. Accordingly, the continued use of Avastin in this situation is, at best, investigational, and of no known clinical benefit.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old male enrollee has requested for occupational therapy for treatment of the enrollees autism.   Findings:  Two physician reviewers found that current recommendations at most major medical centers support the use of occupational therapy as a useful aid in the overall treatment of autism spectrum disorders. There is sufficient data to support occupational therapy is necessary and more beneficial than any other modality of treatment.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for an emergency room visit for treatment of her severe head pain. Findings:  The physician reviewer found that the symptoms did not present suddenly, as would a ruptured aneurysm or subarachnoid hemorrhage. She was not suffering any symptoms suggestive of meningitis, such as fever or neck stiffness. The patient had experienced a headache of this magnitude before. She required only oral pain relievers in the emergency department.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for treatment from a foot and ankle orthopedic specialist for treatment of her hammertoes and bunions. Findings:  The physician reviewer found that bunions and hammertoes are routine podiatric problems than can be safely and effectively treated by a podiatrist. Podiatry care for these complications is totally within the standard of good medical care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has for revisional bariatric surgery (RNY) for treatment of his morbid obesity. Findings:  The physician reviewer found that there is no indication that the weight regain was the result of a medical or surgical complication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested for bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has obesity related comorbidities that will be eliminated or ameliorated by bariatric surgery. Bariatric surgery is medically indicated, as the patients psychiatric issues appear well-controlled.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for hybrid artificial disc replacement at L4-5 with interbody fusion at L5-S1 for treatment of his two-level lumbar disc disease and pain. Findings:  Three physician reviewers found that there are no compelling indications for the requested surgery in this individuals case for what appears to be axial back pain.  There is no evidence of demonstrable instability.  There is no evidence of progressive neurologic deficit.  Furthermore, artificial disc replacement remains investigational, as there are no well controlled studies that have demonstrated its efficacy, and long-term benefits remain to be determined.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old male enrollee have requested for Genotropin growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no evidence to support continued growth hormone therapy for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested for an autologous bone marrow transplant for treatment of his neuromyelitis optica.   Findings:  Two physician reviewers found that therapies which are used for severe and aggressive MS have been tried without success, with resulting severe progression of disease. Bone marrow transplant has been used with success in other cases of severe and aggressive demyelinative disease. All standard therapies have been explored and exhausted.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested for a percutaneous intracranial angioplasty with stent for treatment of her significantly diseased right vertebral artery.   Findings:  Three physician reviewers found that procedure is not standard for treatment of asymptomatic stenosis, and is not indicated for basilar type migraine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested eight weeks of psychiatric residential treatment services for the treatment of her posttraumatic stress disorder, depressive and personality disorders and alcohol abuse. Findings:  The physician reviewer found that a psychiatric residential treatment program would be inadequate to meet this patients needs and is therefore medically inappropriate. I agree with the Health Plans recommendation, and that of the patients treatment team, in recommending a dual diagnosis residential program that would address her depression, borderline personality disorder and alcohol abuse.