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

A 64-year-old female enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of her leiomyosarcoma of the retroperitoneum. Findings:  Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) Practice Guidelines for retroperitoneal soft tissue sarcoma, options regarding primary treatment for patients deemed unresectable include chemotherapy, radiotherapy, or palliative surgery for symptoms.  The purpose of this is to downstage following response to allow for resection.  Under the principles of radiation therapy, pre-operative radiation therapy, delivering approximately 50Gy of external beam radiation therapy is recommended followed by surgery. Radiation boosts could be considered whenever feasible for positive or close margins. Furthermore, the specific guidelines for radiation therapy specify that sophisticated treatment planning with IMRT and protons can be used to improve the therapeutic effect.  If an R1 or R2 resection is anticipated, clips to high risk areas for recurrence is encouraged.  In addition, the guidelines state that radiation therapy does not substitute for sub-optimal surgical resection and the total doses should always be determined by normal tissue tolerance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested for Clomid for treatment of his hypogonadism. Findings:  The physician reviewer found that clomiphene citrate may, in selected men, improve LH and testosterone concentrations. It will not cause lower sperm counts, which can be seen with long-term testosterone treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for a PET (positron emission tomography) scan for evaluation of his mental dysfunction.   Findings:  Three physician reviewers found that PET scanning is helpful for the establishment of Alzheimers disease, frontal temporal dementia, proper selection of patients for epilepsy surgery, and the differential diagnosis of brain tumors.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested for bilateral hip core decompression for treatment of his bilateral osteonecrosis of the femoral heads.   Findings:  Three physician reviewers found that core decompression is especially indicated in a young, active patient with pre-collapse avascular necrosis of the hips. The younger, healthier, and more active the patient, the greater the indication for joint preservation procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for intensive outpatient mental health eating disorder treatment for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient needed additional treatment, but this additional treatment could have safely and effectively been administered at a lesser level of care such as regular outpatient therapy.There is no evidence that would suggest that continued intensive outpatient treatment was medically necessary under these circumstances for the patient, as opposed to the offered alternative of outpatient treatment on a less intensive (but twice weekly) basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested Orthovisc injections (for his left knee) for the treatment of his condition status-post anterior cruciate ligament (ACL) reconstruction and left knee arthritis. Findings:  The physician reviewer found that evidenced-based medicine supports the use of an intra-articular injection of cortisone prior to under going viscosupplementation (Orthovisc) injection.  In the absence of evidence that the patient has tried and failed a full course of conservative management, the request for Orthovisc cannot be supported as being medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested continued intravenous doxycycline and zithromycin for the treatment of his Lyme encephalopathy, babesia, bartonella and mycoplasma fermentans. Findings:  Three physician reviewers found that the Health Plans denial of coverage for further treatment using doxycycline and zithromax for this patient is appropriate, as the patients diagnosis/diagnoses are not clear, are not supported by the clinical notes or by the provided lab data, and the patient has not responded to many prior courses of anti-infective agents. There is no indication for such treatment at this time, as the same and similar treatments have already proven ineffective in this patient. The IDSA (Infectious Diseases Society of America) guidelines state that no scientifically valid studies have shown benefit from prolonged treatment with antibiotics for Lyme disease, and this patients course is consistent with that statement.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested emergency services for the treatment of his acute pharyngitis and early otitis media on the right side. Findings:  The physician reviewer found that this patients symptoms were not acute in onset.  He did not experience any sudden change in his condition.  He did not require any pain control or medical intervention in the emergency department.  The patients symptoms do not meet the prudent layperson definition for an emergency medical condition. The symptoms were not of acute onset or of sufficient severity such that a prudent layperson would conclude that a lack of immediate medical attention would be likely to result in risk of death or disability.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested a TLSO (thoracolumbosacral orthosis) brace and device (L3580-O shoe add instep, Velcro closure) for the treatment of the enrollees kyphosis. Findings:  The physician reviewer found that a TLSO brace meets the Health Plans criteria of DME (durable medical equipment) and medical necessity as DME. The brace will support the patients deformed spine and it will facilitate healing. Even though the patients kyphosis is correctable by voluntary postural effort, due to his developmental disabilities, he is unable to follow through with medical instruction to self-correct. The TLSO brace is medically necessary to prevent and correct his kyphosis, as the patient is not capable of self correction or exercises on a consistent basis due to his developmental disabilities. However, the instep Velcro closure for his shoes (L3580-O shoe add instep, Velcro closure), is not medically necessary, as there is no foot deformity or weakness documented in the submitted medical records.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested Nexium for the treatment of her gastrointestinal reflux disorder (GERD) and hiatal hernia. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of acid suppression therapy, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis. All PPIs are essentially equivalent in healing control of intragastric pH over 24 hours, and act by covalently binding to cysteine residue in H, K ATPase (the proton pumps) in the membrane of the secretor canaliculi of parietal cells. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been demonstrated with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19.  However, milligram for milligram all drugs in this class appear comparable in their effects with regard to clinical or endoscopic end points or side effect profiles.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested a PET scan for an evaluation of his metastatic glucagonoma. Findings:  Three physician reviewers found that the metaiodobenzylguanidine (MIBG) study accurately identified the skeletal metastases as well as the right upper lobe lung lesion. However, due to the small number of cases in the literature, it is reasonable to use every modality available to search for other remote sites of neoplasm. There are some articles present in the literature showing use of PET scans in the restaging of these tumors, and the diagnostic procedure may also be useful in evaluating treatment response. There are no large series providing the efficacy of this technique due to the rarity of the tumor. However, use of the PET scan adds information and is compatible with recently published recommendations for the use of PET scans in all soft tissue tumors by the National PET Oncology Registry.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested for detoxification treatment for treatment of his opioid dependence. Findings:  The physician reviewer found that the reference discusses the efficacy and safety of using Suboxone in patients with opioid and cocaine dependence in an outpatient setting, at doses up to 16mg per day (which exceeds the dose this patient was taking). Suboxone was developed and FDA approved for use in the outpatient setting for this indication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 68-year-old male enrollee has requested a computed tomography angiography (CTA) heart scan for an evaluation of his atrial fibrillation. Findings:  Three physician reviewers found that the use of cardiovascular computed tomography is a well-established, appropriate use of this technology in this patient subset based on the most recent American College of Cardiology (ACC) guidelines. No other diagnostic test or procedure was likely to be as useful as CTA in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested growth hormone therapy (Nutropin) for the treatment of the enrollees growth failure. Findings:  The physician reviewer found that idiopathic short stature is associated with normal growth hormone levels, and the etiology of the syndrome remains unknown. Basically, there is a failure to grow at normal predicted levels despite the presence of normal endogenous levels of growth hormone. However, patients do respond with an accelerated growth velocity when treated with exogenous growth hormone. In general, the earlier the treatment is started, the bigger the effect of the growth hormone treatment will be on the final adult height. Reasons for treatment include avoidance of social stigmas and the adverse psychological effects of an abnormally short stature, as well as to prevent potential physical/occupational limitations related to an abnormally short stature. Growth hormone (GH) therapy is indicated for the treatment of idiopathic short stature, also called nongrowth hormonedeficient short stature, defined by height standard deviation score (SDS) 2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. GH is also indicated for the treatment of short stature or growth failure in children with short stature homeobox-containing gene (SHOX) deficiency whose epiphyses are not closed. The endocrinologist does not affirm this diagnosis. The Health Plans criteria for covering GH do not include the diagnosis of idiopathic short stature. This has been an FDA approved use of GH since 2003. The Health Plan should cover the cost of a trial of GH for three to six months to see if there is a significant increase in growth velocity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested Lyrica for the treatment of his spondyloarthropathy. Findings:  The physician reviewer found that there is a lack of published evidence supporting the use of Lyrica for spondyloarthropathy. One reference (Current Opinion in Rheumatology, 2005) discusses the major treatment modalities in the treatment of spondyloarthropathy, the most recent of which includes the use of the tumor necrosis factors, such as the Enbrel that the patient is taking. However, the use of Lyrica is not part of the discussed treatment approaches, and there have been no studies regarding the efficacy of the use of Lyrica for patients with pain from spondyloarthropathy. The Health Plans criteria are medically appropriate, as Lyrica is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Voltaren gel 1% and Celebrex 200mg for the treatment of his shoulder and ankle pain. Findings:  The physician reviewer found that while the patient does require an NSAID, Celebrex is not medically necessary. The submitted medical records do not document that the patient has tried and failed (due to lack of pain relief or gastrointestinal intolerance) two prescription strength NSAIDs. The letter from the patient notes he has tried and failed one prescription strength NSAID (Arthrotec) due to stomach aches, however, there are no medical records documenting this failure. If GI upset is a concern, there are multiple NSAIDs that can be tried with a PPI or H2 blocker to combat any adverse GI effects.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that there have been a few trials published documenting some degree of efficacy of the combination of oxaliplatin with gemcitabine in hepatocellular carcinoma. There is one phase II study combining these two drugs with Avastin by Zhu and colleagues. This trial demonstrated only that this combination was tolerable in terms of toxicity, but it was inconclusive as to whether the Avastin actually added significant benefit to the combination of oxaliplatin with gemcitabine. While oxaliplatinum with gemcitabine is of clinical benefit in this setting, Avastin remains unproven for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. Research supports the utility of teaching social skills to children on the spectrum as well, with the expectation that skills learned in therapy can be generalized to different settings and people. Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the child has for developing adequate skills to function in the community. Continued speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested ultraviolet light therapy for the treatment of her skin disorder. Findings:  Three physician reviewers found that this enrollee underwent multiple procedures for her acne. The Health Plan has denied coverage for the ultraviolet light therapy provided, and this is the subject of the appeal. The patient was not maximal on her systemic medical therapy. In the absence of documented trial and failure of optimal standard therapies, it has not been established that ultraviolet light therapy was indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested osteopathic manipulative medical treatment from an osteopathic physician (DO) specialist for the treatment of her lymphedema. Findings:  The physician reviewer found that there is no evidence that osteopathic manipulation is more effective than the standard lymphedema treatments offered by the Health Plan in treating her mild persistent lymphedema, and therefore, it is not medically necessary. As stated in literature, the cornerstone of lymphedema treatment is compression garments, manual massage, skin care, and remedial exercises. Such services can be obtained from in-network providers.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Lyrica for the treatment of his severe neuropathic pain. Findings:  The physician reviewer found that Lyrica is FDA approved for fibromyalgia, some seizure conditions, diabetic neuropathy and postherpetic neuralgia. Lyrica is often used off-label for a variety of non-FDA approved neuropathic pain conditions. Gabapentin has an analogous mechanism of action and is used for many of the same conditions as Lyrica. Some patients report better outcomes on Lyrica versus gabapentin. Lyrica has a linear pharmacokinetic profile in that there is a direct linear relationship between higher doses and clinical effect. Gabapentin has a plateau effect, as higher doses may not have a directly linear increase in therapeutic effect. This patient has noted excellent benefit with Lyrica without limiting side effects.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested Allegra D (12 hour) for the treatment of her allergic rhinitis. Findings:  The physician reviewer found that the patients upper respiratory tract symptoms failed to improved on multiple allergy medications, including nasal steroids, Claritin D and Zyrtec D. Her symptoms improved on Allegra D. The Health Plan requires that the patient fail fexofenadine prior to approval for Allegra D. Fexofenadine is not equivalent to Allegra D, which contains a nasal decongestant. The article by Van Cauwenberge and colleagues referenced above supports the use of decongestants as an appropriate adjunct to the treatment of the congestion and airflow obstruction that can occur with allergic rhinitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Aciphex 20mg for the treatment of her GERD, hiatial hernia, and ulcerative esophagitis. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to fight acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant or differences in their effects with regards to clinical or endoscopic end points or side effects profile.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested laparoscopic duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the laparoscopic duodenal switch bariatric surgical procedure has not been shown to have a higher complication rate than other weight loss surgical procedures. Gastric bypass operation is frequently associated with dumping syndrome, marginal ulcers, weight regain and inadequate weight loss, amongst other complications. The Roux-en-Y procedure has been associated with malabsorption and nutritional deficiencies. In addition, this patient would not be able to take NSAIDS. While gastric banding would allow the patient to take NSAIDS, it is associated with lower percentages of excess weight loss following the procedure, and she may not be able to lose sufficient weight with that procedure. The reference cited above does not identify a significant incidence of adverse effects with the duodenal switch compared with gastric bypass and confirms the higher percentages of excess body weight loss in patients with the duodenal switch, as compared with gastric banding. Given the patient's weight and comorbidities, the duodenal switch procedure is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that the superiority of Botox over standard migraine preventive medications has not been sufficiently established.  It does not appear that this patient has exhausted standard preventive medications. In the absence of evidence demonstrating that the patient has attempted adequate trials of standard agents without success, the use of Botox is not supported.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested AlloDerm for the treatment of her condition. Findings:  Two physician reviewers found that the use of AlloDerm is medically reasonable and appropriate in this case. It should be noted that AlloDerm is utilized in breast reconstruction with widespread usage.  Review of the above cited references indicates the usage of AlloDerm is not investigational and has become a standard of care.  Based on the scientific evidence available to date, the use of AlloDerm for this patients breast reconstruction is likely to improve the outcome of her breast reconstruction and therefore AlloDerm should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested for occupational therapyn treatment of her autism.  Findings:  Two physician reviewers found that occupational therapy is neither experimental nor investigational. It is standard of care for children such as the patient, who have difficulties that impact development of the occupations of childhood. Sensory integration therapy is one technique that a skilled therapist can use to facilitate positive change in a child with global deficits. Many techniques may be necessary when dealing with such a broad range of difficulties. The fact that this patient has shown progress with occupational therapy supports the appropriateness of treatment.