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

A 66-year-old male enrollee has requested a CT thorax, CT abdomen, MRI brain and MRI thoracic spine for an evaluation of his upper epigastric discomfort, back pain an headaches. Findings:  The physician reviewer found that this patient presented with pleuritic type chest pain and difficulty breathing.  The chest x-ray showed no acute disease, and the patients symptoms persisted following a trial of antibiotics.  These symptoms could be due to infectious or inflammatory disease of the chest, pulmonary embolism or pericarditis. CT scan of the thorax can evaluate for pulmonary embolism/infarct, small areas of infection not visible on chest x-ray and areas of inflammation within the lung and/or pericardium. With a normal chest x-ray and continued symptoms following antibiotic therapy, a CT of the thorax was medically appropriate. This patients symptoms of pleuritic type chest pain and epigastric pain radiating to the back can be a sign of aortic dissection or aortic aneurism involving the descending thoracic aorta and proximal abdominal aorta. The epigastric pain radiating to the back may be secondary to abnormalities of the pancreas, kidneys or biliary system. The accepted imaging study to evaluate the aorta, the pancreas, kidneys and biliary system is CT scan of the chest and abdomen. Therefore, the CT scan of the abdomen was medically necessary for evaluation of this patients medical condition. This patient had ongoing progressive headaches with no neurological symptoms or physical findings. This patient was noted to have sinus disease on prior plain films.  Headaches in older patients that are persistent and progressive are a red flag and should be evaluated promptly.  Headaches in older patients can be secondary to tumor, vascular abnormalities and intracranial bleeding.  MRI is more sensitive in evaluation of the brain, especially for vascular abnormalities. MRI of the brain can also evaluate for complications of sinusitis that can result in headaches. Thus, MRI of the brain was medically indicated and appropriate for evaluation of this patients medical condition.This patient had mid-back pain that radiated from the epigastric region.  He had no neurological symptoms or neurological findings on physical examination. Thoracic discogenic pain can present with pain that radiates to the trunk.  However, this patients thoracic spine symptoms could also be related to intra-abdominal or intra-thoracic abnormalities.  Treatment of patients with back pain with no history of cancer or recent trauma includes conservative therapy (i.e. physical therapy) for four to six weeks.  If the patients symptoms persist, further evaluation with diagnostic imaging is then indicated.  As this patient did not have any neurological symptoms or findings and had no history of cancer or recent trauma, MRI of the thoracic spine was not medically indicted at the time of this patients presentation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested for chemotherapy regimens Thalomid, Leukine and Revlimid for treatment of his prostate cancer. Findings:  Three physician reviewers found that there is a lack of data that validates the requested combination for prostate cancer.  There is data supporting the use of Thalomid in the literature, and this therapy is medically indicated and appropriate.  However, there is a lack of data supporting the use of Revlimid and Leukine for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested a FreeStyle Navigator continuous blood glucose monitoring system (CGMS) and related supplies for the treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that the requested CGMS device and related equipment will maintain the patients health and increase the likelihood of preventing a severe glycemic excursion leading to life threatening conditions or the consequences of them such as permanent disability. The FreeStyle Navigator CGMS is therefore medically necessary in this patient with uncontrolled diabetes mellitus type 1 and hypoglycemia unawareness.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old female enrollee has requested occupational therapy for the treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  Two physician reviewers found that this patient has been extensively evaluated and followed by a developmental pediatrician for a prolonged period prior to the recommendation for occupational therapy. The patients pediatrician has recognized that, in addition to medications, the patient requires occupational therapy. Schaaf and colleagues noted the effect of occupational therapy using a sensory integrative approach in children with developmental disorders. Miller and colleagues conducted a study that was a controlled investigation into the effectiveness of this technique. The requested occupational therapy is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for bendamustine for treatment of her large B cell non-Hodgkins lymphoma.  Findings:  Three physician reviewers found that there are two peer-reviewed studies involving reasonable numbers of patients that report safety and activity of bendamustine in heavily-pretreated patients with aggressive lymphoma (Weidmann, et al. and Friedberg, et al.). Based on these studies, as well as the fact that there are no other available standard therapies for this patient, it is medically appropriate to conclude that bendamustine is likely to offer superior benefit for treatment of her condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Faslodex for treatment of her metastatic breast cancer.  Findings:  Two physician reviewers found that there is no benefit to concurrent chemotherapy with hormonal manipulation as compared to sequential therapy with these agents. In view of this, the use of concurrent chemotherapy with hormonal manipulation is no longer widely utilized by treating oncologists for the treatment of metastatic breast cancer. The standard of care is to use these treatments sequentially. There have been no studies which have explored the concurrent therapy with Faslodex/chemotherapy as compared to sequential therapy with these agents. This combination is not recommended by the National Comprehensive Cancer Network (NCCN) consensus panel recommendations and is not FDA approved or compendium listed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee has requested for Provigil for treatment of his daytime sleepiness. Findings:  The physician reviewer found that fatigue is a common problem in Parkinson's disease, often the most troubling of all symptoms. It is poorly understood, generally under-recognized, and has no known treatment. Medications for Parkinsons disease can have sedating side effects, but dose reduction can lead to immobility and other disabling motor symptoms. No medications have been approved for treatment of Parkinsons disease-related sedation and excessive daytime sleepiness. Other medications, such as Ritalin, are used, but are not FDA approved for this condition. Clinical studies have demonstrated mixed evidence in favor of Provigil for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for duodenal switch bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines for weight loss surgery set by the National Institutes of Health. The long-term outcome of weight loss surgical procedures is well-documented. The duodenal switch bariatric surgical procedure has a superior long-term success rate as compared to other weight loss surgical procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her plantar fasciitis. Findings:  Two physician reviewers found that the available medical literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects of ESWT. In addition, there have been conflicting results among the randomized controlled studies, raising doubts regarding the efficacy of ESWT for plantar fasciitis. Based on the scientific evidence available to date, there is insufficient evidence to indicate that ESWT was likely to be more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested revisional lap band surgery for the treatment of her morbid obesity. Findings:  Three physician reviewers found that the submitted medical documentation does not provide a detailed assessment of the issues related to failure of the patients RYGB procedure. It is not documented whether the failure was due to noncompliance or mechanical issues such as gastrogastric fistula.  It appears the next appropriate step for this patient would be to obtain an upper gastrointestinal (UGI) series to assess anatomy. In the absence of evidence of an anatomical problem or surgical complication, the failure of the initial bariatric procedure is presumed to be due to dietary incompliance, and as such, revisional lap band surgery is not likely to be any more effective than the patients initial procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Bystolic 2.5mg for the treatment of her hypertension and tachycardia. Findings:  The physician reviewer found that for this patient a beta blocker is a good clinical choice. The patient was tried on two beta blockers with symptoms related to the medications. A formulary beta blocker was recommended by the Health Plan. A trial of a different beta blocker is a reasonable clinical strategy. There is no evidence demonstrating that Bystolic is clinically superior to the formulary beta blockers. The alternative recommended by the Health Plan is medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested partial knee replacement surgery for the treatment of his right knee pain. Findings:  The physician reviewer found that total knee replacement is an accepted procedure with proven durability and excellent outcomes. More recently, there has been an increased interest in unicompartmental replacement in the treatment of arthritis limited in extent. It has been recommended for medial compartment arthritis, with a fully intact anterior cruciate ligament. Unicompartmental replacement is not recommended in cases with anterior cruciate ligament deficiency since this can lead to increased damage to the other compartments, and it is also not indicated in the presence of patellofemoral arthritis. There has been some development of bicompartmental replacement prostheses, but there is a lack of sufficient published information to discuss them. In this case, there is documentation of arthritis in the patellofemoral and lateral joints. In addition, the presence of documented anterior cruciate ligament laxity would tend to increase the risk of additional degeneration in the medial compartment in the future. These would all contribute to the need for total, rather than partial, replacement, as was discussed by the orthopedic consultants noted in the record.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Xyzal 5mg daily for the treatment of her respiratory allergies. Findings:  The physician reviewer found that clinical comparison studies have demonstrated that Xyzal is a more effective second-generation antihistamine than Zyrtec, Claritin, Clarinex and Allegra due to a lower volume distribution and higher receptor site binding capacity (i.e., it provides more protection and has a longer duration). Therefore, the use of Xyzal in this situation is appropriate and generally accepted as the standard of medical care, as the patient has failed other first and second-generation antihistamines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the NCCN guidelines do not indicate that stereotactic radiosurgery utilizing CyberKnife is superior to the standard options available in this setting. Currently, there is insufficient outcome data from which to conclude that CyberKnife is likely to be more efficacious for the treatment of intermediate risk prostate cancer than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested foraminotomy for the treatment of her pain. Findings:  The physician reviewer found that there is no role for cervical foraminotomies for this patient who has the diagnosis of complex regional pain syndrome. The indications for cervical foraminotomies are relatively clear cut and they include soft disc herniation and significant foraminal encroachment by osteophytic spurs. This patient has neither. Surgical intervention is not indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested for Aranesp and Neumega for treatment of his prostate cancer. Findings:  The physician reviewer found that Aranesp is a long-acting version of Procrit. Both are used to increase hemoglobin levels, particularly in patients developing chemotherapy-related anemia. It is often used if Procrit fails, even when the patient is not on chemotherapy at that specific time. Overall, it is indicated when the hemoglobin falls below 10. It appears the patient was on Procrit, but his hemoglobin remained below 9 despite this. Thus, it would be medically reasonable and indicated to attempt treatment with Aranesp. Considering that a patient with hemoglobin below 9 is likely to be symptomatic, Aranesp is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested for Sutent for treatment of his metastatic extra-adrenal paraganglioma. Findings:  Two physician reviewers found that Sutent is one of a newer class of drugs that acts as an inhibitor of vascular endothelial growth factor (VEGF) as well as other factors. It has been approved for use in renal cancer and gastrointestinal stromal tumors. Malignant paragangliomas tend to be very hypervascular and strongly express VEGF. It is a very rare tumor, so there is little data relevant to its treatment, especially with regards to chemotherapy for metastatic disease. There have been sporadic responses reported to a variety of agents. In the report by Joshua and colleagues, three such patients were treated, with the development of a near complete remission in one, and partial responses in the two others. The Hahn report notes some degree of response to Sutent in one such patient. There is a lack of data regarding the treatment of this patients disease due to its rarity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested Cialis 20mg for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction (ED) is caused by multiple factors and sometimes the cause can be difficult to identify. One possible cause of ED is medication used in the treatment of hypertension or side effects of antihypertensive medications. The documentation presented for review indicates that the patient is taking Adalat or Afeditab (both are referenced in the submitted records). These drugs are often used to treat hypertension, and may have the side effect of ED. This patients ED may be a direct result of either of these medications. Cialis is appropriate and indicated for the treatment of ED. There is sufficient documentation in this patients history to establish the medical necessity of Cialis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested a tonsillectomy and adenoidectomy for the treatment of the enrollees chronic tonsillitis. Findings:  The physician reviewer found that clinical indicators for tonsillectomy with or without adenoidectomy include three or more infections of tonsils and/or adenoids per year despite adequate medical therapy, hypertrophy causing dental malocclusion or adversely affecting orofacial growth, hypertrophy causing upper airway obstruction/severe dysphagia/sleep disorders/cardiopulmonary complications, peritonsillar abscess unresponsive to medical management, chronic or recurrent tonsillitis associated with the streptococcal carrier state not responding to antibiotics, and unilateral tonsillar hypertrophy presumed neoplastic. According to the standard of care established by the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS), adenotonsillectomy is medically necessary for treatment of this patients chronic tonsillitis, because she has had three episodes of tonsillitis in the past 10 months. The proposed tonsillectomy with adenoidectomy is medically appropriate and indicated in this case and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested gastroplasty/vertical sleeve gastrectomy for the treatment of his morbid obesity. Findings:  Two physician reviewers found that sleeve gastrectomy was originally performed to bridge patients who were super-morbidly obese to a safer plateau at which point a malabsorptive procedure is performed. The study by Karamanakos and colleagues shows a greater weight loss at 12 months with sleeve gastrectomy with superior appetite suppression compared with laparoscopic Roux-en-Y gastric bypass. Furthermore, sleeve gastrectomy is now widely accepted by the American Society for Metabolic and Bariatric Surgery and is considered a standard procedure at medical centers of excellence. In sum, sleeve gastrectomy is the most appropriate option for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested maxillofacial prosthetics for the treatment of her hemifacial spasm. Findings:  The physician reviewer found that hemifacial spasm is a neuromuscular disorder characterized by frequent involuntary contractions (spasms) of the muscles on one side of the face. Most often, hemifacial spasm is caused by a blood vessel pressing on the facial nerve at the place where it exits the brainstem. Known treatments for this condition include surgery and medication including Botox. Treatment of this condition with oral splints is not a widely accepted form of treatment and there is a lack of studies in the literature to support the use of oral splints for this condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested biofeedback therapy for the treatment of her hemifacial spasm. Findings:  Two physician reviewers found that although there are several case reports of biofeedback for hemifacial spasm in the literature, there are no clinical trials of any magnitude that would suggest this modality of treatment is as effective or superior to the current treatment of Botox. Furthermore, there is insufficient data on the efficacy of biofeedback for other pain conditions to allow for extrapolation of the results to this setting. The submitted medical records do not document the exact nature of the trials and reported failure of Botox for this patients condition. In light of its proven results in this setting, additional attempts with Botox were likely to have greater efficacy than biofeedback, which has not been established as efficacious in this setting. All told, the use of biofeedback remains unproven for use in the disorder of hemifacial spasm, as determined by review of the relevant literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested testosterone pellet implants for the treatment of her endometriosis. Findings:  Three physician reviewers found that the scientific literature suggests that the use of testosterone may be of benefit for treating endometriosis and enhancing libido in postmenopausal women. However, at the present time, it can only be considered investigational as the specific use of testosterone pellets is debatable and not supported in the medical literature. The use of transdermal testosterone affords an alternative delivery system that has been the subject of greater study, and as such, has better outcome data than testosterone pellet implantation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a chest computed tomography angiography (CTA) for an evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found that this patient would be classified as high risk for development of coronary artery disease. Aggressive maximal risk reduction therapy was warranted based on risk factors and history alone. Furthermore, CTA is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset and is not medically acceptable replacement for other conventional screening tests within the standard of care (i.e., treadmill stress testing). CTA is also not a medically acceptable substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. In addition, a negative CTA or stress test would not exclude the possibility of important coronary disease in this high risk patient and coronary angiography without any additional non-invasive testing is also a clinically acceptable strategy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested an off-the-shelf unloader knee brace and related items for the treatment of her left knee, status-post anterior cruciate ligament (ACL) reconstruction, meniscectomy, and chondroplasty. Findings:  The physician reviewer found that the utilization of braces of various varieties has been the subject of much discussion, but evidence of their efficacy following ACL surgery is lacking in the medical literature. A study by Brandsson and colleagues noted that there is some evidence of decreased swelling, pain and wound drainage with bracing in the early post-operative period but on later follow-up, no differences were found. McDevitt and colleagues also failed to find any difference in clinical outcomes between patients who used braces and those who did not, and this has been seen in younger patients as well. Wright and Fetzers randomized clinical trial reached the same conclusion, as have reviews of the literature (noted by Smith and Davies). In this case, an immobilizer was used in the post-operative period and there is support in the literature for that use. However, there is a lack of evidence for the efficacy of the later brace at issue and therefore the denial was appropriate.