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

A 55-year-old female, who has a history of right shoulder pain, has requested authorization for physical therapy services.Reviewer's Findings:The reviewing physician found that the patient showed steady gains in her right shoulder range of motion, strength and functional activities. Without supervised, consistent physical therapy it is doubtful the patient would have achieved such results.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested the medication Fentora 600mcg for treatment of his polyarteritis nodosa.   Findings:  The physician reviewer found that there is no clear evidence of a diagnosis presented in the provided records. The pain specialist states the patient has hereditary autoimmune polyarteritis nodosa. Certainly there are hereditary forms of neuropathy and polyarteritis nodosa (PAN) is a standard rheumatologic diagnosis; however, insufficient information has been provided to support a diagnosis. Furthermore, if the patient actually has PAN, there is no evidence he is receiving treatment relevant to that diagnosis. Reliance on pain medications would not be consistent with standard management of PAN. If he has a significant neuropathy causing pain, no evidence is presented to support such a diagnosis. All told, there is insufficient clinical evidence to support the use of Fentora in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested the Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Three reviewers found that Oncotype DX is a clinically validated assay of the breast tumors expression of 21 genes. This tumor assay quantifies the likelihood of distant recurrence in a select group of women. The assay was validated by the NSABP in a large independent multi-center clinical trial that also demonstrated the recurrence score was predictive of relapse free survival. Its accuracy exceeded standard measures such as patient age, tumor size, and grade. In this particular patients case, chemotherapy would likely have been recommended given the size of her tumor. However, the results of her assay supported treatment with hormonal therapy alone allowing her to forgo chemotherapy. This assay was critical in navigating the patients plan of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX assay has been found to be reliable in predicting the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. It has only been validated in node-negative, estrogen receptor positive cancers. It is very difficult to make recommendations about adding adjuvant chemotherapy for this particular group of women. Not only does the Oncotype assay reliably predict the risk of recurrence without chemoterapy, it has also been found to predict the value of chemotherapy. Oncotype DX is widely accepted and has virtually become standard of care for many oncologists. This diagnostic procedure has clearly established clinical value
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested an Oncotype DX tumor assayfor evaluation of her breast cancer.  Three physician reviewers found that Oncotype DX assay predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor-positive tumors. It has become very important, particularly in cases in which it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, many oncologists have adopted it as part of their standard evaluation of such patients. Additionally, Medicare has approved the use of the Oncotype DX assay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 53-year-old female enrollee has requested continued skilled nursing facility services for treatment of the enrollees multiple medical problems. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient is not a candidate for skilled rehabilitation services as she cannot progress and such services are not necessary to prevent decline. Though range of motion activity is needed to prevent decline, skilled rehabilitation is not. However, the patient has a PEG tube and receives 1800 calories per day via PEG as well as hydration and medication. The reliance on PEG feeds to maintain total nutrition constitutes a skilled nursing service as defined by Medicare regulations. Thus, the patients medical condition and nursing needs are consistent with generally accepted standards of care for skilled nursing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested percutaneous kyphoplasty for treatment of her spinal compression fracture. Findings:  Two physician reviewers found that there is no proven benefit to performing kyphoplasty this early following a compression fracture. The patient has only tried bracing and medical management for a short time. The medical literature suggests that younger persons with compression fractures heal and do very well with bracing for three months. The medical literature does not support kyphoplasty over conservative management this soon after compression fracture. The patient should be afforded more time to heal with the use of a brace and pain medications before kyphoplasty is considered.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested authorization and coverage for autologous stem cell transplant via participation in a clinical trial at Northwestern Memorial Hospital for treatment of his multiple sclerosis (MS). Findings:  Two physician reviewers found that this patient has a moderately progressive course of relapsing-remitting MS. He  has failed treatment with B-interferon 16 (Betaseron). The patient has mild to moderate disability with an EDSS equal to 2.5. Multiple FDA approved therapies for the treatment of aggressive MS are available such as Novantrone and Tysabri. The patient has just begun treatment with Copaxone, and treatment failure has not been established. There are multiple interventional, mostly open label studies of autologous stem cell transplant underway. The data is promising, but the clinical improvements are limited to one to four years and long-term benefit has not been demonstrated. Autologous stem cell transplant is frequently associated with adverse events. Aggressive standard therapy is still the best approach for the treatment of relapsing-remitting MS.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity. Findings:  The physician reviewer found that the Lap Band is presently the most common bariatric surgical procedure performed in the world, and the second most common bariatric surgical procedure performed in the United States (US). The procedure is undisputedly safer than other bariatric procedures in that it involves shorter operative time, no chance of anastomotic leaks, no dumping syndrome and no serious nutritional deficiencies. Current data indicates the Lap Band is at par with other operative procedures for weight loss and the patient should be free to choose among the generally accepted bariatric procedures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested an occupational therapy evaluation for treatment of the enrollees sensory regulation and fine motor difficulties. Findings:  The physician reviewer found that the submitted clinical records provide no medical basis for the patients eye-hand coordination, fine motor function, paragraph summarization and short-term/sequential memory difficulties. Since these issues are only documented as issues with school, they are considered educationally necessary and should be addressed through an Individual Education Plan (IEP). The patient is age appropriate for activities of daily living and self-help skills.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a panniculectomy, belt lipectomy/abdominoplasty for treatment of her excess skin condition. Findings:  The physician reviewer found that the surgery has been proposed as a treatment for recurrent infections, but the records provided do not include objective evidence to verify the accuracy of the patients history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the abdominal fold. Additionally, photographs documenting cellulitis, ulcerations or rashes have not been provided. The plastic surgeons consultation letter indicates that the patient has failed conservative treatment, but office notes confirming this to be the case are not submitted. There is no mention of specific dates on which the patient was treated for infections or specific medications used to treat these infections. Due to the absence of any office notes documenting infections, the patients history of uncontrollable and recurrent intertrigo cannot be verified.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested hereditary non-polyposis colon cancer (HNPCC) testing for evaluation for possible HNPCC syndrome.  Findings:  Two physician reviewers found that by all definitions, the patient meets the Amsterdam criteria for testing for HNPCC. Enhanced screening of the patient secondary to a positive test result could result in an obvious benefit to the patient. HNPCC testing is the best available option to determine the patients risk and may significantly alter the patients clinical management depending upon the results.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested the prescription medication Provigil for treatment of her depression. Findings:  The physician reviewer found that the submitted clinical information does not demonstrate Provigil is medically indicated for this patient. There are many other treatment options available for treatment of her depression prior to augmentation of an anti-depressant with a psycho-stimulant. Provigil is still considered investigational for the treatment of depression as there are concerns about its safety and side effects, particularly for someone with a chronic condition such as Crohns disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested sacroiliac joint arthrography and cortisone injections (sacroiliac joint injections) for treatment of her sacroiliac joint arthritis and bone spur. Findings: Two physician reviewers found that tenderness around the sacroiliac joint area does not necessarily mean the patient has a pathologic sacroiliac joint. There is no documentation in the submitted medical records of any positive sacroiliac joint physical findings such as sacroiliac joint pain on hip Faber testing, which stresses the sacroiliac joint, or sacroiliac joint pain with single leg stance rotation flexion stress testing, which also stresses the sacroiliac joint. Nor is there documentation in the submitted records of a bone scan abnormality of the unilateral left-sided sacroiliac joint or MRI testing of the pelvis documenting any bone density changes, inflammation, or fluid in or around the left sacroiliac joint. Additionally, the concept that the bone spur on the sacroiliac joint may be causing inflammation is valid from an anatomical standpoint. Given the preceding, the clinical indications for sacroiliac joint injections have not been established in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested extracorporeal shockwave therapy (ESWT for treatment of her plantar fasciitis. Findings:  Three physician reviewers found that  ESWT remains experimental for the treatment of chronic plantar fasciitis. There is no class I data clearly supporting the application of this technique. A review of the current literature did not identify a standardized protocol or a general consensus as to the recommended frequency, mode of delivery or type of anesthesia for ESWT. There are still questions regarding the efficacy of ESWT and long-term outcomes in the treatment of chronic plantar fasciitis are uncertain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation. Findings:  The physician reviewer found that postoperative cold therapy is utilized by some orthopedists for managing pain and inflammation. However, use of cold therapy units has not been shown in long-term peer-reviewed literature to offer superiority over the traditional use of ice. The units studied have not been proven to significantly lower the intra-articular temperature of the knee. There is no study literature indicating that use of this device itself would decrease a patients hospital stay or shorten the rehabilitation period.  Appropriate monitoring of the application of ice packs eliminates the concern for skin or tissue break down.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a whole body PET/CT imaging for evaluation of his adrenal abnormalities. Findings:  The physician reviewer found that whole body PET/CT imaging is a useful adjunct to more conventional imaging studies in select oncologic and cardiac situations or to evaluate seizure foci in patients who are surgical candidates for treatment of intractable epilepsy. This patient has no documented malignancy and no suspicious findings on conventional imaging (CT and MRI). PET/CT imaging has not yet been proven to be useful for the evaluation of metabolic disorders such as Cushings disease or to search for an underlying malignancy when conventional imaging is unremarkable.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested Botox for treatment of his neck and shoulder pain.  Findings:  Two physician reviewers found that Botox is an accepted treatment for neuromuscular conditions such as torticollis, but is considered experimental for trigger points and muscle spasms despite the obvious contradiction. The evidence in this case indicates the patient has failed to respond to several of the more standard therapeutic modalities, but has achieved symptom relief with Botox treatments. Subjectively he is pain free and objectively he no longer requires trigger point injections or narcotic pain medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female, with lower back pain, requested authorization for epidural steroid injections provided by a pain management specialist.Reviewers findings:The reviewing physician found that the documentation provided for review did not indicate a need for further epidural steroid injection therapy. There was no note of radicular symptoms or findings on neurological examination. The patient needed be re-evaluated by her PCP prior to any referral for additional interventional therapy. The patient might possibly benefit from additional medical therapies and neurosurgical consultation may be appropriate given the MRI report.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Phisohex 3% for treatment of her MSRA infection. Findings:  The physician reviewer found that while there is no proof that over the counter skin cleansers containing triclosan are ineffective for MRSA, the most effective treatment for elimination of MRSA skin carriage in the United States is the use of either hexachlorophene (in the concentration present in Phisohex) or chlorhexidine, another prescription medication. As such, the use of Phisohex is medically appropriate and clinically indicated for treatment of the patients recurrent MRSA infection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested hip resurfacing arthroplasty with the Birmingham Hip Resurfacing System for treatment of his osteoarthritis.  Findings:  Two physician reviewers found that the patient in this instance has advanced degenerative changes of the hip. While resurfacing arthroplasties have been utilized in hip surgery for years, the technology of metal-on-metal implants continues to evolve. There is concern pertaining to ion release and durability. It is not known whether the resurfacing system will have the longevity of the standard/traditional total hip arthroplasty. There is no long-term data demonstrating the safety and efficacy of metal-on-metal resurfacing and there are no well controlled peer-reviewed studies demonstrating it is superior to traditional replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested an increase in IVIG therapy for treatment of his multifocal motor neuropathy. Findings:  The physician reviewer found that IVIG has been shown to be effective in multiple placebo-controlled studies of multifocal motor neuropathy. The Cochrane collaboration has completed a meta-analysis, which confirms clinical efficacy.  The usual initial dose of IVIG is 2gm/kg to be given over one to five days. The Health Plans approval of one day of treatment per month at a dosage of .4gm/kg is inadequate and not supported by peer-reviewed literature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested keratoprosthesis implantation for treatment of his visual impairment.  Findings: Two physician reviewers found that the requested keratoprosthesis implantation will improve the patients visual function and help to create a more normal appearance. The safety and effectiveness of the procedure is well established in the literature and this approach has been endorsed by the medical community. For this particular patient who cannot undergo keratoplasty using donor tissue, keratoprosthesis implantation is an appropriate alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a hospital bed for treatment of her multiple medical problems.  Findings:  The physician reviewer found that there is no documented medical necessity for the hospital bed at issue. The patient is not bed bound and her legs can be elevated in a regular bed. She has chronic back pain without objective evidence of nerve impingement. There is no evidence in the medical literature that indicates a hospital bed is necessary for the treatment of this patients condition, nor is it the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested an MRI or MRA scan for evaluation of her possible demyelinating disease. Findings:  The physician reviewer found that the information provided does not contain any clinical details that suggest the patients symptoms are progressive, as might be the case with multiple sclerosis, or are recurrent in different areas, which would suggest a clinical uncertainty regarding diagnosis for which MRI and MRA would be valuable. Based on the records that have been provided, there is no need for further imaging, as the records do not substantiate clinical symptoms that are not answered by the known diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested bariatric surgery including duodenal switch and laparoscopic cholecystectomy for treatment of her morbid obesity.  Findings:  The physician  reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity. The question raised relates to what would be the best surgical approach. Serious consideration should be given to the medications the patient is likely to take the rest of her life for her SLE and associated joint pain. Specifically, NSAIDs, Methotrexate, Plaquenil, and potential high-dose steroids with exacerbation of SLE symptoms. These medications can predispose the patient to ulcer formation and other gastrointestinal complaints. In comparing the duodenal switch procedure to the standard Roux-en-y gastric bypass, the literature indicates that the duodenal switch has proven to be superior with regard to gastritis, marginal ulcer formation, dumping syndrome, nutritional abnormalities and the stability of the weight loss.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested enhanced external counterpulsation (EECP) therapy for treatment of his angina. Findings:  Three physician reviewers found that the use of EECP in the treatment of chronic angina refractory to medical management and in patients who cannot be safely revascularized is an accepted treatment modality. However, the current ACC guidelines for the treatment of chronic angina consider EECP  an alternative therapy and make only a class IIb recommendation. A class IIb recommendation recognizes that data on the use of EECP is not clear cut and there is conflicting evidence or a divergence of opinion about the usefulness/efficacy of a procedure or treatment and that the (u)sefulness/efficacy is less well established by evidence/opinion. Given this, the current recommendations for treatment of angina are anti-anginal therapy or revascularization as first line therapies, with EECP reserved for those symptomatic patients that fail a reasonable trial of medications. The use of EECP for this patient was not consistent with the ACC recommendations.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested out-of-country rehabilitation services for urgent care of his post brain hemorrhage. Findings:  The physician reviewer found that there is no indication in the medical records demonstrating that the patient was unsafe for travel as of the period in question. There is clear evidence he had the endurance to be in a wheelchair for extended periods of time, i.e., at least eight hours. The patient was able to travel with supplemental oxygen. He was medically stable for transfer and had coherent speech. His injury was not a contraindication to air travel. Nor was the nature of the rehabilitation services urgent. The submitted records demonstrate the patient was able to travel to the in-plan service area and the services could have been delayed until the patient reached the in-plan service area.