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

A 54-year-old male enrollee has requested for a consultation regarding a liver mass and possible liver transplant for treatment of his liver mass.  Findings:  The physician reviewer found that Yao and colleagues showed that there may be room to expand these criteria without affecting survival outcome (Hepatology, 2001 Jun;33(6):1394-403). In another study, the authors found that patients with HCC meeting the following criteria: solitary tumor less than or equal to 6.5 cm, or 3 or less nodules with the largest lesion less than or equal to 4.5 cm and a total tumor burden less than or equal to 8 cm, had survival rates of 90% and 75.2% at one- and five-years respectively, after orthotopic liver transplantation versus a 50% one-year survival rate for patients with tumors exceeding these limits (Hepatology, 2003;33(6):1394-1403).The evidence demonstrates that this patient has a liver tumor which is 8.6 cm in largest diameter, which even exceeds the expanded criteria, and therefore, he is not deemed an appropriate candidate for liver transplant due to high risk of recurrence of the tumor post-transplant.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested  for two additional days of hospital care for treatment of her right total knee arthroplasty. Findings:  The physician reviewer found that a total knee replacements have a length of stay of three postoperative days.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for transvaginal radiofrequency (Renessa) for treatment of her urinary incontinence. Findings:  Two physician reviewers found that Renessa is marketed as a non-surgical alternative therapy involving radiofrequency heating of tissues lateral to the urethra to treat urinary incontinence in women. A thorough search of existing literature reveals a lack of long-term studies to support its use for this indication at this time. Although there are a few early studies that suggest that incontinence improves with this treatment, the numbers of patients included in the studies and the short-term follow-up are insufficient to draw conclusions as to long-term efficacy. In addition, the improvement noted with this treatment does not seem to be comparable to currently accepted and covered incontinence treatments, such as suburethral slings.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for continued Rocephin IV for treatment of her Lymes disease. Findings:  Three physician reviewers found that There is a lack of evidence of any infectious process to explain the patients symptoms.  With regard to Lyme disease, there is no mention of a tick bite or an erythema migrans eruption. The clinical symptoms described are all non-specific and do not suggest a diagnosis of Borrelia infection. The definitive tests for Lyme disease (IgM and IgG Western Blots) were negative in 2005.  The only positive test for Lyme disease (a urine multiplex) is not a widely recognized or standardized test and is not recognized as being of value by Centers for Disease Control. There is also no evidence of infection with Babesia, except for a positive Babesia FISH assay.  Again, this is not a standard test, and it is not widely used or recognized.  Even if there were evidence of Lyme disease, in almost all forms of disease, the initial recommended therapy is an oral tetracycline. Ceftriaxone is recommended for documented central nervous system disease, myocarditis or persistent or recurrent arthritis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for electro stimulation therapy for treatment of her pain. Findings:  Two physician reviewers found that Nnoaham and colleagues noted that in 13 of 22 inactive control studies, there was a positive analgesic outcome in favor of active transcutaneous electro stimulation treatment. They also noted that for multiple dose treatment comparison studies, 8 of 15 were considered to be in favor of this therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested for Keppra XR 500 mg for treatment of her seizures. Findings:  The physician reviewer found that studies of Keppra immediate release (IR) show a 17-30% reduction in seizures over placebo, depending on dosage. Keppra IR has similar efficacy as Keppra XR, though it requires BID dosing. Keppra XR does not have data showing greater effectiveness in general than Keppra IR.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for X-Stop decompression for treatment of his chronic low back pain. Findings:  Three physician reviewers found that X-Stop decompression has been developed in an attempt to identify an alternative treatment to decompressive laminectomy, with or without fusion, in cases where conservative treatment was not sufficient. Early data has shown some favorable results, but some problems have been reported, and a high failure rate has been noted in cases of spinal stenosis complicating degenerative spondylolisthesis. Further study to determine optimal design and clinical indications has been suggested. At this time, a study to clarify these questions is under way, but the results are not yet available. Until additional data is available the efficacy of X-Stop decompression remains unproven.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested for bilateral implantation of corneal ring segments for treatment of his keratoconus. Findings:  Three physician reviewers found that most patients improved after undergoing the procedure at issue for the treatment of keratoconus, and very few suffered any ill effect. One should generally try to improve the condition of an existing organ with minimal risk before transplanting that organ from an unrelated donor, even if only to postpone the transplantation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the scientific literature is clear when it comes to superior long-term outcome of the duodenal switch operation when compared to other procedures. The benchmarks measured include, weight loss, resolution of co-morbidities and lack of any significant differences between their complications when specifics are compared. The duodenal switch operation does not have metabolic side-effects that are worse than that of the gastric bypass operation.In-fact, gastric bypass patients have a higher failure rate and worse nutritional profile long-term than that of the duodenal switch patient. Furthermore, the resolution of diabetes is far superior with the duodenal switch than that of the gastric bypass.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her condition status post lesion removal.  Findings:  The physician reviewer found that the peer-reviewed literature reveals support for short term follow-up MRI of the breast following benign biopsy results. Lehman and colleagues recommend a six-month follow-up breast MRI in all patients with benign histology. The article by Kozlowski also recommends a follow-up MRI at six months in the case of prior benign biopsy results. The follow-up breast MRI is performed to ensure that the area that was biopsied was indeed benign.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for chiropractic services for treatment of her sciatica.  Findings:  The physician reviewer found that the American Chiropractic Association and CMS guidelines, the treating provider is expected to keep and maintain adequate case records clearly showing and indicating the progression of care (visit to visit), clinical impressions based on documented examinations/re-examinations, provocative and palliative responses to care and onset of exacerbations. The provider is expected to have a clear assessment of the patients condition and evaluation of treatment effectiveness (case management). The SOAP notes fail to follow progression, functional gains, type of chiropractic technique used, and what specific segments were adjusted at each visit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee has requested  for Lupron injections for treatment of her short stature. Findings:  The physician reviewer found that there is little support in the literature for the use of Lupron as an adjunctive means of enhancing final adult height in this population of patients. In a recent consensus statement, Clayton, et al stated, At present, there is no convincing evidence that the addition of GnRH analog treatment [Lupron] to inhibit pubertal progression is associated with additional height gain. Thus, at this time there is inadequate scientific data to establish the usefulness or benefit of Lupron in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has for speech therapy services for treatment of her speech apraxia.  Findings:  The physician reviewer found that it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Verbal apraxia, or apraxia of speech, is an impairment in planning and coordinating movements for speech production as stated in the Nelson Textbook of Pediatrics. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. Lewis and colleagues note that this type of impairment is frequently seen after stroke or with congenital disorders that affect the brain such as Down syndrome, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to articulation problems. Communication at all levels may ultimately be impaired.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for laser destruction of cutaneous vascular lesions for treatment of  her rosacea. Findings:  Three physician reviewers found that there is a lack of studies suggesting that the requested service would be beneficial for the popular/pustular component of rosacea.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for a breast MRI for her breast cancer screening.. Findings:  Two physician reviewers found that MRI of the breast is helpful in diagnosing multifocal disease, multicentric disease, axillary disease and contralateral disease. Proper evaluation in this setting would include an MRI of the breast which can help identify pathology in the contralateral breast or elsewhere within the left breast. Additional findings could affect the treatment and management of this patient who has a history of a mass that was not detectable on mammogram.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old female enrollee has requested for speech and language therapy and occupational therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that the idea behind these therapeutic interventions is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health and function through focused treatment. Thus, specific treatment, including speech and language therapy and occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. This multimodal approach will allow the patient to derive therapeutic benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for the medication Procrit for treatment of her normochromic normocytic anemia. Findings:  The physician reviewer found that Erythropoietin (Procrit) should be started in this case with the presumptive diagnosis of a chronic inflammatory state. The target hemoglobin should be pre-determined and carefully monitored. Further workup and second opinion on the bone marrow exam would be appropriate to rule out myelodysplasia (MDS), a diagnosis in which ESA use would be indicated as well.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for growth hormone (Nutropin) therapy for treatment of the enrollees hormone deficiency.  Findings:  The physician reviewer found that in the case of constitutional growth delay, catch-up growth occurs (albeit delayed) at the onset of puberty, and GH therapy is not indicated. Therefore, the distinction between GH deficiency and constitutional growth delay is important in establishing medical necessity for this patients treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested for K-RAS mutation genetic test for evaluation of his recurrent metastatic cancer. Findings:  The physician reviewer found that this test allows oncologists to give the drugs only to the patients who have a reasonable likelihood of benefiting from them. Though the K-RAS may not be universally accepted at this time, it has rapidly been adopted by many oncologists as a medically necessary step prior to administering cetuximab or panitumumab.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for emergency services for treatment of her rash. Findings:  The physician reviewer found that this patient did have a sudden onset of symptoms. Although she was experiencing itching, she was not experiencing any shortness of breath, airway compromise, or difficulty swallowing. She had not attempted any over the counter medications or treatments prior to seeking treatment in the emergency department.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for total ankle replacement surgery for treatment of his complications from remote ankle injury. Findings:  Two physician reviewers found that total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis (fusion) is a long running clinical debate that has yet to be answered. However, these implants are FDA approved and are supported in the clinical literature as discussed by Haddad, et al. and Knecht et al.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested an abdominal panniculectomy for the treatment of her excess skin status-post gastric bypass. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. Although the submitted photographs demonstrate that the patient has excess hanging abdominal skin, it is not severe and does not hang over the undergarment. As such, the patients excess skin condition does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection. Nor is the amount of excess skin so great as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment. Office visit notes describe no rashes. There is no description of office visits or physician treatment for skin rashes due to sagging skin. There are no rashes or areas of skin breakdown visible in the submitted photographs. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested for a magnetic resonance imaging (MRI) scan of the lumbar spine for evaluation of his low back pain. Findings:  The physician reviewer found that the MRI study is the proper diagnostic study for the clinical diagnosis present in the record (i.e., intervertebral disc herniation). A further reason to proceed with MRI study of the lumbosacral spine is that there is a high risk of iatrogenic drug dependency with prescription of opioids. There is documentation that the dose levels have been increased in this patient. The information obtained through MRI should allow a more focused and effective conservative management program, as well as ruling in or out a number of specific lesions, possible pain generators for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for a chest computed tomography angiography (CTA) for evaluation of his heart condition. Findings:  Three physician reviewers found that there are published guidelines from the American College of Cardiology (ACC) regarding the appropriate use of cardiac CTA. In this case, the patient does not have symptoms of chest pain, but has risk factors for coronary artery disease (CAD). His calcium score is elevated (greater than 400). Other ACC guidelines (Brandis) alternatively recommend stress perfusion testing in this setting. This patient falls under Table 4. Risk Assessment with Prior Test Results, Asymptomatic, of the 2005 SPECT guidelines. Given his CCT score of greater than 400, he falls under Indication 27 Asymptomatic, Prior Coronary Calcium Agatston Score, Agatston score greater than or equal to 400. This indication has an appropriate recommendation for the use of stress perfusion (and not cardiac CTA) testing as a next step.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a duodenal switch for treatment of her morbid obesity.  Findings:  The physician reviewer found that there is high incidence of weight regain and inadequate weight loss with gastric bypass. Nutritional deficiencies common after gastric bypass are iron deficiency anemia, protein malnutrition, and poor eating habit secondary to the stricture at the gastro-jejunostomy anastomosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested for Avastin for treatment of her stage IV non-small cell lung cancer.  Findings:  Two physician reviewers found that Avastin has been demonstrated to have some usefulness when combined with initial chemotherapy with carboplatinum-taxol in metastatic non-small cell lung carcinoma and it is approved for such use. However, there is no data that Avastin combined with other agents later in the course of treatment of non-small cell lung carcinoma has been clearly beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for a PET scan for evaluation of her weight loss, malnutrition and chronic pain. Findings:  Two physician reviewers found that several articles have shown that PET scans can be useful in the evaluation of paraneoplastic neurological syndrome. Talbot and colleagues found success in the use of PET scans for neurological paraneoplastic syndrome but state that the clinical utility of PET scans in other paraneoplastic syndromes has not yet been sufficiently studied. A review of the peer-reviewed literature did not show sufficient support for PET studies in patients with non-neurological paraneoplastic syndrome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for occupational therapy for treatment of the enrollees feeding difficulties. Findings:  The physician reviewer found that Eckman and colleagues noted that occupational therapy has a successful role in teaching patients to respond to therapy. Seabert and colleagues noted the usefulness of multidisciplinary clinics for infants with feeding disorders. To allow a child to avoid many foods may result in a very unbalanced and very unhealthy diet throughout his lifetime. The articles note that these programs are successful and can be curative of feeding disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for radiofrequency lesioning of the sacroiliac joint nerves and thoracic facets for treatment of her degenerative disc disease in her lumbar spine.   Findings:  Three physician reviewers found that Van Wijk and colleagues designed a multicenter, randomized, double-blind, sham treatment controlled trial to determine the efficacy of radiofrequency rhizotomy, as it is routinely performed. The combined outcome measure showed no differences between radiofrequency rhizotomy and sham. Facet blocks are a useful diagnostic procedure but facet denervation has never been shown to be efficacious as a therapeutic maneuver.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for sacroiliac joint injections for treatment of her sacroiliitis. Findings:  Two physician reviewers found that there is no strong scientific data supporting the efficacy or necessity of sacroiliac joint injections for therapeutic relief. A study by Hansen and colleagues found that the evidence supporting therapeutic intraarticular sacroiliac joint injections is limited.