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

SummaryThe patient is a 53-year-old female who has had bilateral below-the-knee amputations and amputation of the left thumb and right index finger, and right hip avascular necrosis.  She also has 90 degree contractures of the metacarpals and impaired web-space opening with the left hand such that she is not able to grasp objects greater than two inches in size.  She is requesting reimbursement for the cost of equipment and installation of the Bruno Electra-Ride III stair lift.  The Health Plan denied her request citing a lack of medical necessity.Clinical Facts:  The patient has had bilateral below-the-knee amputations and amputation of the left thumb and right index finger at the distal phalanx. The record also indicates she has 90 degree contractures of the metacarpals and impaired web-space opening with the left hand such that she is not able to grasp objects greater than two inches in size. The patients grasp strength was 21 pounds on the right and 13 pounds on the left when she was evaluated in July 2005. She has Herrington rods from T4 to T2 with decreased mobility of the spine. Furthermore, the patient has right hip avascular necrosis with limited range of motion in both hips and she has a history of medial meniscus injury to her right knee. Reviewers Findings:The physician reviewer indicated that patient has a complex medical history and considering her various medical conditions, it would be extremely difficult for her to safely ascend or descend stairs even while holding onto the railing with both hands. For this reason the reviewer has concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-five year-old obese female with multiple comorbid conditions is requesting authorization for Lap-Band surgery.  Reviewers Findings:  The reviewing physician found that Pending successful psychological evaluation, the patient is a suitable candidate for Lap-Band surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-two year-old obese female with multiple comorbidities is requesting authorization for Lap-Band surgery.Reviewers Findings:  The reviewing physician found that the clinical information provided demonstrates that the patient is a suitable candidate for Lap-Band surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Twenty-three year-old female patient has been diagnosed with severe, recurrent, major depression starting at the age of 11 to 12 years and has been treated with numerous medications, as well as psychotherapy and electroconvulsive therapy. She has been admitted to inpatient psychiatric care a number of times. In spite of all these interventions, her symptoms of depression have continued. The patient reportedly has decreased activity, increased sleep, poor concentration, social isolation, decreased appetite, irritable mood, suicidal ideation and self-injurious behaviors.  Reviewers Findings:  The reviewing physicians concluded that the psychiatric community at large has not yet embraced VNS therapy as part of the national standard of care for severe depression. The American Psychiatric Association (APA) has gone on record in stating, While VNS therapy has been studied over the past five years, evidence is not yet sufficient to recommend its use in routine clinical care. VNS therapy is not, at this time, included in the APA treatment guidelines for major depression. That said, it is very likely a future iteration of the guidelines will include a recommendation regarding the use of VNS therapy for carefully selected patient and provide a stringent protocol-driven selection process. Clinical and preclinical research with VNS therapy is ongoing and when sufficient data is accumulated the role of VNS therapy in the treatment of depression will become clearer. Until that time recommendations for its use for patients such as this one are premature. Therefore, the reviewers found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Fifty-four year-old male has been diagnosed with lumbar degenerative disc disease. He continues to have pain with activity.  He is requesting an MRI for further evaluation.Reviewers Findings:The reviewer found that based upon the clinical presentation and his examination of the patient, the patients provider has determined an MRI is indicated to further investigate the cause of the patients pain and to better plan his treatment. As the patient has persistent pain, an MRI study is medically prudent and clinically indicated for further workup as to the cause of his pain.  Therefore, the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested authorization and coverage for vagus nerve stimulation (VNS) therapy for treatment of behavioral health problems.  Reviewers' Findings:  The three physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression. Also of concern with VNS are the reports of worsening depression and emergence of mania/hypomania. Additionally, there have been reports of VNS emergent suicide, suicide attempt and suicidal ideation. Over the course of up to two years, 77 serious adverse effects (worsening of depression, suicide attempt and mania) were reported in 60 patients with 12 of 60 patients attempting suicide.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-four year-old male with a diagnosis of chronic fatigue syndrome is requesting authorization an out-of-network referral.  Reviewers Findings:    The reviewing physician found that because of the complexity of the patients case an outside referral is appropriate.  The Health Plan denial was overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of the lumbar sympathetic chain.Reviewers' Findings:The three physician reviewers found that the safety and efficacy of RFA of the lumbar sympathetic chain for the treatment of CRPS has not been established. The use of RFA in this context is not medically indicated and is not consistent with the community standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 51 year old woman with advanced pancreatic cancer and has received multiple courses of chemotherapy without benefit.  She is asking for authorization to participate in a multi-modality Phase I clinical trial.  The Health Plan denied authorization on the basis that it is experimental and therefore, not a covered benefit.  Two of the three  physician reviewers concluded that the proposed trial is clinically appropriate and that the Health Plan denial should be overturned.  The third reviewer determined that the denial should be upheld.Analysis and FindingsClinical Facts:  The patient has metastic pancreatic cancer and received multiple courses of chemotherapy.  A CT scan performed in April 2006 showed metastasis to the liver. The patients CA 19-9 was 12,000. She is status post gemcitabine and Cisplatin, and then gemcitabine, Xeloda and Avastin treatments. In August 2006 there was an increase in her CA 19-9. Her treatment regimen was changed to oxaliplatin, Avastin and Xeloda. The patients CA 19-9 increased to 24,000. The patient is requesting authorization for participation in a clinical trial with combination therapy of Yttrium-90 Labeled Humanized Anti-CEA M5A Antibody and gemcitabine. Reviewers Findings:  One reviewer indicated that there is no evidence that the patient will benefit from the trial, which is for patients with CEA producing malignancies. The trial involves gemcitabine, which has failed in the patient. The reviewer stated that there is insufficient evidence that the proposed therapy will be superior to standard therapy in this setting.  The other two physicians determined that the  patient has exhausted all standard therapies. Radioimmunotherapy has a proven track record in other malignancies (lymphoma).  The proposed experimental therapy has a higher probability of succeeding than no therapy at all. Thus, in this clinical setting where options are extremely limited the proposed trial, as demonstrated in NCCN guidelines, is clinically appropriate.  These reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 51 year old female with uterine fibroids and symptoms of menorrhagia, dysmenorrhea and pelvic pressure and has undergone a previous uterine artery embolization (UAE).  She is asking for authorization of for a repeat UAE procedure.  The Health Plan denied her request based upon a determination that a second UAE is considered investigational.  Two of the three physician reviewers concluded that the proposed treatment is clinicaly appropriate and the Health Plan denial should be overturned.  The third review determined that the denial should be upheld.  Analysis and FindingsClinical Facts:  There is evidence, according to a progress note, that the patient has had a previous myomectomy, the date is unknown. The patients provider noted the uterus was at least 12 weeks in size on pelvic examination. This was confirmed with pelvic ultrasound, with a 14cm length observed. The patient was offered standard treatment options including hysterectomy. She declined surgical intervention and chose uterine artery embolization (UAE). An endometrial biopsy prior to the procedure was benign. The UAE was performed on October 2006. During the procedure the left uterine artery was successfully embolized, but the right horizontal uterine artery could not be cannulated. After the first UAE procedure the gynecologist performed a laparoscopic ovarian cystectomy, and endometrial resection on October 2006.Reviewers Findings:One reviewer indicated that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition.  There is no way to be sure that a repeat procedure would be any more successful than the first.  The review also indicated that the patient is likely to become menopausal in the near future. Interval treatment with hormones to temporarily diminish the symptoms until menopause occurs is consistent with the standard of care. When menopause does occur, the symptoms should abate and the fibroid should decrease is size.The other two physicians determined that the patients requested procedure is likely to be more beneficial for treatment of the patients medical condition.  The right uterine artery could not be cannulated at the time of the initial procedure, the embolization is not considered to be complete unless both uterine arteries are occluded. In this case, the need for a second procedure did not arise from a failure of the initial embolization, but rather from the fact that bilateral embolization could not be accomplished. In this context, a second embolization is not experimental as it is clearly a continuation of the original procedure.  These reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

SummaryThe patient is a 54 year old male who has prolonged acute hospitalization who was subsequently admitted to a skilled nursing facility for physical therapy (PT), occupational therapy (OT), IV antibiotics and wound care.  The patient request reimbursement of the services provided after October 2006.  The Health plan denied his request based upon a determination that the services provided after October 2006 were not medically necessary.  The reviewing physician decided that the Health Plan denial should be upheld.Analysis and FindingsClinical Facts:  The patient has a prolonged acute hospitalization who was subsequently admitted to a skilled nursing facility for physical therapy (PT), occupational therapy (OT), IV antibiotics and wound care. He also had dry gangrene of his toes. PT and OT services were discontinued by October 2006 as well as the patients IV antibiotics and his PICC line. The patients wounds were stage II or less and his feet required only once per day dressing changes. There is no indication he required daily skilled wound assessment or more frequent dressing changes.Reviewers Findings:The physician reviewer indicated the patients IV antibiotics were completed and he had not progressed with PT or OT and remained at a functional level I. Although the patient is likely to benefit from daily range of motion and assistance with positioning tolerance, these are non-skilled interventions. With improvement in his medical condition the patient may, at some later date, benefit from additional PT and OT. The patients wounds do not require daily skilled care or frequent dressing changes.  The reviewer decided that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Thirty-year old female patient with a history of nipple discharge and new asymmetric firmness in her breast is requesting authorization for a diagnostic mammogram.. The patient has a family history of lymphoma, ovarian cancer and a grandmother who had breast cancer (post menopause). The patient had a negative mammogram in 2003, as well as two ultrasounds of both breasts in 2004, and one in 2006, all of which were negative. Additionally, an ultrasound of the right breast performed in 2005 was negative. The reasons for the exams were nipple discharge, pain and palpable abnormalities.Reviewers Findings:The reviewer found that in the case of this patient, nipple discharge has been reported, but the submitted medical records do not include any notes from the patients clinician about the quality of the discharge or the physical findings. The type of nipple discharge is important in determining if further evaluation is necessary. Based upon the information provided, there is a lack of a clear clinical indication for a diagnostic mammography.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

SummaryThe patient is a 30-year-old female with a diagnosis of relapsing-remitting multiple sclerosis (MS).  She request authorization of IV rituximab.  The request was denied by the Health Plan based upon a determination that the therapy is not medically necessary.  The reviewing physician concluded that the Health Plan denial should be upheld.  Analysis and FindingsClinical Facts:  The patient has relapsing-remitting multiple sclerosis (MS). She has had a substantial progression of disability since she was diagnosed in 1999, despite treatment with Copaxone and Rebif. The patient has also been treated with courses of steroids for acute flares, but has not regained her baseline status. An evaluation in the MS clinic resulted in a recommendation for more aggressive therapy with Novantrone. The pursuit of this therapy was halted due to the report of an echocardiogram from another hospital showing an impaired left ventricular ejection fraction (LVEF). Novantrone is contraindicated in the setting of cardiac impairment due to its potential for cardiac toxicity. A recommendation was then made for treatment with Rituxan (rituximab). Following that recommendation, a second echocardiogram was performed on July 2006 which was normal, with a LVEF of 60%.  Reviewers Findings:The reviewer concluded that Rituximab has been the subject of some small studies related to the treatment of MS. It appears to be a promising candidate for immunosuppression therapy in patients with MS, however research is on-going and the clinical benefits and safety profile have not been fully established. Novantrone is indeed contraindicated for individuals with low LVEF due to its potential for cardio-toxicity. However, the patient had a normal LVEF when her cardiac status was evaluated in July 2006, and there are presently no apparent contraindications to Novantrone therapy.  Therefore, the physician reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

SummaryThe patient is a 29-year-old female with long-standing diabetes complicated by severe gastroparesis.  Her provider has recommended gastric electrical stimulation.  The Health Plan has denied coverage for the requested procedure on the basis that it is considered investigational.  All three of the physician reviewers concluded that the Health Plan denial should be overturned.  Analysis and FindingsClinical Facts:  The patient has a history of severe diabetic gastroparesis refractory to medical management. She is currently on total parenteral nutrition (TPN). She suffers from constant nausea and recurrent episodes of vomiting requiring Zofran every six hours. She has sought treatment at the emergency room almost on a weekly basis and has required frequent hospitalization. A gastric emptying study was markedly abnormal with 20% gastric emptying at 30 minutes and 14% gastric emptying at 120 minutes.  The patient has filled multiple anti-emetics and requires continuous use of narcotic analgesics and benodiazepines. She has also used Zofran and a TCA antidepressant. An endoscopy performed in February 2006 was normal. A gastric emptying study performed in May 2006 confirmed severe gastroparesis.Reviewers Findings: The three reviewers found that the patient meets entry criteria as outlined by the manufacturer for use of the gastric electrical stimulator. These include symptomatic gastroparesis for greater than one year, refractory or intolerant to at least two anti-emetic and prokinetic drug classes, frequency of vomiting greater than seven times per week, and delayed gastric emptying defined by greater than 60% retention at 2 hours and greater than 10% retention at 4 hours.  Also, all conservative medical therapy to this point has failed.  Therefore the three reviewers found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-two year-old female with chronic back pain and who is status post two back surgeries is requesting reimbursement for her prior use of as well as prospective authorization for Actiq.Reviewers Findings:The reviewing physician found that Actiq has not been approved for the management of failed back surgery pain.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-nine year-old female who was diagnosed with left sided breast cancer is requesting coverage for the Oncotype DX assay.Reviewers Findings:The reviewing physician found that this test has been shown to be clinically useful and assisted the physician in the care and management of the patient.  The reviewing physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-seven year-old female who has chronic lumbar pain and a history of Barretts esophagus is requesting authorization and coverage for Celebrex. Reviewers Findings:The reviewing physician found that the patient has benefited from Celebrex in the past and is likely to experience continued benefit.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a four year-old male who experienced birth asphyxia and acute renal failure, which has persisted in stable renal failure with growth failure are requesting authorization of growth hormone therapy.  Reviewer's Findings: The reviewing physician found that the submitted clinical information indicates the patient is an appropriate candidate for growth hormone therapy based on the documented diagnosis of chronic renal failure and his severe growth retardation.  The physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-seven year-old male with a history of with post laminectomy syndrome is requesting authorization and coverage for Lyrica.  The patient is currently taking low doses of Neurontin and Ambien for sleep.Reviewers Findings:  The reviewing physician found that Lyrica is not generally prescribed until it has been demonstrated that the patient is unable to tolerate high-dose Neurontin or that the patient has not benefited from high-dose Neurontin.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A thirty-nine year-old obese female with comorbid conditions that include hypertension and sciatica is requesting authorization of Roux-en-Y gastric bypass surgery.Reviewers Findings:  The reviewing physician found that the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery.  The reviewing physician has determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-seven year-old male who presents with memory loss and loss of smell is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that there is not currently sufficient medical evidence to support the application of PET imaging for patients such as this one.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old female who has undergone gastric bypass surgery is requesting authorization of a bilateral thigh lift/dermatolipectomy.  Reviewers Findings:  The reviewing physician found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-nine year-old male with chemotherapy induced peripheral neuropathy is requesting authorization for Anodyne treatment.  Reviewers Findings:  The reviewing physician found that Anodyne is not currently among the accepted standard of medical care for treatment of chemotherapy induced peripheral neuropathy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-four year-old female with premenopausal osteoporosis is requesting authorization of treatment with Zometa.Reviewers Findings:  The reviewing physician found that the patient is obviously at high risk with apparent premature osteoporosis.  The reviewing physician found that the Health Plan denial should be overturned.