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

The parent of a five-month-old male enrollee has requested for Synagis injections for treatment of the enrollees RSV risk. Findings:  The physician reviewer found that the American Academy of Pediatrics guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. The risk factors are school age siblings, day care attendance, airway abnormality, neuromuscular disease, and/or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality, from RSV disease in infants up to 12 months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is 5 times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams, as noted by Holman and colleagues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-month-old female enrollee has requested for Synagis injections for treatment of the enrollees RSV risk. Findings:  The physician reviewer found that the American Academy of Pediatrics guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. These risk factors include school age siblings, day care attendance, airway abnormality, neuromuscular disease, and/or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality, from RSV disease in infants up to 12 months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is 5 times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams, as noted by Holman and colleagues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for surgical resection of lung nodules through a clamshell incision or stage thoracotomies for treatment of her adenocystic carcinoma.  Findings:  The physician reviewer found that the decision to approach by a single operative approach (clam-shell) or separate bilateral thoracotomies is not relatively significant, since they would be considered to be essentially equivalent. Although a biopsy has been recommended, the radiologic appearance is very consistent with metastatic disease, and this seems most likely. The question is whether to proceed immediately to surgery to provide a survival benefit (especially as the patient is currently asymptomatic).
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for emergency services for treatment of herdifficulty, frequency, and pain with urination. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. The patient had no signs of systemic toxicity and could have been safely treated as an outpatient. The duration of the Emergency Department visit was very short, and the patient was in stable condition throughout the entire visit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Provigil 100 mg (#30) for treatment of her fatigue secondary to metastatic cancer.   Findings:  The physician reviewer found that fatigue is among the most commonly reported symptoms of patients with cancer, with prevalence exceeding 60%. The etiology remains poorly understood and all cancer patients should be evaluated for fatigue and all treatment options should be considered for those who are experiencing excessive levels of fatigue. Treatment should be individualized according to the underlying pathology when a specific cause has been identified (anemia, sleep disorder, depression or metabolic disorder). In addition to older therapies such as hematopoietics, antidepressants, corticosteroids, and psychostimulants, Provigil has been shown to promote a sense of well-being, decreased fatigue and increased appetite.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for speech therapy for treatment of the enrollees cleft palate.  Findings:  The physician reviewer found that guidelines for admission to speech and language therapy services by the American Speech-Language-Hearing Association (ASHA) in that: 1) the patients communication abilities are not comparable to those of same chronological age and gender, 2) the patients communication skills negatively affect educational and social status, and 3) individual and family speech services are necessary to achieve and maintain optimal communication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The husband of a 60 year old female enrollee has requested two positron emission tomography (PET) scans for an evaluation of the enrollees metastatic lung cancer. Findings:  Three physician reviewers found that for this patient, restaging with PET/CT was imperative to her treatment planning. The outcome of the PET scans allowed appropriate treatment planning. Standard imaging (CT, MRI) would not have provided adequate clinical information for treatment planning for this patient. The diagnostic procedures at issue were likely to be more beneficial for evaluation and treatment of this patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested emergency services for the treatment of the enrollees ear pain and congestion. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe the patients health to be in jeopardy without immediate medical attention. This patient awoke crying and complaining of earache. She did not receive any pain medication at home. She presented to the Emergency Department in no acute distress. Her vital signs including her temperature were normal. Her otitis media could have been managed safely in an outpatient setting. She could have received pain medicine at home and been seen safely the next day by her primary care physician. Her condition was stable in the Emergency Department. The submitted documentation does not establish the presence of a condition that would cause a prudent layperson with an average knowledge of medicine to reasonably expect that the patients health was in jeopardy without immediate emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested inpatient care for the treatment of her alcohol dependence, anorexia nervosa and major depressive disorder. Findings:  The physician reviewer found that this patient was particularly ill and in need of care in a sub-acute residential substance abuse treatment program, or a higher level of care, during the period in question. She was an overt danger to herself because of her eating disorder and alcohol abuse. She clearly required 24/7 professional supervision without which her purging, use of laxatives and other behaviors would have created a life-threatening event. The records indicate the presence of various treatment plans that were directed toward treatment of a severe mental illness. This included, but was not limited to, psychopharmacologic treatment. The progress notes provide sufficient detail to support the medical necessity of this level of care. There was weekly, and often more than weekly, documented psychiatric visits. The patients ambivalent motivation appears to have been a manifestation of her psychopathology. Based upon the submitted clinical documentation, any lesser level of care would not have been appropriate or safe. This patient required inpatient psychiatric care of the nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested one year of aftercare with private counseling for the treatment of his psychiatric condition. Findings:  The physician reviewer found that due to the extent of the patients cocaine dependence, his very meager social support and baseline Paranoid Personality Disorder, any program which would offer him more support and social skill training so as to maximize his chances of sustained sobriety is medically necessary. As well, the patient attended multiple sessions over the weeks.  He attended IOP approximately twice a week. This is not an excessive use of IOP services given the patients pathology. Overall, I find that the requested additional treatment in IOP is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested the FlexiTouch System for the treatment of her lymphedema. Findings:  Three physician reviewers found that the FlexiTouch System obtained FDA approval in 2002 and again in 2006 (for additional indications) and has demonstrated proven efficacy and benefit. It has been a well-accepted and prescribed treatment for over four years. This patients specific condition can be effectively treated with the FlexiTouch device. At this time, there are no other at home therapy devices as effective as the FlexiTouch System for this patients condition. The other types of standard therapy have been of little or no benefit for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested Transfer Factor Therapy for treatment of his atopic dermatitis. Findings:  The physician reviewer found that there have been no randomized controlled trials to establish the efficacy of transfer factor for atopic dermatitis or contact dermatitis. A meta-analysis of all randomized controlled trials of the various treatments for atopic dermatitis found that there was reasonable evidence to support the use of oral cyclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy. There was insufficient evidence to make recommendations on maternal allergen avoidance for disease prevention, oral antihistamines, Chinese herbs, dietary restriction in established atopic eczema, homeopathy, house dust mite reduction, massage therapy, hypnotherapy, evening primrose oil, emollients, topical coal tar and topical doxepin. Finally, there are no randomized controlled trials to support the use of transfer factor in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for Omnaris nasal spray for treatment of her allergies. Findings:  The physician reviewer found that there is no clear evidence to support that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Botox injections for treatment of her chronic headaches with migraines.   Findings:  Two physician reviewers found that recent evidence has shown that botulinum toxin also blocks the neuronal release of nociceptive mediators such as substance P, glutamate, and calcitonin gene-related protein. In a recent study, Frietag et al. suggested that botulinum toxin may be an effective treatment in chronic migraine without medication overuse. Mathew, et al. and Silberstein, et al. also suggested the efficacy of Botox as a prophylactic treatment for chronic daily headaches. Mathew, et al. (2008)  also opined that chronic migraine patients respond better to Botox than chronic tension-type headaches.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested Lyrica for the treatment of her erythromelalgia. Findings:  The physician reviewer found that erythromelalgia is a rare condition which has no known cure. The pain experienced by patients is usually severe. In fact, the Mayo Clinic has a special three-week program to help patients with erythromelalgia tolerate their pain. Because this patient has tried many medications without adequate relief, a trial of Lyrica would be medically reasonable to treat her pain. Although there are no studies available specifically addressing Lyrica for erythromelalgia, this is due to the rarity of the condition. Given the lack of effective therapies in this setting, Lyrica is medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a sleep study for an evaluation of her insomnia. Findings:  The physician reviewer found that the patient presents with specific symptoms characteristic of sleep apnea as described in all relevant sleep literature and in the Health Plans guideline itself. The description of symptoms is very specific and includes: snoring, gasping, morning headaches, and fatigue. Failure to appropriately diagnose and subsequently treat this patient is likely to lead to increased morbidity. Practice parameters dictate that a sleep study is appropriate and necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested the use of a real time remote heart monitor (electrocardiographic monitor) for an evaluation of her heart condition. Findings:  Two physician reviewers found that this patient clearly had symptoms that could not be confined to a 24-hour period and other options, such as obtaining an electrocardiogram during the episode, were not practicable. The only means to establish the presence of an arrhythmia was by the use of the real-time remote heart monitor (electrocardiographic monitor) during the symptoms. There is every clinical indication to use an event recorder such as this which can be triggered by the patient during her episodes. This would, undoubtedly, help, not hinder in looking after this patient. Thus, the use of a real-time remote heart monitor was appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested topical compound pain medication for the treatment of her atypical facial pain. Findings:  The physician reviewer found that facial pain is difficult to treat effectively for many patients. Often numerous medications and treatments have been used with no relief. The more resistant the pain, the more treatments that are tried, and frequently the new treatments fail as well. The current use of topical medications appears promising for pain relief, but has not been proven by evidence-based studies to be any more effective than placebo. One study attempted to find any traces of the chemical in the blood, and was not able to find even trace amounts. At this time, the use of topical pain medications is not the standard of care. There is not enough medical literature that supports the efficacy of topical agents such as Ketamine HCl for the treatment of pain to warrant their use in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for Alimta (pemetrexed) for treatment of her ovarian cancer.  Findings:  The physician reviewer found that Alimta (pemetrexed) has been approved for use in mesothelioma and non-small cell lung carcinoma, and has begun trials in ovarian cancer. The ASCO 2008 abstract wherein 61 patients similar to this one were treated with Alimta. One patient had a complete remission and 19% had partial responses, with a median overall survival of 11.4+ months. There is a 2009 trial reported (see Vergote, et al.) wherein 102 similar patients were treated with two different doses of Alimta. The overall response rate was about 10% and the median survival was about 11 months. The conclusion was that the drug had some activity in ovarian cancer.Neither of these studies demonstrated a high level of activity, such that Alimta remains an investigational agent in ovarian cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for an intraocular lens implant to correct his left eye cataract condition. Findings:  The physician reviewer found that multifocal lenses are dependent on excellent macular function in order to provide any hope of improvement instead of degradation of vision. This patient did not have excellent macular function prior to surgery, and therefore was not an appropriate candidate for implantation of a multifocal lens.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for an artificial disc replacement for treatment of her low back pain. Findings:  Three physician reviewers found that there are no long-term studies that have proven that lumbar artificial disc replacements are more effective in the treatment of discogenic pain than standard modes of treatment. Further studies are needed before the long-term safety and efficacy of the proposed procedure can be adequately determined.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for an additional 24 sessions of speech therapy (twice weekly) for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that Law and colleagues noted the efficacy of prolonged speech therapy for improving speech developmental articulation defects in children. Thus, applying this data to this specific patient shows that continued speech therapy has potential benefit. The report by Goorhuis-Brouwer and Knijff noted that speech therapy is effective in most intellectually normal children as well as children who are intellectually challenged.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested for in-home physical therapy for treatment of her post amputation. Findings:  The physician reviewer found that the lack of progress from prior therapy. In order for therapy to be medically necessary, there must be evidence of progression or improvement for the services to be continued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for intensive inpatient physical rehabilitation for treatment of her spinal injury with resultant paraplegia. Findings:  The physician reviewer found that the patient has already had an inpatient rehabilitation stay, and there are no medically unstable issues that require inpatient care at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for the prescription medication Aciphex for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. All PPIs are essentially equivalent in terms of healing control of intragastric pH over 24 hours. However, interpatient variability has been seen with PPIs. Milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested a central auditory processing evaluation for an evaluation of the enrollees hearing problem. Findings:  The physician reviewer found that a wide variety of tests can be utilized to provide an appropriate assessment, including auditory discrimination tests and auditory temporal processing and patterning tests. Interpretation of such tests should be performed by individuals experienced in the complexities of central auditory processing disorders. This patient has been evaluated with standard audiologic testing and still eludes diagnosis. She continues to have difficulty hearing instructions in school and differentiating between speech sounds. It is not clear whether her short-term memory loss is related at this time. It is therefore medically necessary and appropriate to pursue further diagnostic studies for possible central auditory processing disorder with personnel experienced in diagnosis and management of the complex disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested Supartz injections for the treatment of his osteoarthritis. Findings:  The physician reviewer found that viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. The Health Plan has reasonable requirements that first-line treatments be tried prior to viscosupplementation, and the patient has not yet met this criteria. There are no documented contraindications to the therapies recommended by the Health Plan. Therefore, the requested therapy is not medically indicated or appropriate for this patients care absent a trial of the above-mentioned first-line treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested Bystolic for the treatment of his hypertension. Findings:  The physician reviewer found that although there are fewer side effects associated with this drug, there is no indication for Bystolic to be selected over any of the other beta-blockers.  The Health Plans position that the patient try a third beta blocker in addition to Coreg and atenolol before being given Bystolic is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a continuous passive motion machine for the treatment of her knee, status-post right knee arthroscopy. Findings:  The physician reviewer found that although the use of the CPM machine after joint surgery has gained popularity among orthopedic surgeons, the literature has been slow to establish evidence-based studies that support the use of the CPM machine for any type of knee surgery. The Health Plans denial of the use of a CPM device is appropriate given the lack of medical literature showing superior outcomes 6 months post surgery, or in other words, the end result is the same with or without the use of the CPM machine after 6 months. The clinical value of post-operative CPM therapy remains unproven in this setting.