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

A 50-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that the patient meets the recommendation set by the National Institutes for Health for weight loss surgery. The Health Plan has instituted a 10% preoperative weight loss prior to surgical intervention. Their own provided technology review document reports that the data in support of this position is lacking.  There is one blinded study with less than 70 patients to support this argument. The patient should be authorized to have weight loss surgery, as the requested procedure is medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested the Vest Airway Clearance System (Vest) for the treatment of her bronchiectasis. Findings:  Two physician reviewers found that the patient has been treated appropriately with ABX-mucous retrieval without success. She has utilized the Vest since March 2007 with significant benefit. The Vest has adequate data to support it as an effective tool in the treatment of cystic fibrosis and bronchiectasis of other etiologies. This patient has made adequate attempts at clearance utilizing other available therapies (e.g., chest physiotherapy, flutter device) without sustained benefit. Therefore, the records demonstrate that the Vest is the most beneficial treatment for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested an emergency room visit for the treatment of her abdominal pain. Findings:  The physician reviewer found that the enrollee suffered from severe abdominal cramps as well as reported nausea, fever, chills and malaise. A prudent layperson would have sought immediate medical attention due to the severity of her pain as well as her associated symptoms. There are a variety of potentially life-threatening conditions that present with such symptoms including appendicitis, kidney stones, urinary tract infection, pyelonephritis, ovarian torsion, pelvic inflammatory disease and others. Although it is fortunate that this enrollees condition improved with anti-emetic treatment, these other potentially life-threatening disorders could not have been ruled out without emergency medical evaluation. If she had not sought care, and had appendicitis or one of the other disorders, her condition could have possibly become life threatening (such as perforation of an infected appendix).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested continued Botox therapy for the treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox is approved for use in blepharospasms (which this patient is reported to have). The patient has also had a reduction in her migraines on this therapy thus further justifying its use. She has failed other first-line therapies for migraine including Topamax, Depakote, and narcotics (among others) and is not a candidate for Imitrex use given her prior stroke history. The use of Botox for this patient is both medically reasonable and necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested microvascular lymphatic reconstruction surgery for the treatment of her lymphedema. Findings:  The physician reviewer found that this patient does not have many options. The conservative measures she has tried have not worked. There is literature to support this procedure. Because there are very few experts dealing with this problem, considerable weight should be given to the physicians willing and able to deal with this complicated process of post-mastectomy/radiation lymphedema. There are no adequate alternatives for this patient, and the requested procedure is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested for a cooling device and combined cooling/heating device for treatment of his post-surgical pain and swelling. Findings:  The physician reviewer found that the literature does not demonstrate any significant benefit of cryotherapy or pneumatic cooling devices over standard intermittent ice pack cold treatment for postoperative recovery following rotator cuff repair surgery. Furthermore, there is no evidence that such devices lead to improved outcomes in the mid and long terms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a seven-year-old male enrollee have requested speech therapy services for the treatment of the enrollees mildly delayed expressive language disorder. Findings:  The physician reviewer found that the records provided demonstrate a clear diagnosis of expressive language delay as well as semantic and syntax problems. The therapy program instituted was reasonable and within the standard of care. The patient clearly had a condition that would benefit from speech therapy. The therapy provided was, in fact, beneficial for this patient. All the information submitted demonstrates that this patient was an appropriate candidate who received an appropriate course of indicated speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for hyperbaric oxygen treatment for treatment of her osteomyelitis. Findings:  The physician reviewer found that there is sufficient retrospective data to support hyperbaric oxygen as adjunctive treatment for this patients condition. Hyperbaric oxygen is commonly utilized for treatment of this patients conditions and has a significant likelihood of assisting in substantially improving this patients condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that proton beam therapy is an effective way to heat prostate cancer with minimal side effects. IMRT is well studied as well, and the literature to date reveals equally effective survival with prostate cancer and diminished side effects compared to conventional radiation therapy. Furthermore, as of now, there is no published superiority of proton beam therapy over IMRT.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for revision of gastric bypass with adjustable gastric laparoscopic banding (Lap-Band)  for treatment of her morbid obesity.   Findings:  Three physician reviewers found that there is no peer-reviewed publication to support Lap-Band placement following failed Roux-en-Y gastric bypass surgery. Furthermore, the fact that the patient has failed one restrictive procedure indicates that she will most likely fail Lap-Band.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for a bi-directional static progressive stretch wrist device for treatment of his displaced fracture of the left distal radius.   Findings:  Two physician reviewers found that joint stiffness or contractures are not uncommon after surgery for treatment of this type of fracture. Physical therapy was instituted appropriately after surgery, but the stiffness persisted. A joint active system (JAS) bi-directional static progressive stretch splint was utilized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for vaginal/bladder reconstructive surgery for treatment of her recurrent cystocele, rectocele, enterocele with incontinence. Findings:  The physician reviewer found that there is no information submitted demonstrating why the vaginal approach would be necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for the prescription medication Humatrope for treatment of her pituitary disorder.  Findings:  The physician reviewer found that there are issues other than growth hormone deficiency, such as hypothyroid state and poor nutrition, that can cause a low IGF1.  Although this patient may have growth hormone deficiency, it has not been established by the tests and other information provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 85-year-old male enrollee requested for skilled nursing and rehabilitation services for treatment of his knee amputation.  Findings:  The physician reviewer found that his family has indicated they do not wish to care for him at home so he has no competent and committed care givers at home.  It is reasonable and medically indicated for him to receive skilled physical therapy and likely occupational therapy as well.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for a bilateral breast MRI study for evaluation of her left breast mastalgia.   Findings:  Three physician reviewers found that breast MRI is a useful adjunct to mammography and ultrasound in a select group of patients. This includes patients with recently diagnosed breast cancer, those patients with known BRCA mutation and patients with axillary node positive breast cancer with a negative mammogram. Breast MRI should not be utilized to avoid biopsy of a suspicious lesion. As set forth above, this patient does not have a family history of breast cancer in a first degree relative (e.g., mother, sister) or a documented BRCA mutation and does not have a recent diagnosis of breast cancer.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for a breast MRI  study for a history of breast cancer.   Findings:  Three physician reviewers found that the use of breast MRI has been shown to be efficacious in certain patient populations for both screening and diagnostic purposes. The breast MRI can better evaluate the remaining left breast tissue and area of scarring for malignancy than mammography.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested for continued Cerezyme infusion therapy for treatment of her Gauchers disease.   Findings:  The physician reviewer found that the elevated blood pressure does not represent an emergency and is not beyond what a person may experience with anxiety. There are a number of ways of dealing with anxiety. People often experience anxiety when undergoing medical procedures. Anxiety does not represent a contraindication to home infusion, nor is it an indication that a hospital outpatient program is medically superior. The blood pressure may also be related to anger and frustration about loss of control. All are normal emotions for someone dealing with an unpleasant procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eleven-year-old female enrollee has requested Applied Behavioral Analysis (ABA) for the treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA is more beneficial than standard autistic treatments and is now considered a non-investigational mainstream therapy. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings, including the home, school and community. ABA-based interventions have been very well-documented. More recently, a review of the state of the science for pediatric primary health care clinicians on autism (Asch. Pediat. Adolesc. Med/Vol 160, Nov 2001) claims ABA is superior to other intervention strategies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Avastin chemotherapy treatment in combination with vinorelbine (Navelbine) for the treatment of her breast carcinoma. Findings:  The physician reviewer found that Avastin has been approved for use in metastatic breast cancer, as first line therapy of metastatic disease, along with Taxol. There is no real data for its use in breast cancer in other situations and/or combinations. Its use here would be a situation in which there is no proven clinical benefit, and it is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a PET/CT scan for an evaluation of his pelvic mass. Findings:  The physician reviewer found that this patient has multiple findings on recent CT studies of the abdomen and pelvis. It is uncertain if these findings are benign or malignant and further imaging of the abdomen and pelvis with MRI would be the next appropriate imaging study. MRI can help determine if the liver lesions are benign or malignant, evaluate the right renal fossa for a mass and further evaluate the pelvic mass. The PET/CT scan that was requested is not medically necessary at this time, as there is no known malignancy. Tissue biopsy is usually obtained prior to PET/CT scan. PET/CT scans are used for staging and restaging purposes and not for the initial diagnosis of cancer.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested an X-Stop Interspinous Process Decompression procedure for the treatment of his moderate lumbar stenosis and intermittent neurogenic claudication. Findings:  Three physician reviewers found that there are no long-term outcome studies to establish the safety and efficacy of the X-Stop device after the device has been implanted. The existing literature is all relatively short-term data.  There is some concern for subsidence of the implant over time and loss of its initial distracting effect on the osteoporotic spinous processes. This 64-year-old patient would present significant concerns for osteoporotic bone based on age alone. Furthermore, significant numbers for outcomes of X-Stop procedures have not been well-defined in the literature, especially in the mid-term and long-term. The gold standard procedure in this case is lumbar decompression using a traditional and simple laminectomy with in situ fusion which can be performed using the laminectomy local bone. This does not involve the placement of metallic spinal hardware adjacent to osteoporotic spinous processes. There is ample literature to support the gold standard simple laminectomy procedure and the laminectomy with in situ fusion. X-Stop is not the most appropriate procedure for this patient and is considered experimental for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested The Vest Airway Clearance System (Vest) for the treatment of his bronchiectasis. Findings:  Three physician reviewers found that the nationally accepted medical necessity criteria for high frequency chest wall oscillation devices (HFCWO) such as the Vest system indicates such equipment is necessary for patients who have a diagnosis of bronchiectasis and have failed available standard treatments. This patient has a diagnosis of bronchiectasis and has failed available standard treatments. The Vest system is medically indicated for this patient and is likely to provide significant benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested feeding therapy for the treatment of the enrollees spastic cerebral palsy, bronchopulmonary dysplasia, feeding dysfunction, G-tube issues and GERD. Findings:  The physician reviewer found that this patient has suffered a number of complications as a result of his extreme prematurity, not the least of which is oral feeding intolerance requiring gastrostomy tube feedings. He has shown some progress with typical feeding therapies, but his care team feels that intensive therapy will provide the best results. Feeding disorders are fairly common in the pediatric population, with up to 25% of children having some form of feeding problem. Up to 80% of developmentally delayed children experience feeding difficulties. Consequences can be significant, including failure to thrive, susceptibility to chronic illness, and even death. The standard approach to feeding problems involves a team of specialists, including physicians, nurses, nutritionists, occupational therapists, speech therapists, and psychologists. For children transitioning from tube feedings to oral feedings, a more intensive biobehavioral approach has proven to be effective. This patient has shown some improvement with standard feeding interventions, but an intensive feeding program is medically necessary to successfully facilitate the transition from gastrostomy tube feedings to full oral feedings.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female enrollee has requested an emergency room visit for the treatment of the enrollees ear pain. Findings:  The physician reviewer found that the Health Plan provides emergency services when medically necessary. An emergent medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the patients health in serious jeopardy. This patient had been suffering from an earache since the morning in question. She was not noted to be in severe pain, and she did not require any pain control in the emergency department. Otitis media is commonly viral in nature. Antibiotics are often prescribed to allow for the possibility that the infection is bacterial in nature. However, the rapidity with which a patient receives antibiotics had not been shown to affect the rate of tympanic membrane rupture. While this patients symptoms likely required medical evaluation, this could have been provided on a less urgent basis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested an artificial intervertebral disc replacement procedure for the treatment of his cervical disc herniation and pain. Findings:  Three physician reviewers found that there is insufficient data to establish the long-term safety and efficacy of disc replacement. In addition, the data does not establish disc replacement as more beneficial than other available procedures. Furthermore, there have been significant re-operations associated with disc replacement.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested biofeedback and physical therapy for the treatment of her dyspareunia and severe painful muscle spasms. Findings:  Two physician reviewers found that there can be a number etiologies and contributing factors to both of these issues, and there appears to have been very little work-up by her physician. From the description of the findings by the physical therapist, there appear to be some elements of vaginismus, and a course of treatment was prescribed, including biofeedback. Biofeedback is treatment given with feedback generated to the patient to know when they are relaxing a particular muscle. The data is limited as to whether biofeedback by itself improves outcomes separate from the physical therapy. There is no evidence that this patient requires the requested services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested a tissue rearrangement procedure for the treatment of the enrollees scalp scar. Findings:  The physician reviewer found that in 1998, the California legislature passed AB1621 (Figueroa), which added Section 1367.63 to the Health and Safety Code. Section of 1367.63 of the Health and Safety Code requires Health Plans to cover reconstructive surgery, which is defined as `surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, in order to improve function or to create a normal appearance, to the extent possible. Cosmetic surgery is defined as surgery `performed to alter or reshape normal structures of the body in order to improve appearance`. Health Plans are not required to provide coverage for cosmetic procedures.  This patients scalp alopecia is an abnormal structure caused by a congenital defect.  The surgery is reconstructive to normalize appearance as it will provide the patient with a complete head of hair rather than enhance an already normal appearance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested the prescription drug Crestor for the treatment of her elevated cholesterol and LDL levels. Findings:  The physician reviewer found that the alternative medication trial with formulary medication is well within the standard of care for lipid control in a patient who has no history of intolerance to statin therapy. Therefore, the Health Plans denial is reasonable, and it cannot be determined that Crestor is medically necessary for this patient. If the recommended trials of the formulary alternatives are ineffective, then Crestor should be considered for the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested sub-acute residential care for the treatment of the enrollees disorders. Findings:  The physician reviewer found that A review the record indicates that the patient is indeed severely disturbed with a complex set of psychiatric and developmental disturbances. He has been given a great deal of expert care in the recent past. However, his progress throughout the course in the residential setting was minimal or even non-existent. He did not progress in the classroom, his social interactions remained poor, and his misbehaviors continued almost unabated.  He did not respond well to interpersonal therapy, correction or redirection.  I agree with the idea of a therapeutic boarding school. Such a facility may more effectively meet the patients needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested the prescription drug Lexapro for the treatment of his major depression. Findings:  The physician reviewer found that the Health Plans criteria for coverage of the requested medication are medically appropriate and reasonable, and the patient has not met these criteria. In addition, the medical data contained in the record is rather limited. The treating physician does not explain his rationale for the current medications that are being used, nor does he explain what about the patient made him so difficult to stabilize. The treating physician suggests the patient has become manic at times, but he does not elaborate. Although the patient is now doing well, there is no specific reason given why this improvement is linked to Lexapro, and why the use of a formulary antidepressant would not be equally effective.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that CyberKnife radiation therapy is a very precise method of delivering radiation to a very specific field, and it has been used in a variety of tumor types where such precision is very important. It also has the advantage of entailing a relatively brief period of therapy (1-5 days) compared to more conventional radiation methods. Submitted with the appeal is the data from a Phase I trial wherein 15 patients with pancreatic cancer were treated with this methodology. As a Phase I study, it was mostly focused on the toxicity and feasibility of such treatment, not the long-term results attained. As expected with this cancer, all patients progressed, and the median overall survival was 11 months.