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

A 29-year-old female enrollee has requested medical services and physical therapy for the treatment of her ulnar nerve inflammation of the left upper extremity and partial tear left rotator cuff. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the physical therapy. The evidence demonstrates that the patient improved with the physical therapy services she received previously. By the time the patient established care with the provider of the services in question, the therapy could have continued as a home exercise program. The patient had achieved maximum benefit from supervised therapy and based on standards of practice, had received a sufficient number of therapy sessions by the date in question. The patient reported that her pain was intermittent. Additionally, there is no evidence that physical therapy is beneficial for ulnar nerve inflammation; medications were likely to be more effective for this condition, but do not appear to have been implemented. With regard to the medical services performed, the evidence does not demonstrate that the manipulation therapy that was provided was effective or indicated. The notes do not document range of motion/strength/tenderness and provide no indication of any improvement from the services provided. Thus, there is no objective evidence that these services were medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested growth hormone therapy (Genotropin) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients relatively advanced bone age indicates that his growth period is by now quite limited. The patient does not qualify for growth hormone therapy under the FDA guidelines for growth hormone therapy. Growth hormone therapy is not medically indicated for this patient. Furthermore, based on the patients relatively advanced bone age, growth hormone therapy is not likely to be of significant benefit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for Botox injections for treatment of her recurring headache, neck and muscle pain. Findings:  Three physician reviewers found that there is some literature to suggest the benefit of Botox for chronic headache disorders, the use of Botox should not be considered a first-line therapy for headache management. Instead, more studied and proven therapies should be attempted first.  Although this patient is taking multiple medications for headache, there is no documentation that she has tried first-line prophylactic medications such as a calcium channel blocker, beta blocker, or amitriptyline, and there is no documentation stating that these medications are contraindicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested use of a continuous passive motion machine (CPM) for the treatment of her right knee, status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that although there is some evidence of benefit in the use of CPM in the early postoperative period after ACL reconstruction, these benefits do not appear to extend with use beyond the initial few days. After several weeks, no significant differences are found with CPM use. Controversy remains regarding the use and duration of use of a CPM device after ACL reconstruction. However, no advantage has been demonstrated for prolonged outpatient use of a CPM device. Thus, the patients use of a CPM machine for several weeks following surgery was not likely to result in an improved outcome.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested the Bioness L300 Foot Drop System for the treatment of his incomplete spinal cord injury. Findings:  Two physician reviewers found that there are sufficient data to support a finding that this device stimulates gait close to normal, and has been successful in improving walking speed. In addition, the Bioness System offers synchronization of the stimulation site and timing, and brings the patients walking pattern closer to normal. This helps avoid hip hiking and should reduce back and hip pain as well. Alternate treatment would be use of an ankle-foot-orthotic (AFO). While an AFO can allow the patient to walk without falling, the ankle will tend to become stiff and the walking pattern is not likely to improve. All told, the Bioness System is superior to any other device available in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested hyaluronan (Euflexxa) injections for the treatment of her bilateral knee pain. Findings:  Two physician reviewers found that it is unlikely that simple introduction of aggrecan into the joint space will be incorporated into the complex structure of joint cartilage. There may be a short-term improvement in the viscoelastic properties of the synovial fluid until the aggrecan dissipates or breaks down. There is insufficient evidence that the hyaluronan injection will substantially alter prognosis or treatment. There are appropriate standard therapies available in this setting including non-steroidal anti-inflammatories (other than those already tried by the patient), a swim exercise program and the use of a cane or crutch to be used in the hand opposite the symptomatic knee. Hyaluronan is not likely to provide significant or lasting pain relief in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a PET-CT scan for an evaluation of his adenocarcinoma of the gastroesophageal junction. Findings:  Two physician reviewers found that while it is intuitive that PET-CT scan could be useful for evaluation of unsuspected tumor recurrence, there are no well-recognized indications using large studies for the use of PET-CT in patients without suspected tumor recurrence after appropriate therapy.  Thus, based upon the evidence and literature to date, there is no proven indication of PET-CT in this patients circumstance. De Potter and colleagues state, Because of its poor sensitivity and low negative predictive value, FDG-PET is not suited for screening purposes in the follow-up of treated gastric cancer.  If a patient has symptoms suggestive of recurrence of gastric cancer or indeterminate findings on a conventional CT scan, then PET-CT scan may be appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested silicone injection into her left heel for the treatment of her left heel pain. Findings:  The physician reviewer found that silicone injections are currently under clinical investigation for heel fractures. At this time, there is no peer-reviewed evidence demonstrating that silicone injections are effective for the treatment of heel pain status post heel fracture. Nor is there adequate data to determine the safety of the proposed silicone injections. In the past, silicone injections have been shown to cause serious liver problems. The use of silicone injection post heel fracture is not generally accepted as standard treatment in this setting, and as such, is not indicated for this patient. Other modalities are available in this setting, such as the use of silicone pads.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested electrical stimulation therapy for the treatment of her low back pain. Findings:  Two physician reviewers found that the efficacy of ESTIM has not been definitively proven for use in chronic low back pain. A review of the literature reveals that there is inadequate data demonstrating that the use of ESTIM results in improved clinical outcomes for this patients diagnosis. Thus, ESTIM is of questionable benefit for this patients condition. Furthermore, the submitted clinical records do not include evidence that the therapy was administered with a clear objective, defined functional goals, or a method to monitor response to the intervention. All told, there is inadequate evidence in both the scientific literature and the submitted clinical documentation to support the use of ESTIM in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested psychiatric residential treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient continued to manifest behavior that required medical intervention and containment in a 24-hour setting during the period at issue. The level of care provided is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) and American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested sub-acute residential psychiatric treatment for the treatment of the enrollees major depression, recurrent, parent/child relational problem, history of attention deficit/hyperactivity disorder, generalized anxiety disorder and eating disorder. Findings:  The physician reviewer found that this patient required further time in residential treatment to more fully integrate the improvements she was beginning to make at that time. Premature discharge may have engendered a regression in the patients symptoms. Of note is her somewhat fragile character, the nature of her relationship with her family and her need to gain better internal controls to function more adaptively outside the residential setting. Accordingly, sub-acute residential psychiatric treatment services provided were medically indicated and appropriate. However, toward the end of her stay, the records suggest that her improvements were greater. Thus, the patient could have been successfully and safely treated at a lesser level of care toward the end of her stay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a power operated wheelchair for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the inability of the patient to perform mobility-related activities of daily living has not been documented in the medical records provided for review. The question of whether the patient's difficulty with mobility could be adequately addressed through alternative devices such as a cane, walker, or manual wheelchair has also not been documented. In addition, the ability of the patient to safely operate a power scooter or wheelchair and the capacity of his home to accommodate such a device has not been documented.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a positron emission tomography (PET) scan for an evaluation of her probable frontotemporal dementia. Findings:  Three physician reviewers found that the issue in this case concerns whether PET scanning is likely to be more beneficial for evaluation of the patients condition than any standard modalities. The specificity of PET scan abnormalities in the diagnosis of frontotemporal dementia has not been adequately established. Overlap of supposed abnormalities in the workup of dementia with PET scan is prominent. Furthermore, there are no therapeutic implications to the results of PET scans in this instance. Accordingly, a repeat PET scan is not likely to yield information that will be of consequence to the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested sensory integration therapy for the treatment of his status post stroke. Findings:  Three physician reviewers found that this patient suffered from a cerebrovascular accident with resultant speech and language problems. He was seen for speech therapy, which included Lessac-Madsen Resonant Voice Therapy. He was billed for standard speech therapy, as well as sensory integration therapy. However, based on the submitted therapy notes, the therapy given does not meet the sensory integration description. Even if the services included sensory integration therapy, such services were not likely to be more efficacious than standard speech therapy services in this setting. There is inadequate data in the peer-reviewed evidence demonstrating sensory integration therapy results in improved clinical outcomes in this patient population.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Botox injections for the treatment of her chronic daily headache. Findings:  Two physician reviewers found that although chronic daily headache is reported, the frequency and severity of the patients headaches are not documented. The documentation suggests frequent use of narcotic analgesics, so medication overuse headache is likely. If the patient has medication overuse headache, it will substantially reduce the efficacy of Botox. She is not using typical acute migraine agents such as triptans. She has not tried a variety of standard migraine therapies, such as beta blockers and valproic acid. She carries a diagnosis of chronic headache, and it is unclear from the records that the International Classification of Headache Disorders diagnosis fits this patient. Given the likelihood of medication overuse, the absence of a clear headache diagnosis and inadequate trials of standard therapy, Botox is not indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested residential care services for the treatment of the enrollees mood disorder, parent-child relational problems, cannabis abuse and post-traumatic stress disorder, chronic. Findings:  The physician reviewer found that the evidence demonstrates that this patient did indeed need residential treatment at the time of admission and that this level of care was consistent with the American Psychiatric Association guidelines. However, based on her documented gains, she could have been safely discharged to a lesser level of care on the date in question. This date reflects the patients improvements documented on resident review. The patient could have been safely and appropriately discharged to a partial hospitalization program (PHP) for treatment of her ongoing therapeutic issues. The anticipated length of stay at PHP level of care would be eight to twelve weeks, but this is only an estimate and would depend upon the patients progress as determined by re-evaluation at two-week intervals.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old female enrollee has requested continued use of Protonix and Vytorin for the treatment of her reflux and hyperlipidemia. Findings:  The physician reviewer found that this patient has a history of gastroesophageal reflux disease and has tried and failed a trial of Prilosec. Prevacid was less effective. The patient has been maintained on Protonix with good results since 2001 and no recurrence of her symptoms. There has been no documented trial of use of the formulary alternative Nexium, or an adequate trial using a double dose of the formulary PPIs. Differences have been found between standard doses of PPIs with regard to the onset of symptom relief of gastroesophageal reflux disease and the healing of esophagitis. Despite these differences, there are yet insufficient data to establish the superiority of any one agent over all others across all disease states treated with these agents. There is no documentation in the medical literature indicating superior results with Protonix over the recommended formulary alternatives. Thus, Protonix is not medically indicated for this patient.  The patient has tried and failed treatment with formulary alternatives simvastatin and Pravastatin. Per the reference cited above, the optimal LDL goal of therapy is less than 100. There is no documentation that the patient has tried and failed maximum dose therapy of the formulary statins. Thus, Vytorin is not medically indicated for treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Botox injections for the treatment of the enrollees headaches. Findings:  Three physician reviewers found that this patient is likely suffering from chronic migraine with associated myofascial pain. The literature shows that Botox is appropriate therapy for chronic migraine with associated myofascial pain for patients who have failed preventive therapies. This patient had tried migraine preventives before Botox without success, and has had previous success with Botox. Thus, Botox was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for to see a pulmonologist for treatment of her chronic obstructive pulmonary disease. Findings:  The physician reviewer found that COPD is often a progressive disease, and even with optimal management, it is anticipated that a patient's lung function will worsen over time. Patients with COPD require frequent monitoring of symptoms and objective measurement of airflow limitation to determine when to adjust therapy and avoid complications. Treatment with a pulmonologist is consistent with the guidelines for the management of chronic obstructive pulmonary disease.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is certainly not a first-line therapy for headache, there is adequate literature demonstrating its use for refractory headache disorders.  This is a case of a patient who has failed numerous first-line therapies for headache, including both prophylactic and abortive therapy.  In addition, her history is significant for a marked previous response to Botox therapy.  This previously documented response to Botox in the context of the refractory nature of her headaches makes the use of Botox medically necessary and appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a Saunders lumbar traction unit for the treatment of her lumbar disc herniation. Findings:  Three physician reviewers found that traction has no proven therapeutic efficacy. The American College of Occupational and Environmental Medicine (ACOEM) guidelines do not recommend traction, for treatment of acute, subacute or chronic low-back pain or radicular pain symptoms. Nor is there any scientific data to support the use of lumbar traction for back pain, and therefore, its efficacy in this setting remains unproven.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested an evaluation for a stem cell transplant for the treatment of his neuromyelitis optica. Findings:  Three physician reviewers found that this patient has been diagnosed with neuromyelitis optica that has been treated with a variety of medications, without control. Neuromyelitis optica is a demyelinative disorder and is often treated with steroids, plasmapheresis and azothiaprine. Evaluation for stem cell transplantation has been suggested. A literature review yields no data regarding treatment of neuromyelitis optica with stem cell transplantation. Review of the literature regarding the treatment of multiple sclerosis with adult stem cell therapy (ASCT) does not confirm clinical efficacy beyond standard therapeutics. Potential complications of ASCT are noted to include opportunistic infection, neoplasm and death. There is insufficient evidence that the suggested therapy is likely to be more effective for this patient than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested Zetia 10mg for the treatment of his high cholesterol. Findings:  The physician reviewer found that the patient has been taking Crestor at the maximum dose. This dose of Crestor is stronger than or equivalent to Lipitor 80mg or simvastatin 80mg per day (formulary alternatives). There is no medical advantage to requiring that the patient switch to the maximum dose of the formulary statin to prove that he will not achieve his target. In this case, Zetia is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Moviprep and Osmoprep in preparation for her colonoscopy. Findings:  The physician reviewer found that the traditional PEG compounds included on the Health Plans formulary are usually effective and are perhaps the safest preparations for colonoscopy procedures. Moviprep is a PEG solution and is similar to the medications included in the Health Plans formulary. As such, the use of Moviprep was not necessary as appropriate alternatives were available. However, once it was established that the patient could not tolerate a PEG (which does occur in a subset of patients), Osmoprep, a phosphate-containing preparation, was necessary. While phosphate tablets are not the ideal alternative, they are the only other safe and FDA-approved regimen available. The patient and her physician had no other choice than to use a product such as Osmoprep, as the use of another PEG compound likely would have precipitated the same negative reaction. The phosphate tablets (Osmoprep) were better tolerated by the patient in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested sacroiliac joint injections for the treatment of her low back pain. Findings:  Three physician reviewers found that SI joint injections are mostly given intraarticularly and are becoming more widely utilized by pain clinics. Although sacroiliac joint injections are a promising treatment for low back pain originating from the sacroiliac joint, there is insufficient outcome data demonstrating that they are more effective in this setting than other therapies. Nor is there adequate evidence supporting their use for diagnostic purposes. Until studies are performed involving larger numbers of patients with longer follow-up, the superiority of sacroiliac joint injections remains unproven. Without more support in the literature, the therapy remains investigational and not likely to be as beneficial as standard modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested bariatric surgery (biliopancreatic diversion with duodenal switch) for the treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure has a proven track record that is superior to that of the gastric bypass Roux-en-Y operation. This includes resolution of co-morbid conditions and percentage of excess weight loss in addition to a better lifestyle that does not include the complication of the dumping syndrome. The Health Plan suggests that dumping syndrome is a rare finding (less than 5%), whereas published scientific data (see Sugerman and colleagues, and Pories and colleagues) demonstrates a much higher incidence of dumping syndrome (greater than 50%). The patient is an appropriate candidate for the duodenal switch procedure, which should be covered as medically necessary in this clinical situation.