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

The parent of a nine-year-old female enrollee has requested Humatrope for treatment of idiopathic short stature.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that this patient has severely retarded growth. However, the hand x-ray suggests abnormal bone structures and the possibility of achondroplasia. This diagnosis should be explored with a skeletal survey. If confirmed, growth hormone may be appropriate, in which case the request for Humatrope should be reconsidered. However, based upon the information presented at this time, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a PET scan for the treatment of her progressive neurologic weakness and dysfunction. Findings:  Three physician reviewers found that the patient has a progressive neurologic disorder with limb weakness and has been diagnosed as having multifocal motor neuropathy, which is an autoimmune disorder. She has had MRI scans of the brain that show non-specific subcortical lesions. Tumor is not within the listed differential. PET scan has value in diagnosing suspected tumor, but no evidence has been submitted showing benefit in the evaluation of subcortical white matter lesions. A PET scan is not indicated in this case, as it is not likely to be superior to other assessments in clarifying the diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested right hip resurfacing arthroplasty utilizing the Conserve Plus device for the treatment of his osteoarthritis of the right hip. Findings:  Two physician reviewers found that the enrollee is relatively young with a previously active lifestyle. The record documents that the patient has a low head/neck ratio and the Conserve Plus is the only device available in 2mm increments. The Conserve Plus hip resurfacing device is in clinical trial under FDA supervision and is classified as a category B1 device. Considering all of the clinical aspects, the Conserve Plus appears to be the most appropriate device for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Xifaxan for treatment of idiopathic chronic constipation.  Findings:  The physician reviewer found that irritable bowel syndrome (IBS) is a frequent diagnosis in gastroenterology, but it is now clear that an altered dynamic equilibrium and bacterial overgrowth in the small intestine may mimic an IBS-like syndrome. Results of clinical trials demonstrate that the reduction or elimination of small intestinal bacterial overgrowth (SIBO) with antibiotics can alleviate IBS symptoms. In a recently published study, SIBO was observed in about 45% of the patients based on abnormal H-2 breath test. These patients were treated with rifaximin 1200 mg for 14 days with significant improvement in their symptoms of IBS, and H-2 breath test in majority of patients. The efficacy of rifaximin in the treatment of IBS was evaluated in a randomized, double-blind, placebo-controlled, parallel-group study of 87 patients who met Rome I criteria for IBS. These patients had not received oral antibiotics in the 3 months prior to the study and were not being treated with tegaserod or antidepressants. Patients received rifaximin (Xifaxan) at a dose of 400 mg three times daily (tid) or identical placebo tid for 10 days. Statistically significant improvement in IBS symptoms was observed with rifaximin over placebo during the 10-week follow-up period among 80 of the 87 patients who had at least one follow-up assessment (36% vs. 21%). In an editorial accompanying the study (Drossman, Annals of Internal Medicine), it was stated although rifaximin improved patients' self-reported global symptoms of IBS in this preliminary, single-centre study, these findings warrant additional multicentre trials with a larger patient population, longer study duration and less subjective outcome measures to confirm the long-term effects of rifaximin on individual symptoms of IBS. Although the above-mentioned results are promising, further data is needed before the safety and efficacy of Xifaxan for the treatment of chronic constipation is established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Botox injections for the treatment of her writers cramp. Findings:  Two physician reviewers found that this patient has tried several different modalities for treatment of her writers cramp. Nonetheless, her symptoms have progressed to the point that they have interfered with her work. Botox is an effective treatment for focal dystonia whereas no other treatments are known to be helpful. In light of the patients history and condition, Botox injections are clearly the best treatment available.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested advanced cardiovascular risk marker testing be performed at the Berkeley Heartlab for an evaluation of her cardiovascular status. Findings:  Three physician reviewers found that this type of testing has not been clearly established in the medical literature. At the present time, there are no clinical trials demonstrating an overall change in health outcomes based on these test results. The American College of Cardiology guidelines have not incorporated advanced cardiovascular risk marker testing as the standard of care for cardiac risk assessment. The basic lipid panel is still the standard for lipid analysis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested laparoscopic cryotherapy for the treatment of renal mass.  Findings:  The physician reviewer found that the submitted imaging study confirms the finding of a left renal mass measuring 3.5 cm. This study is sufficient to recommend intervention. The surgical options include a partial nephrectomy or a radical nephrectomy. The proposed option of tumor ablation either through a percutaneous or laparoscopic approach is still being studied. Although there have been favorable findings to date, further studies with long-term follow-up are required before the durability of these techniques is known.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Celebrex for treatment of systemic lupus erythematosus.  Findings:  The physician reviewer found that Celebrex is the only available Cox-2 inhibitor or NSAID with a documented lack of antiplatelet effect, and as a result, is the agent of choice for patients taking Coumadin who need a non-steroidal anti-inflammatory agent for control of joint symptoms. Use of Celebrex in association with Coumadin may require adjustment of the Coumadin dose due to changes in protein binding, but this is not related to platelet inhibition. The use of Celebrex in this particular setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested Lunesta for treatment of sleep difficulties secondary to Parkinsons disease.  Findings:  The physician reviewer found that Parkinsons disease is associated with fractured sleep and patients often require sleep aids. A sleep aid is medically necessary for this patient. The Health Plan states they have denied coverage for Lunesta due to absence of a failed trial of Ambien. This patient has tried Ambien, and there is documentation indicating the Ambien caused intolerable side effects. Thus, it appears the Health Plan criteria has been met.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain.  Findings:  Two physician reviewers found that review of the medical literature yields mixed reviews in the use of sacroiliac joint injections for management of chronic low back pain. It seems that they do have a diagnostic component. It appears that in selected cases, sacroiliac joints can be of great help in the management of intractable pain due to joint dysfunction. In fact, this patient has had documented improvement from the injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of an eight-year-old female enrollee has requested Singulair for the treatment of the enrollees asthma. Findings:  The physician reviewer found that treatment with ICS (e.g., Qvar) is the preferred method of managing persistent asthma that requires daily medication to manage symptoms. Use of a leukotriene modifier (e.g., Singulair) is an appropriate addition to therapy if symptoms are inadequately controlled with ICS alone. The clinical information and medical records provided fail to demonstrate that this patient has had inadequately controlled symptoms with ICS alone. Rather, it appears from the provided information that she has not taken prescribed medications as recommended. If there is documentation indicating that she was prescribed and using ICS, but symptoms were inadequately controlled at the time of the prescription, then the request for Singulair should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Avastin for the treatment of his glioblastoma. Findings:  Three physician reviewers found that the literature on the use of Avastin in gliomas is compelling and there is evidence of activity noted. However, there is no evidence to support retreatment with Avastin after progression, nor is there any data on its safety in this situation. Given the patients progression while on the drug, there is no clinical indication to re-administer it at this time. Per NCCN guidelines, there are reasonable alternatives available in this setting, such as platinum-based therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested uvulopalatopharyngoplasty (UPPP) for the treatment of his sleep apnea. Findings:  Three physician reviewers found that the indication for the UPPP is generally agreed to be a RDI/AHI of greater than 20 events per hour of sleep. The patients RDI was only 9 events per hour of sleep. Therefore, the UPPP was not clinically indicated for this patients mild sleep apnea. Conservative therapy would have been more appropriate given these clinical findings.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Provigil for the treatment of her multiple sclerosis (MS).   Findings:  The physician reviewer found that Provigil has become the prescription medication of choice for treatment of the fatigue often associated with neurologic illnesses such as MS. In this instance, it is known to be effective for the patient and to dramatically improve her quality of life. Continued treatment with Provigil is medically appropriate and in the best interest of the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Peg-Intron for the treatment of her hepatitis C. Findings:  The physician reviewer found that there is no literature that demonstrates Peg-Intron is superior to Pegasys in terms of efficacy or side effects. Pegasys uses a different molecule than Peg-Intron, with different pharmacokinetics, and adjustments based on weight are unnecessary. There are no apparent contraindications to treatment with Pegasys.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested the prescription medication Provigil for the treatment of her depression. Findings:  The physician reviewer found that this patient has had ample trials of conventional antidepressants, such that Provigil can be appropriately deemed the supplement of choice. Her psychiatrist has detailed the previous medication regimens and the patients response in regard to depression and lethargy/inertia. The patient has responded well to Provigil and continued treatment should be supported.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Amitiza for the treatment of her chronic constipation. Findings:  The physician reviewer found that this patient has been refractory to all over the counter laxatives. She had been on Zelnorm in the past (which is only available under IND program) and Miralax, and had not achieved any relief with these medications. Based on the results of the above studies, she fits the clinical profile of the patients with idiopathic constipation that should respond to Amitiza, and therefore, the medication should be approved for her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a one-year-old female enrollee have requested molding helmet therapy for the treatment of the enrollees dolichocephaly.    Findings:  The physician reviewer found that the patient has documented nonsynostotic dolichocephaly and plagiocephaly and has been receiving care at a specialty craniofacial clinic. Conservative treatment has not been successful in this instance. There is growing evidence in the literature that molding helmet therapy prevents future problems related to the orbit, jaw, ear and related structures. This therapy is thus considered reconstructive and not cosmetic, and is clinically appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of her potential coronary artery disease (CAD). Findings:  Three physician reviewers found that EBCT calcium scoring has been advocated for many years by some, for the assessment of cardiovascular risk. However, its role in the evaluation of asymptomatic or low-risk patients such as this patient, has not been established. According to two recent consensus reports published in the Journal of the American College of Cardiology, EBCT CAC scoring is not deemed appropriate for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the patient was treated with exercises for adductor muscles, hamstrings, iliotibial band, midback stretches, isotonics for SLR abduction and bridging, and manual interventions for erector spinal or psoas. While the patient indicates that this therapy was for her right leg and plantar fascia, the physical therapy notes repeatedly indicate treatment to the low back and left hip and the procedures performed are consistent with this. In addition, while the patient did get additional treatment for plantar fasciitis, it is also clear that treatment for her back continued during this time frame as documented by the physical therapy notes in terms of the procedures performed (such as midback rotations and quadratus muscles exercises, etc.) Thus, the incident which initiated another prescription of therapy does reflect a flare-up of the back pain treated. Furthermore, review of the therapy notes again documents the same procedures of manual interventions to erector spinal, quadratus stretching to iliotibial band, hamstrings, SLR abduction, adduction, and similar modalities. Thus, the treatment regimen was not significantly different from the therapy she previously received. The goals were to achieve improved strength, which the patient received instruction in doing with the 12 previous sessions of PT. Walking, sitting, and standing tolerance were 0-10 minutes. Thus, there is no objective documentation of improvement and the patient could have continued strengthening using the home program she had received. Nor is there any evidence additional physical therapy is warranted at this point in time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested intravitreal Avastin injections for the treatment of her recurrent vitreous hemorrhage. Findings:  Three physician reviewers found that although originally studied for the treatment of wet (age-related) macular degeneration,  Avastin has been effective in other ocular applications such as PDR. Avastin therapy is widely accepted among practitioners in this specialty area. The patients vitreous hemorrhage has responded to Avastin and these injections present less risk than further surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain. Findings:  The physician reviewer found that the request for continued manual treatment is consistent with a maintenance program and not a restorative program at this point. As such, additional physical therapy sessions are not clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested left knee osteochondral allograft for the treatment of her knee pain. Findings:  Two physician reviewers found that it is unclear from the record what conservative measures were rendered after the arthroscopic procedure. There is no documentation of formal physical therapy or the patients response to physical therapy. There is no indication that a cortisone injection was administered either diagnostically or as a potentially therapeutic modality. There is no apparent consideration of visco supplementation for early degenerative joint disease with well maintained joint spaces. The records do indicate the patient has lesions in the trochlear and the patellofemoral articulation as well as the medial femoral condyle but there is no documentation that the lesions were sized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for an MRI of the bilateral hips for evaluation of his bilateral hip pain and dysplastic osteoarthritic hips. Findings:  The physician reviewer found that the MRI was indicated and warranted given the discomfort the patient was obviously experiencing. He was limping, and anti-inflammatory medications did not help. The MRI of the hips was medically necessary for further work-up of the patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for intravitreal Avastin (bevacizumab) injections for treatment of her proliferative diabetic retinopathy (PDR). Findings:  Two physician reviewers found that the uses of bevacizumab continue to evolve, and its off-label applications have benefited many ocular conditions.At this juncture, other therapies are warranted and further injections of bevacizumab are unlikely to improve the macular edema.Given the possible association of elevated blood sugars with triamcinolone injections and the patients hyperglycemic response, it was reasonable to try bevacizumab.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A six-year-old male enrollee has requested for speech therapy for treatment of his autism. Findings:  The physician reviewer found that standard management of children with autism recommends ongoing monitoring of the childs progress and modification of interventions. If ongoing assessment of the childs progress shows an intervention has not been effective after an adequate trial period, it is recommended that one intervention or specific aspects of its application be changed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 15-year-old male has requested psychiatric residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that given the intensity of the patients obsession with losing weight in spite of the very deleterious effects from standpoints of his health, social function, and school performance, as well as the failure of prior partial hospitalization, it was eminently reasonable to refer him to a more intensive program. Residential treatment is the only venue in which the patient can be actively prevented from continuance in the aforementioned behaviors of extreme exercise and binging and purging. Clearly, continuing along at home has done nothing to prevent those behaviors. All told, the patients admission to a residential program was medically indicated and continues to be necessary for treatment of his significant eating disorder.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male has requested a magnetoencephalogram (MEG) for the evaluation of epilepsy.  Findings:  Three physician reviewers found that review of the relevant scientific literature demonstrates that MEG may yield information helpful in localization of seizure focus in patients such as this patient. He had exhausted other standard modalities available in this setting. The requested MEG is likely to result in sufficient information in this case to allow for surgical planning.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old male has requested prescription medication Actos for the treatment of Lyme disease.  Findings:  Three physician reviewers found that the theory behind the request for Actos is to minimize the pro-inflammatory cytokines which are often elevated in individuals with biotoxin induced illness. A search of the literature does not reveal any studies in peer reviewed journals to support the above theory. There is also no evidence for the efficacy of cholestyramine and Actos in the treatment of Lyme disease. The literature submitted is opinion; it has not been published in a peer reviewed journal and is not supported by scientifically derived data. There are no double-blind, placebo-controlled trials to show the efficacy of these treatments. Further, there is little clinical evidence to support the diagnosis of late-stage Lyme disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male has requested proton beam radiation therapy for the treatment of prostate cancer.  Findings:  Two physician reviewers found that based on the patients clinical stage, Gleason score, and PSA value, he would be deemed a low-recurrence risk according to the 2007 NCCN Clinical Practice Guidelines, with a life expectancy greater than ten years. Initial treatment options include expectant management, radiation therapy (3-D CRT, or brachytherapy) or radical prostatectomy.  3-D conformal or IMRT techniques would be employed under the NCCN Guidelines. Furthermore, doses of 7000 to 7500 cGy to the prostate in 35 to 41 fractions are appropriate for patients with low-risk cancer.  For patients with intermediate or high-risk disease, dosages between 7500 and 8000 cGy appear to improve PSA levels and overall disease control. The current recommendation (proton beam) is to deliver 8100 cGy, and this dosage falls outside of the NCCN dosage guidelines and seems excessive for a patient with low-risk disease. Additionally, NCCN Guidelines do not list proton beam irradiation as a standard option for patients with early-stage prostate cancer. The patient was appropriately started on conventional treatment with IMRT and there is nothing in the record to indicate that he would be better served with proton beam irradiation.