Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested testing with the Bravo pH Monitoring System for the evaluation of gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that wireless esophageal pH monitoring (Bravo) was approved by the FDA in 2002 for the evaluation of the patient with GERD. The Bravo Esophageal PH monitoring system is now considered the standard of care for the evaluation of patients with suspected or possible gastroesophageal reflux disease (GERD). With this system, there is now the ability to perform 48-hour wireless capsule pH monitoring. This is considered a major advance in patient comfort and acceptance, while providing the opportunity to gather an additional day of monitoring. Such monitoring is the single best way to evaluate patients for the presence of abnormal esophageal acid exposure or reflux, to determine whether reflux is occurring during the day or night, and to correlate the presence or absence of reflux with continuing symptoms. Compared to catheter probe monitoring study, it does not cause inconvenience, discomfort and does not interfere with day to day activities during the duration of the monitoring.  Therefore, it has replaced the catheter based system nationally and has become the standard of care for the evaluation of suspected GERD. Based upon the studies published in the peer reviewed journals, Bravo PH monitoring is considered safe and efficacious for the evaluation of patients with GERD or with extraesophageal manifestations of GERD. In various studies the comparison of the 24-hour pH probe to the Bravo 48-hour period has clearly indicated that the 48-hour pH capsule is superior to the 24-hour pH capsule probe for a variety of reasons. The Bravo pH capsule allows collection of data over a 48-hour period as opposed to a 24-hour period. The 48-hour period pH capsule is a physiological measurement of acid reflux. Unlike catheter probe system, the wireless capsule does not cause inconvenience and discomfort to the patient, does not limit day to day activities or food intake and gives more accurate evaluation of the patient's underlying GERD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male has requested acupuncture for treatment of neck and back pain.  Findings:  The physician reviewer found that the patient appears to have experienced some relief from the pain medication, epidurals, etc. There is potential that acupuncture will provide this patient sustained relief. A trial course of acupuncture is a reasonable course of treatment for this patient. The patient should receive 8 acupuncture treatments at a frequency of not less than twice a week, with evaluation upon completion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for chemical dependency residential treatment services for treatment of the her amphetamine dependency. Findings:  The physician reviewer found that while this patient was in residential treatment she was not suicidal, homicidal or psychotic. In addition, she was medically stable. the patient did not meet nationally accepted medical necessity criteria (ASAM) for residential treatment services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for plastic surgery consult for breast reconstruction for treatment of the her breast ptosis following weight loss. Findings:  The physician reviewer found that the records do not include any office notes that document longstanding problems with sleeping, sexual dysfunction or emotional distress that have failed to respond to conservative treatments.In general, mastopexy is not a functional or reconstructive operation; it is a cosmetic operation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested an evaluation by an infectious disease specialist for treatment of her reported parasite symptoms. Findings:  The physician reviewer found that the patients complaints are consistent with a diagnosis of delusional parasitosis.   This is a syndrome in which individuals claim they are being invaded by parasites.   Often patients bring skin pieces or other debris to their physician and state that these are the parasites or their eggs or excretia. The patient has had symptoms that are not consistent with any recognized parasitic disease. She has had extensive evaluation by her providers. She has recognized psychiatric disease
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested discography for the treatment of his low back pain. Findings:  The physician reviewer found that the operative report demonstrates the procedure was carried out following the current standards and that the results were reliable. The study showed a painful disc at L5-S1 with reproduction of the patients usual pain upon pressurization of the nucleus at 14 psi over opening pressure. The morphology was characterized by a grade IV annular tear. This procedure was carried out in order to triage the patient for possible further treatment. The medical literature has validated the use of pressurized discography for purposes of diagnosing discogenic pain related to internal disc disruption. This is particularly important if further treatments are considered such as fusion or nucleoplasty. As presented by Cohen et al. response to nucleoplasty may be directly related to positive discography and documentation of annular integrity, which is the case in this particular patient as evidenced by a grade IV tear with no spread of contrast into the epidural space and hence, integrity of the outer annulus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Rocephin IV for the treatment of her Lyme disease.  Findings:  Three physician reviewers found that the patient does not have a clear diagnosis of neuroborreliosis or past history of Lyme disease. She has no clear exam findings or laboratory/imaging confirmation of this diagnosis. She has already received multiple courses of antibiotics with no clear benefit. In cases of neuroborreliosis, the standard treatment is four weeks of antibiotic therapy. Therapy with repeated or extended courses has not proven efficacious and is associated with some risk. There are no double blind placebo controlled trials that demonstrate efficacy in treatments beyond 30 days for Lyme disease
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  The physician reviewer found that this patient received Botox in a pattern and documentation consistent with cosmetic treatment. The patients only submitted records are from her dermatologist whose extensive billing records only document treatment of dermatologic conditions. There are no records or diagnostic codes concerning diagnosis or treatment of migraines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested residential treatment for treatment of amphetamine dependence, alcohol abuse, marijuana abuse, ADD, OCD, major depression and panic disorder without agoraphobia.  Findings:  The physician reviewer found that at the time of admission to the residential faculty she was not described as being acutely ill. She was not suicidal, homicidal or psychotic.  Her illicit drug use was significant, but not causing acute medical problems. A specified criterion for admission to a residential treatment facility requires that the patient demonstrate an inability to be managed at lower levels of care. The patients past history of noncompliance with intensive outpatient treatment does not mandate that she would be noncompliant ten months later. It would have been prudent to treat the patient at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female has requested Nutropin for treatment of growth hormone deficiency.  Findings:  The physician reviewer found that the patients specialty physician provides results from two stimulation agents, clonidine and L-dopa, each of which shows an insufficient growth response well below 10 ng/mL. A rather low IGF-1 level lends further support to the reliability of the diagnosis of idiopathic growth deficiency. Most important, prior height measurements further confirm the presence of a decreasing height percentile over the last 5 years. An absolute stature below 2.5 SD is not essential for establishing a diagnosis of growth hormone deficiency. The above listed parameters (lack of a sufficient GH response to stimulation, a low IGF-1 level and a subnormal growth velocity) all serve to confirm the medical necessity of replacement growth hormone therapy for this patient. The patients impressive growth response to the initiation of GH therapy further confirms the appropriateness of GH treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 81-year-old female enrollee has requested skilled nursing facility services for the treatment of her clostridium difficile colitis. Findings:  The physician reviewer found that the patient did not progress with PT. However, she showed steady progress with OT and needed to complete her training program with the trapeze to improve her bed mobility. The days in question were used to provide OT, and they were properly provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested Proton Beam Radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that this patient has a low volume, low grade and a low PSA prostate cancer. Practically any form of radiation therapy will offer him a good chance of tumor control. He has coverage for IMRT which provides as good local control as proton beam. In summary, the patient has low volume of cancer in his prostate.  Proton beam radiation therapy is not superior in cure rates, survival rates or side effects to normal tissues as compared to IMRT.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Subutex for the treatment of his back pain. Findings:  The physician reviewer found that buprenorphine is a high-affinity partial mu-agonist. Its use for analgesia has been clearly proven. Injectable buprenorphine is available as an analgesic medication and has been for many years. More recently, sublingual buprenorphine (Suboxone/Subutex) was released with the indication for opioid maintenance therapy in patients with a history of opioid abuse. However, the active drug is the same. Sublingual buprenorphine is being used for the treatment of opioid abuse due to its high affinity and partial effect on the mu-receptor, deterring the patient from using full mu-agonists such as heroine. Although additional studies documenting the use of sublingual buprenorphine for chronic pain management are warranted, the decision to approve the use of this medication must be done on the basis of its success in managing chronic pain in an individual who has failed numerous treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a total abdominal hysterectomy for the treatment of her abnormal vaginal bleeding. Findings:  The physician reviewer found that the patient has been diagnosed with abnormal vaginal bleeding, although the specific characteristics and duration of this condition are not clearly documented. Treatment for abnormal bleeding requires serious consideration of the patients age, medical status and fertility status and includes medical and surgical alternatives. Medical treatment generally involves the administration of progestins, which is contraindicated in this patient due to her history of stroke. Surgical options include endometrial ablation and hysterectomy. With abnormal bleeding and a previous diagnosis of cervical cancer, a hysterectomy would be an acceptable option and medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested residential treatment services for the treatment of the enrollees bipolar disorder and depression. Findings:  The physician reviewer found that the patient was not consistently seen by a child and adolescent psychiatrist on a weekly basis (as a minimum) as specified by the AACAP criteria. Nonetheless, the patient is a seriously disturbed teenager who required continued residential treatment and 24-hour monitoring by a professional staff. Although weekly sessions with a child and adolescent psychiatrist are encouraged, the Academy does indicate in the AACAP Introduction that it is a guideline and should not be routinely interpreted literally. The patient is under the care of a psychiatrist who consults with the patient every other week in person and is reported to converse with the patients therapist on the off weeks. The patient appears to have been engaged in the program with appropriate parental involvement. Other criteria AACAP for continued residential care appear to have been met.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested surgery by an out-of-network provider for the treatment of her recurrent leiomyosarcoma. Findings:  The physician reviewer found that in the textbook Surgical Oncology:  Contemporary Principles and Practice, there is a chapter that addresses a strategy for treatment of patients with recurrent sarcoma.  There is clearly a precedent for the use of surgery in these patients. Based on this, there is supportive precedent for use of surgical debulking of recurrent sarcoma. However, there is no evidence that the patients surgery needed to be performed at a sarcoma treatment center, or that surgical intervention was necessary prior to December 2007. The submitted evidence does not establish that the surgical debulking was not within the scope of practice of an in-network oncologist/surgeon.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested Lamisil for the treatment of his onychomycosis. Findings:  The physician reviewer found that the patient has painful onychomycosis, with functional impairment. The diagnosis of onychomycosis is confirmed by the demonstration of hyphae on microscopic examination. There are no identified contraindications and the prescribed dosage of one 250 mg tablet, once daily for 12 weeks, is the standard treatment for this condition. Lamisil oral therapy is clinically appropriate for treatment of the patients onychomycosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Rituxan (rituximab) for the treatment of his cryoglobinemia. Findings:  Three physician reviewers found that cryoglobulinemia is relatively rare, and it is unlikely that a large, controlled clinical trial will be forthcoming anytime soon. For a patient such as this patient, treatment options include immunosuppressive therapy such as cyclophosphamide or cyclosporine, or rituximab. Rituximab is an attractive alternative as the potential risks are minimal and the results in small case series are promising. Treatment with rituximab may also improve renal function and abrogate the need for regular plasma exchanges.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a liver resection for the treatment of her metastatic cancer. Findings:  Three physician reviewers found that multiple reports have documented the rationale and potential gains of hepatic resection for metastatic breast cancer. In an excellent review of the literature, Friedrich, et. al. examines the evidence and concludes hepatic resection may play a role in selected patients. Additionally, Selzner, et. al. reported on 17 women treated over a span of 18 years who had undergone such resection in the absence of systemic disease otherwise, and noted a 22% long-term survival in carefully selected patients. A report by Vlastos, et. al. on 31 patients indicated the median survival with hepatic resection was over five years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Celebrex for the treatment of her knee pain. Findings:  The physician reviewer found that the submitted clinical information indicates Celebrex has been beneficial for the patient. There is no reason to have the patient try and fail additional NSAIDs and risk untoward side effects. Celebrex has been shown to be effective for the patient and continued treatment is medically appropriate and clinically indicated given her medical history.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested adult mental health inpatient treatment for the treatment of his bipolar disorder and obsessive compulsive disorder. Findings:  The physician reviewer found that from the standpoint of the patients escalating volatility at home, clearly reenacted while he was on the unit, the approach to his treatment was well within community standards for treatment of Bipolar Disorder.  Review of the unit notes, inclusive of nursing staff and psychiatrist, point to his impulsivity, aggression, verbosity, and intrusion as flagrant problems, which did not sizably lessen until very close to the point of discharge.  In the context of how serious these problems are for the patient, both in and out of the hospital, placement is an integral part of his treatment plan. A few more days were appropriate in order to ensure the patient was stable and to allow for transition to a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested revisional gastroplasty for the treatment of his gastrojejunal stoma dilation. Findings:  The physician reviewer found that the patients gastrojejunal stoma is now 2 cm in diameter as compared to a normal stoma is 0.7 cm in diameter. Reoperation is associated with significant morbidity, and the details of the operative plan are not clear from the record. It appears that dietary  noncompliance is a factor and three to six months of medical supervision is warranted prior to surgical intervention. Endoscopic stoma and pouch revision might also be considered at the appropriate time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Intradiscal Electrothermal Therapy (IDET) for the treatment of her discogenic pain syndrome involving the L5-S1 disc. Findings:  Two physician reviewers found that the IDET procedure has been performed by a number of different practitioners and results are often varied.  There are no good long term studies documenting the efficacy of this treatment plan. This patient has degenerative disc disease, which is often treated conservatively with activity modification, anti-inflammatory medication, home exercises and long term weight loss. There is insufficient evidence that the requested IDET procedure will result in a superior clinical outcome over other treatment options in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested a microprocessor controlled lower limb prosthesis for the treatment of his status post amputation. Findings:  Two physician reviewers found that the microprocessor controlled lower limb prosthesis is appropriate for this patient with a transfemoral amputation and the functional level described. Though data on computer-based prostheses is still being gathered, they are routinely prescribed for patients such as this patient. Some studies find improved performance with the microprocessor controlled prosthesis. Improved mobility with decreased oxygen consumption may be critical for this patient with COPD and CAD. As such, there is sufficient evidence of the benefits of the microprocessor controlled prosthesis to support its use in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested robotic laparoscopic prostatectomy for the treatment of his high-risk prostate cancer. Findings:  The physician reviewer found that robotic-assisted laparoscopic prostatectomy has advantages over conventional surgery and was likely to provide increased benefits for this patient. Given the extensive nature of the patients disease and his history of thrombocytopenia, the use of robotic assistance was a safer option than standard surgery. The decision to perform robotic laparoscopic prostatectomy was medically appropriate and clinically indicated in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested surgical removal of excess skin on her thighs/legs, arms and abdomen for the treatment of her excess skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present.  The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. The patient also does not meet the 2007 Apollo managed care guidelines for a skin resection.  According to these guidelines, skin resection is medically necessary if the pannus hangs below the pubis and chronic intertrigo is present and remains refractory to conservative medical therapy for at least three to six months.  The records do not document three to six months of physician supervised medical management for intertrigo.  Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested chemical dependency residential rehabilitation services for the treatment of his alcoholism. Findings:  The physician reviewer found that for this patient there was no need for inpatient treatment for detoxification. The patient had been on 2 mg of Ativan per day. This dosage represents a very nominal dosage from which he could well be detoxified on a diminishing regimen, purely on an outpatient basis. Therefore, there was no clinical justification for the residential treatment program, whether for Ativan or alcohol addiction. All told, there were no medical grounds to warrant the residential rehabilitation services at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Lyrica for the treatment of her meningitis. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of Lyrica therapy. The patient did not have a diagnosed condition for which Lyrica was indicated. There were other therapies available for management of this patients condition. There is no indication for the use of Lyrica over standard therapies for treatment of headaches or meningitis.