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

A 51-year-old female enrollee has requested for sacroiliac joint arthrography and injections for treatment of her chronic low back pain.   Findings:  Three physician reviewers found that the literature does not support the long-term efficacy of sacroiliac joint injections. This patient has multiple degenerative changes in the lumbar spine. The outcome of non-invasive treatments for back pain was reviewed by Van Tulder, et al. The meta-analysis of the literature does not support the use of sacroiliac joint injections for sacroiliac joint pain. More data is needed to establish the long-term efficacy of sacroiliac joint injections for the treatment of sacroiliac joint pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested for physical therapy for treatment of her endometriosis. Findings:  The physician reviewer found that there is a lack of medical evidence to support this manual therapy for the treatment of abdominal or pelvic adhesions.  The only studies in this area are uncontrolled pilot studies which do not provide sufficient evidence of efficacy to justify physical therapy for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for revision of gastric bypass to a duodenal switch for treatment her condition.   Findings:  Two physician reviewers found that revisional surgery is associated with two to four times the incidence of anastomotic leak and twice the incidence of wound infection and other major morbidity. Revisional surgery has also been associated with increased mortality. This is because the operations are often complicated by the presence of adhesions or patients may still be morbidly obese or tissue perfusion may not be optimal, which can all inevitably affect anastomotic healing.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for antibodies screening for evaluation of her loss of balance.   Findings:  Two physician reviewers found that the testing recommended by the patients provider has the potential to assist in the patients diagnosis and treatment planning and is the best available alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a CT of the coronary arteries for evaluation of her heart blood vessels.   Findings:  Three physician reviewers found that there is no documentation to indicate the patient has an uninterpretable ECG or is unable to exercise. In this circumstance, coronary CT angiography has not been shown to be more beneficial (or even as beneficial) as stress testing, if further evaluation of chest discomfort is thought to be necessary. Appropriateness criteria for coronary CT angiography have been published, endorsed by several national organizations, and do not recommend using the test in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for inpatient residential care for treatment of the enrollees condition. Findings:  The physician reviewer found that tt is clear that the patient does not need 24-hour supervision at the inpatient residential level of care.  The patient was not noted to be a danger to himself or others, unable to care for himself or psychotic.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee have requested for occupational therapy for treatment of the enrollees pervasive developmental disorder.   Findings:  Two physician reviewers found that occupational and speech treatments are not considered experimental for this diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old male enrollee have requested for growth hormone therapy for treatment of the enrollees isolated growth hormone deficiency. Findings:  The physician reviewer found that it would seem that the patient had some delayed maturation with a pre-medication adult height close to the mid-parental target. As the patient likely would have been close to mid-parental height without therapy, there is no indication for growth hormone therapy. In addition, the lack of IGF-1 and IGFBP-3 does not assist in establishing a need for growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a Positron Emission Tomography (PET) scan of the brain for evaluation of her cognitive symptoms.   Findings:  Three physician reviewers found that the records submitted do not demonstrate the patient has had a complete work-up for her dementia, and there is no evidence of a lumbar puncture with studies for multiple sclerosis. In addition, a repeat MRI with contrast is indicated. Without this work-up, there is no indication for a PET scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested removal of breast implants and a mastopexy for the treatment of her pain. Findings: The physician reviewer found that the implant removals and capsulectomies performed were cosmetic. The patient had a periprosthetic capsular contracture, which is a known complication of breast implants. There is no evidence of an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Thus, the procedures at issue did not constitute reconstructive surgery. Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated. The American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation conclude that the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, and interference with the diagnosis or treatment of breast cancer. Based upon the evidence provided, the patient does not meet these criteria. Nor do the records document problems with activities of daily living or a need for narcotic analgesics. As such, the medical necessity of these procedures has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 33-year-old female enrollee have requested acute rehabilitation services for the treatment of her condition. Findings:  The physician reviewer found that the patients condition is chronic. It requires longitudinal management rather than a short acute stay. Her condition primarily indicates outpatient longitudinal management or chronic institutional stay with outpatient follow-up. The patient made little progress in acute rehabilitation. She had one psychiatric visit with oral medication adjustment. She was limited in her ability to participate in physical therapy, and this has continued.  The likelihood of benefit from acute management was low. Contracture and spasticity management is a long-term management challenge. It is not resolved with acute stays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 49-year-old male enrollee has requested Botox injections for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patients spasticity is refractory to medications. Botox can be used in selected patients with multiple sclerosis with localized, medically refractory spasticity. The requested Botox therapy is medically appropriate for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested a bariatric sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient is a morbidly obese 29-year-old female who is seeking authorization for sleeve gastrectomy. The Health Plan considers this procedure investigational and has denied authorization. The Health Plan has recommended Lap-Band or gastric bypass for treatment of the patient's condition. The patient has an increased CRP, which is likely a result of her obesity. There are no data demonstrating that increased CRP is a contraindication to Lap-Band. In fact, the Lap-Band would be preferred in this patient, since it gives the ability to deflate the band if she becomes pregnant. Furthermore, there is no indication for sleeve gastrectomy for treatment of this patient, as her obesity is not extreme, and she does not have a need for chronic NSAIDs or significant hepatomegaly.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested Hyalgan injections for the treatment of her knee pain. Findings:  Three physician reviewers found that Hyalgan injections are not indicated for meniscal pathology. The requested therapy is not medically indicated or appropriate for this patients condition. Hyalgan injections are not likely to be more efficacious than alternate standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Lipitor 20mg for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation of side effects with any formulary statin, and there is no treatment failure. Current National Cholesterol Education Program guidelines recommend an LDL of less than 160mg/dl with only one other risk factor (hypertension, in this case). A more aggressive goal may be an LDL of less than 130mg/dl. In either case, this goal is achieved on the current Pravastatin dose. There is no evidence to support improved outcomes by lowering the LDL further than noted above in this setting of primary prevention with only one other cardiac risk factor.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee have requested speech therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that this child has been in continuous speech therapy since the age of two. The weekly individual program is now integrated in a public school program. The child has shown significant improvement in the program. This combined program is medically necessary to bring the child up to normal language skills. Most recent tests have placed him in the 16th percentile of receptive language, which qualifies him for continued speech therapy. Speech therapy is indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested Enablex 7.5mg for the treatment of her bladder infection. Findings:  The physician reviewer found that the Health Plans requirement that the patient try the formulary alternative to Enablex prior to approval is reasonable and appropriate. The selective bladder anticholinergics which are prescribed for bladder overactivity are not specifically difficult to tolerate based on stomach issues. This is not a common or well-reported side effect. It is medically reasonable that the patient try the recommended alternatives. The Health Plan has provisions in place to substitute if the formulary drug is not tolerated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested an Austin bunionectomy step down with internal fixation on her right foot for the treatment of her foot pain. Findings:  The physician reviewer found that there are different medical opinions as to how to alleviate the patients foot pain and correct her hallux limitus. While both joint arthrodesis and an Austin bunionectomy step down with hemi implant are viable options for correction of hallux limitus, the latter (hemi implant) will preserve joint motion. The requested procedure is medically necessary for treatment of this patients condition and would be the superior treatment versus the joint arthrodesis. Joint preservation will allow for unencumbered ambulation.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the patient was diagnosed with an upper respiratory infection, the signs and symptoms that he presented with are consistent with a variety of more serious and potentially life-threatening diseases that need to be ruled out. Some of these possible diseases include meningitis (fever, headache, myalgias), pneumonia (cough, fever, congestion), sinusitis (headache, fever, congestion), influenza (myalgias, fever), gastroenteritis (diarrhea, vomiting, fever), bacteremia/sepsis (all presenting symptoms plus abnormal vital signs of high heart rate and low blood pressure), and other infectious disorders.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested for emergency services.  Findings:  The physician reviewer found that at the time of presentation at the hospital, the patient reported that the abdominal pain had dissipated. There is no mention of abdominal pain in the chart, and his abdominal examination was documented as benign. Blood work was unremarkable.The patient describes having suffered from extreme abdominal pain as well as rectal bleeding. This constitutes acute symptoms of sufficient severity that would lead a prudent layperson to believe failure to obtain immediate medical attention could result in serious jeopardy to health, bodily functions, and/or life.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested a spinal cord stimulator for the treatment of her chronic lower-back pain. Findings:  The physician reviewer found that this patient continues with back pain and bilateral leg symptoms. Follow-up MRI revealed spinal stenosis at L3-4 due to graft migration with canal compromise. The spinal cord stimulator is not the most appropriate procedure for treatment of this patient. Correction of her stenosis is medically appropriate and indicated. Additionally, she has not met the other necessary criteria for the spinal cord stimulator. Further surgery is not indicated. The requested procedure is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested surgery to remove excess skin on her bilateral medial and anterior thighs for the treatment of her bilateral leg pain. Findings:  The physician reviewer found that this patient has redundant thigh tissue, but has already had thigh lift surgery.  Her primary complaint is thigh pain, and the surgeon notes that he has not previously performed thighplasties for pain reduction.  The medical literature provides no evidence that thigh lift surgery is an appropriate treatment for thigh pain, and even if this were the case, the patient has already had thigh lift surgery.  The physicians exam shows well-healed, non-painful thigh scars and no focal areas of tenderness along the thigh muscles.  Thigh lift surgery is cosmetic.  Her redundant thigh skin is not an abnormal structure of the body, and the requested surgery will not improve function. The surgery will primarily improve appearance and is cosmetic.  She has extra thigh skin, but the extra skin is not abnormal in any way.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested the medications Lyrica and Qualaquin for the treatment of her condition. Findings:  The physician reviewer found that Quinine has been the subject of an FDA drug advisory specifically declaring the use of quinine as too risky for the treatment of leg cramps. At the time the advisory was released, there were 665 reports of serious adverse events tied to quinine, including 93 deaths. Pregabalin is currently being studied for pain control in multiple sclerosis.  Its use prior to completion of this trial would be experimental and unproven. Neither medication is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested Crestor 10mg/day for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that this patient has developed intolerant side effects to a formulary statin (Zocor). The patient has hypercholesterolemia and has responded to Crestor without reported side effects. The disputed therapy is well within the standard of care. Crestor is medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested radiation/hyperthermia for the treatment of her invasive ductal carcinoma of the left breast. Findings:  Three physician reviewers found that hyperthermia given with radiation therapy as the primary treatment of breast cancer has no proven clinical benefit and at best is considered investigational. Systemic treatment, even simple hormonal therapy, would be an appropriate treatment in an effort to shrink the tumor maximally before applying any further local therapy, whether that will be conventional radiation therapy and/or surgery.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency 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 members health in serious jeopardy. This patients symptoms had commenced gradually over two days and were not acute in onset. Although she reported her pain as 9 out of 10, she was described as being in only mild distress. She attempted no intervention prior to her arrival in the emergency department, such as over the counter pain medication. Records document that the patient had occasionally experienced similar symptoms in the past, and therefore would know that menstrual cramping would not immediately threaten her health. The records provided do not support that this patients symptoms meet the prudent layperson definition of an emergency.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patient had a one day history of mild bilateral ear pain.  Due to the fact that she was not in severe pain and that her life and well-being were not in jeopardy, the Prudent Layperson Standard is not met.  Her complaints were not of sufficient severity that would lead a patient to make a reasoned decision to seek immediate care in an emergency department.  It was not likely that any delay would result in serious jeopardy to her health or function.  Her condition was urgent and not emergent.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested bilateral excision of breast tissue for the treatment of her bilateral lipomas. Findings:  The physician reviewer found that excision of the axillary breast tissue is medically necessary. Accessory breast tissue can be painful during the menstrual cycle and may present problems with breast cancer screening, both of which have been problems for this patient.  The tissue serves no functional purpose, and the medical records describe axillary pain for over one year. Breast cancer can arise in axillary breast tissue and carries a poor prognosis because of the often delayed diagnosis. The patients axillary breast tissue is causing functional problems with activities of daily living.  Her complaints are similar to those described in the medical literature for women with axillary breast tissue, and surgery is curative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a PET/CT scan for an evaluation of her cervical cancer. Findings:  Three physician reviewers found that the use of PET/CT scans in the initial staging of cervical cancer is now covered under Medicare guidelines when used as an adjunct to conventional imaging (CT and/or MRI). This patient has extensive disease found outside the uterus. In order to properly plan treatment for this patient, the exact extent of this patients disease is needed. Studies have shown that the use of PET/CT scans for patients with cervical cancer is clinically relevant when the stage of disease is in question. PET/CT scan is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested artificial disc replacement surgery for the treatment of his headaches and neck pain. Findings:  Three physician reviewers found that cervical artificial disc replacement remains experimental for the treatment of cervical spondylosis. More outcomes data is needed in the mid-term and long-term to establish the safety and efficacy of this device. Complications in the mid-term and long-term are not clear at this time. Additionally, this patient also had previous fusion at other levels of the cervical spine. Outcomes of artificial disc surgery in cases of previous cervical fusion are not known, and complications are not known.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested a CT of the heart for an evaluation of his condition. Findings:  The physician reviewer found that the diagnostic procedure at issue is an appropriate test to diagnose serious pathology which can present with symptoms radiating to the back as listed by the treating physician. CT angiography was not ordered, and the presence of calcification in the left anterior descending is an incidental finding. The diagnostic procedure at issue represented a non-experimental, appropriate use of CT technology well within the standard of care to exclude disease for workup of this particular patients chest discomfort.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient was suffering from a viral infection which caused coughing, headache and tactile fevers. This was an acute illness. He had seen two physicians in the previous five days and had been prescribed medication that did not improve his condition. Although it does not seem to have caused him severe pain, he was suffering from a persistent cough so severe that a prudent layperson would make a reasoned decision to seek immediate emergency care. In this case, it was important to rule out other diseases such as pneumonia, tuberculosis, as well as cardiac diseases that may cause patients to present with similar symptoms.