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

A 51-year-old male enrollee, who is morbidly obese, has diabetes mellitus type 2, chronic kidney disease, hypertension and obstructive sleep apnea, has requested coverage for the medication Byetta.  Findings:  The physician reviewer found that the patient has already experienced significant benefit from Byetta with a decrease in his weight, A1C and insulin dose. As such, the continued use of Byetta is medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee, with a history of osteoarthritis in both knees, has requested coverage for repeat Orthovisc injections.  Findings:  Two physician reviewers found that at this juncture repeat Orthovisc injections are likely to prove beneficial in terms of offering the patient some degree of intermediate relief. In light of the reported success following his original Orthovisc injections, Orthovisc is a reasonable option to help delay the need for total knee arthroplasty, which would otherwise be the next appropriate step.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee, with diabetes mellitus type II (DM2), has requested coverage for Byetta. Findings:  The physician reviewer found that there are alternative treatments that do not appear to have been tried, such as meglitindes, low dose thiazolidinediones or low dose basal insulin. Although the patients hemoglobin A1c decreased with the use of Byetta, there is as yet no data on the benefit of lowering a hemoglobin A1c from 6.1% to 5.6%.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested a cooling device and pump for local anesthetic infusion for a rotator cuff tear.  Findings:  The physician reviewer found that there is inadequate literature to support the use of a cooling device following rotator cuff surgery. There is no available data demonstrating that cryotherapy is more effective than the application of ice packs. No long-term data exists showing that cooling devices result in improved outcomes in this clinical setting. Furthermore, the use of an analgesic pump was not medically necessary based on the information provided. Standard pain management modalities would have been sufficient in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for the treatment treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that there is an identified abnormality of the corpus callosum.  Abnormalities in the corpus callosum have been demonstrated to lead to speech and language deficits.  Early speech therapy can be of benefit for patients to improve pragmatic language skills.  The Health Plan has offered no alternative plan of treatment for the speech and language deficits.  Speech therapy goals should be objective, quantifiable and reasonably attainable within a six-month timeframe.  Progress toward the revised speech therapy goals should be reviewed by the neurologist at the end of the six-month period; if the goals are reached then therapy should proceed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for a continuous passive motion (CPM) device for post-operative rehabilitation.  Findings: The physician reviewer found that there are no well-controlled clinical studies establishing the long-term benefits of CPM use beyond the period of hospitalization following ACL reconstruction or even following knee replacement. Many of the touted benefits are theoretical. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-year-old female enrollee has requested a referral to a pediatric gastroenterologist for suspected fatty liver disease and G-tube care.  Findings:  The physician reviewer found that the patient does not require ongoing care with her pediatric gastroenterologist. The Health Plan indicates the patients primary care physician can request a referral to a GI specialist if needed. No evidence has been provided that the patient is unable to receive appropriate care from another gastroenterologist on an as needed basis or that the nature of her condition requires that she continue to be followed by her pediatric gastroenterologist.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested coverage for total hip arthroplasty for treatment of her hip pain. Findings:  Two physician reviewers found that the major advantages of resurfacing include preservation of the femoral head and neck permitting standard total hip replacement if required at a later date. In addition, the procedure allows for a larger head size, which increases stability resulting in fewer dislocations and providing greater mobility. Although additional studies are being conducted, experience with total hip arthroplasty has been encouraging to date. Furthermore, the patient is an appropriate candidate for the procedure given her young age.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested coverage for Nexavar 400mg twice a day with Temodar for treatment of the enrollees metastatic melanoma. Findings:  Two physician reviewers found that review of the medical literature for the treatment of aggressive PNST as well as sarcoma, the two more common categories from which data and decision-making may be extrapolated reveals insufficient evidence to support the proposed regimen. The literature from malignant melanoma is not as relevant, as the patients tumor is melanotic/pigmented, but has not been classified as malignant melanoma, which is distinct biologically, histologically, and immunophenotypically from the diagnosis indicated in the pathology report.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested coverage for the prescription medication Lyrica for treatment of his testicular pain. Findings:  The physician reviewer found that the patient had an acute onset of exquisite testicular tenderness. The clinical picture and the quality of the pain do not suggest neuropathic pain, but are more likely a primary inflammatory condition. The patient was not tried on the usual pain management therapies for either somatic pain or neuropathic pain such as gabapentin or tricyclic antidepressants. While Lyrica may have provided some pain relief, it was used as a first-line agent when many other alternatives were available. This is not consistent with the standard of care within the neurological community.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested coverage for excision of skin of the abdomen, hips, thighs, buttocks and lipectomy of the lower extremities for treatment of her excess skin condition. Findings:  The physician reviewer found that correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative therapy.  The submitted records do not include convincing and confirmatory evidence of a chronic functional problem that has not responded to reasonable attempts at conservative therapy.Surgical lipectomies or body contouring for medically necessary indications should be reserved for patients that have failed optimal medical management for intertrigo, which has not been shown to be the case for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested coverage for CyberKnife radiosurgery for treatment of his anal squamous cell carcinoma. Findings:  Two physician reviewers found that the patient has essentially exhausted all conventional treatment modalities to control his tumor. He has experience with CyberKnife for his right pelvic mass and would like to attempt  treatment for this left pelvic recurrence. A surgical approach is not superior at this juncture. Surgery may not be successful in completely removing the pelvic tumor and might still require CyberKnife rescue. At this stage in treatment, a less invasive therapeutic modality offers clear advantage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested coverage for laser therapy for treatment of hi psoriasis. Findings:  Three physician reviewers found that the Excimer laser stimulates broadband UVB in individual psoriasis plaques. It is specifically indicated for treating a few plaques, which is precisely the situation in this case. The patient has localized plaques that are painful. Given the failure of standard topical therapies and ultraviolet treatment, laser therapy is medically appropriate and has a greater likelihood of success than any other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 74-year-old male enrollee has requested coverage for X-STOP implantation surgery for treatment of his lumbar stenosis. Findings:  Two physician reviewers found that the X-STOP device is designed to distract the posterior elements of the stenotic segment of the spine and place it in flexion to treat neurogenic claudication. These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain (with or without back pain) that was relieved with flexion and the ability to walk at least 50 feet. However, the FDA documents were released before a public hearing on the product raised concerns that the X-STOPs effectiveness decreases over time. Studies found that about 15% of patients who had the implant reported symptoms returning. It appears that the X-STOP is only effective for about a year and then efficacy begins to decline, according to the FDA. Additionally, this patient has multi-level disease at L3-4, L4-5 and L5-S1 that would be a relative contraindication to the use of the X-STOP device.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested coverage for Rituxan therapy for treatment of her idiopathic thrombocytopenia purpura (ITP).  Findings:  The physician reviewer found that patients with ITP that relapse despite IVIG and/or WinRho and who no longer respond to steroids, often require splenectomy. Rituxan is a well-established alternative to splenectomy and is fast becoming standard of care  in this setting. The patient had a platelet count of less than 20,000 and treatment with Rituxan was a medically reasonable approach.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested coverage for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that according to all resources, including the Partin tables, this patient has an early cancer with no involvement of the seminal vesicles or the pelvic lymph nodes. Additionally, his total volume of tumor burden is less than 20% of the right lobe. With this presentation, any form of radiation therapy would effectively destroy this cancer, including 3DCRT and brachytherapy, which were offered by the Health Plan. The patient was concerned about a secondary bladder cancer from standard radiation therapy. There is a very low incidence of this and the risk is present even with proton beam radiation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested coverage for CT scan of the abdomen for treament of his abdominal pain. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates a CT scan was medically reasonable and appropriate in this clinical setting. The patient had abdominal pain and required further workup. In light of his weight issues, a CT scan was likely to be of greater clinical value than an ultrasound or other diagnostic test.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested coverage for a low air loss mattress with an alternating pressure option for treatment of her multiple sclerosis. Findings:  The physician reviewer found that review of the submitted clinical evidence indicates the patient is at high risk for pressure ulcers due to immobility secondary to multiple sclerosis and her history of a prior ulcer. In this clinical setting, it is important to intervene prior to the development of another ulcer. A low air loss mattress with alternating option is likely to significantly reduce the risk of pressure ulcers in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested  coverage for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that the patient has a T2a, Gleason 6 (3+3), PSA 2.0 prostate cancer. According to the Partin tables, there is an 18% probability his tumor is confined to the prostate, a 17% probability of capsular involvement and a 1% probability of seminal vesicle involvement; there is no pelvic lymph node involvement (N0).  Treatment options including conventional radiation therapy, permanent seed brachytherapy, temporary HDR, hormonal therapy and IMRT have been reviewed with the patient. Based on the clinical data and the Partin table analysis, I would agree with the assessment of the radiation oncologist that the patient has a very small volume of tumor and the conventional treatment modalities discussed previously are clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 30-year-old male enrollee has requested coverage for diagnostic testing for treatment of the enrollees progressive neurological symptoms. Findings:  The physician reviewer found that there is no clear demonstrable role for the proposed diagnostic testing. The rationale for the requested cisternogram and CT myelogram is not clear from the information provided. Furthermore, no evidence has been provided which shows how information derived from any of the proposed tests would be clinically useful in this setting. Given the lack of compelling evidence that the proposed tests will have a significant impact on the patients treatment plan, the medical necessity of the requested diagnostic testing has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested coverage for speech therapy.Findings:  The physician reviewer found that the patients speech-language disorder is significant and is attributable to his autism spectrum disorder. The patient requires ongoing speech-language therapy. Continuing therapy will allow the patient to maximize his functional abilities and to prevent behavior problems associated with frustration at being unable to express himself. The patient should continue to receive speech therapy for a six-month period. At the end of the six-month period, the patient should be re-evaluated by his providers to determine if continued speech therapy is indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested coverage for Cyberknife stereotactic radiosurgery for treatment of his metastatic colon cancer.Findings:  Two physician reviewers found that stereotactic radiosurgery is a method of delivering precisely localized radiation to a very defined area of tumor. It has been used quite successfully with intracranial targets and there is growing interest in using it in extracranial sites. In cases such as this there are obvious concerns with attempting any type of radiation in a field that already has received full dose radiation. Furthermore, it is not known if treating one more area of metastases will significantly contribute to the patients longevity or survival. However, on the other hand, the porta hepatic nodes do appear to be the only residual areas of tumor and therefore a case can be made to treat this area aggressively. The only method that could eradicate this particular area of tumor is indeed the Cyberknife radiosurgery, so, though it is investigational in this application, it is more likely than any other mode of treatment to eliminate this area of tumor.   Findings:  Two physician reviewers found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested coverage for Synvisc injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the patient is relatively young and has a severe condition in her right knee. She has not responded to anti-inflammatory medications. Based on the fact the patient has osteoarthritis, persistent knee pain and has failed treatment with oral medications, a series of Synvisc injections is the best treatment alternative at this time. This treatment should not be precluded for lack of a failed steroid injection. Synvisc therapy can reasonably be expected to alleviate her pain and postpone the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested  coverage for a motorized wheelchair for his mobility.Findings:  The physician reviewer found that while it appears that the patient could potentially benefit from a POV for community mobility, he is able to use his light-weight wheelchair for home activities. The Health Plans coverage criteria requires that the POV is needed for the patients mobility within the home.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested coverage for growth hormone (GH) therapy for treatment of his non-Hodgkins lymphoma.Findings:  Three physician reviewers found that the use of human growth hormone to increase the yield of stem cells in patients who have inadequate response to Neupogen or Leukine is investigational. However, there is one paper published in the journal Blood which documents the efficacy of this approach in 16 patients. Although the data is limited, growth hormone therapy does appear to be more promising that conventional therapy at this juncture.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested coverage for a pelvic floor stimulator for her stress urinary incontinence.Findings:  Two physician reviewers found that there is no question that behavioral therapies (i.e. bladder training, pelvic muscle rehabilitation, biofeedback) have a place in the treatment of incontinence and in fact are usually recommended as first-line conservative management prior to consideration of surgical treatment. With regard to efficacy, the pelvic floor stimulator was found in a randomized, controlled study to be an effective behavioral therapy in the treatment of incontinence. The pelvic floor stimulator has FDA approval and is commonly prescribed by physicians in the gynecological community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an eight-year-old male enrollee have requested coverage for a circumcision revision for treatment of the enrollees redundant foreskin. Findings:  The physician reviewer found that this patient had an incomplete circumcision as a newborn and he is now having medical problems with the residual prepuce. By history, there have been multiple episodes of inflammation, evidenced clinically by the patients scratching of the area. This condition could reasonably be diagnosed as balanitis or balanoposthitis which is directly related to the redundant skin condition. Given the history of problems with the residual prepuce, the urologist has recommended re-doing the incompletely performed circumcision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has coverage for the NESS  H200 functional electrical stimulator for treatment of his spinal cord injury.Findings:  The physician reviewer found the patient is clearly a candidate for NMES therapy to assist in his functional recovery. However, effective NMES can be supplied via conventional units. There is no documentation in case-controlled, peer-reviewed literature to show that the efficacy of the Bioness NESS H200 functional electrical stimulator is superior to conventional NMES therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested coverage for percutaneous neuromodulation therapy (PNT) for treatment of her spinal pain.Findings:  Three physician reviewers found that a review of the national treatment guidelines indicates PNT is an investigational treatment. Studies such as the Balzar study have demonstrated some initial promise, but lack a control group or data on long-term outcomes. Additional clinical study is needed before PNT can be recommended for the treatment of spinal pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested inpatient psychiatric services for treatment of his bipolar disorder and chemical dependency. Findings:  The physician reviewer found that this patient did not meet criteria for continued inpatient psychiatric hospitalization after the date in question. His treatment could have been managed at a lower level of care. A residential treatment program or a sober living arrangement combined with an outpatient chemical dependency program supervised by a psychiatrist would have been appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an X-Stop procedure for treatment of her back pain.  Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is a superior treatment option in this clinical setting. Simple laminectomy is the gold standard procedure for patients such as this patient.  No study has demonstrated that X-Stop is more effective than laminectomy.