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

A 62-year-old male enrollee has requested a portable oxygen concentrator for the treatment of the enrollees chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patient has severe COPD and cor pulmonale, which requires that he be on supplemental oxygen at a rate of 2 LPM, 24 hours per day. Currently, the patient has a home oxygen concentrator as well as a conserving device. There is no evidence that this equipment is not functioning properly. The patient is requesting that he receive a portable oxygen concentrator, preferably one that is FAA approved, so that he may travel for both work and pleasure.  The requested equipment is being sought for convenience and ease of travel and therefore is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested  for laser therapyfor treatment of her pervasive periungual warts. Findings:  Three physician reviewers found that the clinical management of verruca vulgaris is often challenging, and an ideal treatment does not currently exist. While no treatment is universally effective, some patients respond better to one treatment than another. No guidelines have been published as to which patient will respond best to which treatment. Given that there are no specific antiviral therapies to cure HPV infection, destructive methods such as pulse dye laser are sometimes employed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested the medication Byetta for the treatment of her diabetes mellitus.  Findings:  The physician reviewer found that the patient has had type II diabetes since 2006. Her hemoglobin A1C in April 2007 was 5.6%, which is only slightly above the normal range. After Byetta, her hemoglobin A1C was noted to be 5.9%. The patient does not appear to have complications from diabetes. Based on the clinical information provided, Byetta is not indicated for this patient at this stage of her diabetes. Life-style interventions with or without a low dose of Metformin will most likely be sufficient to keep the patients blood glucose under control.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested proton beam therapy for the treatment of prostate cancer.Findings:  The physician reviewer found that given the small volume of tumor, conventional radiation therapy is likely to be effective. Both IMRT and proton beam radiation are equally effective. Proton beam therapy has no clinical or physical superiority over IMRT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested prescription medication Invega for the treatment of attention-deficit hyperactive disorder (ADHD).  Findings:  The physician reviewer found that the FDA approved indications for this medication do not include the treatment of ADHD in children or adults. There are no studies available to support the use of Invega in the treatment of pediatric ADHD. Invega is not known to be an effective in this setting and its use is not consistent with the community standard of care for the treatment of ADHD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested prescription medication Lyrica for the treatment of neuropathic pain.  Findings:  The physician reviewer found that while the initial studies of Lyrica were limited to neuropathies related to post herpetic infection and diabetes, Lyrica is clearly helpful for a broad spectrum of neuropathic pain disorders. It is the standard of care for many neurologists and pain management specialists when more standard medications fail to provide relief.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a wireless capsule endoscopy for the evaluation of an ileal lesion.Findings:  Three physician reviewers found that it is the standard of care to fully evaluate the small bowel in this setting. Capsule endoscopy is more sensitive than standard diagnostic techniques and can better identify a lesion in the distal ileum.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested Protopic 0.1% for the treatment of bullous pemphigoid. Findings:  The physician reviewer found that review of the medical literature regarding the use of Protopic as an adjunct in the treatment of bullous pemphigoid shows that the results are promising. Protopic is at least as safe as topical steroids. Protopic ointment is likely to be of clinical value, and there is no increased risk associated with its use.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested biofeedback therapy for the treatment of chronic pain. Findings:  Two physician reviewers found that review of the submitted clinical evidence demonstrates that the patient has maximized conservative treatment. The only option showing any benefit has been biofeedback therapy. As such, biofeedback therapy is medically appropriate and justified in this clinical context. The patient is not likely to experience better results with standard treatments given their failure to provide relief in the past.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Byetta for the treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that whether Byetta has replaced the patients insulin or the patient is treated with a combination of Byetta and insulin is immaterial. In either event Byetta is not medically indicated. There is no evidence demonstrating that the patient requires the addition of Byetta to her treatment regimen. Without such evidence Byetta cannot be considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested growth hormone therapy for the treatment of idiopathic short stature. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient fulfils the Food and Drug Administration criteria for growth hormone therapy for idiopathic short stature, as he is abnormally short, and has a projected short adult height, which is well below his mid-parental target. Additional clinical support comes from a low IGF-1 level and a good growth response to previous treatment with growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a PET scan of the brain for dementia evaluation.   Findings:  Two physician reviewers found that while PET imaging can show abnormalities within the brain in patients with dementia, the findings on PET imaging do not always contribute to the treatment planning of the patient. A review of the peer-reviewed literature revealed no significant evidence to support the use of PET imaging for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested revisional total hip replacement surgery for treatment of his postoperative leg length discrepancy.  Findings:  The physician reviewer found that the patient does not require re-operation of the hip for a 1cm leg length discrepancy. A 1cm leg length discrepancy is quite normal as far as essential hip function is concerned. The patient should be able to easily compensate for this leg length discrepancy. There was one reference in the record to a leg length discrepancy of 2, but this was not confirmed by x-ray or physician examination. As such, revisional surgery is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 17-year-old male enrollee have requested residential treatment service for treatment of his bipolar disorder.  Findings:  The physician reviewer found that according to the clinical record, the patient is violent and aggressive, and these behaviors are a manifestation of a severe psychiatric disorder, i.e., bipolar disorder. The patients aggressive behavior is a danger to others, especially those in his home and he has been unable to contract for safety. The patients condition has not stabilized despite several recent acute hospitalizations and he is not able to properly utilize outpatient treatment. There is a strong probability the patient will require further inpatient care if he remains at home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested growth hormone (GH) therapy for the treatment of idiopathic short stature (ISS).  Findings:  The physician reviewer found that the patient is a young adolescent male with short stature. Based on the growth-retarded male tables of the Greulick and Pyle Atlas, he is likely to become a short adult without growth-promoting therapy. These medical facts conform to the criteria established by the FDA for treatment of idiopathic short stature with GH therapy. A six-month trial of GH therapy is medically indicated and continued therapy should be based upon an appropriately documented increase in IGF-1 levels and height velocity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Abraxane therapy for treatment of ovarian cancer.  Findings:  Two physician reviewers found that Abraxane is a protein-bound form of Taxol and has been found to be at least as effective as Taxol in the treatment of breast cancer, without the property for acute toxic reactions. Though it is expected that Abraxane will eventually be useful as a substitute for Taxol in a variety of cancer types, there is as yet, no real data that Abraxane can be successfully used instead of Taxol in ovarian cancer. However, the use of a taxane (whether it be Taxol or Taxotere) is an important component in the treatment of ovarian cancer. This patient has experienced acute and severe allergic reactions to both Taxol and Taxotere, precluding their further use. Abraxane is a reasonable and medically indicated substitute taxane without the known risk of an acute toxic reaction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested PET/CT imaging for evaluation of ovarian cancer.   Findings:  Three physician reviewers found that the sensitivity and specificity for combined PET/CT is higher than CT alone; 83% versus 70% for sensitivity and 92% versus 83% for specificity. The negative predictive value is also higher for PET/CT combined versus CT alone; 73% and  59% respectively. Studies have shown that PET is more sensitive than CT for suspected recurrent ovarian cancer when there is a rising CA 125. In a study of 56 women, PET/CT resulted in a major change in treatment plan for 58% of the patients. In another recent study it was concluded that, FDG-PET/CT has the greatest utility in settings of suspected ovarian cancer recurrence, particularly in patients with rising CA-125 levels and negative conventional imaging.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested Botox injections for treatment of her neck pain.  Findings:  Two physician reviewers found that the patient has chronic left neck pain with elements of torticollis and muscle shortening.  She has responded to previous Botox injections. Although her condition may have elements of myofascial pain, there are also elements of torticollis. The benefit of Botox therapy for the treatment of torticollis is acknowledged by the Health Plan. Given the patients clinical history and the failure of more traditional therapies, further treatment with Botox is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested Nexavar for treatment of her glioblastoma.  Findings:  Three physician reviewers found that Sorafenib (Nexavar) is a new multikinase inhibitor with FDA approval in renal cell cancer. It is being explored in multiple other tumor types and is considered experimental in all settings other than renal cell cancer. A search of the relevant literature on Nexavar for brain tumors revealed no published data to support its efficacy, and no data to support its safety in the use in CNS tumors, especially if used with Temodar and radiation. There is inadequate evidence to suggest that Nexavar is likely to be more beneficial than standard therapy for treatment of this patients disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested surgical vein stripping for treatment of his varicose veins.  Findings:  The physician reviewer found that general practice guidelines in the specialty of vascular surgery dictate that symptomatic varicose veins warrant invasive treatment when there are complications such as bleeding, ulceration or recurrent thrombophlebitis or there are chronic symptoms which are severe enough to interfere with activities of daily living. Additionally, the symptoms must be refractory to at least three months of conservative therapy inclusive of prescription compression stockings. Treatment of the great saphenous and small saphenous veins by ligation, division and stripping is warranted only when reflux is demonstrated in these veins by duplex ultrasound. In this instance, there is insufficient documentation that the patients symptoms interfere with his activities of daily living and the use of an Ace wrap is not equivalent to prescription compression stocking use. Finally, no reflux was demonstrated in the great saphenous or small saphenous veins of the right leg.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested psychiatric residential treatment services for treatment of his behavioral health problems.  Findings:  The physician reviewer found that the patient came to the program with genetic loading for depression and gifted intellectual functioning. His symptoms of depression were significant, if not profound.  However, he denied suicidal ideation, homicidal ideation and had no evidence of a thought disorder clinically or by psychological testing. While the patient did benefit from his residential treatment stay, his condition could have been treated with more frequent and appropriate office-based medication management or psychotherapy visits as of the date in question. The interventions the patient received while in residential treatment could have been obtained in the community including psychological testing, individual therapy twice a week and family therapy. All told, the submitted evidence demonstrates that the patient would have been able to be safely treated at a lower level of care as of the date in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested vision therapy and a visual examination for treatment of his visual defects.   Findings:  The physician reviewer found that it is not uncommon to find children with myopia, in one of both of their eyes, who are wearing glasses that are under corrected by 1 to 2 diopters. The patient sees 20/40 in each eye and is not amblyopic. The cause of his decreased visual acuity is congenital nystagmus. The patient is also said to have mild developmental delay and learning disabilities. There is no scientific evidence to support the use of vision therapy for learning disabilities or for congenital nystagmus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an out-of-network referral to a multidisciplinary functional rehabilitation program for treatment of complex regional pain syndrome.  Findings:  The physician reviewer found that Complex regional pain syndrome is a commonly encountered and managed pain diagnosis. Sympathetic blocks are a commonly performed interventional procedure in the management of complex regional pain syndrome. Any trained, board certified pain management specialist is capable of adequately managing complex regional pain syndrome and performing sympathetic blocks. A review of the record indicates the Health Plan has appropriate providers qualified to treat the patients condition. There is no evidence to support the need for treatment from an out-of-network specialist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a laparoscopic gastric bypass procedure for treatment of morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 38.5 and a weight-bearing joint injury that will likely be ameliorated or eliminated by bariatric surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested Increlex therapy for treatment of his short stature due to Cystic Fibrosis.   Findings:  The physician reviewer found that Cystic fibrosis is usually associated with short stature due to chronic lung infections, pancreatic steatorrhea and anoxia as complicated by diabetes. IGF-1 levels tend to be low because of poor nutritional status. Vigorous management of these factors is associated with better growth outcomes. At this time, there are insufficient studies documenting that IGF-1 therapy results in a worthwhile anabolic effect and growth response in cystic fibrosis patients. The benefit of Increlex remains unproven in this setting and the therapy could worsen the diabetic state.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a power-operated vehicle (POV) for her mobility.  Findings:  The physician reviewer found that The records provided are not supportive of the patients need for a POV. There is no evidence of a condition or illness that would prevent the use of a standard heavy-duty wheelchair for mobility. The patient appears to have full use of her upper extremities and is fully capable of propelling a manual wheelchair. There is no indication of a need for a POV for mobility-related activities of daily living.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Mepron for the treatment of Lyme disease. Findings:  The physician reviewer found that standard treatment of late stage Lyme disease consists of 30 days of Ceftriaxone. Standard treatment of Babesiosis is a seven to ten day course of atovaquone and azithromycin or quinine and clindamycin. There is no evidence in support of prolonged or repeated courses of antibiotics for either of these disease states nor does the documentation provided demonstrate the presence of either of these disease states.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 16-year-old female enrollee have requested Increlex for treatment of short stature.Findings:  The physician reviewer found that Increlex is FDA approved only for children with GH resistance syndromes. There were no clinical features identified that would support a GH-resistant phenotype.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested Rozerem for the treatment of sleep apnea and jet lag.Findings:  The physician reviewer found that Modafinil has an FDA approved indication for certain types of circadian rhythm disturbances - Rozerem does not. According to the FDA, Rozerem is indicated for the treatment of insomnia characterized by difficulty with sleep onset.  Although insomnia and circadian rhythm disturbances can present in similar fashions, they are distinct conditions. A search of relevant literature did not reveal any published studies utilizing Rozerem for circadian rhythm disturbances in humans. Although there is information suggesting the safety of this agent in patients with mild to moderate sleep apnea, no evidence of such a published trial was identified in a search of the published literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested an MRI of the right breast for evaluation of her breast cancer. Findings:  The physician reviewer found that there are several indications for MRI of the breast including pre-operative evaluation of extent of cancer, post-operative evaluation of residual cancer, evaluation of extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene.  High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. Based on the clinical evidence provided, the patient falls within the high-risk category given her history of breast cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested IVIG treatment for the treatment of his multiple sclerosis. Findings:  The physician reviewer found that while there have been some reports that IVIG is beneficial in treating multiple sclerosis, it is not the standard of care or FDA approved for this indication. At this time, there is inadequate scientific data demonstrating that IVIG has clinical value in the treatment of patients with multiple sclerosis. As such, the use of IVIG in this clinical setting is not medically justified.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested stereotactic body radiotherapy (SBRT) as part of the Trilogy protocol for the treatment of her pancreatic cancer. Findings:  Two physician reviewers found that the patient has unresectable, locally advanced, pancreatic cancer. A protocol involving chemotherapy followed by SBRT single-fraction treatment and then further chemotherapy was recommended. The previous SBRT studies for pancreatic cancer have shown improved local control but there was no improvement in overall survival. There is no phase III randomized trial yet. Until the results of the current protocol study are available, it cannot be concluded that the disputed procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.