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

A 79-year-old male enrollee has requested the prescription medication Revatio for the treatment of his pulmonary hypertension. Findings:  The physician reviewer found that in this circumstance, maximizing cardiac treatment is usually the best approach to treating pulmonary hypertension and is preferred over the use of pulmonary vasodilators as first-line treatment. The patients elevated LVEDP with preserved cardiac output indicates that attempts at increasing diuretic dosing would be appropriate. Increased afterload reduction may also be of benefit. If the patient experiences moderate to severe pulmonary hypertension and symptoms after a decrease in LVEDP, it would then be appropriate to consider a trial of a pulmonary vasodilator.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a whole-body PET/CT scan for thr evaluation of her gastrointestinal stromal tumor (GIST). Findings:  The physician reviewer found that this patient has high-risk GIST and is status post surgical resection. She has had several prior PET/CT scans. It has been shown the PET/CT is slightly superior to PET and CT obtained separately and significantly better than CT alone in assessing tumor response to treatment. Research has found that for patients treated with imatinib (Avastin), PET/CT improves staging, accurately separates responders from non-responders in an early phase and is helpful during follow-up. With respect to GIST, there is sufficient evidence in the literature to establish the efficacy of PET/CT in disease detection and assessment of early response to treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested surgical implantation of a bone anchored hearing aid (BAHA) for treatment of his hearing loss.   Findings:  The physician reviewer found that the BAHA is indicated for use in patients with hearing loss who cannot tolerate the use of a conventional amplification device. In the past, this was often interpreted to mean patients with external or middle ear disease that precluded the use of traditional hearing aids. Over the years, the use of this device has been expanded to include patients with severe unilateral sensorineural hearing loss. It has been found that there is a reduction in head-shadow effect and enhancement of speech recognition with the use of a device that routes sounds from a hearing impaired ear to a contralateral normal or lesser impaired ear. Both the BAHA and the contralateral-routing of signal (CROS) hearing aid accomplish this. While there have been some recent study results which indicate that patients prefer the BAHA over the CROS hearing aid, objective data in this regard is not yet conclusive. As this patient has had a long-term trial of external hearing amplification and no longer finds it effective, the likelihood that he will benefit from the use of a CROS hearing aid is minimal. At this time, the BAHA is the best option for this patient. Given the current literature, it is most likely that with a bit more time and study, use of the BAHA will become the standard of care for patients such as this.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested the prescription medication Lyrica for treatment of post-polio syndrome.  Findings:  The physician reviewer found that Only two brief progress notes from the patients primary care physician were submitted. There is also a medication flow sheet contained within the record, but no medications other than the Lyrica and Toprol are listed. There is no specific information about the patients diagnosis of post-polio syndrome or the dosage, duration or response to previously prescribed medications. The provider did not describe the severity of the patients pain or note the degree of her disability, if any. In general, polio is a motor neuron disease and post-polio syndrome is associated with muscle pain, but not typically with neuropathic pain. Based on the evidence contained within the record, there is no medical indication for treatment with Lyrica.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested a panniculectomy/abdominoplasty procedure for treatment of her excess skin.  Findings:  The physician reviewer found that the patient has a body mass index of 26.5.  The color photographs reveal a female standing erect without obvious assistance and no abdominal pannus overhanging the inguinal ligament or mons pubis. She has excess skin of the mid abdominal wall. There is no skin ulceration noted. There is no evidence of subjective complaints of skin rashes in the clinical records or rashes documented by physical examination. There is a lack of documentation of a chronic skin problem with intertrigo, rashes and skin ulcerations with failure of conservative treatment over a period of time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested imaging studies and laryngeal function studies for evaluation of the enrollees sleep apnea and snoring.  Findings:  The physician reviewer found that after failing a trial of CPAP therapy for treatment of his obstructive sleep apnea, the patient underwent some studies at a treatment center for craniofacial pain. It appears these studies were performed at the time the patient was being fitted for the dental appliance. There is documentation of a pharyngometer laryngeal study and several x-rays including x-rays of the cervical spine and nasal bones. These diagnostic modalities are not included within mainstream evaluation and treatment of sleep apnea. The clinical value of the services at issue has not been established in this setting. As such, the use of these modalities was not medically justified in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested growth hormone therapy for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that this patient is being followed by a pediatric endocrinologist.  Based upon the clinical information provided, he is destined to become a short adult without treatment. The patient qualifies for growth hormone therapy under the 2003 FDA guidelines for idiopathic short stature. Growth hormone therapy is clinically indicated for this patient and is likely to be beneficial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested upgraded Nucleus 24 Freedom bilateral sound processors for treatment of his mixed conductive and sensorineural hearing loss.  Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the patients ESPrit 3G processors were non-functioning at the time he received the Nucleus 23 Freedom processors. While there has been some improvement in the patients performance with the Freedom processors, the changes are small, and did not result in a dramatic difference in the patients functional status. Based upon the evidence provided, there was not a compelling need to switch to the Nucleus Freedom processors.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Tarceva for the treatment of his pancreatic cancer. Findings:  Three physician reviewers found that Tarceva has been found to be of marginal effectiveness in combination with Gemzar in the initial treatment of pancreatic cancer. There is no data whatsoever as to its efficacy in combination with any other chemotherapy drugs or as a second or third-line therapy for pancreatic cancer. The use of Tarceva is certainly investigational and is of no known clinical benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested the medication Zetia for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation provided which demonstrates that Zetia is medically necessary for this patient. While the patient does require therapy to achieve an LDL lower than 130 by NCEP criteria, there is no evidence that he has tried therapy with a water-soluble statin (e.g., Pravachol) to see if he can achieve his LDL goal without the side effects of myalgias. Thus, the patient should undergo a trial of therapy with a formulary water-soluble statin prior to consideration of Zetia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested surgical implantation of a bone-anchored hearing aid (BAHA) for treatment of her hearing loss. Findings:  The physician reviewer found that The BAHA is indicated for use in patients with hearing loss who cannot tolerate the use of a conventional amplification device. In the past, this was often interpreted to mean patients with external or middle ear disease that precluded the use of traditional hearing aids. Over the years, the use of this device has been expanded to include patients with severe unilateral sensorineural hearing loss. It has been found that there is a reduction in head-shadow effect and enhancement of speech recognition with the use of a device that routes sounds from a hearing impaired ear to a contralateral normal or lesser impaired ear. Both the BAHA and the contralateral-routing of signal (CROS) hearing aid accomplish this. While there have been some recent study results which indicate that patients prefer the BAHA over the CROS hearing aid, objective data in this regard is not yet conclusive. This patient has not had a trial of CROS amplification. A three to six-month trial of the CROS hearing aid is a reasonable next step, rather than an immediate jump to surgical intervention and its related risks. If the patient continues to function poorly in her work situation, thus failing the trial, then authorization for BAHA placement should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested total hip resurfacing arthroplasty for treatment of her osteoarthritis.  Findings:  Two physician reviewers found that total hip resurfacing arthroplasty is medically reasonable and has certain advantages.  In theory the resurfacing arthroplasty will preserve bone stock of the femoral neck and make femoral revision surgery more predictable.  In an active young individual these advantages are not insignificant. Regarding the socket side of the surgery, there have been issues historically pertaining to longevity of this implant, but considerable modification has been made to optimize longevity. Furthermore, the proposed procedure has distinct advantages over a traditional arthroplasty. The risk of dislocation is reduced, bone stock is preserved so that future revision surgery is possible, and other common problems and accommodations are decreased with this surgery as compared to traditional total hip replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested an increased number of Imitrex kits per month for treatment of migraine headaches.  Findings:  The physician reviewer found that there is no evidence in the submitted medical records that the patients headache pattern has accelerated secondary to medication overuse (rebound) headache. Use of Imitrex at a frequency of 2 doses daily x 2 days weekly x 4 weeks monthly would result in acceptable use of 16 doses monthly. Therefore, 8 Imitrex kits (16 doses) monthly should be authorized for this patient. Consideration should also be given to specialty headache medicine consultation to evaluate novel approaches to prevention such as Botox therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested growth hormone (GH) therapy for treatment of her idiopathic short stature (ISS).  Findings:  The physician reviewer found that in retrospect, this appears to be a young male with constitutionally delayed adolescence. Based on his height and bone age, his adult predicted height would be close to 56 according to the tables of the Greulick and Pyle Atlas. With a diagnosis of constitutional delay, the patient would be expected to attain a normal adult height without GH therapy. This prediction, though probable, is somewhat uncertain because the patient has received GH therapy for the past two years. Should his adult height prediction fall to less than 54 without GH therapy, a resumption of treatment should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested hyaluronate injections for treatment of osteoarthritis. Findings:  Two physician reviewers found that the requested series of hyaluronate injections is medically reasonable in this patient for her recurrent ongoing arthritic knee complaints. Other treatment options seem to have been tried in terms of over-the-counter medication, physical therapy and activity modification. Often in these cases, knee replacement surgery is the only other option that is likely to be of benefit. In this case, since this patient had good relief from the injections for at least one year, it is medically reasonable to repeat the injections at this time in an attempt to give her ongoing comfort without the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her alcohol dependence and major depression. Findings:  The physician reviewer found that the patient clearly met the established criteria for continued acute inpatient psychiatric care. She underwent a prolonged detoxification process and was acutely ill with depression and anxiety. Her anxiety escalated to panic when discharge was imminent. The patient underwent ECT for treatment of her depression with plans to continue this intervention on an outpatient basis. Multiple medications were prescribed for depression, anxiety, mood stabilization and relapse prevention and dosages were titrated throughout her stay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested sub-acute rehabilitation services for treatment of acute coronary syndrome and encephalopathy. Findings:  The physician reviewer found that the submitted clinical information does not demonstrate that additional sub-acute rehabilitation services are medically necessary for this patient. There is inadequate documentation that the patient requires such services. The records provided do not include objective data documenting the patients functional status and current deficits. As such, there is inadequate evidence that the requested services are medically indicated or likely to result in clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for pre-surgical workup for evaluation of her pancreatic cancer. Findings:  The physician reviewer found that the current radiologic evaluation does not clearly demonstrate advanced disease, and the ascites fluid was not found to harbor malignant cells. Thus, it is not clear that the patient does in fact have unresectable disease. Since surgery is the only treatment that may offer long-term survival, it should not be ruled out based on ambiguous radiologic findings. The proposed MRI should be performed; if no additional information is obtained, the proposed diagnostic laparoscopy and liver biopsy should be performed to resolve the issue of advanced disease versus resectable disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested Lamisil for treatment of his nail fungus.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that three months of Lamisil treatment was partially successful. In light of these findings, it was reasonable to conclude that longer treatment with Lamisil was likely to be helpful. No evidence has been provided that prolonged treatment with Lamisil would result in a significantly increased health risk. Given the patients previous partial response to treatment, an extra month of Lamisil was clinically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested panniculectomy/abdominoplasty and bilateral breast lift for treatment of her redundant skin condition.  Findings:  The physician reviewer found that the records do not establish medical necessity for the proposed panniculectomy/ abdominoplasty or breast lift. The patient has generalized skin laxity consistent with her history of massive weight loss. 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 plainly 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. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. The proposed procedures do not meet this standard as there is no documentation over time of skin infections in the abdominal folds or under the breasts (e.g., series of office notes, dermatology consultations, or prescription records) and no photographs documenting cellulitis, ulcerations or rashes were submitted. Additionally, the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss has not been satisfied as the records do not document panniculitis or the failure of medically supervised conservative therapy to control intertrigo. Breast lift and panniculectomy/abdominoplasty may be desirable for aesthetic reasons, but they are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for laparoscopic biliopancreatic diversion/duodenal switch for treatment of her morbid obesity.   Findings:  The physician reviewer found that Peer reviewed  articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the duodenal switch as compared to other surgical procedures. The published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the duodenal switch. The patients assertion that the duodenal switch is the most effective surgical weight loss alternative is well supported in the literature and this option should be made available to her.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested a laparoscopic sleeve gastrectomy procedure for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the patient has ulcerative colitis and may subsequently require a total abdominal colectomy with or without pouch. Patients are more likely to get dehydrated following a colectomy and gastric capacity should be maintained. Additionally, a sleeve gastrectomy procedure could possibly fistulize. This patient may be an appropriate candidate for the laparoscopic gastric banding.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for an out-of-network referral for surgical services for treatment her arteriovenous malformation. Findings:  The physician reviewer found that review of the medical literature regarding treatment of AVM includes a study in which operative intervention was directed at primary resection in 15 cases, stage resection in 7 cases, embolization and resection in 5 cases, and evacuation of hematoma in 3 cases. Operative mortality in this surgical series was 7%, with significant morbidity in 13% of patients. Open surgery is associated with multiple potential complications including cerebellar mutism, paralysis and death. There is also a high likelihood of leaving residual AVM behind depending on the pattern of venous drainage. Use of modern microsurgical techniques in removal of posterior fossa AVMs may offer better results than the natural history of the disease process, especially in patients who present with hemorrhage. Radiosurgery is an acceptable treatment for patients with small AVMs in whom a higher obliteration rate can be achieved with lower risks of interval hemorrhage compared with the reported results in the general population. Careful follow-up observation is required, however, even after angiographically verified obliteration.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested the human papillomavirus (HPV) vaccine, Gardasil for the treatment of nasal papillomas.  Findings:  Three physician reviewers found that this vaccine is not a cure for papillomas, but a preventative measure. As such, it is not indicated for the treatment of existing papillomatous disease. There is no literature to support the use of Gardasil in patients with nasal papillomas.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 17-year-old male enrollee have requested a bilateral reduction mammoplasty for the treatment of gynecomastia.  Findings:  The physician reviewer found that there is no evidence of rashes, nipple drainage or obvious masses. The record reveals no evidence of functional impairment due to this condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for the treatment of migraine headaches.  Findings:  Two physician reviewers found that although Botox is not FDA approved for the treatment of migraine headaches, it is often used for the prevention of medication resistant headaches. However, a patient should have adequate trials of three or more prophylactic medications before treatment with Botox is indicated. These medications should be from several different classes, such as anti-depressants, anticonvulsants, beta blockers and calcium channel blockers.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a percutaneous intracranial balloon angioplasty with possible stenting for the treatment of basilar artery stenosis.  Findings:  Two physician reviewers found that multiple medical organizations have statements supporting intracranial angioplasty/stenting, and the Food and Drug Administration has approved two intracranial stenting devices. The procedure is being routinely performed in many academic stroke centers in the United States.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested an MRI study of the right knee for the evaluation of knee pain.  Findings:  The physician reviewer found that the only other option would be an arthroscopic evaluation of the knee, which is invasive. As such, an MRI study is the next appropriate step in the evaluation and treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a wireless capsule endoscopy for the evaluation of gastrointestinal problems.  Findings:  The physician reviewer found that the diagnosis of Crohns disease had already been established based on the colonoscopic biopsies. Her terminal ileal biopsies revealed no abnormality and a small bowel series was normal. The findings of a wireless capsule endoscopy would not change the therapeutic strategy in the case of this patient.