Persius/imr-appeals huggingface dataset:
A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While the patient has evidence of breast ptosis, this is a natural consequence of weight loss and aging. There is no evidence that the ptosis is secondary to macromastia. As such, the patient does not have an abnormal structure of the body. In the absence of evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, this patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Based on her photographs, this patient does not have heavy breasts. Rather, she has involutional ptosis from her weight loss. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well-established, the medical literature provides no evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The plastic surgeons consultation note describes problems with intertrigo, but the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or, despite initial response, have recurred and caused significant functional impairment. Likewise, the records do not include any office notes that document long-standing musculoskeletal symptoms that have failed to respond to conservative treatments. The patient has been treated by a chiropractor, but office notes are not submitted that document the indications and response to treatment. Irrespective of whether the patient has musculoskeletal symptoms, there is no scientific evidence that the proposed treatment will be effective for her complaints. Bilateral mastopexy is not medically necessary for this patient.
A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer. Findings:  The physician reviewer found that chemoembolization is considered a relatively standard treatment for unresectable hepatocellular carcinoma and is endorsed by National Comprehensive Cancer Network Guidelines. Chemoembolization is not curative in this setting, but is used to improve disease control. Typically, if both lobes are involved, the lobes will be treated sequentially. Based upon the evidence provided, the patient was an appropriate candidate for the therapy and its use in this setting was clinically indicated.
A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware. Findings:  The physician reviewer found that the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation. It was imperative that pain relief was adequate after the patients nerve block wore out and prior to discharge. The acute hospital stay services provided on the dates in question were medically indicated and appropriate for this patients postoperative care.
A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that there have been a few trials published documenting some degree of efficacy of the combination of oxaliplatin with gemcitabine in hepatocellular carcinoma. There is one phase II study combining these two drugs with Avastin by Zhu and colleagues. This trial demonstrated only that this combination was tolerable in terms of toxicity, but it was inconclusive as to whether the Avastin actually added significant benefit to the combination of oxaliplatin with gemcitabine. While oxaliplatinum with gemcitabine is of clinical benefit in this setting, Avastin remains unproven for this patients condition.
The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.  Partial hospitalization allows for close monitoring of medication while adjustments occur, and it also allows for intense interventions for impulsivity and aggression and abnormal involuntary movements by a multi-disciplinary team.
A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition. Findings:  The physician reviewer found that this need can be met by taking frequent breaks while driving, or he can recline in a private vehicle being transported by someone else. There is no documentation that the patient has any unusual anatomy or skin breakdown such that he cannot be positioned in a private vehicle.
A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition. Findings:  The physician reviewer found that the CPM device is used routinely postoperatively following knee replacement surgery. It has been used extensively for more than twenty years. The equipment is used for one to two weeks postoperatively, and it is sometimes used for knee procedures other than total knee replacement. The CPM device was medically indicated and appropriate for treatment of this patient.
A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that a patient must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although this patient did report pain, the pain was not acute in onset. His testicular pain had been present for two months. Further, the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain. While his ongoing testicular pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, his symptoms do not meet criteria for an emergency.
A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition. Findings:  The physician reviewer found that there is a lack of documentation justifying the MRI scan. There is no orthopedic exam is available to review in order to justify the MRI scan.  The MRI report describes some vague findings with respect to the menisci.  Grade II signal commonly is associated with myxoid degeneration of the meniscus, and there is no unequivocal description of pathology within the knee which even retrospectively could be construed as findings requiring operative intervention or even more conservative management such as lack of weight bearing.
The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition. Findings:  The physician reviewer found that there was no indication that the patient was profoundly depressed, oppositional, suicidal or homicidal. He was not acting out in an overly aggressive or disturbed manner.
A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions. Findings:  The physician reviewer found that this patient meets nationally accepted criteria for authorization of bariatric surgery. This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension. The 2004 Bariatric Surgery Consensus Conference statement supports prompt bariatric surgery in this circumstance.  There is documentation that full reversal of diabetes is severely diminished when surgery is delayed.  Further, surgery will improve the patients life expectancy.  Additionally, and quite significantly, non-operative approaches have nearly 100% failure rate in class III obese patients, such as this patient.
The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that Botox is a well-accepted and standard of care medication amongst headache specialists for patients failing multiple medications in multiple classes of prophylactic drugs.
A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain. Findings:  Three physician reviewers found that artificial disc replacement is a unique technique for the surgical treatment of discogenic back pain. However, there is a paucity of controlled studies and clinical trials showing the safety and efficacy of this procedure, particularly as compared to interbody fusion surgery.
A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms. Findings:  Two physician reviewers found that the use of subcutaneous hormone replacement therapy (HRT) has been reported for many years. Subcutaneous HRT is particularly useful when patients require testosterone supplementation. Subcutaneous testosterone supplementation has been shown to be effective in improving bone density and treating reduced libido and other psychosexual problems. There is no other option currently available (such as transdermal patches) that is as reliable as this method. Transdermal creams and gels cannot be delivered in consistent, accurate doses. Estradiol replacement can be offered simultaneously with subcutaneous testosterone supplementation, providing good benefit and convenience.
A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain. Findings:  The physician reviewer found that the request for continued manual treatment is consistent with a maintenance program and not a restorative program at this point. As such, additional physical therapy sessions are not clinically indicated.
A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma. Findings:  Two physician reviewers found that avastin appears active in glioblastoma when combined with chemotherapy and continues to be used in randomized trials to evaluate its efficacy in this population. A phase II trial of Avastin and CPT-11 showed a 63% radiographic response rate with 72% progression-free survival at six months. In this study, all 32 patients had progressed despite radiation therapy and Temodar. In another retrospective study, chemotherapy (carbo/etoposide/or CPT-11) was used with radiation therapy with a report of responses in 7 of 14 patients treated this way.
A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.  Findings:  The physician reviewer found that the best measure of good diabetic control is currently a hemoglobin A1C of less than 6.5%. When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta; suggesting his glycemic control is dependent on other factors such as diet and exercise. Research has not yet determined the incremental benefit of improving postprandial blood glucose levels when the hemoglobin A1C is already at over below goal.
A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.Findings:  Two physician reviewers found that the use of PET scans in the evaluation of large-cell lymphoma is endorsed by National Comprehensive Cancer Network (NCCN) guidelines and by the International Working Group (IWG). PET scans are recommended as baseline evaluations. If they are positive at baseline, they should be performed in follow-up. According to the IWG, PET is essential for post treatment follow-up of diffuse large B-cell lymphoma. PET scans are considered standard of care in this setting.
A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin, sulfonylureas, or thiazolidinediones, alone or in combination, but have not achieved adequate control. This patients blood glucose is under excellent control. She was apparently begun on Byetta to help her lose additional weight which is not the intended purpose of the medication.
A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain. Findings:  The physician reviewer found that the patient has been diagnosed with cervical dystonia and is being treated appropriately. Lyrica is not indicated for the pain associated with cervical dystonia. This residual pain is likely to respond to any of a number of interventions including more aggressive Botox therapy, muscle relaxants, Gabapentin or Amitriptyline. The use of Lyrica for this patient would not be considered the standard of care.
A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain. Findings:  The physician reviewer found that it is clear from the clinical record that standard measures have not adequately addressed the patients  severe, on-going pain. It is also clear that surgical correction of the lumbar radiculopathy or the carpal tunnel syndrome is not feasible because of other complicating medical problems. This is not a situation where high-potency narcotics are being utilized as an off-label substitute for more definitive measures to resolve the pain. Rather, this is a case in which the best available means of pain management has been employed and found to be effective.
A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX assay has been found to be reliable in predicting the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. It has only been validated in node-negative, estrogen receptor positive cancers. It is very difficult to make recommendations about adding adjuvant chemotherapy for this particular group of women. Not only does the Oncotype assay reliably predict the risk of recurrence without chemoterapy, it has also been found to predict the value of chemotherapy. Oncotype DX is widely accepted and has virtually become standard of care for many oncologists. This diagnostic procedure has clearly established clinical value
A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation. Findings:  The physician reviewer found that postoperative cold therapy is utilized by some orthopedists for managing pain and inflammation. However, use of cold therapy units has not been shown in long-term peer-reviewed literature to offer superiority over the traditional use of ice. The units studied have not been proven to significantly lower the intra-articular temperature of the knee. There is no study literature indicating that use of this device itself would decrease a patients hospital stay or shorten the rehabilitation period.  Appropriate monitoring of the application of ice packs eliminates the concern for skin or tissue break down.
A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma. Findings:  Two physician reviewers found that the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant, which can be performed with curative intent for myeloma. Thus, no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma. Given this patients age and prognosis, the proposed clinical trial is likely to be his best opportunity for disease control/eradication under these clinical circumstances. The proposed post-transplant randomization does not compromise the standard of care, and appears to be testing the role of a drug known to be active in this clinical setting.
The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).  Reviewers Findings:  The reviewing physician found that RSV infection has been associated with tachyarrhythmias including SVT that may be hemodynamically significant in infants such as this one.  The reviewing physician found that the Health Plan denial should be overturned.
The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that a review of the recent peer-reviewed literature indicates that MEG and magnetic source imaging can play an important role in epilepsy mapping. While the procedures are not widely used, their use in select patients with intractable seizure activity has allowed physicians to determine if a patient is appropriate for epilepsy surgery and to provide detailed mapping for pre-surgical planning. In the past, the gold standard for epilepsy mapping was the use of intracranial electrodes. There is risk associated with any surgical procedure and  particularly with brain surgery. MEG is a safer, non-invasive means of obtaining the same information as would be obtained from intracranial EEG (ICEEG).
A forty-three year-old female with severe urticaria is requesting authorization of Xolair.Reviewers Findings:  The reviewing physician found that the FDA approved indication for Xolair is moderate to severe persistent asthma in patients who have: a positive skin test or in vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and pre-treatment total IgE levels of 30 or greater. The submitted records document the patient does meet the criteria. The reviewing physician found that the Health Plan denial should be upheld.
The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.  Reviewers Findings:  The reviewing physician found that the relevant literature concerning MR spectroscopy shows there is insufficient proof of its value in this clinical setting at this time.  The reviewing physician found that the Health Plan denial should be upheld.
A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services.Reviewers Findings:The reviewing physician found that the patient appears to have been greatly compromised by her eating disorder.  The reviewing physician found that the Health Plan denial should be overturned.
A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.  Findings:  Three physician reviewers found that Desmoid tumor (aggressive fibromatosis) can be a recurrent, though not metastatic, form of neoplasia. Standard chemotherapy has rarely been of much value. Gleevec, which is approved for use in chronic myelogenous leukemia and gastrointestinal stromal tumors, has indeed been reported to have some efficacy in desmoid tumors. There are multiple papers documenting this as cited above. Because of the rarity of desmoid tumor, Gleevec will probably never be approved for treatment of this condition. However, there is enough data to believe it is more likely to be effective than any of the more conventional forms of chemotherapy than might be offered.
A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.Reviewers FindingsAfter reviewing the requests, two of the three physicians found the electrogastrogram was not likely to be more beneficial for evaluation. Two of the three physicians found that antroduodenal motility/manometry studies were likely to be more beneficial for evaluation.  The reviewing physicians found the Health Plan denial should be partially overturned.
The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.The use of a bone growth stimulator in this case was medically reasonable and acceptable. If the bone growth stimulator was effective, the patients pain would have diminished and her condition would have improved without the need for invasive treatment (i.e., surgery). Unfortunately, in this case union was not achieved and surgery was required. However, since the bone growth stimulator provided the potential of preventing the patient from having surgery, its use was clinically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful post-operatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the cold therapy unit following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.