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

A 59-year-old male enrollee requested methadone 50 mg daily for medical treatment of the enrollees spinal stenosis and cancer pain.  Findings:  The physician reviewer found that the requested methadone 50 mg per day is not medically necessary for treatment of this patients medical condition. The records indicate that this patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee requested a 12-week course of Sovaldi 400mg for medical treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Per the medical records, this patient has minimal to no fibrosis.  The documentation noted that a trichrome stain of the liver was normal.  The requested treatment is not indicated in this patients case.  His fatigue is likely multifactorial and most likely secondary to depression.  This symptom is not an indication for treatment of his hepatitis C.  All told, the requested 12-week course of Sovaldi 400mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested a 12 week course of Sovaldi and Olysio for medical treatment of her hepatitis C genotype 1.  Findings:  The physician reviewer found that there is no demonstration of advanced fibrosis (stage F3 or greater), by either liver biopsy, elastography, of liver fibrosis panel. The current medical literature does not support treatment with Sovaldi and Olysio in patients with only minimal fibrosis and inflammatory activity. Given the lack of evidence that the patient has advanced fibrosis, the requested medication regimen consisting of a 12 week course of Sovaldi and Olysio is not supported as medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested authorization a 12-week course of Sovaldi 400mg and Olysio 150mgfor treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination in this patients case.  This patient has been diagnosed with hepatitis C, genotype 1a.  On the date incdicated, ultrasound of the abdomen showed normal liver morphology.  In this patients case, there is no demonstration either through liver biopsy, liver fibrosis panel or elastography that the patient has significant fibrosis.  There is a lack of support for the requested medication combination in this clinical setting.  The advantage of treatment in patients with minimal to no fibrosis has not been established.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is not medically indicated that the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested Norco (hydrocodone-acetaminophen) for medical treatment of his rotator cuff tears and lumbar disc herniations.  Findings:  The physician reviewer found that the requested Norco (hydrocodone-acetaminophen) is not medically necessary for treatment of this patients medical condition. The records indicate that the patient requires two tablets of Norco every four hours as needed. This type of narcotic at this dosing is currently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. Additionally, the dose of Norco poses a risk for acetaminophen toxicity. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under the close monitoring of a certified pain management physician (Fishman).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee  requested Tecfidera Starter Pack (dimethyl fumarate capsule DR starter pack 120mg and 240mg for medical treatment of his multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has multiple sclerosis, but the documentation provided by his providers indicates he has a progressive form of multiple sclerosis, either primary progressive, or secondary progressive multiple sclerosis.  In this patients case, there is no documentation of relapse since the initial diagnosis.  Per the current medical evidence, with the exception of Novantrone, disease modifying agents are indicated only for relapsing forms of multiple sclerosis.  Given the fact that he is not having relapsing disease, the requested Tecfidera Starter Pack (dimethyl fumarate capsule DR starter pack 120mg and 240mg) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested a 12-week course of Sovaldi 400mg and Ribapak 600/400mg for medical treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  In this case, the patient likely has advanced fibrosis and has cryoglobulinemia.  The recommended first-line treatment in this clinical setting includes sofosbuvir (Sovaldi).  Data from genotype 4 patients is favorable, and sofosbuvir is known to be pan-genotypic.  All told, the requested 12-week course of Sovaldi 400mg and Ribapak 600/400mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 The parent of a 17-year-old male enrollee requested surgery to realign the spinal cord for medical treatment of his spinal cord injury. Findings:  The physician reviewer found that this patient has sustained devastating body injuries and remains seriously ill. Despite consideration for surgery, the patient is not a candidate for surgery because of his co-morbidities including pulmonary, sepsis, fever, and skin breakdown at multiple sites. The patients thoracolumbar injury severity score (TLISS) is 4 given the burst compression fracture, ASIA A spinal cord injury, and intact posterior elements. In the medical literature, a TLISS score of 4 places the patient in the non-operative category (Ellenbogen, et al; Vaccaro; et al). In addition, Stannard and colleagues noted that indications for surgery are based on the stability of the injured spine. This patients records document spinal stability. Further, the patients posterior elements are not injured, thus making this a stable fracture. All told, the requested surgery to realign the spinal cord is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee requested immediate neuropsychiatry assessment to determine whether his behavior is attributable to his brain injury, psychiatric condition or combination of both; an assessment to make a differential diagnosis of his brain condition and psychiatric condition; learning and coping skills so he can have a productive life; an assessment of his psychological defects and his psychiatric/psychological condition; and intensive individual psychiatric therapy (not group therapy) with cognitive behavioral dialectical therapy, with any other therapies a neuropsychiatrist can provide for medical evaluation of his late effects of anoxic brain injury.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The neuropsychological evaluation encouraged the patient to seek community-based specialty resources.  As such, a routine neuropsychiatric assessment is indicated.  However, as the patient is not experiencing an acute psychiatric syndrome or demonstrating imminent safety concerns, an immediate or emergent evaluation is not medically necessary.  The requested assessment to make a differential diagnosis of the patients brain condition and psychiatric condition is not medically indicated.  A neuropsychiatric assessment will provide the differential diagnosis of the patients brain and psychiatric conditions, and a separate assessment is not necessary.  With regards to the requested learning and coping skills, this patient has been involved in comprehensive physical medicine and rehabilitation services and outpatient psychotherapy.  Further, he has been encouraged to participate in mental health services at a higher level of care to address clinical needs related to enhancement of coping skills and optimization of learning strategies.  Thus, unless these particular services are recommended by the neuropsychiatric assessment, they are not medically necessary.   Per the submitted documentation, the requested assessment of this patients psychological defects and his psychiatric/psychological condition is not medically necessary.  Additionally, the requested intensive individual psychiatric therapy (not group therapy) with cognitive behavioral and dialectical therapy, with any other therapies a neuropsychiatrist can provide is not medically necessary.  An individualized, patient-centric treatment plan is a key element for clinical success.  If the treatment team determines that specific evidence-based psychotherapies are indicated, they should be made available to the patient.  However, at this time, based on the documentation provided, it is premature to specify the particular therapeutic modalities and treatment settings necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested germline testing (MLH-1 dup/delete variant (CPT 81294); MSH-2 dup/delete variant (CPT 81297); MSH-6 dup/delete variant (CPT 81300) and PMS-2 dup/delete variant (CPT 81319)) for medical evaluation of his cystic sebaceous tumor.  Findings:  Two physician reviewers found that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient has a personal history of a sebaceous adenoma with loss of MSH-2 expression, presence of MLH-1 expression, a family history of a constellation of cancers that are strongly suggestive of possible Lynch syndrome or Muir-Torre syndrome, and is of maternal and paternal Russian Ashkenazi Jewish descent.  Full gene sequence testing for all four genes in question was authorized.   Therefore, the additional request for testing of deleted and duplicate variants of the four genes are not clinically indicated at this time. Testing of the deleted and duplicate variants may potentially be indicated, if the full sequence testing of all four genes is negative. As such, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested ligation of perforator veins (CPT 37761), stab phlebectomy (CPT 37765), and injection of sclerosing agent (CPT 36471) for treatment of her varicose veins. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a variant of the common form of venous insufficiency, with her provider documenting reflux from a thigh perforator.  In this clinical setting, it is appropriate to treat the varicose veins that are causing the symptoms, either by phlebectomy or with sclerotherapy.  However, the current literature does not support treatment of an underlying perforator vein that is refluxing.  In this patients case, the phlebectomies and removal of the branches are medically necessary.  However, the treatment of the perforator, whether by ablation with heat or sclerotherapy, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested Ketamine combined with another medication that serves as a booster for the Ketamine for medical treatment of his leg pain.  Findings:  The physician reviewer found that Ketamine combined with another medication that serves as a booster for the Ketamine is not medically necessary for this patients chronic medical condition. This patient failed to receive benefit with previous Ketamine infusions. Moreover, the patients chronic pain condition is not consistent with complex regional pain syndrome. Given the lack of an appropriate indication for Ketamine, the requested combination therapy including Ketamine and a medication to serve as a booster for the Ketamine is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old enrollee has requested a crocodile gait trainer for medical treatment of the enrollees hypotonia and myoclonus.  Findings:  The physician reviewer found that as the documentation indicated, the patient would be utilizing this assistive gait trainer to be more independent and participate more effectively in the school environment. Without this device, the patient is confined to a chair or to the floor, limiting their effective interaction with their peers. Further, the patients provider reports the patient has a previously used gait trainer, but it is too heavy to be transferred to and from school, therefore limiting her independence in certain environments. The requested gait trainer would be used for pre-ambulatory training, in an attempt to build lower extremity muscle strength, and eventually walk with less extensive devices. Moreover, the gait trainer is appropriate for use in the home, and is able to be transported to other locations to allow the patient to complete instrumental activities of daily living, which are more complex tasks required for independent living. The expected health benefits from use of this device include increased bilateral lower extremity muscle strength, continued and improved ergonomic use of the upper body, and to prevent muscle atrophy of both the bilateral upper and lower extremities. Therefore, the requested crocodile gait trainer is medically necessary and an acceptable piece of durable medical equipment. As such, the requested device (custom crocodile gait trainer E1399) is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a Walk Aid (functional electrical stimulation unit) for medical treatment of her multiple sclerosis. Findings:  Two physician reviewers found that the requested Walk Aid is likely to be more effective for this patient than other available treatment options. According to the documentation submitted for review, this patient has gait impairment due to MS with residual spasticity and foot drop. The patients foot drop continues to impair gait, despite use of an AFO. The medical literature on the use of FES has shown potential benefits in speed of walking, oxygen uptake, and physiological cost in patients with spasticity from chronic central nervous system (CNS) lesions, as occur in MS, stroke, traumatic brain injury, or spinal injury. Moreover, a trial of the Walk Aid FES by the patient demonstrated benefit beyond that with an AFO. Therefore, based on the records provided for review it has been demonstrated that similar results could not have been achieved with a standard AFO. As such, the requested device is likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested bilateral breast magnetic resonance imaging (MRI) for medical evaluation of the enrollees dense breasts.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  This patient has a family history of breast cancer with at least one first-degree relative with the disease.  Her breast tissue is heterogeneously dense on mammography.  However, the current medical evidence does not support the requested diagnostic procedure in this clinical setting.  While MRI is the most sensitive means with which to detect early breast cancer, this technique is medically necessary when there is a greater than 20% lifetime risk of breast cancer or when there is BRCA genetic mutation.  Per the submitted records, this patient has not completed a Gail risk assessment and does not have known BRCA mutation, as genetic testing does not appear to have been performed.  All told, the requested bilateral breast MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested inpatient psychiatric hospitalization level of care for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was admitted as a transfer subsequent to presentation at another facility where she had stated  she was suicidal with a plan to overdose.  She reportedly had ingested numerous Soma, but denied that this was a suicide attempt.  Her diagnoses were major depressive disorder recurrent, severe, without psychotic features and chronic pain.  The medical records noted a history of abusing opiate pain medication.  She was placed on an opiate detoxification protocol; she denied suicidal or homicidal ideation, plan, or intent.  She was not a danger to herself or others.  The patient was stable, no new problems had emerged, and she did not require 24-hour nursing supervision.  She was tolerating her medications and any changes could have been done on an outpatient basis.  The current medical evidence does not support inpatient psychiatric hospitalization level of care in this clinical setting.  All told, inpatient psychiatric hospitalization level of care was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee requested substance abuse intensive outpatient program services for medical treatment of the enrollees alcohol dependence and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support intensive outpatient program level of care in this clinical setting.  This patient was not exhibiting any withdrawal symptoms and displayed mild psychiatric symptoms overall.  Group therapy progress notes indicated that the patient was cooperative in therapy and was open regarding his need for treatment.  Individual progress notes noted that the patient was not experiencing any suicidal or homicidal ideation.  Per American Society of Addiction Medicine Patient Placement Criteria, outpatient services were appropriate for the treatment of this patient.  In this patients case, he could have been treated safely and effectively at a less restrictive setting.  All told, substance abuse intensive outpatient program services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male enrollee requested social skills group with peers for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature supports social skills groups for children with autism as a valuable adjunct to ABA services (Bohlander, et al; Casenhiser, et al). In this case, the patient is high functioning on the autism spectrum and appears to be tolerable to social skills training which should be augmentative to his ABA elopement operant training. Participation in the requested social skills group as part of a comprehensive treatment program including ABA therapy, speech therapy and occupational therapy is medically appropriate and indicated for this patient with social skill deficits. Given the submitted clinical documentation, in addition to the medical literature cited above, the request for social skills group with peers is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee requested genetic testing (whole exome sequencing) (CPT codes 81402, 81403, 81404, 81405 and 81406) for medical evaluation of the enrollees medical conditions.  Findings:  Two physician reviewers found that the requested whole exome sequencing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature does not support the requested services in this clinical setting. Glissen and colleagues applied whole genome sequencing to 50 patients with severe intellectual disability and their unaffected parents. The authors reported a high yield of positive findings on whole genome sequencing in patients with intellectual disability and all of these patients also had whole exome sequencing with negative results. Moreover, it is unlikely that the patients multiple medical issues can be fitted into a unifying cause of disease. Therefore, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested increased dosage of Staxyn 10 mg #27 (once a day if needed) for treatment of the enrollees erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication dosage. The need to treat erectile dysfunction is not entirely a medical issue. After serious medical etiologies have been excluded to prevent other medical concerns, the treatment of impotence or erectile dysfunction is based on providing a support to the emotional and psychological well-being and its potential impact on lifestyle and relationships. Although erectile treatment is indicated, the requested dosage is not medically necessary. The alternative of Staxyn 10 mg #6 per month is appropriate. The requested dosage over that amount is not justified by the literature. Therefore, the medical necessity of the requested medication dosage has not been established in this patients case.