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

A 49-year-old female enrollee requested dextroamphetamine for medical treatment of the enrollees fatigue.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Dextroamphetamine may be indicated for the treatment of narcolepsy and attention deficit/hyperactivity disorder.  However, there is a high potential for abuse when using amphetamines, and prolonged use should be avoided.  There is no indication to use dextroamphetamine to treat the sedating side effects of opioid analgesic medications.  There is no supporting documentation indicating that the patient has been diagnosed with narcolepsy or chronic fatigue syndrome.  All told, dextroamphetamine is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee requested  Genotropin growth hormone (GH) therapy for medical treatment of his adult GH deficiency.   Findings:  Two physician reviewers found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, in patients who have previous history of head trauma and who have documented low IGF-1 levels, GH therapy is indicated if stimulation testing with glucagon is performed and peak GH levels are documented to be less than 3.0. This patient has a prior history of head trauma, low documented IGF-1 level, and a peak GH level of 2.1 after stimulation with glucagon. For these reasons, the requested Genotropin GH therapy is likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested abdominoplasty for medical treatment of her excess skin.  Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. The patient presents with significant weight loss following gastric surgery for gastric cancer. She is documented to have excess abdominal skin following this weight loss. However, there is a lack of documentation demonstrating the patient has a functional deficit related to this extra skin.  The skin excess related to the patients weight loss is relatively mild.  Surgical treatment with an abdominoplasty would attempt to improve on a relatively normal appearance, which is consistent with cosmetic surgery.  Thus, the requested procedure would only offer a minimal improvement in the abnormal appearance of the patient. Therefore, the requested abdominoplasty does not meet reconstructive surgery criteria.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee requested MiniMed 530G with Enlite (E0784, A9277 and A9276 for medical treatment of her diabetes.  Findings:  Three physician reviewers found that the requested equipment is likely to be superior over other available options.  The medical records are consistent with some degree of hypoglycemic unawareness.  The MiniMed 530G with Enlite is likely to lower the amount of time this patient spends in the hypoglycemic range overnight.  There is sufficient support for the requested equipment in this clinical setting.  Thus, the requested MiniMed 530G with Enlite (E0784, A9277 and A9276) is likely to be more efficacious than other available alternatives.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old male female enrollee requested services on an emergent or urgent basis. Findings:  The physician reviewer found that criteria for urgently needed services were not met in this case. The patient presented to the facility while four months pregnant but had no other significant medical condition.  She denied suicidal/homicidal ideation, intent, or plan; there was no evidence of self-harming behaviors. She did not have any functional limitations in her daily activities or personal care. The patient was not in acute withdrawals nor was she intoxicated and the care provided could have been rendered in a less acute setting on a non-urgent basis. In sum, the criteria for urgently needed services were not met in this case. There was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of the health of the patient or her fetus. Thus, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested mental health partial hospitalization program services 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.  The patient was not at risk of harm to herself or others.  She did not demonstrate dangerous or risk-taking behaviors.  Per the submitted records, her mood had improved, and her eating disorder behavior had decreased to episodic.  The patient was taking Lexapro.  She followed her treatment plan and participated in therapy and groups, although she did have difficulty abstaining from exercising.  Her vital signs were stable, and her treatment plan did not require frequent amendments.  She lived at home with her husband, who was actively involved in her treatment.  She demonstrated that she was able to self-manage as evidenced by the reduction in her eating disorder behaviors and medication compliance.  All told, mental health partial hospitalization program services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested magnetic resonance imaging (MRI) of the abdomen for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The patient has had an extensive work-up recently for her symptoms, and this testing has been negative.  In particular, evaluation of the gastrointestinal tract has been endoscopically negative.  Additionally, CT of the abdomen and pelvis revealed no abnormality requiring clarification.  The CT allowed for optimal visualization of the diaphragm, pleura, lung bases, spleen and pancreas.  This patient has no history of tumor or infection, and there are no documented indications for MRI of the abdomen in this clinical setting.  All told, the requested MRI of the abdomen is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee requested inpatient psychiatric hospitalization for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that documentation supports the medical necessity of a portion of the services.  This patient evidenced symptomatologies of parasuicidality and affective illness interwoven with his underlying characterological organization, addictive tendencies and chronic pain.  This patient had several concerning risk factors supporting initial admission.  He was suicidal and had recently lost two close relationships.  He had just returned to work and felt unsupported by his peers.  Additionally, he had chronic pain.  Thus, hospitalization was reasonably expected to improve his condition and prevent a more serious episode of illness.  While in the hospital, he received appropriate care delivered in accordance with a treatment plan.  He attended groups and individual cognitive behavioral therapy.  The inpatient team involved his family and aggressively adjusted his medications.  Subsequently, he was tolerating his psychotropic medications without side effect.  He was sleeping well at night and had no cognitive impairment or psychosis.  In sum, there was no acute psychiatric syndrome or contraindication to less restrictive treatment setting.  Thus, a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee requested genetic testing, cytogenetic microarray testing for copy number variation for medical evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that the requested services are likely to be more effective than other modalities.  This patient has intractable epilepsy.  Olson and colleagues noted that copy number abnormalities may have an important role in patients with epilepsy.  The authors recommended the implementation of chromosomal microarray testing for evaluation of unexplained epilepsy.  Medical studies have shown that identification of a genetic basis for epilepsy can result in different treatment options.  This patient may benefit from genetic testing, with resulting better understanding of the source of her intractable seizure disorder, and resulting alteration of the treatment regimen.  Therefore, the requested cytogenetic microarray testing for copy number variation is likely to be of greater benefit than other available alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested real-time intra-fraction target tracking during radiation therapy for medical treatment of her breast cancer.  Findings:  Two physician reviewers found that there is insufficient scientific data demonstrating that the use of real-time intra-fraction target tracking during radiation therapy results in greater clinical benefit compared to other techniques available in this particular setting.  The submitted documentation fails to demonstrate that the patient could not be safely and effectively treated with standard dose-limiting techniques. All told, real-time intra-fraction target tracking during radiation therapy was not likely to have been superior over other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee requested gene testing (CPT codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) for medical evaluation of his adenoid cystic carcinoma.  Findings:  Two physician reviewers found that in this patients case, these services were not likely to have been more effective than other available options.  The Foundation One assay seeks to find a genomic alteration that could be used as a target for a particular drug.  Generally, the focus has been on the analysis of breast, colon and lung cancers, with a small sampling of adenoid cystic carcinomas.  At this time, the National Comprehensive Cancer Network guidelines have not recommended this testing.  There is a lack of data demonstrating that use of this assay can improve survival in patients with metastatic cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested the drug combination Sovaldi, Ribavirin and peginterferon for medical treatment of the her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested drug combination in this patients case.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  Based on the medical records, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy now out of concern that her liver disease may otherwise progress.  Delaying treatment may encourage progression of liver disease and compromise treatment efficacy.  Therefore, the requested drug combination Sovaldi, ribavirin and peginterferon is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested to be admitted to a hospital for further testing and treatment of his chest pain.  Findings:  The physician reviewer found that in this clinical setting, cardiac evaluation has been exhaustive and negative for any ischemic coronary cause to the patients complaints. Likewise, additional evaluation has also been negative to assess for other life-threating causes of the patients ongoing chest symptoms. There are no documented symptoms or findings to warrant ongoing inpatient evaluation and treatment of the patients chronic chest discomfort. Based on the extensive and repeated negative evaluations performed, ongoing evaluation and treatment of the patients chronic chest pain can be safely continued as an outpatient at this time.  For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested muscle-skin graft head/neck (CPT code 15732) and acellular derm matrix implant (CPT code 15777 for treatment of her fascia torn on neck/back after spinal cord tumor removal.   Findings:  Two physician reviewers found that this patient presents with a fascial hernia of the trapezius muscle. She has pain and her provider has recommended repair of the trapezius. The two referenced case reports describe successful repair of non-abdominal fascial hernias with acellular dermal matrix. In addition, numerous studies support a role for acellular dermal matrix in the management of abdominal wall hernias. The surgeons plan to repair the muscle dehiscence and to reinforce the repair if necessary with acellular dermal matrix is therefore reasonable and consistent with the studies supporting the efficacy of acellular dermal matrix for abdominal wall and extremity hernias. For these reasons, the requested muscle-skin graft head/neck (CPT code 15732) and acellular derm matrix implant (CPT code 15777) is likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested intracapsular enucleation for medical treatment of her vagal nerve schwannoma.  Findings:  The physician reviewer found that although this patients tumor is considered benign, the records demonstrate that it has shown growth over the period of observation. The patient is young and delaying surgery in this clinical setting slowly increases the risk of damage, both from the tumor itself and the slowly increasing complexity of the necessary surgery. These are rare tumors and it is medically necessary for this patient to have the surgery performed by an experienced surgeon to decrease the chances that she will require additional procedures to address laryngeal or other potential consequences. All told, the requested surgery consisting of intracapsular enucleation is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-month-old female enrollee has requested a cranial helmet for treatment of the enrollees cephalic index of 96.3 (+4 standard deviations above mean).  Findings:  The physician reviewer found that based upon a review of the information provided, the patient is documented to have a cranial vault diagonal diameter of 2 mm. The diameter of 2 mm falls into a category of mild plagiocephaly, according to the available medical literature. In 2011, the American Academy of Pediatrics (AAP) published a statement that mild positional cranial vault abnormalities could be treated with positioning and observation. Consistent with these recommendations, the requested cranial helmet is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested an in-lab sleep studyfor medical evaluation of her history of snoring, witnessed pauses in breathing at night, and non-arteritic anterior ischemic optic neuropathy.   Findings:  The physician reviewer found that this patients records document a history of poor sleep, snoring, and witnessed pauses in breathing at night, as well as non-arteritic anterior ischemic optic neuropathy.  The provider noted concern that the patient is at risk of OSA.  Further, the patients co-existing medical conditions support the utility of a lab sleep study in lieu of a home sleep study.  Based on these findings, the requested laboratory sleep study for OSA is supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested LINX Anti-Reflux Management System procedure for treatment of the enrollees gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The requested procedure is indicated for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Based on the documentation submitted for review there is a lack of documentation demonstrating that the patient has failed maximum medical management to necessitate the requested procedure. In addition, the risk of exacerbating dysphagia with LINX procedure is not clear in patients who have previously reported pharyngeal dysphagia, such as in this case. Given these concerns, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee requested partial hospitalization program services for medical treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  In terms of pharmacotherapy, the patient was recently started on a serotonergic-enhancing medication for a diagnosis of depression.  The medication was prescribed at a conservative dose.  Thus, the evidence-based pharmacologic intervention had yet to approach a therapeutic trial.  While in the program, the patient was cooperative and attentive.  He was minimally participative in classes and groups.  Despite his dysphoria and affective flattening, the patient was not disruptive, agitated, psychotic, homicidal or suicidal.  He was not using substances.  There was no evidence to suggest that discontinuing partial hospital services would have resulted in an exacerbation of symptoms or clinical deterioration that would have necessitated treatment at a higher level of care.  As such, partial hospitalization program services were not medically necessary for the treatment of this patient.  Additionally, resumption of partial hospitalization program is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee requested Suboxone 8mg-2mg film for the medical treatment of his knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  There is a lack of support for the use of Suboxone for the treatment of this patient.  Suboxone has been approved by the U.S. Food and Drug Administration for opioid dependence.  However, in this patients case, Suboxone has been prescribed for the treatment of chronic pain.  Per the current medical evidence, other alternatives for pain management are more effective in opioid dependent patients.  All told, the requested Suboxone 8mg-2mg film is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested genetic testing (Pathwork Tissue of Origin Test) for medical evaluation of his malignant neoplasm of the stomach.  Findings:  Two physician reviewers found that the testing was not likely to be more effective for this patient than other available treatment options. The testing is not routine in oncology practices and not clinically indicated in this particular clinical setting. The classification of the patient as having a carcinoma of unknown primary is open to question since histologically and immunohistochemically the findings are consistent with pancreaticobiliary origin. However, with lab and imaging studies, treatment could be planned and administered with this diagnosis alone. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee requested the LINX Reflux Management System procedure for medical treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the request for LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The gold standard in this clinical setting is Nissen fundoplication. In addition, there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Additionally, anti-reflux surgery is designed to be effective long-term, longer than 10 years, which is seen with the standard operation of Nissen fundoplication. Moreover, the patient may suffer from problematic dysphagia after the procedure due to abnormalities with bolus clearance. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee requested rush (rapid) oral immunotherapy for peanut desensitization for medical treatment of the enrollees peanut allergy.  Findings:  The physician reviewer found that the medical literature does not support the use of the two day rush oral immunotherapy desensitization as medically necessary. Further, there is no information whether the patient will be pretreated with Xolair. Overall, there is evidence that this procedure has high risk of adverse reactions, often requiring epinephrine. Studies to date are small and there are is a lack of randomized controlled trials to support its use. All told, the requested rush (rapid) oral immunotherapy for peanut desensitization is not medically necessary for treatment of this patients peanut allergy.