Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee requested for P-STIM (neuroelectrodes) for treatment of her fibromyalgia and chronic pain syndrome.  Findings:  Two physician reviewers found that peripheral nerve stimulation is not likely to be more beneficial in this setting where conservative therapy has failed to reduce the patients chronic pain condition. The patient does not have a diagnosis of neuropathic pain and there is lack of documentation to rule a psychological association to her pain. Thus, the requested P-STIM is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested zoledronic acid (Zometa) for medical treatment of his metastatic prostate cancer.  Findings:  The physician reviewer found that the two major indications for Zometa include treatment for bony metastases and osteoporosis.  Zometa is indicated in the treatment of metastatic prostate cancer to the bone (Ross, et al; Saad, et al). This patients records do not include a diagnosis of bony metastases. The diffuse marrow signal cannot be assumed to be metastatic cancer since it may be due to a primary marrow process or due to changes after radiation therapy.  A bone biopsy or marrow biopsy is needed to confirm the presence of bony metastases.  In addition, the patients PSA remains low, suggesting that his back pain may be originating from severe degenerative disease, spinal stenosis, or radiculopathy.  Consistent with these findings, the requested Zometa is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested implantation of subcutaneous implantable cardioverter defibrillator (ICD) for medical treatment her medical condition.  Findings:  Three physician reviewers found that the requested services are likely to be more effective than other treatment options.  This patient is at high-risk due to long QT syndrome and family history of sudden death.  There is sufficient support for the requested services in this clinical setting.  Subcutaneous ICD has been shown to be efficacious in treatment of ventricular arrhythmias, especially in patients who do not require pacing, as compared to transvenous ICD and do not involve transvenous or intra-cardiac leads.  In sum, the requested implantation of subcutaneous ICD is likely to be superior over other available options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee requested proton beam therapy for medical treatment of her left temporal anaplastic astrocytoma.  Findings:  Two physician reviewers found that Proton beam therapy is not likely to be more effective for this patient than other available options. Proton beam therapy has a role in the treatment of some cancer patients. However there are physical uncertainties about proton depth dose delivery which may render the actual radiation deposition in tissue less conformal than it may appear based upon the treatment plan (Paganetti). In addition, there is a lack of data in the medical literature that demonstrates that proton therapy is superior to photon therapy with respect to outcomes for astrocytomas. The current National Comprehensive Cancer Network (NCCN) guidelines for central nervous system tumors do not address proton therapy for gliomas. Moreover, there is a paucity of published data in support of proton therapy for gliomas and such studies are small. Due to these reasons provided, proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested a two-level cervical total disc replacement (arthroplasty) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that artificial total disc replacement versus fusion for the cervical spine has not been proven to be more beneficial in the treatment of patients with spine pathology.  Multiple studies are currently being undertaken to determine the efficacy and safety of cervical arthroplasty.  As such, there is a lack of medical evidence to indicate that the proposed two-level cervical total disc replacement would be more beneficial than a standard anterior cervical discectomy and fusion in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested chemotherapy infusion with Doxill for medical treatment of her adenoid cystic carcinoma.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available treatment options. Adenoid cystic cancer is a rare malignancy, which is primarily treated with surgery and radiation.  In this case, a gene expression analysis was performed indicating that an anthracycline would potentially be active against this tumor. Unfortunately, results of the described assay, and the rationale for the use of Doxil, is absent from the records provided. However, it should be noted that other anthracyclines besides Doxil are available, notably mitoxantrone and doxorubicin, both of which are listed in the National Comprehensive Cancer Network (NCCN) guidelines as active agents. In sum, based on the documentation submitted for review, it has not been established that Doxil is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee requested surgical resection of small intestine carcinoma for medical treatment of his small intestine cancer.  Findings:  The physician reviewer found that the request for surgical resection of small intestine carcinoma is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is 37-years-old and has advanced recurrent cancer. Modalities such as chemotherapy and radiation have not been shown to be beneficial in this setting (Higashi, et al). Further, as noted above, the patients oncologist indicates his tumor is not chemo-sensitive, further limiting the potential benefit of chemotherapy. Surgical intervention is the only treatment option that is likely to be palliative if not curative. In sum, given the lack of available treatment options in this setting, the requested procedure is medically reasonable and necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested the Vest Airway Clearance System for treatment of the enrollees asthma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  High-frequency chest wall oscillation was developed to improve airway clearance in patients in whom normal mucociliary transport system has failed. Medication management of secretions has been achieved with mucolytic agents such as hypertonic saline. This patient has persistent asthma despite adequate medication management, as well as difficulty clearing secretions.  Vest therapy has provided significant clinical relief of symptoms and he has failed treatment with standard therapies.  All told, the Vest Airway Clearance System is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female enrollee  requested psychiatric intensive outpatient program (IOP) service for medical treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that there is a lack of clinical documentation with regard to the indicated autism progress report, which included revised treatment goals and specific recommendations that suggest the most recent clinical interventions have been insufficient and requires a higher level of care to achieve therapeutic success. In addition, the diagnoses of mood disorder and generalized anxiety disorder, which are conditions that may be appropriate for IOP level of care in context of suboptimal response to outpatient services, are not substantiated in the documentation provided. Therefore, based on the clinical documentation and medical literature cited above, the request for psychiatric IOP services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested a 12-week course of Sovaldi, Pegasys and ribavirin for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication combination.  Per the current medical evidence, the proposed treatment regimen is safe and effective for the eradication of hepatitis C virus.  The requested medication combination is likely to assist in prevention of progression of liver disease.  The current guidelines support treatment in this clinical setting.  All told, the requested 12-week course of Sovaldi, Pegasys and ribavirin 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 Zohydro for medical treatment of his chronic pain due to lumbosacral spondylolysis. Findings:  The physician reviewer found that in 2014, the U.S. Food and Drug Administration (FDA) approved Zohydro as a new formulation of extended release hydrocodone for pain. In their statement with approval, the FDA noted that there is less chance of liver failure as it is not combined with a non-narcotic mediation. Common side-effects matching other narcotic medications are noted to be constipation, nausea, and somnolence. Finding the appropriate combination of medication short- and/or long-acting narcotic is not without risk due to side effects and risk of addiction and abuse. Providers have to independently evaluate every patient for risk evaluation and mitigation strategies (REMS). Argoff and Silvershein reported that a review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. Given the current standard of care for this patients medical conditions, the requested Zohydro is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee requested residential treatment and resumption of residential treatment for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  The patient had attempted treatment in a less restrictive setting.  However, his alcohol consumption quickly re-established domination of his daily routine, and continued to negatively impact his relationships and cause significant impairment across multiple domains of functionality.  At the time of presentation, the patient had completed a complicated detoxification and his social setting and living environment as arranged were unable to support his sobriety.  As such, residential treatment services were safe, appropriate and consistent with good practice.  Considering the clinical presentation and peer-reviewed literature, residential treatment was medically indicated for the treatment of this patient.   However, the record does not justify that a resumption of residential treatment is required at this time.  The patient had done well earlier with fairly brief residential admissions.  His most recent relapse occurred following the completion of an IOP program.  He had successfully maintained sobriety in settings less restrictive than residential.  Thus, there was no evidence to suggest that an intermediate setting, such as partial hospitalization or IOP with supportive living, would be insufficient.  As such, based on the documentation provided, the resumption of residential programming is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested bilateral hip resurfacing for treatment of her hip pain.   Findings:  The physician reviewer found that documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. Based on the documentation submitted for review, the patient has a significant medical history and conditions for which bilateral hip resurfacing is contraindicated. The peer reviewed literature indicates that resurfacing in patients who are obese or overweight can result in significant complications.  Furthermore, bone density is a significant factor in determining patient selection for resurfacing. It was noted that the patient has a medical history of osteopenia, and the patient was noted to be a female.  In sum, the patient is noted to have significant comorbidities which contraindicate the proposed procedure. The patients risk of complication is increased due to said comorbidities. Given the documentation submitted for review and the peer-reviewed literature, the medical necessity for bilateral hip resurfacing has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested acute psychiatric inpatient treatment services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that acute psychiatric inpatient treatment were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the goal of the hospitalization was to stabilize the patient prior to admission to a residential treatment center. The documented descriptions of his behavior demonstrate that the patient was compliant with his medications and he was not aggressive or suicidal. In sum, the patient did not meet the medical necessity for inpatient level of care.  He was not at risk of harming himself or others and was not demonstrating severe behavioral problems. Thus, the services were not medically necessary and the patient was stable for transfer to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested a combination of ribavirin 200mg and Sovaldi 400mg for six months for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that based upon the submitted laboratory testing results, this patient has advanced liver disease which is greater than or equal to F3 fibrosis.  This is evident by the elevated serum ammonia and thrombocytopenia.  A non-invasive or invasive measure of liver fibrosis is not necessary.  For patients with hepatitis C, genotype 3 the current medical evidence supports Sovaldi with ribavirin for 24 weeks.  This patient has already failed interferon and should not be treated again with this agent.  All told, the requested combination of ribavirin 200mg and Sovaldi 400mg for six months is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.  Findings:  Three physician reviewers found that neuroblastoma is a malignancy of childhood, with 90% of diagnoses occurring in children younger than five years of age. When diagnosed in adolescents and young adults it is often characterized by a prolonged course with use of chemotherapy. Because of the relative rarity of the disease, there are no large randomized trials that provide high-grade evidence on the most effective treatments. The available evidence indicates that radioactive MIBG is an efficacious agent, with response rates in various studies ranging from 0% to 75%. However, in this case, the patient has already responded to the treatment modality requested which provides a reasonable expectation that the treatment would work if administered again. All told, I131-MIBG targeted radiation therapy is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee requested tooth extraction(s) to occur in a hospital setting with monitored anesthesia care (MAC) for medical treatment of the enrollees tooth extraction.  Findings:  The physician reviewer found that the patient is symptomatic with a history of POTS. The neurology consultation resulted in a recommendation to perform the procedure in a hospital setting.  Although it is not always possible to predict how an individual patient will respond during a planned procedure, in this case the patient has a known diagnosis of POTS, which makes her more susceptible to syncope and autonomic dysfunction, which can arise after an event that causes stress, such as a tooth extraction. Based on the consideration of the patient specific factors and the recommendation from pediatric neurologist, the requested tooth extraction to occur in a hospital setting with MAC is medically necessary. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested monitored anesthesia care during a colonoscopy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this patients case, the criteria for monitored anesthesia care have not been met.  This patient did not present with a significant history that would require monitored anesthesia care.  Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care.  All told, monitored anesthesia care was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested acute inpatient psychiatric services  for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the patient was plagued with a debilitating unilateral affective disorder and a co-occurring chronic anxiety disorder. The patient had an exacerbation of her mental illness that compromised her baseline functionality. Although future oriented and not acutely suicidal, her thoughts of death and largely neurovegetative symptom complex that generated prompt consideration of electroconvulsive therapy as a primary therapy warranted hospitalization initially.  However, the record does not support treatment at the acute inpatient level of care shortly thereafter.  The nursing staff completed a suicide risk assessment during intake and the patient denied suicidal ideation. She had no psychosis, chemical dependency or insomnia. She endorsed multiple protective factors including a child in the home, supportive peer network, good connection with her therapist and doctor, and the ability to consider alternatives to suicide, utilize positive coping skills and seek help if needed. The following day, the patient slept well. She participated in only one group. She denied suicidal ideation. She had no plan to end her life and she was medication adherent with no side effects. The patient was motivated for the partial hospital program and had a close, supportive friend in the community.  Although symptomatic and in need of specialty care, the medical record indicated that the patient was not suffering from an acute psychiatric syndrome.  As such,  I have determined that a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested genotype testing (CPT codes 81226, 81225, and 81281) for medical  evaluation of the enrollees major depressive disorder, panic disorder, and generalized anxiety disorder.   Findings:  Three physician reviewers found that the American Psychiatric Association (APA) suggests that more research is needed before genetic testing can be recommended for routine clinical use.   Regarding this particular clinical scenario, significant case-specific psychosocial issues were referenced. Such external stressors typically do not respond to pharmacological interventions and this may help explain this patients suboptimal response to medications. Additionally, there was no mention of any community-based interventions. Although psychodynamic and cognitive behavioral therapies were noted in the psychiatry documentation, there was no mention of treatment trials from other therapists or in alternative levels of care, such as an intensive outpatient or partial hospital program.  Further, there was no comprehensive treatment plan or validated rating scales to judge the effectiveness of the therapeutic interventions.  Thus, genotype testing (CPT codes 81226, 81225, and 81281) was not likely to have been more beneficial in this patients evaluation and treatment than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee requested 40 hours per week of home health skilled nursing care to include a licensed vocational nurse (LVN) and two hours per month of case management with a registered nurse (RN) for medical treatment of the enrollees ventral septal defect status post closure, atrial septal defect, esophageal reflux, and congestive heart failure.  Findings:  The physician reviewer found that based upon a review of the information provided, approval of 20 hours per week of home health private duty LVN services and 2 hours per month of RN supervision is supported as medically necessary for treatment of this patients medical condition. The patient is medically complex with multiple medical needs including jejunostomy feeding, venting of the gastrostomy tube, administration of oxygen at night, and intermittent monitoring of pulse oximetry. It is medically appropriate given all of the care required for this patient that 20 hours of LVN home health nursing be provided to the patient in order to ameliorate some of the effects of his chronic conditions. This includes maintaining safety of the patient during feeding, reinforcing care with the mother, medication administration, supplemental oxygen administration, and checking oxygen saturations. All told, the medical records support 20 hours per week of home health private duty LVN services and 2 hours per month of RN supervision as medically necessary for treatment of this patients medical condition.