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

A 65-year-old female enrollee has requested paraesophageal hernia repair surgery for treatment of the enrollees paraesophageal hernia.  Findings:  The physician reviewer found that submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. In this case, the patient has paraesophageal hernia and organoaxial volvulus documented on chest x-ray. The patients shortness of breath and wheezing is likely due to her paraesophageal hernia as patients in this clinical setting often suffer from chronic aspiration which causes progressive pulmonary damage and shortness of breath. The patients shortness of breath precludes exercise which prevents her from managing her weight loss effectively. As such, the surgical repair of the paraesophageal hernia will likely improver her pulmonary function and her shortness of breath and prevent the potential of emergency repair of acute volvulus. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested urgent care services for treatment of his intermittent swelling of the left toes and left great toe. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient presented to an urgent care facility with swelling and redness of his toes for three weeks. His symptoms had commenced gradually and his pain was rated as mild. In a letter from the patient he states that he had excruciating pain and there was pus coming from his nail. However, this was not confirmed by the medical documentation provided. The medical records indicate the patient was afebrile, had mild pain and not in acute distress. On a subsequent date the patient returned to the urgent care facility and reported no improvement. He described his pain as 5/10, which was not severe. His nail was partially removed. During both dates of service in dispute, the patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested general anesthesia to be administered during a dental procedure for treatment of the enrollees early childhood caries.  Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often used to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for extensive dental treatment makes general anesthesia an appropriate treatment modality for pediatric patients. Forsyth and colleagues reviewed and collected data from general anesthesia records for over 700 pediatric patients over a two-year period. The authors reported that general anesthesia allowed for comprehensive and high quality dental care especially in young patients who required extensive dental treatment. Bader and colleagues noted that the most common indication for general anesthesia was the childs inability to cooperate and undergo dental treatment. According to this patients provider, the severity and extent of dental caries, possibility of dental abscess, and inability to cooperate, support the medical necessity of the requested general anesthesia services for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested proton beam therapy for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment modalities.  The current medical literature has not established the superior efficacy of proton beam therapy for the treatment of this patient.  Palliative therapies which have been administered for individuals with this patients condition include external beam radiotherapy, brachytherapy, systemic chemotherapy, radiofrequency ablation, and transarterial chemoembolization or radioembolization.  Due to the ability to deliver higher doses of radiation directly to tumor, intensity modulated radiotherapy and stereotactic body radiotherapy have also been used in this clinical setting.  Based upon the available evidence, proton beam therapy is not likely to be more advantageous than other available forms of radiation in terms of outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee requested 32 hours per week of one-on-one applied behavioral analysis (ABA) therapy; 2 hours per month of parent training and 8 hours per month of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  The physician reviewer found that the medical literature supports ABA services in this clinical setting. One-on-one therapy at a frequency of 24 hours per week is medically appropriate and necessary to reinforce acquired skills and allow for ongoing trials with other skills. The alternative service of 15 hours per week of ABA therapy is a significant reduction from the 32 hours of weekly therapy the patient had been receiving and would likely lead to regression in skills already acquired and slowing of progress. As such, ABA services at the frequency of 24 hours per week of one-on-one ABA therapy; 2 hours per month of parent training and 8 hours per month of ABA supervision are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested periodic UroVysion (CPT 88120) for medical evaluation of his bladder cancer.  Findings:  Three physician reviewers found that periodic testing with UroVysion is not likely to be more effective for this patient than other available options. The peer-reviewed literature does not support the use of UroVysion in this clinical setting. UroVysion is a fluorescence in situ hybridization (FISH) assay that detects bladder cancer in urine specimens. At this time, cystoscopy and cytology, and possible biopsy, is medically indicated in this clinical setting regardless of the results of FISH testing. Therefore the requested services are not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee requested computed tomography (CT) scan of the abdomen and pelvis (CPT code 74178 for medical evaluation of his medical condition.  Findings:  The physician reviewer found that the clinical notes document multiple episodes of gross hematuria, and the presence of gross hematuria is a well-recognized indication for CT of the abdomen and pelvis.  This examination searches for potential etiology of unexplained hematuria, including tumors, stones, and benign masses arising in the urinary tract.  All told, the CT scan of the abdomen and pelvis was medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee requested Botox injections for medical treatment of the enrollee, who has been diagnosed with chronic migraine. Findings:  Two physician reviewers found that this patient has been diagnosed with chronic migraine, with three to four headache days per week.  She has been treated with Botox, with reported benefit.  The records do not document that she has taken any preventives in the past for migraine.  Although Inderal was prescribed several years ago, the records do not indicate whether it was tried, and what side effects or benefits were noted.  Per the current medical evidence, topiramate has been demonstrated to be beneficial for chronic migraine and is an appropriate treatment in this clinical setting.  Therefore, the requested Botox injections are not likely to be more efficacious than other treatment alternatives for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested emergency services for treatment of his polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma-proliferative disorder, skin changes (POEMS,) abdominal distension, and edema.   Findings:  The physician reviewer found that the enrollee presented himself to the emergency department (ED) when he developed chest tightness and palpitations. The enrollee reported that he was visiting China with his wife and shortly after landing experienced dyspnea and lower extremity edema. The ED note states that the enrollee developed sudden palpitation, chest tightness, dyspnea, shortness of breath and weakness in lower extremities due to tiredness from travel. The ED note also indicates that the enrollee underwent paracentesis in the United States, but abdominal distention was not evidently relieved and became aggravated gradually.  In this case, the enrollee presented to the ED with a diagnosis of POEMS syndrome, and he was symptomatic from abdominal distention. According to the ED record, the enrollee was reported to have palpitation, chest distress, dyspnea, handicapped mobility and weakness of bilateral lower limbs. Thus, the submitted ED records demonstrate that a prudent layperson would have sought immediate medical attention for evaluation and treatment of these symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested the combination therapy of Pegasys Proclick 180mg (approved), Sovaldi 400mg and Ribavirin (Ribapak) 400mg for 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.  There is very little data on the treatment of hepatitis C, genotype 6 and most of the recommendations extend from trials on other genotypes.  Per the current medical evidence, the requested medication combination of Sovaldi, Ribavirin and Pegasys Proclick may be medically appropriate for patients with hepatitis C, genotype 6.  However, there is a lack of support for the requested medication combination in his case.  Per the clinical notes, evidence of significant fibrosis supporting the requested medication combination was not documented.  Therefore, the requested combination therapy of Pegasys Proclick 180mg (approved), Sovaldi 400mg and Ribavirin (Ribapak) 400mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested  positron emission tomography (PET) imaging with computed tomography (CT) attenuation from skull to thigh for medical evaluation of her T-cell lymphoma. Findings:  Two physician reviewers found that the Centers for Medicare and Medicaid Services (CMS) has approved the use of PET/CT in the evaluation, staging, treatment progress and follow-up for all solid tumors including lymphoma. Thus, the use of PET/CT in this instance is likely to be more beneficial for this patient than any regular imaging modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested the Acessa procedure that uses radiofrequency ablation for medical treatment of her uterine fibroids.   Findings:  Two physician reviewers found that Radiofrequency ablation is a type of myolysis and is a new alternative, with initial small studies that indicate that in appropriate patients it may become a reasonable surgical alternative.  Per the current medical literature on laparoscopic therapies for fibroids, the preferred approach is still laparoscopic myomectomy rather than myolysis.  This patient has indicated that preservation of her fertility is a goal, and many experts do not recommended myolysis for women who wish to preserve future fertility.  As there are a number of available standard treatments that have not been tried in this patient, the requested Acessa procedure that uses radiofrequency ablation is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested Norco for medical treatment of his pain.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current 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.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees mood disorder, not otherwise specified, with suicidal ideation. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was symptomatic and was engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness.  On the date indicated, the dosage of escitalopram, a serotonergic-enhancing antianxiety and antidepressant medicine started five days prior, was increased.  He was attending groups, and the multidisciplinary treatment plan was updated.  On the subsequent date, the patient was anxious and irritable.  Aripiprazole, a second generation antipsychotic commonly used to augment medications like escitalopram, was added to his regimen.  The medicine resulted in sedation.  On the date indicated, the aripiprazole was changed to nighttime dosing.  The patient remained anxious with suicidal intent.  He continued to attend groups on the unit.  On the date indicated, the patient had a brighter affect and was engaging with peers on the unit.  His escitalopram was reduced the following day.  The records noted that a family meeting evidenced persistent parent-child relational problems.  Afterwards, the patient continued to endorse suicidal ideation.  The current medical evidence supports inpatient psychiatric hospitalization services in this clinical setting.  All told, inpatient psychiatric hospitalization services provided from the time period specified were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee requested a cycle ergometer (motorized functional electrical stimulator cycle ergometer) for treatment of his spinal cord injury. Findings:  Two physician reviewers found that according to the current peer-reviewed literature, home-based functional electrical stimulation cycling is likely to be of greater benefit than other available standard therapy.  As paralyzed patients are at an increased risk for cardiovascular disease, exercise or therapy which is able to increase cardiovascular strength will help to decrease the risk for further adverse events.  Use of the requested device will help to increase cardiac stroke volume and cardiac output, and enhance overall neurologic and body composition health.  Functional electrical stimulation cycling has been shown to benefit patients with complete spinal cord injuries in terms of redeveloping and sustaining muscle mass and improving cardiac health.  Therefore, the requested cycle ergometer (motorized functional electrical stimulator cycle ergometer) is likely to be more efficacious than other modalities in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested continued acupuncture for medical treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. According to the documentation submitted for review, acupuncture has provided the patient some temporary relief without any functional improvements documented in terms of activities of daily living (ADLs) improvement, medication intake reduction, or exam findings showing progress towards self-reliance. The peer review literature supports the use of acupuncture for hip osteoarthritis (Witt, et al; Linde, et al), but also indicates that extension of acupuncture care is medically necessary if functional gains are documented such as improvement in activities of daily living, reduction in work restrictions, or reduction in medication intake (Official Disability Guidelines Hip). Therefore, given the lack of evidence of significant quantifiable response to treatment obtained with previous acupuncture care, a request for additional acupuncture is not supported. In addition, the request for acupuncture is open-ended, without indicating frequency or duration and the peer review literature indicates that any condition treated should be monitored to adjust the care and evaluate the benefits obtained. Based on the reasons provided, continued acupuncture is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested skin injections and a referral to a dermatologist for medical treatment of the enrollees psoriasis.   Findings:  The physician reviewer found that this patients records do not include a biopsy to support a clinical diagnosis of psoriasis. This patient indicates that her condition worsened and spread to other parts of the body since discontinuation of injections. Considering the known side effects from chronic corticosteroid use, the requested intralesional Kenalog treatment is not medically necessary for treatment of this patients medical condition. All told, the patient needs to be referred to a dermatologist for diagnosis and treatment. Therefore, the requested referral to a dermatologist is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested parathyroid planar imaging with single photon emission computed tomography/computed tomography (SPECT/CT) scanning for medical evaluation of the enrollees hyperparathyroidism.  Findings:  Three physician reviewers found that the literature shows the advantages of SPECT/CT in the evaluation of well selected patients for parathyroid adenomas since 20% of tumors are extra-parathyroid in nature. Thus, the merging of the pharmacologic agent with cross sectional anatomy is the most revealing technique available in the search for parathyroid adenomas. Further, the scientific data has demonstrated that SPECT with CT is superior to planar nuclear medicine imaging as well as SPECT without CT in this clinical setting. All told, the diagnostic procedure at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee requested medical services on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention. In this case, the patient presented for an office visit with a neurosurgeon after previously have been seen in the ED with an acute episode of neck pain and left upper extremity pain and diagnosed with a radiculitis.  At that time of the neurosurgeon appointment, his pain had significantly decreased. Moreover, the neurosurgeon told him that surgery was not emergent and could be planned. In addition, the ED notes that the need for surgery was not emergent given that his strength is nearly intact. Thus, the neurosurgeon office visit did not need to be provided on an emergent basis and surgery was also not emergent. In addition, this patients symptoms were not sudden or acute in onset that would lead a prudent layperson to believe their health to be in imminent danger. Finally, there was no sudden deterioration in his physical condition to justify immediate evaluation or treatment on the date in dispute. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested  Juxtapid (lomitapide) 5 mg capsule for treatment of her hypercholesterolemia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. Based on the medical records provided, the patient has coronary disease and several coronary risk factors including marked hyperlipidemia. However, there is no documentation to support homozygous familial hypercholesterolemia, a rare disorder effecting only one in one million births, since there is no documentation of LDL levels greater than 500 mg/dl, similar hyperlipidemia in parents, xanthomatosis in childhood, or supravalvular aortic stenosis from plaque accumulation. Further, Juxtapid (lomitapide) was approved by the U.S. Food and Drug Administration (FDA) only for the treatment of homozygous familial hypercholesterolemia.  In addition, its use is restricted since therapy is associated with elevated liver aminotransferase levels in roughly 40% of patients and hepatic fat accumulation in roughly 8% of patients (Cuchel, et al (2007)). Moreover, there is a lack of trials in the peer-reviewed literature to support that treatment with Juxtapid improves cardiac outcome.  This is important since some other novel lipid agents have not been associated with improved cardiac outcomes even though they have been shown to significantly reduce lipid levels (Kastelein, et al). For the reasons provided, the medical necessity of the requested medication has not been established in this patients case.