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

A 68-year-old male enrollee has requested community based adult services (CBAS) for treatment of his type II diabetes and hypertension.  Findings:  The physician reviewer found that the Institute of Medicine Committee on the Quality of Long-Term Care Services indicates that many patients currently receive some type of long-term care (LTC) in their own homes or in residential care settings other than nursing facilities. CBAS offers services to eligible older adults and adults with disabilities to restore or maintain their optimal capacity for self-care. This patient was assessed as being within normal limits neurologically. In addition, he is independent in all ADLs except for assistance with meal preparation and accessing resources. For these reasons, he does not meet the criteria for participation in a CBAS program. CBAS is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a 24-week course of Sovaldi (400 mg) and ribavirin (400 mg) combination therapy for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medications. According to the clinical documentation submitted for review, she is interferon ineligible and has a Metavir fibrosis score of about 2. In addition, she has evidence of active viral replication and no contraindication to treatment, such as hepatocellular carcinoma. Therefore, the request for 24 weeks of Sovaldi and ribavirin is medically necessary in this clinical setting. Based on the medical records submitted for review and the medical literature cited above, the request for a 24-week course of Sovaldi (400 mg) and ribavirin (400 mg) combination therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested bilateral breast reduction and lateral chest liposuction for treatment of her medical condition. Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain and skin breakdown if they are present.  In her case, it is not clear that her neck and back pain are due to macromastia as the symptoms have been present since she was 12 years old with an A cup.  The submitted documentation fails to demonstrate the medical necessity of the requested services in her case.  The Schnur scale was developed to relate the amount of  breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from medically necessary breast reduction surgery prior to surgery.  In the absence of breast cancer, as the amount of breast tissue removed is increased, the procedure changes from a cosmetic procedure to a medically necessary procedure.  In this case, the proposed removal of 200 grams on the right and 225 grams on the left does not meet the Schnur criteria amount.  The clinical notes do not document shoulder bra strap grooving or intertrigo.  Per the submitted documentation, no abnormal structure of the body is present with respect to the breasts.  The requested surgery will not improve function or turn an abnormal appearance into a normal appearance.  All told, the requested bilateral breast reduction and lateral chest liposuction are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a 12-week course of Sovaldi in combination with ribavirin for treatment of his hepatitis C virus (HCV).   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication combination. At this time there is a lack of clinical documentation that shows the patient has significant liver disease. An assessment of fibrosis is necessary as part of the treatment process as there is no advantage in treating patients with minimal or no fibrosis. Acceptable testing includes liver biopsy, transient elastography, and serum markers for fibrosis. In addition, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review, the patients request for Sovaldi and ribavirin is not medically necessary. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested the brand name drug, Focalin XR. for treatment of the enrollees attention-deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Generic products by definition should be considered interchangeable with the innovator brand product. However, the U.S. Food and Drug Administration (FDA) allowed variability in generic medication concentrations is +/- 20 percent (Carron and Correll).  Multiple studies over the last ten years have recorded this allowed variability. Carron and Correll performed a literature review of clinical studies comparing branded with generic psychotropic drug formulations. The authors reported that generic-generic switches may vary by more than +/- 20 percent from each other in individual patients since the pharmacokinetic properties of each generic may differ from the innovator drug in opposing directions. In this case, the patient has a diagnosis of ADHD and was responding well to a moderate dose of dexmethylphenidate in the form of brand name Focalin when a generic formulation became available. The patient tried the generic formulation, but the patients parent recognized significant behavioral and physical alterations after one month with the substitution. After a trial period of one month the generic methylphenidate was replaced with brand name Focalin with a resolution of the flared up symptoms. As such, the generic version has failed as reported by the patients parent and the continuation of brand name Focalin XR is medically necessary for this patient. In addition, increasing dosage of the generic medication would run the risk of side effects and take the patient beyond the recommended maximum dose. Therefore, the request for brand name drug, Focalin XR is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee requested insulin potentiation therapy and low dose chemotherapy for medical treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available treatment options. Insulin potentiation therapy and low dose chemotherapy has not been supported by the scientific community, and there is a lack of published clinical trials of sufficient quality and scope to support its use in clinical practice. Therefore, the services at issue were not and 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

A 61-year-old female enrollee requested surgery to remove abdominal adhesions and/or Suboxone for medical treatment of her pelvic pain.   Findings:  The physician reviewer found that the patient is at high risk for complications with another operation. When adhesions are lysed, generally more develop, so this is not recommended. In addition, her pain predates the development of her adhesions, and has continued despite repeat surgeries. With regard to the request for Suboxone, considering the length of time the patient has been treated with narcotics, the medications may actually be contributing to her pain. Further, the U.S. Food and Drug Administration (FDA) has not approved Suboxone for the treatment of chronic pain in this clinical setting. Consistent with these findings, there are multiple FDA approved treatments available to this patient for pain management and she should continue to explore these options with her providers. However, the requested surgery to remove abdominal adhesions and/or Suboxone is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee requested Stelara 90 mg every eight weeks for medical treatment of his psoriasis.  Findings:  The physician reviewer found that Stelara is a human monoclonal antibody indicated for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Stelara every 12 weeks is effective for most patients with moderate-to-severe psoriasis, intensification of dosing to once every eight weeks with Stelara 90 mg might be necessary to elicit a full response in patients who only partially respond to the initial regimen. Consistent with these findings, the requested Stelara 90 mg dosing every eight weeks is supported as medically necessary for treatment of this patients psoriasis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee requested  panniculectomy with extended abdominoplasty for  medical treatment of her excess skin.  Findings:  The physician reviewer found that a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. As noted by Manahan and Shermak, common functional problems associated with an overhanging pannus or skin redundancy are described to cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. All told, the requested panniculectomy has been documented to be reconstructive in nature and medically necessary, and the extended abdominoplasty is not reconstructive in nature and not medically necessary for treatment of this patients excessive skin and soft tissue secondary to weight loss.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee requested the Prometheus Anser adalimumab (ADA) laboratory test (CPT code 84999) for medical evaluation of her Crohns disease.  Findings:  Two physician reviewers found that the patient did not have symptoms consistent with a Crohns flare-up at the time of testing. A standard approach to evaluating this patients condition includes gastrointestinal (GI) imaging to correlate symptoms with disease activity or to empirically restart low-dose corticosteroids or initiate a trial course of frequency-intensified weekly ADA.  All told, the Anser ADA testing was not likely to have provided greater benefit for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested Minimed 530G with Enlite (E0784 insulin pump; A9277 continuous glucose monitor (CGM) transmitter; A9276 CGM sensor for medical treatment of her diabetes. Findings:  Three physician reviewers found that the patient is using an insulin pump and still has low early morning blood glucose levels.  There is sufficient support for the requested equipment in this clinical setting.  The use of the requested Minimed 530G with Enlite is likely to be beneficial for this patient.  The requested equipment may assist in decreasing the frequency of severe low blood glucose levels which occur overnight.  Thus, the requested Minimed 530G with Enlite (E0784 insulin pump; A9277 CGM transmitter; A9276 CGM sensor) is likely to be more effective than other treatment options in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the medical literature does not support the services at issue in this clinical setting. In this case, the patient is asymptomatic with no reports of dense breast tissue. Although breast tomosynthesis has a role in screening as an adjunct in a select group of patients, this is not the case in this clinical setting. Therefore the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee requested residential level of care for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this patients case, substance use was problematic despite enhanced outpatient services.  However, she possessed several positive biopsychosocial factors and had not failed the intermediary setting of partial hospitalization.  The patient did not have a psychiatric illness or medical condition that required a 24-hour supervised setting.  Additionally, she was not having difficulty maintaining her self-care or activities of daily living.  The documentation provided does not support the clinical need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, residential level of care was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee requested residential treatment center for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services.  In this patients case, treatment at the residential level of care was medically appropriate.  The services were for active treatment and were reasonably expected to improve her condition and prevent a more serious episode of illness.  Based on the documentation provided and current treatment guidelines, residential treatment was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Euflexxa injections for treatment of her  right knee pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, this patient has a patellofemoral instability syndrome with valgus orientation of the knee and abnormal tracking of the patella in the trochlear. The MRI has documented chondromalacic changes at the lateral femoral condyle and facets of the patella. There are also abnormalities found in the lateral meniscus. In the face of these mechanical and alignment issues, hyaluronate injection is not clinically indicated as it is not likely to provide benefit. Based on the medical literature cited above, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee requested intensive outpatient program for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that the the patient was having impairment across multiple functional domains due to his alcohol use, which was complicated by a formidable anxiety burden.  The submitted documentation evidenced a pattern of substance use that was unlikely to change with outpatient and community resources alone.  Despite the services at the intensive outpatient program level of care, the patient continued to struggle in maintaining sobriety.  The patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided thereafter was reasonably expected to improve the patients condition while preventing a more serious episode of illness.  In sum, considering the relevant peer-reviewed literature and current practice guidelines, intensive outpatient program services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested modafinil (Provigil) 600 mg (three 200 mg tablets) for medical treatment of her narcolepsy.   Findings:  The physician reviewer found that the objective findings on exam are suggestive of significant hypersomnolence.  Given her symptoms, she may meet the criteria for narcolepsy.  Provigil has been approved by the US Food and Drug Administration (FDA) for treatment of idiopathic hypersomnia.  This patients records document that she has responded well to treatment with Provigil for many years.  Due to the patients response, the requested Provigil 600 mg (three 200 mg tablets per day) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested Aubagio for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication for the treatment of this patient.  The medical records note a diagnosis of relapsing-remitting multiple sclerosis.  The patient has been on Rebif, but has developed intolerable side effects of pain and bruising.  Per the submitted records, she is unable to self-inject due to incoordination and needle phobia.  The inability to self-inject is an appropriate reason to switch to an oral disease modifying agent.  All told, Aubagio is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested  growth hormone (GH) Genotropin for treatment of the enrollees short stature.  Findings:  The physician reviewer found that this patient has short stature but normal height velocity, normal growth factors, normal bone age, and a normal response to provocative GH testing. Thus, he does not have classic GH deficiency. His bone age is too young to make a formal prediction of final adult height. According to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the information provided, this patient does not meet most of these criteria. All told, the requested GH therapy with Genotropin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that during her residential stay the patient was not demonstrating ongoing active suicidal behavior, self-harm behavior, ongoing danger to others, or experiencing a grave disability. While there were reports of ongoing passive suicidal ideation, the records provided do not demonstrate that the patient was actively suicidal with intent or plan to harm herself during the period at issue. Given this, the patient did not require 24-hour supervision in a residential setting and could have safely been treated at a lower level of care. Based on the medical literature cited above and the documentation submitted for review,  RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested a bronchial thermoplasty treatment for medical treatment of her asthma.  Findings:  Two physician reviewers found that there is a paucity of medical literature supporting bronchial thermoplasty as a first-line therapy for patients with persistent asthma.  Iyer and Lim concluded that recent results of the AIR-2 trial raise serious questions about the efficacy of bronchial thermoplasty.  There is also a lack of long-term follow-up data demonstrating improved health outcomes with bronchial thermoplasty over standard therapies.  All told, bronchial thermoplasty was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested alcohol sclerosing injections for treatment of her plantar fasciitis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support alcohol sclerosing injections in this patients case.  The submitted records document plantar fasciitis, and the patient has a history of heel pain.  There is a lack of support in the medical literature for the use of alcohol sclerosing injections for the treatment of plantar fasciitis.  Cortisone injections are standard of care for the treatment of this patients condition.  All told, the requested alcohol sclerosing injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee requested or laboratory testing including immune cell function assay for medical evaluation of the enrollees liver transplant.  Findings:  Three physician reviewers found that this assay has been approved by the US Food and Drug Administration (FDA) for immune monitoring functions. In addition, the laboratory testing at issue is FDA approved for monitoring immune function in a transplant patient in this clinical setting. The safety and efficacy have been established in the medical literature and its utilization is considered a standard of care protocol in some transplant centers. Consistent with this support, the testing at issue was likely to have been more beneficial than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested ambulance services on an emergent or urgent in nature basis.  Findings:  The physician reviewer found that based on the patients clinical presentation, the symptoms would not cause a reasonable and prudent layperson to believe he or she required immediate medical attention. Thus, his symptoms on did not meet prudent layperson criteria for emergent care or urgently needed services.