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

A 56-year-old female enrollee requested oxycodone, HCl 5 mg for medical treatment of her medical conditions.  Findings:  The physician reviewer found that, based on a review of the documentation submitted, the requested medication is indicated and is a low dose. The medical literature demonstrates that low dose medication avoids multiple adverse consequences including tolerance, dependency, immunosuppression and other side effects. In addition, it appears the patient has fewer complications when acetaminophen is avoided with opioid, thus oxycodone without acetaminophen is recommended. All told, oxycodone HCl 5 mg is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee requested venous blockage repair (venous angioplasty) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this case, the services at issue were indicated to prevent the thrombus from dislodging and going to the lung and enhance IVC flow. For these reasons, the venous angioplasty performed was likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested lumbar surgery for treatment of his low back and leg pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested surgery. In this case, there is no documented lumbar instability, fracture, or tumor. Also, there is no documentation of a recent trial and failure of adequate conservative measures to include six weeks of physical therapy for back pain. In addition, there is no documentation of failure of previous fusion surgery. For the reasons provided, the requested surgery is not clinically indicated and not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested Lyrica 75 mg for medical treatment of his peripheral neuropathy.  Findings:  The physician reviewer found that the requested medication is not supported as medically necessary for this patient given the lack of documentation that he has failed other therapeutic options or that the patient is a non-candidate for such therapy. The available medical records describe a trial of gabapentin without benefit at 800 mg three times per day but do not demonstrate failure of duloxetine. Further, the records do not demonstrate ongoing risk or a potential of risk related to duloxetine use. Although the available medical records do support that the patient failed treatment with gabapentin, it does not support that duloxetine was tried and failed or that there was contraindication to duloxetine. Thus, the requested Lyrica 75 mg is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested intensity modulated radiation therapy (IMRT), CPT codes 77338, 77301, 77385 and 77386 for treatment of his colon cancer. Findings:  Two physician reviewers found that in this case, the patient has recurrent cancer with multiple surgeries and other adjuvant treatments. The patient now has metastatic disease in mediastinum and retroperitoneal areas. This is a palliative condition which can be treated with a lower dose with conventional 3D conformal treatment. In addition, there is a lack of data demonstrating the safety and efficacy of IMRT in this patients clinical scenario. In fact, IMRT is still being evaluated in lung cancer. Moreover, there is no dose-volume histogram (DVH) comparison provided. For the reasons provided, IMRT 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

A 64-year-old female enrollee requested surgical resection of recurrent pancreatic cancer mass and surgical reconstruction of superior mesenteric artery and celiac artery for medical treatment of her pancreatic cancer. Findings:  The physician reviewer found that there is a lack of data to demonstrate any efficacy of resection of local recurrent mass for pain relief from recurrent pancreatic cancer. The pain is usually due to perineural invasion by the tumor, and unlikely to be completely resected for any pain relief, especially with the risks associated with celiac and superior mesenteric artery reconstruction after a prior Whipple procedure. In summary, there is no demonstrated benefit for surgical resection of recurrent pancreatic cancer and there is enormous risk associated with the planned procedure. Thus, the requested surgical resection of recurrent pancreatic cancer mass and surgical reconstruction of superior mesenteric artery and celiac artery is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee requested Vyvanse 60 mg twice per day for medical treatment of his attention deficit hyperactivity disorder (ADHD). Findings:  Two physician reviewers found that in the medical records provided for review, there is no clear documentation explaining the duration or doses of any of the other medication that the patient has tried in the past. Further, there is no documentation to support that the patient has been treated with the maximum doses of the other medications he has tried, which have more safety data available. In addition, there is a lack of documentation of the specific symptoms or behaviors that are being addressed by the medication or the symptoms that were not controlled by his previous medication trials. Overall, there is insufficient peer-reviewed data to support Vyvanse at a dose of 120 mg per day without adequate supporting clinical data. In conclusion, the requested Vyvanse at a dose of 60 mg twice per day is not 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 67-year-old male enrollee requested intensity modulated proton radiation therapy for medical treatment of his adenoid cystic carcinoma. Findings:  The physician reviewer found the patient has locally advanced adenoid cystic carcinoma with base of skull involvement as shown on imaging.  In order to eradicate the cancer radical radiation treatment is required. This is a complex case with skull base involvement, due to the close proximity of normal structures. In this case, these structures include the temporal lobe, optic nerve, and brain stem. Unfortunately, the radical radiation doses required to eradicate the cancer exceed the tolerance doses of these normal structures.  Adenoid cystic carcinoma of the head and neck with skull base involvement is a rare condition.  Therefore, treatment recommendations have to be based on retrospective case series. Based on the peer-reviewed literature and ASTRO model policy, intensity modulated proton radiation therapy in comparison with intensity modulated radiation therapy with photon is more likely to achieve disease control with less treatment related toxicity. Thus, the requested services are medically necessary for treatment this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee requested residential mental health and substance abuse treatment program services for medical treatment of her schizophrenia, anxiety disorder, and polysubstance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) dimensions, the patient does not meet the criteria for residential treatment. Given her history, psychotic features of her major depressive disorder, and poor sober support system, her potential for relapse supports the need for treatment at a lower level of care. While some progress was made, not enough was accomplished to warrant continued treatment at the residential level of care. For these reasons, residential mental health and substance abuse treatment program services were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Harvoni 90mg-400mg for treatment of his hepatitis C. Findings:  Two physician reviewers found that in this patients case, the requested medication is not medically indicated.  The submitted laboratory testing results are consistent with negligible fibrosis, at a stage considerable lower than the F2 stage indicated by the provider.   As noted by the patients provider, the American Association for the Study of Liver Diseases considers patients with non-alcoholic steatohepatitis (NASH) and debilitating fatigue as high priority for treatment.  However, this patients transaminases are not elevated.  Based upon the records, this patient does not meet American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as highest priority, high priority, or at increased risk for treatment.  Therefore, the requested Harvoni 90mg-400mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested Norco for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The medical records indicate myofascial pain, especially in the upper and lower back.  The patient reportedly has had a number of conservative measures for her pain, including acupuncture, massage therapy and chiropractic treatment.  However, there is a lack of support for Norco in this patients case.  Per the current medical evidence, there are other modalities which have not been tried which may be of benefit, including trigger point injections.  The literature does not support long-term use of Norco with the current pain syndrome.  All told, the requested Norco is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested genetic testing for evaluation of his salivary gland cancer.  Findings:  Two physician reviewers found that the testing performed was likely to be more effective for this patient than other available options. Adenoid cystic carcinomas are rare cancers usually arising from the salivary glands presenting as oropharyngeal masses although metastatic presentations have been described (Bhattacharyya, et al). The tumors can be slow growing but have a high propensity for recurrence. Since the tumor is very rare, large randomized clinical trial evidence cannot be expected. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoffman and colleagues studied 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Hoffman, et al). All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested treatment of her hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response, which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. Hence, Harvoni treatment for eight weeks is medically necessary for this patient who has HCV viral load less than 6,000,000 IU/mL, is treatment-naive, and non-cirrhotic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested 14 transcranial magnetic stimulation treatments for treatment of her major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course for transcranial magnetic stimulation is four to six weeks.  The current medical evidence does not support the services at issue in this patients case.  At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy.  It was not reasonably expected that the therapy would improve the patients condition or prevent a more serious episode of illness.  Further, there was no mention of the specifics of the psychotherapy being provided or the extent of specialty care directed towards her co-occurring eating disorder.   The medical evidence does not support a longer duration of transcranial magnetic stimulation therapy in this case while the medical records indicate that standard therapies had not been exhausted.  All told, 14 transcranial magnetic stimulation treatments provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested residential treatment services for treatment of her depression and suicidal ideation.  Findings:  The physician reviewer found that based on the available medical records, this patient had extensive inpatient psychiatric treatment before admission to residential treatment. While at the residential unit, she was not at risk of harm to herself or others. Her insight and judgment were fair. She was not psychotic or cognitively impaired, and she was cooperative with her program. She was not provided with any treatments that required 24-hour medical or nursing treatment. Consistent with the American Psychiatric Association (APA) guidelines, this patient could have been transitioned to a partial hospitalization program (PHP) that would have provided the appropriate medication management, individual, family and group therapy. All told, the patient could have been safely and adequately treated in a less restrictive environment than residential level of care. Therefore, the residential treatment services provided were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-month-old male enrollee has requested a DOC band (cranial reshaping band) for treatment of the enrollees positional plagiocephaly.  Findings:  The physician reviewer found that based on the clinical documentation received and the peer-reviewed medical literature, the requested DOC band (cranial reshaping band) is not medically necessary for treatment of this patients medical condition. According to Xia and colleagues, studies show evidence that molding therapy may reduce skull asymmetry more effectively than repositioning therapy. However, the authors noted that further research is warranted. An additional article from Mortenson and colleagues on orthotic treatment for deformational plagiocephaly also found that more data is needed to better understand the parameters for use, long-term outcomes, and natural history of the impact on caregiving. This patient is noted to have a 7 mm difference in diagonal diameters of the cranium. All told, the need for a DOC band (cranial reshaping band) 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 15-year-old male enrollee has requested  gynecomastia surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the current medical evidence, surgical management of gynecomastia should be reserved for severe and refractory cases.  Pruthi and Jones noted that nonsurgical interventions and medical therapies be considered as initial therapy for adolescents with a breast mass or breast hypertrophy.  The clinical documentation submitted for review indicated the patient had the condition for at least five years.  However, there was a lack of documentation indicating nonsurgical interventions and medical therapies had been considered as an initial therapy.  There is a lack of support for the requested gynecomastia surgery in this patients case.  All told, the requested gynecomastia surgery 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 female enrollee has requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The medical records document a serious risk of harm due to the patients episodic suicidal ideation.  The clinical notes indicate a history of seizures.  Additionally, the records indicate minimal positive treatment response in the past.  The current medical evidence supports the services at issue in this clinical setting.   This patient was experiencing anxiety and depression symptoms that appeared to improve during her residential treatment stay.  Due to her suicidal actions and thoughts, her poor cooperation in therapy and her anxiety issues, residential treatment services were indicated during the period in dispute.  All told, for residential treatment provided from the date indicated was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested  combination ledipasvir/sofosbuvir (Harvoni) 400 mg #90 tablets for treatment of her hepatitis C.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (90 mg/400 mg) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni 400 mg #90 tablets is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested  radiofrequency ablation for treatment of her sacroiliitis. Findings:  Three physician reviewers found that currently, there is a lack of adequate peer-reviewed literature that supports the long-term efficacy and safety of the requested radiofrequency ablation procedure. Additionally, there is a paucity of evidence that the requested procedure provides additional medical benefits as compared to traditional standard of care treatment options. Moreover, there remains a lack of standardization for radiofrequency ablation of the sacroiliac joint and it remains unclear what types of patients are the best candidates for this treatment. As noted by Cohen and colleagues, larger, multicenter studies with long-term follow-up and comprehensive outcome measures are needed to support radiofrequency ablation, further established safety, determine how best to identify candidates for the treatment. Consistent with these findings, the requested radiofrequency ablation of sacroiliac joint is not likely to be more beneficial for the patients medical condition than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested genetic testing for medical evaluation of possible Ehlers-Danlos Syndrome, type IV. Findings:  Two physician reviewers found that the testing was likely to be more effective for this patient than other available options. EDS type IV is associated with aneurysms and arterial dissections and for patients with the disorder there is a significant risk of carotid arterial dissection associated with angiography. Given the mothers genetic diagnosis of this dominantly inherited connective tissue disorder and the inherent risks of vascular manipulation in this disorder the testing at issue was indicated. Therefore, genetic testing was more likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested cortisone injections/selective nerve root block (SNRB) for medical treatment of his flat back syndrome due to spinal fusion from L1-S1.  Findings:  The physician reviewer found that the patients physical exam is not consistent with thoracic radicular pain or facet pain for which the combination of injections was required.   Additionally, there is lack of documentation of an MRI of the thoracic or lumbar spine to provide corroborating evidence for the treatment provided. The peer-reviewed medical literature provides evidence for epidural steroid injections and facet injections in documented cases of nerve root compression or facet arthropathy. However, given the lack of documentation in the medical records of pathological findings consistent with radicular pain and/or facet pain, the treatment requested was not indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee requested the medication Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Based on the available data, the patient has minimal liver fibrosis.  There appears to be a component of fatty liver disease as well.  At this point, the patient is not likely to benefit from eradication of hepatitis C with only stage 1 fibrosis.  The standard of care would be to undergo yearly assessments of fibrosis by methods such as FibroSure.  All told, Harvoni is not medically indicated for the treatment of this patient.