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

A 24-year-old male enrollee has requested residential treatment services for treatment of his substance abuse.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient was medically and psychiatrically stable. There was no suicidal/homicidal ideation or evidence that there was any danger to others. He was cognitively intact and there was no evidence of psychosis. Although not at immediate risk due to the contained environment, the patient demonstrated a pattern of inability to maintain sobriety as evidenced by his attempting to bring drugs into the facility. He actively worked on reading assignments with counselors, shared in groups, and was learning the need for help in maintaining sobriety.  He was developing recognition of triggers and learning coping skills for relapse prevention. Prior to his initial admission to this facility he was living on the streets. He was planning to discharge to live with his mother or sober living. Given his history and recent drug seeking behavior, residential level of care was appropriate and clinically indicated in order to give him the necessary boundaries and supervision to help solidify his skills in learning impulse control before stepping down to a lower level of care. As such, residential level of care was medically necessary for the days specified, after which he could be stepped down to a lower level of care. Therefore, residential treatment services provided from the time period specified were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options (National Institutes of Health). Zaltrap has been used off-label in ovarian cancer. There are phase II data that demonstrate efficacy with limited toxicity especially in the resolution of malignancy ascites. Based on this medical evidence, it is medically appropriate to treat this patient with Zaltrap. Thus, the Zaltrap provided from the time period specified and forward was and 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 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees bulimia nervosa, depression, and anxiety.  Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) practice guidelines, the RTC services provided to this patient from the date indicated forward are supported as medically necessary. The records document that the patient had suicidal ideation on admission with passive suicidal ideation since that time. The patient has demonstrated poor motivation and was noted on several occasions to have been unwilling to discuss her problem behaviors. In addition, she has been documented to need constant supervision due to compulsive exercising. Further, she continues to be preoccupied with repetitive intrusive thoughts 4-6 hours per day. She has struggled with anxiety and mood lability throughout her treatment. Her psychiatric medications have been increased and changed to maximize control of her symptoms. Overall, this patient has numerous characteristics of her eating disorder that suggest a worse long-term prognosis including onset below or at age 12, comorbid psychiatric issues, and suicidal ideation. It is also well documented that patients with bulimia have more self-injurious behaviors such as cutting, and have more character pathology and are more difficult to treat. She has failed treatment in the past in less restrictive settings and is undergoing severe psychosocial stressors that she is unable to adequately cope with. In summary, the RTC services provided from the date indicated forward were and are medically necessary in order to treat this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested chiropractic treatment for treatment of her hip pain. Findings:  The physician reviewer found that the chiropractic treatments provided were medically necessary for treatment of the patients diagnoses of lumbosacral segment dysfunction and hip enthesopathy. On the date indicated, the patient was sufficiently evaluated through physical examination and review of x-rays to formulate a diagnosis and treatment plan. The chiropractic treatment visits in dispute were medically necessary for treatment of the patients medical conditions. In addition, the records document that the patient showed improvement with chiropractic care. Based on clinical documentation and the above-cited chiropractic guidelines, the chiropractic treatments provided were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee requested accessories for the allowed power wheelchair for medical treatment of the enrollees infantile hemiplegia and cerebral palsy.  Findings:  The physician reviewer found that according to the National Institutes of Health (NIH), the goal of treatment for patients with cerebral palsy is to foster independence to the extent possible. Wheelchairs, walking aids, muscle and bone braces, hearing aids, and glasses may help with communication and learning. Physical therapy, occupational therapy, orthopedic health and other treatments may also be needed to help with daily activities and care. The records indicate that this patient is able to operate a manual wheelchair but only for limited distances. A manual wheelchair would mean she could only independently navigate in the home which would be very limiting for her. Given these findings, the requested equipment, including the recommended seating system, is medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested OxyContin Extended Release 80 mg (one tablet four times per day) for medical treatment of her cervical and lumbar myofasciitis status post lumbar fusion. Findings:  Three physician reviewers found that it is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. High dose opiates may also cause adverse outcomes and therefore the patients requested authorization and coverage for OxyContin Extended Release 80 mg is not indicated. The prescribed dose exceeds the recommended maximum dose of OxyContin 80 mg twice per day. Thus, the requested OxyContin Extended Release 80 mg (one tablet four times 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: Upheld Decision of Health Plan

A female enrollee requested in-home occupational therapy and in-home physical therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that for those with diabetic neuropathy and gait disorders, aerobic exercise training can provide some benefit in function.  In this case, the patient has undergone significant home physical therapy and she has progressed to ambulating short distances at stand by assistance.  She was discharged from her treating home physical therapist and is independent with self-care.  Further improvements in endurance can be achieved as tolerated with custodial level supervision and assistance from caregivers.  No marginally significant improvements in outcomes or clinical course would be expected with further home therapies beyond an independent exercise program with custodial level supervision and assistance.  All told, the requested in-home occupational therapy and in-home physical therapy are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested  radiofrequency ablation of the right sacroiliac (SI) joint for treatment of her low back pain and SI pain.  Findings:  Three physician reviewers found that radiofrequency ablation of the right SI joint is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there were no provocative maneuvers reported on physical exam. The pain over the SI joint is described as right parasacral muscular tenderness, which could account for the pain independent of the SI joint. In addition, there are no supporting x-rays or imaging submitted for review. In sum, the documentation submitted for review does not support the use of radiofrequency ablation in the patient at this time. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested ledipasvir/sofosbuvir (Harvoni) 90-400 mg for medical treatment of her chronic hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related comorbid conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. Additionally, treatment of patients before their condition progresses to F3 or F4 fibrosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni 90-400 mg is medically necessary for treatment of this patient hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested an additional 12 weeks of Harvoni for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions (Class I, Level A recommendation). Per AASLD/IDSA, treatment with Harvoni for 24 weeks is recommended for patients with CPT Class B or C cirrhosis, the provided records indicate the patient meets these criteria. Based on the evidence of safety and efficacy in the published literature, and clinical guidelines, the treatment of Harvoni for 24 weeks is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested sofosbuvir/ledipasvir (Harvoni) 400 mg #90 for treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the current treatment guidelines state that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Moreover, the guidelines support using Harvoni for treatment-naive patients with hepatitis C virus genotype 1a infection. The guidelines recommend combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. However, effectiveness of Harvoni in patients who are treatment naive and non-cirrhotic is the same with eight weeks and 12 weeks in patients who had baseline hepatitis C virus RNA levels below 6,000,000 IU/mL. Accordingly, Harvoni for eight weeks is medically necessary for this patient who has hepatitis C with a viral load less than 6,000,000, is treatment-naive, and non-cirrhotic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee requested residential treatment for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the record does not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, family counseling, school-based services or evidence-based psychotherapies and pharmacological strategies targeting her addictive illness and psychiatric conditions during the episode of illness.  Further, there is a lack of treatment plans or daily progress notes submitted to support the medical indication for the residential treatment setting.  All told, residential treatment center services were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested genetic testing (Genecept Assay) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. There is a lack of treatment history provided for review. The patient has major depressive disorder and in this clinical setting, there are many standard treatment modalities available for this patient. The most common treatment for major depressive disorder is selective serotonin reuptake inhibitor and psychotherapy. There is no indication that this patient has utilized any of these therapies. Other types of antidepressants including monoamine oxidase inhibitors (MAOIs) and bupropion are also available as are augmentation strategies with medications such as Seroquel and Abilify. As such, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested inpatient mental health services for medical treatment of her schizoaffective disorder. Findings:  The physician reviewer found thatthe submitted documentation supports the medical necessity of a portion of the services at issue.  This patient evidenced profound psychiatric symptomatologies in the context of acute marital discord upon admission.  Subsequently, nursing reported appropriate behavior, communication, mood and affect.  The patient was adherent with treatment.  The records indicated that her pain was less and her mood was better.  The mental status examination noted pleasant affect and the absence of suicidality, homicidal ideation and psychosis.  All told, initial inpatient mental health services were medically necessary.  However, the records fail to demonstrate the medical necessity of subsequent inpatient mental health services.  I have determined that a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee requested speech therapy three times per week for medical treatment of the enrollees speech delay. Findings:  The physician reviewer found that based on the available medical records, this patient is profoundly speech delayed, but there is evidence that his speech delay is at least partly due to intellectual developmental factors. Whether increased frequency of speech therapy will accelerate the development of speech in a cognitively delayed child is not well defined in the medical literature (Goorhuis-Brouwer and Kniff).  In regard to cognitively impaired children, there is a paucity of data addressing with the impact of frequency and intensity of speech therapy in a child who is intellectually delayed. Given these findings, the requested three hours per week of speech therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee requested finger joint manipulation under anesthesia for medical treatment of her medical condition.  Findings:  Two physician reviewers found that this patient was diagnosed with small flexor tenosynovitis. The usual progression of treatment includes treating with NSAIDs, rest and bracing, followed by physical therapy or occupational therapy.  More acute cases are treated with corticosteroid injections.  The current medical evidence has not established the superior efficacy of the services at issue.  There is a lack of support for the use of manipulation under anesthesia to break up the scar tissue in this clinical setting.  There is a paucity of medical studies demonstrating that this treatment is helpful for joints such as fingers.  Therefore, the superior effectiveness of finger joint manipulation under anesthesia has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested Lipitor for medical treatment of her hyperlipidemia.  Findings:  The physician reviewer found that based on the records provided, the patient presents with a documented intolerance to at least two statin medications prescribed for treatment of hyperlipidemia. Changing from generic atorvastatin to brand name Lipitor does not alter drug metabolism and should not be expected to result in a change in myalgia side effects. Current recommendations also suggest changing to a statin that is less metabolized by cytochrome P450 if myalgia prohibits medication continuation. There is no scientific study that I could find to indicate a difference in tolerability due to myalgia between generic atorvastatin and brand name Lipitor. All told, the request for brand name Lipitor is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his memory disturbance.  Findings:  Three physician reviewers found that this patient has documented cognitive impairment and conventional imaging showing atrophy. The use of PET scan in this scenario has proven to be a beneficial functional imaging tool in establishing the diagnosis of Alzheimer disease differentiating the disease from frontotemporal dysplasia.  Therefore, the requested PET scan is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested mental health residential treatment center level of care for treatment of the enrollees generalized anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and Aspergers disorder.  Findings:  The physician reviewer found that although diagnosed with PTSD, depression, anxiety and autism, the patients symptom complex, behaviors and longitudinal history are also consistent with reactive attachment disorder. This may help explain her self-defeating coping strategies and emerging dysfunctional personality traits. Further, the patient has a poorly defined self-concept which complicates her process of identity formation and undermines her ability to effectively manage her emotions, impulsivity, and intrapsychic conflicts. In reviewing the clinical documentation, by the date indicated the patient had not yet consolidated the treatment gains needed to succeed in a less restrictive setting. Her treating providers continue to recommend residential care. On the subsequent date, the patient had suicidal ideation and attempted to depart the facility and run into traffic. Combining the current status, recent behaviors and clinical history, the patient will likely decompensate in the absence of the disputed treatment setting. Her behaviors will likely jeopardize her safety and possibly those whom she encounters in the community. All told, the evidence-based services provided thus far have been for active treatment and have been delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The services are reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the case in its entirety, and applying the current practice guidelines and relevant peer-reviewed literature, residential treatment services from the date indicated forward were and are safe, appropriate and consistent with good medical care and thus medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested proton beam therapy for medical treatment of his acoustic neuroma.  Findings:  The physician reviewer found that although this patient does not have useful hearing in his left ear, failure to treat this intracranial tumor could result in its growth and subsequent development of balance difficulty, facial nerve pain, numbness, dysphagia and vertigo. Given the current medical literature, proton beam therapy has an advantage over other forms of radiation in the management of acoustic neuroma (Combs, et al; Link, et al). This includes central nervous system lesions measuring less than 3 cm in diameter adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord. The critical structure in relation to a CP angle tumor is the brainstem. Based on these findings, the requested proton beam radiation therapy is medically necessary for treatment of this patients acoustic neuroma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee requested magnetic resonance imaging (MRI) of the lumbar spine without contrast (72148), cervical spine (72141), and bilateral shoulder without contrast (73221) for medical evaluation of his bilateral broken clavicle.   Findings:  The physician reviewer found that clinical evaluation did not include a neurological examination or a detailed shoulder exam on either side. Overall, there are no red flags to provide an indication for MRI imaging of the cervical, lumbar spine, or either shoulder. In addition, there is no note in the records of any attempt to treat the patient conservatively with physical therapy before considering any advanced imaging. The requested MRI of the lumbar spine without contrast (72148), cervical spine (72141), and bilateral shoulder without contrast (73221) are not medically necessary for evaluation of this patients medical condition.