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

A 63-year-old male enrollee requested a 12-week course of Sovaldi and Olysio  for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per the current medical evidence, once-daily treatment with Olysio and Sovaldi, with or without ribavirin, has also been shown to be highly effective in both treatment-naive patients and prior  responders infected with hepatitis C, genotype 1, including patients with cirrhosis.  However, the combination of Sovaldi and Olysio has not been approved by the U.S. Food and Drug Administration (FDA).  There are other FDA approved treatment options in this clinical setting.  While this patient is interferon-ineligible, the records do not demonstrate that he is ribavirin-ineligible. There is support for daily Sovaldi and weight-based ribavirin for interferon-ineligible patients with hepatitis C, genotype 1. Therefore, the proposed 12-week course of Sovaldi and Olysio is not medically indicated since FDA-approved therapeutic alternatives exist.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee requested urgent care services for his medical condition.  Findings:  The physician reviewer found that this patient presented with upper body itching and burning, however, he was not in acute distress. His symptoms had been present for four days. The records do not document that the patient was having difficulty breathing.  There was no evidence that the patients condition was deteriorating or that he was in acute distress. The patients physical exam showed a normal oral phalanx without angioedema and there is no clinical documentation of breathing difficulties. His treatment could have been delayed without jeopardizing his health.  Based on the patients clinical presentation, the patients symptoms would not cause a reasonable and prudent layperson to believe he required immediate medical attention. As such, the patients symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee requested Somatropin growth hormone for medical treatment of the enrollees growth hormone deficiency.  Findings:  Three physician reviewers found that there is no documentation of growth hormone stimulation testing or other clinical information to support a diagnosis of growth hormone deficiency. The records do not include a rationale for growth hormone and there is no documented history of pituitary disease, surgery or radiation or stimulation tests results. Further, the patients IGF-1 levels are normal. Although the patients IGF-1 levels may have been tested as normal while the patient was on growth hormone therapy, additional testing is needed to support an indication for growth hormone therapy. Consistent with these findings, request for Somatropin growth hormone and future treatment is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested Actiq (fentanyl lozenge) and hydromorphone HCL 10 mg/ml vial injection for medical treatment of the enrollees intractable pain.  Findings:  The physician reviewer found that the request for Actiq (fentanyl lozenge) and hydromorphone HCL 10 mg/ml vial injection is not medically necessary. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. The current opioid medications and at the requested dose is recommended and indicated for malignant pain (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee requested physical therapy for medical treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the current medical evidence supports the requested physical therapy in this clinical setting.  The report by Hagen and colleagues evaluated the evidence regarding the effects of exercise therapy on physical function and pain for patients with musculoskeletal conditions. The authors noted that exercise therapy has beneficial clinical effects for musculoskeletal conditions.  The submitted documentation indicated the patient was slow with his gross motor skills and had poor trunk control.   The clinical notes indicated the patient was unable to walk backward, run, or walk up stairs.  In this case, the requested physical therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee requested eating disorder intensive outpatient program (IOP) for medical treatment of her eating disorder, bipolar disorder, and alcohol abuse.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, IOP services are appropriate for a patient when there is partial motivation, the patient is preoccupied with intrusive, repetitive thoughts for more than three hours per day, and there is a need for structure. This patients provider noted that intensive treatment was required as lack of treatment would have led to rapid decline in her overall level of functioning. The patient had increasing obsessive thoughts about food and was eating compulsively. All told, IOP services were appropriate to treat this patients condition, could not have been provided safely on an outpatient basis, and were medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee requested a specialized treatment plan for medical treatment of her quadriplegia secondary to spinal thrombosis.  Findings:  Two physician reviewers found that while it is noted that this patient has made an improvement in function with the specialized exercise program, there is no indication that this patient will not receive the same quality care at a standard rehabilitation facility.   The patient has been previously engaged in an occupational therapy program and diligently performed the home exercise program and continued to work with physical therapy.  The patient was evaluated and discharged after demonstrating an improvement in manual muscle testing and sensation in the right upper extremity. Given that the patient has participated in occupational therapy at a standard rehabilitation facility and demonstrated improvement, there is no indication that she requires treatment at a specialized facility. Thus, the specialized treatment plan is not 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

A 32-year-old transgender female enrollee requested laser facial hair removal or electrolysis for medical treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that as defined in a paper by Elghblawi, Hirsutism is the excessive and increased bodily and facial hair growth in women in locations where hair is normally minimal or absent. It refers to the growth of hair in a pattern normally occurring only in men, and therefore primarily raises psychological, cosmetic and social concerns. According to Blume-Peytavi, unwanted facial hair is a particular concern, due to its negative impact on perceived femininity. There may not always be a direct correlation between degree of severity diagnosed objectively by the physician and level of concern and impact upon the patient. For a female with hirsutism, it is necessary to remove hair for psychological and social reasons. The negative perception of excessive hair on an individuals femininity would have an even greater impact on a transgender female. Therefore, facial hair removal utilizing laser or electrolysis is medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-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 the patient has a concerning depressive illness and OCD disorder with contemporaneous treatment refusal, parental pathology and a home environment, which in its current state, is not conducive to meaningful treatment gains. The patient has a formidable symptom complex that is impairing multiple domains of functionality and jeopardizing her developmental task of identity formation. Additionally, the patients impulsivity and dysphoria have resulted in several potentially harmful situations. Her parental relations are disharmonious and disarrayed. She does not have a nurturing and reliable relationship with an adult figure or a supportive peer group. Finally, the patient has failed less restrictive interventions. Therefore, treatment at the residential level of care in this case is reasonably expected to improve her condition and prevent a more serious episode of illness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-month-old male enrollee requested intravenous immune globulin (IVIG) treatments for treatment of the enrollees immune deficiency.  Findings:  The physician reviewer found that the patient does have otitis requiring antibiotics and failure to respond to bacterial and viral vaccinations. His supplementary studies suggest high cell turnover with significant ongoing inflammation and probably an intracellular signaling defect blocking his ability to make effective antibodies. While other possibilities such as leukocyte adhesion deficiency or a toll-like receptor defect are possible, it is medically necessary to treat this patient with IVIG treatments for 6 to12 months while more definitive studies are completed.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee requested  intensity modulated radiation therapy (IMRT) for medical treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that IMRT was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is abundant single institution data to suggest that IMRT for pancreatic cancer yields improved plans versus conventional radiation with respect to normal tissue sparing (Landry, et al). IMRT for pancreatic cancer in select cases, such as in this case is clinically indicated as a superior treatment.  Given the dosimetric justification provided for review, the IMRT provided was and is 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 54-year-old male enrollee requested 35 visits of enhanced external counterpulsation (EECP) for medical treatment of his angina.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has known coronary disease but no hemodynamically significant stenosis identified on most recent angiography and no ischemia identified on most recent stress testing.  In this circumstance of no significant epicardial stenosis and no provokable ischemia during chest pain, EECP is not considered standard accepted practice.  The normal stress test and angiographic results support that the patients symptoms are more likely non-ischemic in origin and therefore not likely to benefit from EECP.  There is a lack of evidence indicating that repeated courses of EECP provide additional benefit.  All told, the requested 35 visits of EECP are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee requested Procrit for medical treatment of his sickle cell disease.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. This patient has had serious life-threatening complications from his SCD. He has been appropriately treated with hydroxyurea, the only drug that has been proven in randomized trials to reduce the rate of complications such as pain crises and acute chest syndrome (Lanzkron, et al; Brawley, et al; Halsey and Roberts). Unfortunately, hydroxyurea also induces cytopenias and can exacerbate the anemia that is already present in many SCD patients. It is in this context that erythropoietin therapy has been investigated. There are studies that show a benefit when used in combination with hydroxyurea in increasing the hemoglobin F concentration (el-Hazmi, et al; Rodgers, et al). The National Institutes of Health reviewed their use of erythropoietin and they concurred with these previously published studies (Little, et al). In sum, there is sufficient medical evidence to justify its use in this patient. Therefore, the medical necessity of the requested medication has been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee requested tocilizumab (Actemra) for six months for medical treatment of the enrollees medical condition status post kidney transplant. Findings:  Three physician reviewers found that the treatment of acute antibody-mediated rejection by any modality is not currently supported in the peer-reviewed medical literature (Kasiske, et al). Based on available data, this patient should receive immunoadsorption or plasmapheresis plus bortezomib with close monitoring by his physician (Roberts, et al). Currently, the use of Actemra should be limited to clinical trials. All told, the requested Actemra for six months is not likely to provide this patient with a greater benefit than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested hip resurfacing arthroplasty for treatment of his right hip osteoarthritis.  Findings:  The physician reviewer found that this patient has developed progressive degenerative joint disease in his right hip. He has had a successful left hip resurfacing and wishes to pursue this for his right hip. He has failed conservative measures. As this patient has already had a resurfacing on his contralateral hip and he is aware of the risks as with any other procedure, this procedure is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee requested stereotactic body radiation therapy for medical treatment of his prostate cancer.  Findings:  Three physician reviewers found that stereotactic body radiotherapy is likely to be equivalent, but not more beneficial than standard treatment consisting of conventionally fractionated radiation therapy.  At this time, there is a lack of randomized phase III trials comparing the two modalities, although studies are underway.  The available studies suggest possible equivalence between the two treatments.  In sum, the requested stereotactic body radiation therapy is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee requested (certolizumab pegol) Cimzia syringe kit for medical reatment of the enrollees Crohns disease.  Findings:  The physician reviewer found that Cimzia is a pegylated tumor necrosis factor alpha (TNF-a) inhibitor that was U.S. Food and Drug Administration (FDA)-approved in April 2008 specifically indicated for reducing signs and symptoms of Crohns disease and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. In the medical literature, de Bie and colleagues noted that while not FDA-approved for use in the pediatric population, Cimzia has been used off-label to treat refractory pediatric inflammatory bowel disease. The authors also noted that despite the growing experience with these drugs in children with inflammatory bowel disease, optimal treatment strategies still need to be determined. Mahadevan and colleagues reported that scheduled infusions of infliximab (Remicade) are effective at inducing and maintaining remission. Given that this patients records do not demonstrate that he has been adequately treated with Remicade consistent with FDA recommendations, the requested Cimzia is not supported as medically necessary for treatment of the patients Crohns disease.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee requested positron emission tomography (PET) for medical evaluation of his tonsil cancer.  Findings:  Two physician reviewers found that the services at issue were and are likely to be more effective for this patient than other available options. In this clinical setting the PET scan incorporates a diagnostic-quality anatomic imaging component, which can correctly identify clinically inapparent synchronous tonsil cancers and assist in the evaluation for distant disease. In addition, there is support in the medical literature for PET scans in order to direct the choice of biopsy sites at the time of panendoscopy, thereby increasing accuracy in detecting singular or synchronous primary cancers (Price and Pickles; Strobel, et al).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested community based adult services at the frequency of three times per week for medical treatment of her mental health.  Findings:  The physician reviewer found that according to California Department of Healthcare Services, community based adult services may be considered for patients who are diagnosed by a physician as having an organic, acquired traumatic brain injury and/or have a chronic mental illness; or a medication induced movement disorder; who require a need for assistance or supervision with at least two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management and hygiene or one of the activities of daily living previously listed and help with money management, accessing resources, meal preparation or transportation.  Although there is documentation showing that the patient has been diagnosed with major depressive disorder, there is a lack of evidence showing that the patient requires assistance with activities of daily living, requires assistance with medication use, or requires assistance in making meals. In addition, the community based adult service assessment provided for review indicates that the patient did not meet the eligibility criteria for community based adult services. Therefore, the request for community based adult services at a frequency of three times per week is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee requested substance abuse partial hospitalization program (PHP) services for treatment of his substance abuse.  Findings:  The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. This patient had completed detoxification and was not at risk for withdrawals. He denied suicidal/homicidal ideation, plan, or intent. There was no evidence that he represented a danger to himself or others. He was medically stable and his depression was safely being managed with medications. The patient has undergone multiple prior treatments, apparently without significant impact upon his substance abuse behavior. There is a lack of evidence demonstrating that he has worked on the development of coping skills throughout all of his prior treatments. In this clinical setting, outpatient treatment, such as daily 12-step meetings and the support of a sponsor is likely to be beneficial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested BRCA genetic testing for medical evaluation of her risk for breast cancer.   Findings:  The physician reviewer found that well-established guidelines identify those patients in whom genetic screening is warranted. In this case, the patients risk has been extensively evaluated by more than one geneticist that agree the patients provided family history indicates that her risk of a germ-line BRCA mutation is low, and that testing is not warranted. All told, based on the available documentation, the requested BRCA genetic testing is not supported as medically necessary for evaluation of this patients medical condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested intensive outpatient program services for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The submitted records indicate that the patient was making progress.  The final note indicated an increase in weight, 90-100% of meal plan adherence, and no binging or purging.  Although the patient was anxious and restricted in affect, there were no acute psychiatric safety issues or concerning symptomatologies such as psychosis, cognitive impairment, homicidal ideation or suicidality.  Her medications had been streamlined and were managed by a psychiatrist in the community.  The patient was working 20 hours per week, and she intended to resume a second job.  Based on the submitted records, the patient had improved.  She was adhering to a meal plan.  She had gained weight and was not binging or purging.  In sum, intensive outpatient program services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested expanded mutation profile testing for medical evaluation of the enrollee, who has been diagnosed with metastatic adenocarcinoma of the lung.  Findings:  The physician reviewer found thatthe therapy of advanced non-small cell lung cancer has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens.  Recently, the mutational landscape of non-small cell lung cancer has significantly expanded to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences.  It is generally accepted that the panel of mutations typically analyzed in non-small cell lung cancer are mutually exclusive somatic driver mutations.  Generally, KRAS, TP53, and BRAF are included in these panels and are informative.  KRAS and EGFR mutations are usually mutually exclusive so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. The current medical evidence supports the requested services in this clinical setting.  All told, the requested expanded mutation profile testing is medically necessary for the evaluation of this patient.