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

A female enrollee requested partial hospitalization program (PHP) level of care services and intensive outpatient program (IOP) level of care services for medical treatment of her eating disorder.   Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) guidelines, the patients significant comorbidities including PTSD and depression, she remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of initial PHP services. In sum, the PHP services were initially medically necessary for treatment of this patients medical condition, while later  PHP services and IOP services forward were not and are not medically necessary. I have determined that a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested an additional one hour of speech therapy per week (two hours of speech therapy per week for medical treatment of the enrollees expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that the patients evaluation showed that his language skills were severely delayed. ABA services address communication goals, specifically pragmatic language goals. Speech/language therapy addresses expressive and receptive language goals. Reichow and colleagues showed that early intensive intervention provides the best outcome for children with autism spectrum disorder. The patients speech progress report shows he is making progress, but he is still behind his peers. For the reasons provided, it is medically necessary for this patient to have an additional one hour of speech therapy per week (two hours of speech therapy per week).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested Botox injections (Xeomin) for medical treatment of the enrollees post-concussion migraines.  Findings:  Two physician reviewers found that Botox has been well studied in treatment of chronic migraine and there is evidence that Botox injections can be of benefit in treatment of chronic migraine consequent to TBI. However, Xeomin is a different product, with no indication for chronic migraine. According to Xeomins prescribing information insert The potency units of Xeomin are not interchangeable with other preparations of botulinum toxin products. There is a lack of data in the peer-reviewed literature supporting Xeomin for chronic migraine. Based on the peer-reviewed literature and clinical documentation provided, the requested Botox injections (Xeomin) 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 female enrollee requested Benlysta 11.6 mg/kg (920 mg) infusions for medical treatment of her systemic lupus erythematosus.  Findings:  The physician reviewer found that per the current medical literature, Benlysta has been evaluated in major clinical trials at doses of 1, 4, and 10 mg/kg.  A review of the literature did not find support for use of dosages above 10 mg/kg.  There is not sufficient information available to indicate that a dose of 11.6 mg/kg is medically indicated in this patients case.  All told, Benlysta 11.6 mg/kg (920 mg) infusions are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested L4-5 artificial lumbar disc replacement with ProDisc-L for medical treatment of her L4-5 postlaminectomy syndrome and degenerative spondylosis. Findings:  Three physician reviewers found that anatomical testing documents multilevel intervertebral disc, facet joint, neural foraminal and central spinal changes that reasonably may be the source of this patients lumbosacral pain. The clinical record supports a diagnosis of complex regional pain syndrome rather than a more specific diagnosis justifying specific intervention at a single level. Consistent with these findings, the requested L4-5 level artificial disc replacement with ProDisc-L 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 Lynparza for medical treatment of her breast cancer.  Findings:  The physician reviewer found that according to Lynparzas prescribing information, 2% of patients enrolled in olaparib monotherapy developed MDS or acute myeloid leukemia (AML). This case is particularly complex because the patient has MDS.  Olaparib is not recommended unless hematological toxicities of prior chemotherapy have resolved to less than grade 1, Common Terminology Criteria for Adverse Events (CTCAE) criteria. Furthermore, according to the label if MDS/AML are confirmed then olaparib is to be discontinued. In this patients case, olaparib could accelerate the MDS process to AML. Therefore, the request for Lynparza is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested intravenous immunoglobulin (IVIG) infusion therapy for medical treatment of her Satoyoshi syndrome.  Findings:  Three physician reviewers found that despite Trileptal, the patients myoclonus remains disabling with upwards of 100 myoclonic jerks of the face and neck during the day. In this clinical setting, the next treatment option is IVIG infusion therapy. IVIG has been utilized empirically in a number of pediatric self-immune disorders for a number of years. There is support in the medical literature for treatment of Satoyoshi syndrome with IVIG (Asherson, et al). Therefore, based upon the medical literature and the documentation submitted for review, the request for IVIG is likely to be more beneficial for treatment than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for the partial hospitalization program (PHP) level of care for medical treatment of her eating disorder.  Findings:  The physician reviewer found that although the patient has a significant eating disorder complicated by a poorly defined self-concept the clinical documentation provided does not support the medical necessity of the disputed intervention. Overall, the medical records do not include critical documents.  Although the patient will need long-term specialty care, there is a lack of evidence to indicate that she would have experienced a recrudescence of the symptoms if she transitioned to a less restrictive setting, such as intensive outpatient programming. In sum, the PHP services were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that based on the clinical information provided, the patient does not have evidence of advanced fibrosis of F3 or greater or evidence of extrahepatic manifestations of hepatitis C. The patient is asymptomatic. For this patient, a reasonable medical approach would be to follow the patient longitudinally with periodic assessments for progression using non-invasive testing such as Fibroscan or Fibrosure. As such, Harvoni for 12 weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested speech therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the current medical evidence supports speech therapy in this clinical setting.  Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Norco for medical treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that the records lack documentation that the patient has cancer or a condition that would support the use of Norco. The peer-reviewed literature indicated that opiates are not appropriate for the treatment of nonmalignant pain and not appropriate for the treatment of CIDP. Given the documentation, the requested Norco is not medically necessary for the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested ribavirin 400 mg and sofosbuvir (Sovaldi) 400 mg for medical treatment of the enrollees hepatitis C virus genotype 2b. Findings:  Two physician reviewers found thatp per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, the recommended regimen for treatment experienced patients with hepatitis C virus genotype 2 is daily sofosbuvir 400 mg and weight-based ribavirin for 12 weeks. In addition, the guidelines cite three clinical trials demonstrating the safety and effectiveness of this medication regimen in patients with genotype 2 hepatitis C. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested ribavirin 400 mg and sofosbuvir (Sovaldi) 400 mg should be approved as medically necessary for treatment of this patients medical hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested monitored anesthesia care (MAC) for medical treatment of his medical condition.  Findings:  The physician reviewer found that the monitored anesthesia care services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. In this clinical setting, the patient could have received a combination of a benzodiazepine and narcotic for sedation. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested hyaluronan (Orthovisc) injections for medical treatment of her hip pain.  Findings:  Three physician reviewers found that viscosupplementation is safe and effective for treatment of pain due to osteoarthritis of the knee and temporomandibular joints. However, it is not U.S. Food and Drug Administration (FDA) labeled for osteoarthritis of joints other than knees and temporomandibular joints. Currently, there is a paucity of randomized controlled clinical trials that demonstrate the safety and effectiveness of viscosupplementation of the hip. Based on the literature and American Academy of Orthopaedic Surgeons (AAOS) clinical guidelines, viscosupplementation cannot be recommended as standard treatment in hip osteoarthritis. For these reasons, the requested hyaluronan (Orthovisc) injections are 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 male enrollee requested autism behavioral intervention therapies (ABIT) 15 hours per week of therapy, 5 hours per month of supervision and 3 hours of treatment planning for treatment of his medical condition. Findings:  Two physician reviewers found that the services at issue were not and are not medically necessary for this patient. Pervasive developmental disorder, a subgroup of autism spectrum disorders (ASD), includes qualitative impairment in interpersonal communication as a core symptom.  There is a lack of peer-reviewed data demonstrating the efficacy of ABIT in this clinical situation. As such, the medical necessity of ABIT for treatment of this patients condition has not been established. The Health Plans authorization of monthly social skills group to assist with building interactive communication skills with peers is medically appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A transgender female enrollee requested bilateral orchiectomy for medical treatment of her gender identity disorder.  Findings:  The physician reviewer found that although not all patients with gender identity disorder wish to undergo surgical intervention, this patient has expressed a desire for surgery in treatment notes for a significant period of time. She has followed recommendations for surgery including living as a woman, participating in psychotherapy and undergoing hormone therapy. As such, there is sufficient evidence to support the medical necessity of the requested bilateral orchiectomy for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Plegridy for medical treatment of his multiple sclerosis.   Findings:  The physician reviewer found that as this patient has been having significant breakthrough disease on Copaxone, he needs to be treated with another disease modifying agent. Plegridy is a medication that is U.S. Food and Drug Administration (FDA) approved for treatment of relapsing forms of multiple sclerosis. Plegridy is an interferon beta 1a, and is given once every two weeks. This substantially reduces the frequent flu-like symptoms and injection site reactions compared to Rebif which is given three times per week. It is clinically indicated for this patient to change therapies, and given that the frequency of injection with Plegridy is less frequent than with Rebif, Plegridy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni 90/400 mg for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that the patient has chronic hepatitis C and has an advanced stage disease.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Hence, per the national guidelines, this patient should be treated urgently with Harvoni.  All told, Harvoni 90/400 mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested anterior interbody fusion at the diseased levels, followed by stabilization and decompression as needed posteriorly for medical treatment of his low back pain.  Findings:  The physician reviewer found that the patient does not meet the established criteria for lumbar fusion surgery. There is no documented fracture or instability. There are no red flags for lumbar fusion surgery such as fracture, tumor, or progressive neurologic deficit. All told, the request for anterior interbody fusion at the diseased levels, followed by stabilization and decompression as needed posteriorly is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Otezla for medical treatment of his psoriasis.  Findings:  The physician reviewer found that this patient has a history of extensive plaque psoriasis and has responded reasonably well to topical therapies.  However, the extent of his disease requires systemic treatment for best control.  There is no documentation of trial and failure or contraindication to treatment with methotrexate, acitretin, cyclosporine, or ultraviolet light phototherapy.  Given that other first-line therapies have not been trialed, the requested medication Otezla is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested a cooling/heating device for medical treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the equipment at issue in this patients case.  Per the clinical notes, there was no documentation of a contraindication to an at-home local application of an ice/heat pack, as opposed to a motorized mechanical device.  All told, the cooling/heating device was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that in recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested acute inpatient psychiatric hospitalization services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that a portion of the services were medically necessary for treatment of the patients medical condition. Early discharge would have been premature and more than likely would have resulted in undue morbidity and prompt readmission. Although the provider recommended that the patient would benefit from ongoing observation and stabilization, the medication regimen was maintained without modification and there was no update to the treatment plan or specific articulation rationalizing the medical necessity of the acute setting to achieve the clinical recommendation. In sum, acute inpatient services were no longer reasonably expected to improve the patients condition as he was not suffering from an acute psychiatric syndrome. Based on the documentation provided, discharge to a less restrictive setting would have been safe, appropriate and consistent with good medical practice. Thus, the initial acute inpatient psychiatric hospitalization services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested left knee platelet rich plasma (PRP) injections for treatment of the enrollees osteoarthritis with complex degenerative tear of the anterior horn and body of the lateral meniscus and chondromalacia patella.  Findings:  The physician reviewer found that based on the available documentation, it is not medically necessary for this patient to receive left knee PRP injections for treatment of left knee pain. There are general concerns as to the efficacy of PRP injections. Consistent with the weak support for efficacy of the use of PRP, the American Academy of Orthopaedic Surgeons has not recommended for or against the use of PRP in treatment of symptomatic osteoarthritis of the knee. Similarly, Moraes and colleagues concluded that there is currently insufficient evidence to support the use of PRP for treating musculoskeletal soft tissue injuries.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni (ledipasvir-sofosbuvir tablets 90-400 mg) for medical  treatment of his hepatitis C.  Findings:  Three physician reviewers found that the U.S. Food and Drug Administration has approved Harvoni for patients with early stage disease.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  Earlier initiation of treatment may avoid complications from advanced disease.  All told, the requested Harvoni (ledipasvir-sofosbuvir tablets 90-400 mg) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee has requested Harvoni for medical treatment of her hepatitis C virus genotype 1a.   Findings:  Three 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.  Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested treatment with Harvoni should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested percutaneous peripheral tibial nerve neurostimulation for medical treatment of her medical condition.  Findings:  Three physician reviewers found that percutaneous tibial nerve stimulation is considered an acceptable third-line treatment option for overactive bladder when first-line and second-line options have failed, according to the current American Urological Association guidelines.  However, there is no documentation that first-line treatments have been tried.  The submitted records indicate that only a single second-line treatment that has been tried, oxybutynin chloride.  All told, percutaneous peripheral tibial nerve neurostimulation was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, patients, 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. Therefore, this patient should be approved for Harvoni to prevent further progression of fibrosis to cirrhosis, and to prevent further worsening of thrombocytopenia due to underlying HCV. For the reasons provided, the request for Harvoni is medically necessary for treatment of this patients medical condition.