Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested Botox injections for medical treatment of her migraines.  Findings:  Three physician reviewers found that while Botox should not be considered a first-line therapy for migraine headaches, there is good literature for its use in well selected patients. In this particular case, the patient has failed a standard preventative and two abortive medications. In addition, she has had a noted benefit on Botox with reduced headache frequency. For these reasons, the continued use of this medication is warranted. Thus, the requested Botox is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the Acellular Derm Matrix Implant (CPT code 15777) and the Flexhd/Allopatchhd/Matrixhd (code HCPCS-Q4128) for medical treatment of her right breast capsule contracture.   Findings:  Two physician reviewers found that the placement of an acellular dermal matrix or other matrix material during a capsulectomy for a breast periprosthetic capsular contracture is widespread, with many surgeons considering this to be the standard of care for a breast augmentation revision for the reason of a pathologic capsular contracture. Given these findings, the use of the Acellular Derm Matrix Implant (CPT code 15777) and the Flexhd/Allopatchhd/Matrixhd (code HCPCS-Q4128) was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Subutex for medical treatment of his chronic back pain.  Findings:  The physician reviewer found that the use of Subutex for chronic back pain is not supported in the medical literature. Given that this patient does not have an approved indication for treatment with Subutex, the records do not support the medical necessity of the requested medication for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested breast magnetic resonance imaging (MRI) for medical evaluation of her right breast pain.  Findings:  Two physician reviewers found that there is a lack of data supporting breast MRI for pain in the presence of a negative right breast ultrasound and physical exam in this patient without an increased risk for breast cancer. All told, a breast MRI was unlikely to have been more beneficial for evaluation of the patients medical condition than other standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  This treatment may reduce liver-related adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, the requested Harvoni is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested radiofrequency ablation (RFA) on the third occipital nerve for medical treatment of her occipital neuralgia. Findings:  Three physician reviewers found that in the documentation available for review, the patient underwent a medial branch block of the C2 and C3 facet joints that did not give her any sustained relief for the duration of the local anesthetic. The third occipital nerve can be a cause of headaches and can be improved with RFA in well selected patients (Hamer and Purath). However, the records indicate that this patient did not obtain the relief that would be necessary to suggest that the RFA would be helpful (Bogduk and Marsland; Derby, et al). Consistent with these findings, the requested RFA of the third occipital nerve 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 female enrollee requested abdominal panniculectomy with abdominoplasty and umbilical transposition for medical treatment of her abdominal panniculitis.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient has a functional impairment related to the lower abdominal pannus. The patients examination is consistent with a functional impairment related to the lower abdominal overlap. As such, the request for abdominal panniculectomy is medically necessary for treatment of the patients medical condition.  However, abdominoplasty with umbilical transposition is generally considered cosmetic treatment. In this case, there is a lack of documentation that demonstrates a functional deficit exists for the upper abdomen that would be corrected with an abdominoplasty. The functional impairment of this patient is related to the lower abdomen and not the upper abdomen. Therefore, an abdominoplasty is not medically necessary. In sum, the panniculectomy is medically necessary while the requested abdominoplasty with umbilical transposition is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested genetic testing (CPT codes 81226 and 81479) for medical evaluation of the enrollees behavioral health condition.  Findings:  Two physician reviewers found that according to the progress notes the patient had behavioral issues as well as mood swings and impulsive actions. Her physician has indicated that she has been difficult to manage and has asked for pharmacogenetic testing in order to help with management of her symptoms. However, there were no recent medical records included. Thus, it is not clear as to what types of behavioral therapies or medication trials she has received in the recent past. Due to the lack of clinical documentation of recent medication trials, details of side effects, there is a lack of support demonstrating that evidence-based standard treatments have been tried and failed. In sum, 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: Upheld Decision of Health Plan

A female enrollee requested treatment by a psychotherapist who utilizes touch therapy, the Poly Vagal theory of Stephen Porges, and/or somatic resourcing techniques for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that a search of the current literature failed to demonstrate well-designed or adequately powered studies illustrating consistent and reproducible results that demonstrate the effectiveness of the requested therapies.  As such, the requested treatment by a psychotherapist who utilizes touch therapy, the Poly Vagal theory of Stephen Porges, and/or somatic resourcing techniques are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested magnetic resonance (proton) imaging, brain (including brain stem) without contrast for medical evaluation of his migraine headaches.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patients more severe headaches, as characterized by the treating provider and the patient are diagnostic of migraine, but there appears to be other more mild headaches that are not well characterized. In general, patients with migraine and a normal neurologic examination do not need an imaging study. However, in this case, the patients diagnosis has not been established. In order to be certain this patient does not have a secondary headache, an imaging study is appropriate. All told, the requested magnetic resonance (proton) imaging, brain (including brain stem) without contrast is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested skilled nursing facility (SNF) services for medical treatment of his subcapital fracture of the left hip.  Findings:  The physician reviewer found that at admission, the patient required maximum assistance or was dependent with activities of daily living (ADLs) while subsequently he was able to ambulate up to 200 feet with moderate assistance, and continued to require maximum assistance with lower extremity ADLs and moderate assistance with upper extremity ADLs. Transfers appear to have plateaued with the patient requiring moderate assistance. Based on the patients prior functional status, his comorbid medical conditions, and his progress to date, further meaningful gains in a reasonable period of time with additional SNF services are unlikely to occur. Further, the records do not identify needs for daily skilled nursing assessment or interventions. All told, SNF services after initial treatment 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 male enrollee requested Norco for treatment of his chronic pain. Findings:  The physician reviewer found that the request for Norco is not medically necessary. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The patient should wean off short-acting 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. Moreover, long-term, short acting opiates may cause adverse outcomes. Based on the documentation submitted for review and the peer-reviewed literature, the requested Norco is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested inpatient psychiatric hospitalization services for treatment of the enrollees major depressive disorder, gender dysphoria, and multiple past suicide attempts. Findings: The physician reviewer found that this patient has several chronic problems that add to her depression and make her prone to sudden thoughts of self-harm or suicide. The treatment team was working with the patients family to help them understand her gender dysphoria and develop a treatment strategy. Without improvement in the family dynamics, the patient was likely to continue to engage self-harm if not in a highly structured environment. The notes indicate that even in such an environment, she continued to have some increase in suicidal thoughts. As soon as she contracted for safety, she was discharged the next day to partial hospitalization program (PHP). Thus, the initial inpatient psychiatric hospitalization services were medically necessary for treatment of the patients medical condition.  Further, it was noted that the patient was readmitted with strong suicidal thoughts and a plan to either overdose or use a tourniquet-like object, which she has at home, to asphyxiate with the intent to end her life. The patient continued to have suicidal ideation and subsequently was finally feeling brighter with better coping strategies. Accordingly, the documentation supports the medical necessity of the initial and subsequent inpatient psychiatric hospitalization services. However, the additional services provided after that period were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested growth hormone (GH) therapy treatments with Omnitrope for medical treatment of his chronic fatigue syndrome. Findings:  Three physician reviewers found that this patients clinical presentation is not consistent with hypopituitarism. He does not meet the standard criteria to be treated with GH therapy as he has a mid-range normal IGF-1 and does not have evidence of three or more pituitary deficiencies. As noted by Molitch and colleagues, GH deficiency confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. In the absence of a clinical indication for GH therapy, the request for Omnitrope was not and 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 Synvisc One injections for medical treatment of her osteoarthritis.  Findings:  The physician reviewer found that hyaluronic injections should be used following failure of conservative care or in conjunction with conservative care. However, this patients documentation does not show that the patient has tried any other forms of conservative treatment to address her pain. There is no clinical evaluation of the bilateral knees documenting the presence of significant functional deficits or significantly limited activities of daily living provided for review. Although the provided records state that the patient was receiving improvement following the Synvisc injection, there is a lack of documentation showing physical evidence of an objective improvement in function as well as a quantitative decrease in pain to support that the injections were providing a satisfactory response. Without this information, the requested Synvisc One injections are not considered medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested lumbar spinal fusion for medical treatment of his low back pain radiating down the right leg. Findings:  The physician reviewer found that this patient fails to meet criteria for lumbar fusion as he does not have a lumbar radiculopathy or spinal stenosis with spondylolisthesis and neurogenic claudication. Moreover, he has not been treated with cognitive behavioral therapy and there is no documentation of epidural steroid injections and physical therapy within the last six months. He has no evidence of instability, infection, fracture, or tumor. He has no evidence of recurrent disc herniation, pseudarthrosis, or adjacent segment degeneration. According to the radiologist, there is a small protruding disc at L4-5 without evidence of nerve compression. This indicates that there is no pinched nerve. Even if there were a more substantial disc herniation, correlation of imaging studies with the clinical information has not been met. Given these findings, the requested ALIF at L4-5 and L5-S1 with posterior instrumented fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome gene testing for medical evaluation of her family history of colon cancer.  Findings:  Two physician reviewers found that the requested testing is not likely to be more effective for this patient than other available options. The National Comprehensive Cancer Network (NCCN) guidelines for Lynch syndrome testing criteria indicate the patient must meet the Amsterdam criteria or the revised Bethesda guidelines. Both guidelines require at least one family member diagnosed with cancer before the age of 50. In this case, the patients relatives were diagnosed at approximately 50 years of age. As such, the requested HNPCC genetic testing is 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 female enrollee requested admission to a tertiary center, such as University of California at Irvine, for diagnostic pelvic magnetic resonance imaging (MRI) or computed tomography (CT) scan and hysterectomy for medical evaluation and treatment of her anemia and menorrhagia. Findings:  The physician reviewer found that for patients with bleeding significant enough to require transfusion, a work-up for the underlying pathology is indicated, especially given the high risk of uterine and/or endometrial cancer. In this case, the patient will likely require surgery to help control her bleeding because of the size of her uterus, known large fibroid, and degree of menorrhagia that has led to anemia and transfusion. In addition, her ongoing risks of hyperplasia and malignancy related to her morbid obesity as well as her overall medical history makes her a poor candidate for conservative treatments. Thus, the patient requires work-up that includes a facility that can accommodate her weight issues, such as imaging capabilities, operating room table and equipment. Therefore, the medical necessity of the requested admission to a tertiary center for diagnostic pelvic MRI or CT scan and hysterectomy has been established in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested urgent care services on an emergent or urgently needed basis.  Findings:  The physician reviewer found that submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. The patient presented to an urgent care facility with complaints of a rash. The patient states he was concerned he had shingles, however there is no documentation to support that the rash had acutely worsened or that the patient was experiencing symptoms such as high fever or respiratory distress. Moreover, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old enrollee requested inpatient psychiatric treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that inpatient psychiatric services were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed a pattern of serious maladaptive behaviors, improved for a few months, and then resurfaced a few weeks before admission. The patient had many triggers for her anger and aggression, and had no respect for authority. She became physically aggressive both at home and at school and required police to be called on three occasions. In this clinical setting, the patient must be able to cope with stress better before transitioning to a lower level of care. The patient continued to be extremely irritable and labile and over-react to seemingly minor stressors until shortly before discharge. Given her history of relapse, it was medically necessary for the patient to continue at the inpatient psychiatric level of care to ensure that she was stable before transitioning to a lower level of care. All told, the acute inpatient psychiatric services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested intravenous immune globulin (IVIG) for medical treatment of her antibody deficiency. Findings:  The physician reviewer found that a trial of prophylactic antibiotics is typical of the treatment of specific antibody deficiency (Orange, et al). However, this patients disease appears to be more severe. As such, there is evidence specific antibody deficiency, for which IVIG is one of the medically accepted treatment options (Orange, et al). Although there are no randomized control studies, several smaller studies have demonstrated benefit (Zora, et al). For these reasons, the requested IVIG is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested follow-up with a trauma surgeon for medical treatment of his 6th and 7th rib fractures status post motor vehicle accident. Findings:  The physician reviewer found that based on the available documentation, this patient has two non-displaced rib fractures without any other medical issues such as hemothorax. The treatment of non-displaced rib fractures does not require surgical intervention and can be managed medically without the services of a specialist. Primarily, the treatment is focused on pain control and prevention of atelectasis. Thus, the requested follow-up with a trauma surgeon is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Kalydeco (ivacaftor) for medical treatment of her cystic fibrosis.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has cystic fibrosis transmembrane conductor mutation R117C.  The U.S. Food and Drug Administration (FDA) approved the use of Kalydeco for treatment of patients with cystic fibrosis who have mutation R117C. Thus, the requested medication, Kalydeco, is FDA-approved for the patients medical condition and is medically necessary. All told, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Orthovisc or Synvisc injections for medical treatment of her left knee osteoarthritis.  Findings: The physician reviewer found that the records submitted for review indicate the patient has had Synvisc and Orthovisc knee injections which were reported to be beneficial. However, there was a lack of documentation of clinical improvement from the initial course of injections evidenced by improvement in pain utilizing the visual analog scale (VAS), objective functional improvement evidenced by range of motion values, an increase in daily activities, reduction in dose of nonsteroidal anti-inflammatory drugs (NSAIDs) or a reduction of intra-articular steroid injections for the six month period following the Orthovisc injection. Based on the peer-reviewed literature and clinical documentation, the requested Orthovisc or Synvisc injection is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an eight-week course of Harvoni 90/400 mg for medical treatment of her hepatitis C virus, genotype 3a.  Findings:  Three physician reviewers found thatreview of the submitted documentation fails to establish the medical necessity of the requested medication. Harvoni is not indicated for the treatment of HCV, genotype 3. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treatment of HCV, the combination of sofosbuvir and weight-based ribavirin for 24 weeks is the preferred treatment regimen for patients with genotype 3 infection. For these reasons, the requested medication is not medically necessary for treatment of the patients medical condition.