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

A 44-year-old female enrollee requested endoluminal ablation of varicose veins for medical treatment of her varicose veins.  Findings:  Three physician reviewers found that the requested services are likely to be more effective than other treatment options.  The patients symptoms of edema, varicosities, and dilatation of the greater saphenous vein suggest longstanding venous reflux in the left leg.  Given the noted reflux throughout the greater saphenous vein, there is sufficient support for the requested endoluminal venous ablation.  Current treatment guidelines support the requested services in this clinical setting.  Thus, the requested endoluminal ablation of varicose veins is likely to be of greater benefit than other modalities for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee requested a blood test for measurement of serum concentration of infliximab and antibodies to infliximab for medical evaluation of the enrollees ulcerative colitis.  Findings:  Two physician reviewers found that the requested services were not likely to have been more effective than other methods of evaluation.  There is a lack of support for the measurement of infliximab levels and antibodies to infliximab in this clinical setting.  The appropriate drug level to target has not been clearly established.  The incremental benefit of this testing beyond clinical care has not been demonstrated when assessing efficacy.  Although high levels of antibody have been associated with lower drug levels and infusion reactions, these antibodies have not been consistently demonstrated to have neutralizing capabilities in vitro.  All told, the blood test for measurement of serum concentration of infliximab and antibodies to infliximab was not likely to have been of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee requested  Sovaldi 400 mg, Pegasys and ribavirin for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found in many cases, using the F3 liver fibrosis score cutoff is appropriate, however in this particular case treatment with the requested medications is medically necessary. This patient is relatively young, and despite mild chronic obstructive pulmonary disease (COPD), he has an anticipated extended lifespan. Thus, treatment is recommended in this particular case. As such, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg, Pegasys and ribavirin is medically necessary in this clinical setting. Therefore, the medical necessity of the requested medications has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee requested a 12-week course of Sovaldi 400mg and Olysio 150mg for medical treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination for the treatment of this patient.  There is sufficient support for the requested 12-week course of Sovaldi 400mg and Olysio 150mg in this clinical setting.  This patient has established cirrhosis, and further documentation of fibrosis by biopsy or liver fibrosis panel is not medically necessary.  Treatment with interferon is not medically appropriate due to mild decompensation and severe thrombocytopenia.  In this patients case, it is imperative to clear the virus and prevent post-transplant recurrence, as he eventually may need a transplant.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested a 12-week course of Sovaldi 400mg and Olysio 150mg for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  There is a lack of support for the requested medication regimen in this clinical setting.  The patient has hepatitis C, genotype 1b and he is treatment-naive.  It appears that he has minimal or no hepatic fibrosis based on laboratory testing and imaging.  Per the current medical evidence, the benefit of therapy is of unclear value in patients with minimal disease.  In this patients case, further stratification of disease burden with liver biopsy or fibrosis panel is needed.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee requested magnetic resonance imaging (MRI) of the left knee for medical evaluation of the enrollees left knee pain.  Findings:  The physician reviewer found this patient sustained substantial blunt force trauma to the knee and continues to have significant pain.  Although plain films were normal, bone contusion or even microfracture is not excluded and the knee would be best evaluated by MRI.  The requested MRI of the left knee would allow for evaluation of possible internal derangement.  The requested diagnostic procedure will allow for evaluation of bone pathology which might not be evident on plain radiographs.  Although the requirement of conservative therapy prior to MRI is usually reasonable, in a case of blunt force mechanical trauma and persistent pain, imaging evaluation prior to physical therapy is medically reasonable.  All told, the requested MRI of the left knee is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested bilateral hip resurfacing surgery for treatment of her osteoarthritis.  Findings:  The physician reviewer found that based on review of the available records, hip resurfacing surgery is medically necessary for treatment of this patients osteoarthritis. The scientific data demonstrates that hip resurfacing surgery is an alternative to total hip replacement in young, well selected, active patients. Moreover, the medical literature reports excellent outcomes in terms of implant survival and patient satisfaction. In this patient, the criteria for medical necessity has been met for hip resurfacing surgery based on her young age, normal bone density and lack of large subchondral cysts or evidence of avascular necrosis. All told, the requested hip resurfacing surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested blue light cystoscopy with carcinoma in situ (CIS) procedure for treatment of his urothelial carcinoma in situ.  Findings:  Three physician reviewers found that photodynamic diagnosis of nonmuscle-invasive bladder cancer with hexaminolevulinate cystoscopy is unlikely to be more beneficial in the diagnosis and treatment of superficial bladder cancer than traditional cystoscopy and biopsy. The rate of false positive diagnosis is high in patients that have recently been treated with intravesical BCG. In addition, the current American Urological Association (AUA) guidelines do not support the routine use of this technology. Given the lack of scientific data demonstrating superior health outcomes with the requested blue light cystoscopy, the requested services are not supported as 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 51-year-old female enrollee requested chiropractic services for medical  treatment of her lumbar sprain.  Findings:  The physician reviewer found that  according to the evidence based literature, this treatment is not indicated for this patients cervicalgia, muscle spasm, lumbago, spondylolisthesis or lumbar sprain.  In addition, the patients response to treatment has not been positive overall and the provider did not include documentation to substantiate the need for ongoing treatment.  Given the lack of documentation as required by the Council on Chiropractic Guidelines and Practice Parameters, chiropractic services are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested capsule endoscopy (CPT 91110) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case.  Both push endoscopy and capsule endoscopy would be appropriate for evaluation of the small bowel.  The records do not establish that the requested capsule endoscopy is likely to be of greater benefit than push endoscopy in this clinical setting.  All told, the requested capsule endoscopy is not likely to be more efficacious than other modalities for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee requested diagnostic testing for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  An appropriate gastroenterology evaluation was conducted, and a diagnosis of ulcerative colitis was made.  The medical documentation indicates that a thorough laboratory work-up and physical examination were unrevealing for any other diagnosis than what was rendered and treated.  The requested additional diagnostic testing is not expected to alter the patients treatment or outcome.  All told, the requested additional diagnostic testing is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Olysio (simeprevir) 150 mg for treatment of his hepatitis C.  Findings:  Two physician reviewers found that Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) is likely to be more effective for this patient than other available options. The requested regimen is now well-accepted as a first-line therapy for genotype 1a especially in a patient such as this who is not a candidate for interferon.  In fact, the HCV guidelines put forth by the American Association for the Study of Liver Diseases (AASLD) recommend the combination of Sovaldi and Olysio as a preferred first-line treatment.  As such, the request for Sovaldi (sofosbuvir) 400 mg in combination with Olysio (simeprevir) 150 mg capsules for 12 weeks is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested diagnostic procedure in this clinical setting. The medical literature demonstrates that MRI is more sensitive than mammography in detecting tumors in women with an inherited susceptibility to breast cancer. According to the patients history, she has one first-degree relative (mother) and two second-degree relatives (aunt and grandmother) with diagnosed breast cancer. Thus, this patient meets criteria as having a high familial risk for breast cancer and the patient qualifies for annual screening MRI of the breast. All told, the request for MRI of the breast is likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested a magnetic resonance imaging (MRI) of both breasts for medical evaluation of the enrollees health condition.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. Based upon the patients family history and medical history she does not have a lifetime risk of breast cancer greater than 20-25%, and thus, is not a suitable candidate for a screening MRI exam for breast cancer. In addition, she has no BRCA mutation, no personal history of breast cancer, no personal history of radiation to the chest, and her family history of only one first-degree relative is not strong enough to give her a lifetime risk of greater than 20-25% for having breast cancer. Thus, this patient does not meet criteria as having a high familial risk for breast cancer and does not qualify for screening MRI of the breast. All told, the requested MRI of both breasts is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee requested a 12-week course of Olysio 150 mg in combination with Sovaldi 400 mg for medical treatment of the enrollees hepatitis C genotype 1a.  Findings:  Three physician reviewers found that applying the guidelines from the American Association for the Study of Liver Diseases (AALSD), the use of the requested combination of medications is not likely to provide this patient with an improved health outcome beyond that expected with standard therapies. Further, the combination of Sovaldi and Olysio has not been shown in large, prospective, randomized, controlled clinical trials to be superior to standard alternatives in the treatment of hepatitis C. All told, the requested medications are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested digital breast tomosynthesis for medical evaluation of the enrollees breasts.  Findings:  Two physician reviewers found that there is sufficient support for digital breast tomosynthesis in this clinical setting.  Initial and ongoing studies have shown a significant decrease in the recall rate from screening mammography and a detection of small cancers not readily apparent on traditional full field digital mammography.  Thus, the technique is now commonly used as an adjunct to standard digital screening mammograms.  All told, digital breast tomosynthesis was likely to have been more effective than other modalities for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee requested keloid removal for medical treatment of the enrollees keloid scar. Findings:  The physician reviewer found that based on review of the available records, removal of keloid via surgery is reconstructive in nature and medically necessary for treatment of this patients keloid. A keloid constitutes an abnormal structure of the body resulting from the disease of collagen metabolism in the wound site. In addition, removal of the keloid will create a normal appearance to the extent possible, and provide a more than minimal improvement and alleviate the psychological impact of the disease. While surgical excision is reconstructive in nature and medically necessary, surgery alone most likely will not be curative. The patient should be advised to consult a dermatologist experienced with treating keloids for comprehensive therapy. For these reasons, the requested removal of the keloid is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee requested graft product, Veritas collagen matrix for medical treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. In this case, there is no description of inframammary fold malposition, rippling, capsular contracture or implant malposition to justify the necessity of revision surgery.   If the tissues were thin enough for ADM to be medically indicated there would be visible rippling in the photo provided and a description of such a condition in the medical records. Moreover, Veritas is non-cross-linked bovine pericardium and AlloDerm is non-cross-linked human dermis. In animal studies there is significant loss of tensile strength in the non-cross-linked prosthetics such as Veritas and AlloDerm as compared with the cross-linked materials like Permacol at six months. Therefore, there is a lack of proven advantage of Veritas over other materials in the medical literature. Thus, the requested services are not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested AmniSure testing for medical evaluation of the enrollees pregnancy.  Findings:  Three physician reviewers found that the services at issue were not likely to have been more effective than other methods of evaluation.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure.  There is no evidence that routinely available tests for the diagnosis of ruptured membranes were performed prior to fetal fibronectin testing, amniotic fluid volume testing, and AmniSure testing.  All told, AmniSure testing was not likely to have been superior over other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested modafinil (Provigil) 200 mg oral tablet for medical treatment of the enrollees cognitive disorder. Findings:  The physician reviewer found that this patient has been diagnosed with a non-specific cognitive disorder. The records note difficulty with concentration, but no more specific diagnosis is reported. Provigil is approved for conditions including narcolepsy, shift work sleep disorder, and sleep apnea. Studies on Provigil have shown potential benefit for other conditions, including cognitive disorders associated with drug abuse.  However, there is a lack of literature demonstrating that Provigil is useful for nonspecific cognitive dysfunction. Therefore, Provigil 200 mg oral tablet is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee requested a sleep study (polysomnography) for medical evaluation of the enrollees sleep disorder. Findings:  The physician reviewer found that based on review of the available records, the patient does meet the criteria for a sleep study. The patient does have symptoms suggestive of sleep apnea including loud snoring, non-refreshing sleep, and excessive daytime somnolence. In addition, the patient was noted to have a family history of obstructive sleep apnea. However, due to the need to evaluate the patient for sleep apnea, a home study would have been adequate. Golpe and colleagues concluded that home sleep studies are a viable form of diagnosing sleep apnea/hypopnea syndrome while polysomnography should be reserved for patients with inconclusive home studies. All told, the scientific data does not support the medical necessity of the polysomnography.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested bariatric revision surgery Apollo OverStitch for medical treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Some bariatric surgical patients do not achieve meaningful weight loss, or regain lost weight over time.  A recent systematic review by Dakin and colleagues determined that endoluminal procedures for weight regain tend to be well-tolerated with limited efficacy.  Endoscopic approaches for weight regain have yet to be proven effective in the long-term, and are currently not the standard of care in patients who regain weight after a remote bariatric procedure.  Gastro-gastric fistulas can lead to gastric ulcers in the pouch and abdominal pain.  Gastro-gastric fistulas have been associated with weight gain, but also have been discovered incidentally in patients who have maintained weight loss.  Whether these fistulas need to be corrected when found in a patient with weight regain following gastric bypass surgery, and whether fixing these fistulas can lead to durable weight loss has yet to be determined.  All told, the requested Apollo OverStitch is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested the medication Belviq for medical treatment of the enrollees obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The cornerstone of the medical management of obesity is behavior modification of exercise and eating habits.  Drug therapy and surgery are other options to consider.  A trial of drug therapy or surgery should be reserved for patients with comorbid conditions such as impaired glucose tolerance, hypertension, dyslipidemia, diabetes mellitus or sleep apnea.  Belviq is a serotonin agonist which may be indicated in treating obese individuals who have at least one comorbid condition.  In this patients case, there is a lack of information regarding details of prior dietary and behavior modification efforts that have been tried or failed.  Further, there is a lack of documentation of any comorbid conditions which would support the requested medication.  All told, Belviq is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 8-year-old female enrollee requested applied behavioral analysis (ABA) services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of ASD has not been established. In this patients case, she has current diagnoses of mixed receptive-expressive language disorder, ADHD and anxiety disorder. Confirmatory evidence of a current diagnosis of ASD is lacking. In the absence of evidence of a recent evaluation confirming a diagnosis of ASD, the request for ABA services is not medically necessary for treatment of the patients medical condition.