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

A 60-year-old female enrollee has requested anti-reflux surgery (LINX) for treatment of her gastroesophageal reflux disease (GERD), hiatal hernia, and Barretts intestinal metaplasis.  Findings:  Two physician reviewers found the patient has a history of GERD manifested by the presence of Barretts esophagus. Per the medical history provided for review, the patient has not had an adequate response to medical therapy. There is no mention whether the patient experiences significant regurgitation. The request for the LINX procedure in lieu of hiatal hernia repair with fundoplication is not supported in the peer-reviewed medical literature. The long-term efficacy and durability of fundoplication have been well established. Ganz and colleagues published a cohort series that suggests the data on the LINX procedure remains premature. The authors also reported a substantial rate of dysphagia as a recognized complication. All told, there is a paucity of medical research and well designed randomized controlled trials demonstrating the superiority of the LINX procedure over standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 71-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her depression.  Findings:  The physician reviewer found that the transcranial magnetic stimulation (TMS) was medically necessary for treatment of the patients medical condition. TMS is endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this particular case, the patient was reportedly experiencing an acute major depressive episode that caused significant functional impairment despite prescription of an appropriately dosed selective serotonin reuptake inhibitor. In addition, a serotonin-norepinephrine reuptake inhibitor was not efficacious. She was previously prescribed medications from the tricyclic and monoamine oxidase inhibitor classes of antidepressants. She was treated in the outpatient and intensive outpatient levels of care and electroconvulsive therapy resulted in problematic side effects. Given this documentation in the medical records reviewed and endorsement from the APA and the expanding peer-reviewed literature base, TMS was medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Two physician reviewers found that this patients records lack documentation of recent severe asthma exacerbations, emergency room visits, hospitalizations, or intubations within the past two years. These are the categories that would benefit from bronchial thermoplasty. In the absence of documentation of poorly controlled asthma while on inhaled long acting bronchodilators and inhaled high potency corticosteroids, the requested bronchial thermoplasty is not likely to be more beneficial than standard therapies including omalizumab.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested laser therapy for treatment of his peripheral neuropathy. Findings:  Three physician reviewers found that in this patients case, the requested laser therapy is not likely to be superior over other available treatment modalities.  There is a lack of scientific support for the use of low level laser therapy to treat neuropathy.  There are several studies which indicate there are no significant differences in visual analog scale (VAS) pain scales in treated versus untreated patients.  At this time, there is a lack of evidence to suggest laser therapy has any role in the treatment of neuropathy.  Thus, the requested services are not likely to be more efficacious than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested eating disorder residential treatment center (RTC) for treatment of her eating disorder.  Findings:  The physician reviewer found this patient has profound ego fragmentation which manifests as a chronic and debilitating symptom complex. In reviewing the clinical notes, the patient was symptomatic throughout the disputed timeframe. She had insomnia with negative ruminations and intense urges to purge. Her distorted schemas, anxiousness and depression had not resolved, and she continued to subscribe to a firmly entrenched negative body image. In addition to comprehensive therapy, another psychotropic medication was added to her regimen on a specified date. On that same day, the provider noted continued residential placement was indicated as the patient posed a risk to herself and had not consolidated the treatment gains necessary to maintain weight and eat healthily without purging in an unsupervised setting. Accordingly, the residential treatment was safe appropriate and consistent with the American Psychiatric Association (APA) practice guidelines. Thus, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the submitted documentation and relevant literature supports the use of LINX Reflux Management System (LINX) in this clinical setting. A review of the medical records shows the presence of pathologic acid reflux as the etiology of the patients symptoms. The patient has failed medical therapy but has partially responded to a PPI making him a candidate for surgery. The LINX procedure has undergone a number of uncontrolled trials verifying that it reduces esophageal acid exposure and markedly reduces symptoms. Bonavina and colleagues concluded based on the 2012 study that, The new laparoscopically implanted sphincter augmentation device eliminates GERD symptoms without creating undue side effects and is effective at 1 and 2 years of follow-up. Thus, the LINX procedure is a viable surgical treatment for medically-refractory GERD and this patient is an appropriate candidate. Therefore, LINX Reflux Management System is likely to be more beneficial than standard medical therapy and is appropriate treatment for the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Lap-Band adjustable gastric banding for treatment of her unresolved co-morbidities.  Findings:  Three physician reviewers found that the records provided for review do not document the presence of any overt complication of the previous procedure. The patient has documented poor follow-up since the time of her original gastric bypass procedure. The requested Lap-Band to be placed over gastric bypass is not a standard primary treatment for obesity and should only be performed as part of a clinical trial. There is a paucity of peer-reviewed published literature on the use of Lap-Band over bypass. Overall, the studies are not randomized and only provide medium follow-up in very small numbers of patients. Therefore, the requested revision lap-Band adjustable gastric banding surgery 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 20-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  The physician reviewer found that Transcranial magnetic stimulation is a well-tolerated intervention supported by a growing body of evidence in the peer-reviewed literature which demonstrates efficacy for the therapy.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association in its current practice guideline for the treatment of individuals with acute phase depression.  However, the guideline notes that there is insufficient evidence supporting transcranial magnetic stimulation for the initial treatment of major depressive disorder.  In this case, since achieving sobriety, the patient had not completed a first-line treatment for depression.  The documentation provided does not describe a structured, evidence-based course of psychotherapy, such as interpersonal therapy or cognitive behavioral therapy, proven effective in the treatment of depression.  Additionally, there is no mention of intermediate treatment settings, such as intensive outpatient services or partial hospitalization programming. Further, the patient was not prescribed standard alternative antidepressants or augmentative medications.  Finally, there is no discussion of or contraindication to electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured.  All told, transcranial magnetic stimulation is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested surgery to correct the asymmetry and excessive tissue in the right forearm and underarm for treatment of her excess tissue. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a weak and stiff right shoulder due to trauma and post-traumatic surgery.  The medical records document obesity.  Photographs show excess skin and fat around both arms, right greater than left.  The skin is normal, and there is no abnormality such as excess upper arm skin hanging below the level of the elbow or lymphedema. The appearance is as expected for a patient with this body mass index.  Thus, the asymmetry and excessive tissue in the right forearm and underarm do not constitute an abnormal structure of the body.  Further, the requested surgery would not improve function or create a more normal appearance than is present.  In sum, the requested surgery to correct the asymmetry and excessive tissue in the right forearm and underarm is not medically necessary and is not reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Euflexxa injections for treatment of her right knee osteoarthritis.  Findings:  Three physician reviewers found that Viscosupplementation has a moderate to mild benefit for patients with osteoarthritis of the knee. Several large studies and evidence-based guidelines have demonstrated that viscosupplementation results in mild improvement at best. However, there are no studies on multiple courses of viscosupplementation, and no data to support one brand over the other. All told, there is a lack of data suggesting the requested Euflexxa injections will provide an improved health benefit for treatment of this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  testing for the MTHFR gene mutation for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the testing at issue.  There is no rationale provided to justify testing for the MTHFR gene mutation.  There is no mention of a family history or personal history of thrombosis.  The MTHFR variants have a poor predictive value for future thrombosis.  The current medical evidence does not support the testing at issue in this clinical setting.  Per the most recent recommendations from the American College of Medical Genetics, MTHFR testing should be dropped from thrombophilia panels.  All told, testing for the MTHFR gene mutation was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested all four  quadrants scaled at one time in order to limit the enrollees exposure to one course of antibiotic therapy for treatment of her severe osteoporosis.  Findings:  The physician reviewer found that there is no supporting compelling medical need submitted for review that specifically states why the patient should be treated in one visit rather than over the course of two visits. There is also a paucity of current literature that identifies osteoporosis as a condition that should be treated with scaling and root planing in one visit. The current recommendations for standards of care by the American Dental Association and the American Association of Orthopedic Surgeons do not indicate that a patient with severe osteoporosis should receive scaling and root planing in one visit versus two visits. The literature does reflect that the scaling and root planing procedure does create a bacteremia greater than other dental procedures. It could be of concern to perform four quadrants of scaling and root planing as the bacteremia would be greater than two quadrants and could place the patient at risk for post treatment infection. In addition, providing local anesthetic to all quadrants of the mouth places the patient at risk for iatrogenic injury to the mucosal tissue and tongue while the patient is numb. All told, the requested antibiotic therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested psychiatric acute inpatient services for treatment of her mental health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, the hospital course has consisted of active treatment supervised by a physician.  The inpatient services are reasonably expected to improve the patients condition and are for the purpose of diagnosis.  The patient had significant medication changes on the dates indicated.  She has orders pending for neuropsychological testing and brain imaging.  The patient has remained anxious, depressed and suicidal.  On the specified date, she had impaired reality testing.  In sum, the patient remains acutely ill from the psychiatric perspective while a definitive diagnostic assessment has yet to be determined.  To release a patient from the acute setting under such circumstances would be inconsistent with the standards of good medical practice.  All told, the services at issue were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested positron emission tomography/computerized tomography (PET/CT) scan for evaluation of his Hodgkins lymphoma.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines place this patient at high risk for recurrence due to prior two recurrences. However, there is no clinical or biochemical marker to suggest recurrence at this time. In addition, the records indicate that the patients last two PET scans have been negative. While PET/CT is easier to interpret than conventional CT due to the physiologic capacity of PET, the literature does not support the use of PET for routine surveillance without clinical evidence to suggest recurrence. The guidelines recommend routine CT surveillance every six months for two years and then re-evaluation for a plan of surveillance in an asymptomatic patient. Thus, the requested PET/CT scan is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested acute hospitalization admission for treatment of her abdominal pain.  Findings:  The physician reviewer found that the submitted medical records do not support the medical necessity of the requested services.  This patient has severe recurrent abdominal pain which remains idiopathic.  She has had a very comprehensive evaluation.  Although it is possible the patient has diabetic gastroparesis, the abdominal pain symptoms appear to be too severe and she has not responded to Reglan.  However, the submitted documentation does not demonstrate the need for acute hospitalization at this time.  Inpatient care may be necessary if the patient has intractable vomiting or is unable to maintain hydration.  All told, the requested acute hospitalization admission is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested Botox injections for treatment of the enrollees chronic headaches.   Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. Although Botox is not considered first-line therapy for chronic migraine, there is solid evidence supporting its use in refractory cases. In this case, the patient has failed multiple first-line therapies or has a contraindication for their use, hypotension. Furthermore, the patient was noted to have pronounced benefit from a prior trial of Botox. Thus, use of Botox was and is likely to be more beneficial than other standard therapies for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested Focalin IR 40mg three times a day and Focalin XR 20mg to 40mg daily for treatment of her behavioral health condition.   Findings:  The physician reviewer found that Focalin IR 40mg three times a day and Focalin XR 20mg to 40mg daily are not medically necessary for this patients medical condition. According to the U.S. Food and Drug Administrations (FDA) and the manufacturers prescribing information, the combination of both Focalin IR and XR is not recommended. Anecdotal evidence of augmentation or booster dosing exists, however, FDA and manufacturers guidelines do not indicate the use of both preparations simultaneously. In a letter by the patient she identifies the necessity for the requested doses of Focalin as relating to her higher tolerance for medication due to opiate use, lack of efficacy of other tried agents and continued use of lithium as having a negative impact on normal dosing. The FDA and manufacturers prescribing information shows no evidence of opiate induced tolerance and/or diminished efficacy with comorbid lithium administration. Furthermore, the combined dosage of both preparations exceeds FDA guidelines and is not consistent with generally accepted standards of practice. While the patient cites the combination and dosage to be effective, there are safety concerns associated with this combination given the increased potential for cardiac symptoms, mood dysregulation and potential for abuse. For the reasons provided above, the requested medications are not medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the outpatient psychotherapy provided from the date indicated forward was not and is not medically necessary for this patients medical condition. The patient has received more than three years of weekly psychotherapy treatment; the patients notes reflect no measurable improvements, treatment goals or attainable discharge dates. Despite the therapy received to date, the patient remains symptomatic. According to Gelenberg and colleagues, For psychotherapy, treatment should be reassessed if there has not been a meaningful improvement after a few months. Patients should be reassessed every 3-4 months to ensure adequate improvement. Regardless of treatment modality, lack of improvement over time warrants reconsideration of interventions. Continued weekly insight-oriented sessions are not consistent with the standard of care in this setting. All told, the services at issue have not produced any measurable gains or improvement and continued use of this modality at this frequency is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested Botox injections for treatment of her pelvic floor muscle spasms. Findings:  Two physician reviewers found that Botox injections are not likely to be more beneficial for treatment of the patients pelvic pain than any available standard therapy. This patient has pelvic pain and pelvic floor dysfunction with low back pain and abdominal heaviness. She has had pelvic floor therapy; however, there is no evidence of a trial of medication. At this time, there is insufficient data demonstrating that Botox therapy constitutes a superior modality for the treatment of pelvic floor pain as compared to standard therapies. Given the lack of confirmatory peer-reviewed data supporting the efficacy of Botox injections in this clinical setting, the requested therapy 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

The parent of a 17-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the records indicate that as of the specified date, the patient was no longer a threat to herself or others. The psychiatrist and primary therapist documented that she was developing some coping skills and had insight into the nature of her problems. Therefore, she does not meet the American Academy of Child and Adolescent Psychiatry (AACAP) criteria for continued inpatient treatment. On the date indicated, the patient would have been able to safely transition to a lower level of care. Therefore, continued stay in an inpatient hospital setting from the time frame specified was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested tomograms for evaluation of her temporomandibular joint dysfunction.  Findings:  The physician reviewer found that in this patient with TMJ dysfunction, the requested imaging of the TMJ will be of little value unless there is advanced degenerative osteoarthrosis of the TMJ, which is unlikely at her age. The use of tomography will yield little or no information concerning the soft tissues of both joints. The presence or absence of joint fluid and meniscal dysmorphology, which are findings associated with TMJ dysfunction, will not be evaluated with standard tomography. The literature indicates that if imaging is clinically indicated, then MRI is the procedure of choice for TMJ disorders since the technique allows for evaluation of the morphology of the mandibular condyles, motion with jaw opening and the analysis of the soft tissues including the discs and joint cavity. Based on the records provided for review, the requested tomograms are not medically necessary for further evaluation and treatment of this patients medical condition.