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

A 60-year-old female enrollee requested Oxycontin 60 mg tablets SR 12 hour for medical treatment of the enrollees fibromyalgia and myofascial pain.  Findings:  The physician reviewer found that the request for Oxycontin 60 mg tablets SR 12 hour is not medically necessary.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, and abnormal pain sensitivity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested ondansetron (Zofran) 8mg, one tablet every six to eight hours, for medical treatment of her nausea and vomiting. Findings:  The physician reviewer found that the patient was treated for postoperative nausea with Zofran 8mg orally every six to eight hours.  Zofran 8mg is not approved for the treatment of postoperative nausea with vomiting.  The documentation does not support that the patient required the prescribed dosage of Zofran.  All told, Zofran 8mg, one tablet every six to eight hours was not medically indicated for the treatment of this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee requested a power wheelchair for medical treatment of the enrollees knee and foot pain.  Findings:  The physician reviewer found that a power mobility device is not medically necessary given that the records do not establish any mobility deficits in the home that would not be more appropriately addressed by other means.  In addition, there is no documentation of physical examination findings, imaging findings or other objective findings that establish upper limb, cardiovascular or other pertinent organ system impairment that would preclude manual wheelchair propulsion for accomplishing mobility-related activities of daily living outside of the home.  The patient has multiple chronic health conditions which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for patients with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested magnetic resonance imaging (MRI) for medical evaluation of his right posterior knee and calf pain.  Findings:  The physician reviewer found that the patient presents with point tenderness of the right proximal calf consistent with gastrocnemius strain or tear. No profound weakness is described. MRI has been requested to differentiate between tear and strain. The literature demonstrates that surgical treatment of gastrocnemius rupture is rare and conservative management is considered the standard of care. Ultrasound has been described as being useful in the differentiation between tear and strain and is a good first-line exam. Since the treatment is almost always conservative, the requested MRI is not medically necessary since the treatment will likely be conservative even if a tear is found.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that hospitalization was for purposes of diagnosis, in addition to active treatment that was reasonably expected to improve the patients condition while preventing a more serious episode of illness. In addition, hospitalization was medically necessary for continued care and installation of a treatment plan aimed at mitigating the risk for readmission and reducing both psychiatric morbidity and violent behaviors in the home. In sum, the treatment setting was safe, appropriate and consistent with good medical practice. Considering the case in its entirety, and applying the current practice guidelines and relevant peer reviewed literature, it was medically necessary for the patient to have been treated at an inpatient level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee requested Vimpat 200 mg, two per day for medical treatment of his seizures.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Vimpat (lacosamide) is medically indicated for partial onset seizures. The study by Flores and colleagues noted that lacosamide is an effective and safe antiepileptic drug when used as adjunctive therapy in patients with refractory partial epilepsy. This patient presents with intractable epilepsy resistant to Keppra monotherapy. The documentation submitted for review shows that the patient has responded to Vimpat add-on therapy at 200 mg twice daily. The continued use of a combination antiepileptic drug that produces good seizure management is medically necessary in this clinical setting. Further, the transfer of this patient to another antiepileptic drug would place him at significant risk of additional seizures and status epilepticus. Based on the medical literature provided above and the documentation submitted for review, the medical necessity of the requested medication has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee requested 36 sessions of vision therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested services are not medically necessary and do not meet the standard of care in this clinical setting.  This patient has diagnoses of convergence insufficiency and exotropia.  The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with convergence insufficiency.  In this case, the recommended 36-session in-office treatment program does not correlate with studied protocols in the medical literature for treatment of convergence insufficiency or other eye disease.  The group of study participants referenced above in the Convergence Insufficiency Treatment Trial Study Group is older than the patient in this case.  There is a lack of evidence indicating that vision therapy treatments for younger children can treat convergence insufficiency or exotropia.  All told, the requested vision therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee requested intensive outpatient program services for treatment of the enrollees eating disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient had no suicidal, homicidal, or psychotic ideation.  She was not a danger to herself or others.  The patient was medically stable and she was managed on Prozac.  She participated in her treatment and meal plans.  The patient showed significant improvement as evidenced by the reduction in her eating disorder behaviors.  She had steadily gained weight and was at 105% of her ideal body weight.   Her treatment plan did not require frequent modifications or contact with staff requiring this intensive level of care.  The current medical evidence does not support the requested services in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee requested sofosbuvir (Sovaldi) 400 mg daily #30, and ribavirin 200 mg twice per day #60 for treatment of his hepatitis C.   Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), when a provider chooses to treat a patient without pegylated interferon, then the duration of the treatment is 24 weeks. In this patients case, the provider has not documented in the clinical information provided the clinical rationale for not using interferon. The treatment of hepatitis C virus therapy with triple or dual regimen is appropriate. Therefore, the requested sofosbuvir (Sovaldi) 400 mg daily #30, and ribavirin 200 mg twice per day #60 is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested extracorporeal shockwave therapy for medical treatment of her plantar fasciitis and Achilles tendonitis. Findings:  Two physician reviewers found that in the peer-reviewed medical literature on the use of extracorporeal shockwave therapy for the treatment of chronic heel pain, there is a paucity of scientific data demonstrating improved health outcomes when compared to standard therapies. Many studies have small numbers of patients evaluated and the strength of the extracorporeal shockwave therapy is poorly defined. All told, the patient is likely to benefit from a comprehensive, well documented physical therapy approach, combined with splinting and orthotics. For these reasons, extracorporeal shockwave therapy is not likely to be more beneficial for treatment of this patients medical condition than any available conventional therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested a portable (home) sleep study device for medical evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that based on the medical records submitted for review, the patient has insomnia. However, no snoring or daytime sleepiness is documented on the test order form. Although the sleep study report does document snoring, this is not corroborated by the other documentation provided for review. Moreover, an Epworth Sleepiness Scale score of 10 without supporting information of sleepiness does not necessarily indicate sleep pathology. Based on the documentation submitted for review, the patients presentation is not suggestive of obstructive sleep apnea. Moreover, insomnia is not an indication for sleep testing, and the home sleep study provided was not medically necessary. Given that the portable sleep study device was not medically necessary for treatment of the patients medical condition, it was not medically necessary for the results of the test to be interpreted by a physician.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested lorazepam 1 mg three times per day for medical treatment of the her anxiety.  Findings:  The physician reviewer found that in the medical literature, benzodiazepines are not recommended for long-term use due to the risk of dependence. As tolerance to its anxiolytic effects develops with long-term use, a patients anxiety may actually increase, and tolerance to its hypnotic effects develops quickly. An antidepressant may be considered a more appropriate treatment for an anxiety disorder. Consistent with these findings, the requested lorazepam 1 mg three times per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee requested the MiniMed 530G with Enlite (E0784, A9276, and A9277 for medical treatment of the enrollees type 1 diabetes.   Findings:  Two physician reviewers found that according to American Association for Clinical Endocrinologists (AACE) guidelines, insulin pump therapy with continuous glucose monitor systems are indicated in patients with type 1 or type 2 diabetes mellitus who need to reestablish blood glucose control. These devices enable switching from conventional insulin injections to pump therapy, and manage sustained elevations of glycosylated hemoglobin, unstable blood glucose levels with large glycemic fluctuations, as well as respond to episodes of hypoglycemic unawareness and frequent or severe nocturnal hypoglycemia. This patient has long-standing type 1 diabetes mellitus and has unstable blood glucose levels with large glycemic fluctuations and wide fluctuations in preprandial blood sugars as well as hypoglycemia. Given this support, the MiniMed 530G with Enlite (E0784, A9276, and A9277) is 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 47-year-old female enrollee requested substance abuse residential treatment center (RTC) level of care services for treatment of the enrollees substance abuse.  Findings:  The physician reviewer found that substance abuse RTC services were not medically necessary for treatment of the patients medical condition. At the time of admission, the patient was stabilized on a Librium taper. There was no evidence of suicidal/homicidal ideation, intent, or plan. There was no evidence of risk of danger to self or others. There was no psychotic ideation in any modality. The patients medical and psychiatric medication regimen and any adjustments did not require 24-hour supervision and could have been managed on an outpatient basis.  She had not attempted a lower level of treatment such as intensive outpatient or outpatient. She described her husband in positive terms and has a good relationship with her children. All told, the patient did not meet the medical necessity criteria for residential treatment level of care and could have been treated at a lower level of care such as intensive outpatient programming (IOP) or an outpatient office based treatment, in conjunction with community based services such as a 12-step program along with a sponsor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested surgical procedures related to anterior lumbar intercorporal fusion (ALIF) at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 for medical treatment of his low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation. Findings:  The physician reviewer found that based on the available documentation, the ALIF at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 were not medically necessary for treatment of this patients low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation. The efficacy of instrumentation and fusion as treatment for complex lumbosacral and pelvic regional pain syndrome remains controversial and the use of lumbosacral fusion is supported by Level III and Level IV case series studies at best. The accepted criteria for chronic pain with mechanical instability have not been demonstrated in the patients records. All told, the ALIF at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 was not medically necessary for treatment of this patients low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested spinal surgery (implantation of total disc prosthesis in segments L2-3 and L5-S1) for medical treatment of his vertical segment instability at L5-S1 and L2-3 with stenosis at L2-3.   Findings:  Three physician reviewers found that currently, there is a paucity of peer-reviewed medical data demonstrating superior health outcomes with artificial disc replacement versus conventional interventions. Spinal fusion for patients with kyphosis and nonunion has been shown to be safe and effective. In addition, decompression for spinal stenosis is reasonable and appropriate. In the absence of clinical data supporting the spinal surgery (implantation of total disc prosthesis in segments L2-3 and L5-S1,) the services were not likely to have been more beneficial than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention.  The patient presented with reported symptoms of itching and jaundice for more than 20 days. There is no documentation during this pre-hospitalization window, nor immediately following hospitalization, of hemodynamic instability, respiratory compromise, or shock which might necessitate emergent treatment. In addition, the records do not support that an emergency medical condition existed at the onset of symptoms or in the early days of hospitalization.  All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee requested assessment and medication management by an adult cardiologist who specializes in the treatment of congenital heart disorders and defects and continued cardiac electro-physiology studies performed by a cardiology specialist familiar with the enrollees complex heart defects, two valve replacements and pacemaker implantation for medica; treatment of her medical condition.  Findings:  The physician reviewer found that given the complexity of her medical problems, she is best managed by a cardiologist specializing in adult congenital heart disease.  The patient is status post multiple surgical procedures, including aortic valve replacement, mitral valve replacement and pacemaker placement.  She is at an increased risk for future cardiovascular complications.  All told, continued assessment and medication management by an adult cardiologist who specializes in the treatment of congenital heart disorders and defects and continued cardiac electro-physiology studies performed by a cardiology specialist familiar with the patients complex heart defects, two valve replacements and pacemaker implantation are medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested an inpatient sleep study test in a center (sleep lab) for medical evaluation of his fatigue.   Findings:  The physician reviewer found that there is no documentation of a sleep medicine history or physical examination. Further, the records lack the patients Epworth sleepiness score, mallampati score, witnessed apnea, awakening gasping, awakening with headaches, daytime hypersomnia, cataplexy, hypnagogic hallucination, sleep paralysis or profound snoring. The patient has a BMI of about 30 and has fatigue. Consistent with the current medical literature, there is insufficient documentation to substantiate the medical necessity of the requested sleep study for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested platelet-rich plasma prolotherapy for treatment of her knee pain.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  At this time, further studies are needed to establish the long-term efficacy of platelet-rich plasma prolotherapy.  Large, well-designed trials are needed to effectively evaluate the use of platelet-rich plasma in this clinical setting, including evaluation of benefit compared to standard treatment options which are currently available.  Therefore, the superior efficacy of platelet-rich plasma prolotherapy and future platelet-rich plasma prolotherapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested a positron emission tomography/computed tomography (CT) scan (CPT code 71270 for medical evaluation of her right eye tumor and possible malignancy. Findings:  The physician reviewer found that in the medical literature, metastatic tumors of the retina are rare, and that the diagnosis is often delayed. Muzaffar and colleagues reviewed a total of 8,430 PET/CT reports from August 2006 to June 2011. The authors noted that whether the findings are apparent or very subtle, as in the case of abnormalities within the orbit, they can have a profound impact on patient management and appropriate follow-up. Given this patients differential diagnosis and concern, PET/CT can provide meaningful information toward the further evaluation of this patients retinal lesion. For these reasons, the requested PET/CT scan is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee requested psychiatric residential treatment center (RTC) level of care services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found thatthe RTC services provided were and are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient is at moderate but stable risk of harm and needs medium-intensity 24-hour monitoring to ensure her safety. This is based upon her lacking a will to live and not being afraid of negative consequences. She also has moderate to severe interference with addiction recovery. Her history, combined with the present situation, predicts that she would likely destabilize without medium-intensity residential treatment. In addition, the patient needs intensive motivating strategies in a 24-hour structured program to address minimal treatment engagement. She is also unable to control use and avoid serious impairments without a 24-hour structured program because she is unable to overcome environmental triggers. Finally, the patients home environment poses a risk to her recovery, based upon the amount of dysfunction that is present due to the lack of unity between parents. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.