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

A 58-year-old male enrollee requested the immune cell function assay testing for medical evaluation of his medical condition status post heart transplant. Findings:  Three physician reviewers found that in reviewing evidence based guidelines, there is no inclusion of the immune cell function assay in the 2010 International Society of Heart and Lung Transplantation (ISHLT) guidelines. Additionally, two studies from 2008 and 2014, which assessed the role of immune cell function assay in pediatric heart transplant monitoring, reported no conclusive evidence that the test results were beneficial for monitoring or intervention in regards to infection or rejection was found (Rossano, et al; Wong, et al). All told, immune cell function assay testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

47-year-old female enrollee requested infusion medication (ceftriaxone) for treatment of her medical condition.  Findings:  Three physician reviewers found that the patient does not present with a diagnosis of neuroborreliosis, Lyme arthritis or cardiac complications of Lyme disease. There are no physical exam findings, laboratory or imaging results that indicate the diagnosis of Lyme disease. The symptoms and MRI findings are non-specific and do not demonstrate Lyme disease. Moreover, the treatment of Lyme disease is a three-week course of intravenous antibiotics. Longer or repeat courses have not been shown to be efficacious in the treatment of Lyme disease. Thus, infusion medication with ceftriaxone was not and is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee requested arthroscopic surgery on the left shoulder for medical treatment of his partially torn rotator cuff. Findings:  The physician reviewer found thatbased on the medical records, the requested left shoulder arthroscopic surgery is medically necessary for treatment of this patients MRI documented and clinically documented condition of superior to anterior labral tear associated with a paralabral cyst. It is not likely that further conservative care will be beneficial in the face of these objective findings. It is medically necessary for this patient to have arthroscopic shoulder surgery, repair of the SLAP lesion and repair of the 4.6 cm paralabral cyst as recommended by his provider.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-month-old male enrollee requested a cranial DOC band for medical treatment of the enrollees plagiocephaly.  Findings:  The physician reviewer found that the requested cranial DOC band is not reconstructive in nature and not medically necessary for this patient. Clinical orthotic devices are not considered medically necessary in infants with mild to moderate plagiocephaly. According to the documentation provided, this patient has mild to moderate left plagiocephaly. Mortenson and colleagues reported that the data supports the use of repositioning in young infants and the start of orthotic helmet treatment for infants with significant deformational plagiocephaly at four to six months. The authors concluded that further research is needed to better understand the parameters for use, long-term outcomes, and natural history on the impact on caregiving. Thus, the cranial DOC band is not expected to provide a more than a minimal improvement of the appearance of the patient. All told, the medical records do not support the medical necessity of the requested DOC band for treatment of this patients mild to moderate left plagiocephaly.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested a dynamic knee ankle foot orthosis (Otto Bock C-Brace for treatment of his Charcot Marie Tooth disease. Findings:  Three physician reviewers found that the patient is able to ambulate with bilateral AFOs and a cane. Studies of the Otto Bock C-Brace are currently limited. Further, comparative studies have not demonstrated the C-Brace to be superior beyond the standard care option of an AFO (de Wit, et al; Geboers, et al). Given the lack of scientific data showing improved health outcomes and improved ambulation with the C-Brace in this clinical setting, the requested equipment is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested hyaluronan (Supartz) injections to the ankle for medical treatment of his ankle pain.  Findings:  Three physician reviewers found that current medical evidence has not established the superior efficacy of the requested services in this patients case.  There is a lack of evidence demonstrating that the requested services are superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy, or other conservative measures.  The peer-reviewed literature indicates that additional studies are required to support the effectiveness of hyaluronan injections for ankle osteoarthritis treatment.  Therefore, the requested hyaluronan (Supartz) injections are not likely to be of greater benefit than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.  Findings:  Two physician reviewers found that although this patient has a family history of breast cancer, she does not meet the criteria for being at high-risk for developing breast cancer.  In this patients case, using MRI instead of routine mammography, breast sonography, and even tomosynthesis may lead to unnecessary biopsies. This patient has already had two biopsies. In sum, medical management should be based on clinical grounds, and there is no indication that the patient currently has any signs or symptoms that would necessitate the requested MRI. All told, the requested breast MRI 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 30-year-old male enrollee requested sacroiliac (SI) joint fusion for medical treatment of his back pain.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. According to the U.S. National Library of Medicine, conservative management for sacroiliac joint pain includes rest, ice therapy, heat therapy, massage, and oral pain medication. An injection may be administered to help with pain and inflammation.  Based on the clinical information received and peer-reviewed literature, the sacroiliac joint fusion is not indicated in this clinical setting. As such, the requested services are not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence.  Findings:  A 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence.  Findings:  The physician reviewer found that substance abuse residential rehabilitation was medically indicated for the treatment of this patient.  Based upon the medical records, the services provided were for active treatment and were reasonably expected to improve the patients condition while preventing a more serious episode of illness.  Further, the duration of treatment was consistent with community treatment standards.  All told, substance abuse residential rehabilitation was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee requested proton beam therapy for medical treatment of his prostate cancer.  Findings:  Three physician reviewers found that there is a lack of clinical data supporting the greater efficacy of proton beam therapy as compared to intensity modulated radiation therapy.  There is a lack of evidence supporting the superior benefit of proton beam therapy over intensity modulated radiation therapy for either treatment efficacy or long-term toxicity.  Therefore, the requested proton beam therapy is not likely to be of greater benefit than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested Sovaldi and Ribapak for medical treatment of her hepatitis C genotype 2a. Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, Sovaldi and Ribapak is the only recommended regimen for treatment-naive patients with hepatitis C genotype 2, regardless of eligibility for interferon therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested Soma three times per day for treatment of her chronic pain.   Findings:  The physician reviewer found that the current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Soma is a muscle relaxant with more addictive and abusive properties than opioids. Additionally, Soma is a centrally acting muscle relaxant, associated with a high risk of dependence and tolerance. The aim of current guidelines is to protect patients from the adverse effects of medication therapy.  Soma as requested by the patient would be contradictory to providing safe and effective healthcare. For these reasons, the requested Soma three times per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested an ambulatory electroencephalogram (AEEG) for medical evaluation of her post-concussion syndrome and seizure disorder.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested AEEG. In this case, there is a lack of rationale demonstrating the medical necessity for a 72-hour AEEG.  Further, a routine EEG would be adequate to evaluate any seizure disorder that is interfering with ongoing mentation. Finally, an AEEG is generally utilized to determine if someone is having seizures, and not utilized once a seizure disorder is documented. For the reasons provided above, the request for an AEEG is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee requested magnetic resonance imaging (MRI) of the knee for medical evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the current medical evidence does not support the MRI of the knee in this patients case.  Per the medical records, there were no red flags to indicate immediate MRI imaging.  There was no evidence of effusion, ligamentous laxity on physical examination, fever, or abnormal equivocal findings on plain films prior to the study.  National Imaging Associates guidelines do not support the diagnostic procedure at issue in this clinical setting.  All told, the MRI of the knee was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested monitored anesthesia care (MAC) during a colonoscopy for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services. The patient did not present with a significant history that would require monitored anesthesia care. In this case, conscious sedation was indicated. McQuaid and Laine compared the efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. The patient could have been provided with a combination of a benzodiazepine and narcotic intravenous. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested Adderall XR 20mg per day for treatment of his deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  Attention deficit/hyperactivity disorder is a common disorder affecting approximately 7% of school-aged children. Per the current medical evidence, up to 65% of children with attention deficit/hyperactivity disorder will continue to have impairing symptoms into adulthood.  Adderall XR is a once-a-day psychostimulant medication consisting of a mixture of amphetamine and dextroamphetamine salts, and has long been a trusted intervention in the treatment of attention deficit/hyperactivity disorder.  Although concern has been raised in this case about the patients substance use comorbidity and the potentially addictive nature of stimulant medications, the diagnosis of attention deficit/hyperactivity has been documented.  The patient has tried both stimulant and non-stimulant medication alternatives.  He has reportedly done best on a reasonably-dosed stimulant medication.  Additionally, the stimulant preparation is extended-release which provides up to 12 hours of coverage with a single dose and thus minimizes the potential for abuse and rapid variance in serum drug levels.  Stimulant medication is the first-line treatment for attention deficit/hyperactivity disorder.  All told, the requested Adderall XR 20mg per day is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of his psychosis, not otherwise specified (NOS).   Findings:  The physician reviewer found thatthe records indicate this patient was plagued with a serious psychotic episode and co-occurring addictive illness, and his condition was determined to be gravely disabled. Thus, a conservative hospital stay was appropriate.  The services were for active treatment and delivered in accordance with a treatment plan. Additionally, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness. In the absence of inpatient services, this patient would have more than likely experienced unnecessary psychiatric morbidity, which in turn could have jeopardized the successful transition to a less restrictive treatment setting and resulted in prompt re-admission to the inpatient level of care. Thus, the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee requested chiropractic treatment for medical treatment of his back and leg pain.  Findings:  The physician reviewer found that the initial chiropractic treatments were medically necessary for treatment of the patients spine. However, subsequent chiropractic treatments were not medically necessary. Initially, the patient was sufficiently evaluated through physical examination and review of imaging to formulate a diagnosis and treatment plan. However, only the initial 12 chiropractic treatment visits were medically necessary for treatment for the patients medical condition. The treating chiropractic office notes after that point lack the necessary clinical documentation to warrant the need for continued treatment. The chiropractic treatment records do not show orthopedic or neurological re-testing was performed. Moreover, there is a lack of adequate evidence in the peer-reviewed literature to support the use of spinal decompression. Based on the lack of clinical documentation for continued treatment and the above-cited chiropractic guidelines, the initial chiropractic treatments were medically necessary for treatment of the patients medical condition, however not thereafter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested residential treatment detoxification services and residential sub-acute rehabilitation services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the residential treatment detoxification services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed mild symptoms of diaphoresis and tremulousness, and did not endorse cravings. He was not at risk for developing significant withdrawal. He was depressed and anxious, however this was his baseline. He was no longer on Serax. As his symptoms were of a mild nature, he no longer required 24-hour medical/nursing supervision and could have been managed at a lower level of care. In addition, the residential sub-acute rehabilitation services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed no withdrawal symptoms. He had co-existing medical illnesses however these could be managed on an outpatient basis. He denied suicidal/homicidal ideation, intent, or plan. He expressed eagerness to attend groups, demonstrating motivation and implying desire for recovery. Relapse is an inherent risk in this population, and is not in and of itself a reason to keep a patient at this level of care in the absence of other factors such as suicidal ideation. Therefore, he no longer required residential level of care and could have been treated in a less restricted setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested a pain management consultation for medical treatment of her neck pain, fibromyalgia, carpal tunnel syndrome, and sciatica. Findings:  The physician reviewer found that based on the available medical records, a pain management consultation is not medically necessary for treatment of this patients medical condition. Overall, there is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the patients primary care physician. Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications. Additionally, the results of the imaging do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee requested inpatient psychiatric treatment for medical treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient initially evidenced dramatic symptomatologies of psychotic illness.  Discharge would have been premature and likely would have resulted in undue morbidity.  The psychiatrist was titrating ziprasidone, a second generation antipsychotic.  Thus, inpatient psychiatric treatment was initially indicated.  However, the records do not support the medical necessity of subsequent inpatient psychiatric treatment.  Although the patient was still delusional at times, he had improved.  He was sleeping well and was not suicidal.  The patient was taking his psychotropic medication, and he responded well to nursing support and redirection.  The records indicate the acute syndrome had resolved and the acute level of care was no longer medically necessary.  Considering the peer-reviewed literature and community treatment standards, inpatient psychiatric treatment was initially medically indicated.  However, based on the documentation provided, subsequent inpatient psychiatric treatment was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 59-year-old male enrollee requested the neuromuscular electrical stimulating ergometer (RT300 functional electrical stimulation (FES) cycle rehabilitation system) for medical treatment of his spinal cord injury. Findings:  Two physician reviewers found that the equipment at issue was not likely to be more effective for this patient than other available treatment options. The patient has T4 paraplegia.  At the T4 level, the patient is expected to be independent at a wheelchair level and should be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. Based on the information provided, the requested RT300 functional electrical stimulation cycle rehabilitation system is not clinically indicated as the patient at the T4 level should be able to achieve health benefits without the use of the requested equipment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested the LifeVest wearable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  The physician reviewer found that studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction  35% before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). A wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition.