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

A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the services at issue were not likely to have been more effective than other available modalities.  Per the submitted documentation, the available blood and imaging records gave no indication for advanced liver disease or tumor.  Contemporary measurement of liver fibrosis is made serologically and/or by elastography.  The systematic review and meta-analysis by Singh and colleagues noted that the degree of liver stiffness, using elastography, can predict outcomes in patients with chronic liver diseases.  Per the authors, liver stiffness measurement may be used in risk stratification.  Thus, the superior efficacy of SPECT scan has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 15-year-old male enrollee requested  Otrexup (methotrexate) 25mg/0.4ml injectable for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Methotrexate is important in the treatment of juvenile scleroderma.  In a retrospective study by Koch and colleagues, the authors noted that methotrexate was efficacious in the treatment of linear morphea in young patients, with or without corticosteroids.  In this patients case, the medical records do not document any treatment failure on conventional injectable methotrexate.  Documentation indicated that the patient is afraid of needles and would prefer to use the Otrexup auto-injector.  However, there appears to be no reason why the patient cannot have conventional parenteral methotrexate administered by a nurse or family member.  All told, Otrexup (methotrexate) 25mg/0.4ml injectable is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested Somatic Experiencing Trauma Therapy for medical treatment of his posttraumatic stress disorder.  Findings:  The physician reviewer found that although some preliminary positivism can be found in the medical literature regarding the application of Somatic Experiencing Trauma Therapy, there is an absence of randomized, well-controlled, adequately powered, exploratory and confirmatory studies supporting this treatment.  This therapy is not endorsed by current practice guidelines.  Further, it does not appear that the patient has failed evidence-based interventions shown to impart durable treatment gains for this condition.  Treatments such as cognitive processing therapy and prolonged exposure have 10-year follow-up data and represent first-line treatments for posttraumatic stress disorder.  All told, the requested Somatic Experiencing Trauma Therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested Lyrica 800 mg per day for medical treatment of her fibromyalgia.  Findings:  Three physician reviewers found that the requested medication dosage is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According the manufacturers prescribing information Lyrica is indicated for fibromyalgia with a maximum dose of 450 mg per day. Moreover, current studies and reviews recommend dosing at 450 mg per day. In a randomized, double-blind, placebo-controlled, phase III trial for the monotherapy treatment of pregabalin for patients with fibromyalgia, dosing regimens were evaluated at 300 mg per day, 450 mg per day and 600 mg per day. The authors concluded that at the dosage of 450 mg per day, pregabalin demonstrated improvement in pain score, patient global impression of change, and function.  All told, the requested Lyrica at the dosage of 800 mg per day 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 40-year-old male enrollee requested weekly psychotherapy visits for medical treatment of his behavioral health condition.  Findings:  The physician  reviewer  found that the patients therapist reported that the patient had achieved remission, which is indicative of clinical progress and the consolidation of treatment gains. Thus, a reduction in the services needed to achieve remission would be safe and appropriate.  There is no evidence that less-frequent therapy would hasten a clinical deterioration and necessitate treatment at a higher level of care. In sum, based upon the documentation provided, there is a lack of support demonstrating the medical necessity for psychotherapy visits at a frequency of once per week. Thus, the services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested a real-time heart monitor for medical evaluation of her atrial fibrillation. Findings:  Two physician reviewers found that given this patients complex congenital heart disease, history of recurrent atrial fibrillation, and limited medical therapy options because of bradycardia, the real-time cardiac monitoring was the most appropriate and likely the highest yield diagnostic test available. Thus, the real-time heart monitor was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee requested bariatric surgery, gastric sleeve for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports bariatric surgery in this clinical setting.  The medical records document morbid obesity and comorbid medical conditions related to her obesity including diabetes, obstructive sleep apnea, hypertension, gastroesophageal reflux disease, asthma, and dyslipidemia.  She has tried and failed non-surgical attempts at weight loss.  She has been appropriately screened and cleared for bariatric surgery by numerous providers.  This patient meets generally accepted criteria for bariatric surgery.  All told, the requested gastric sleeve procedure is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.   Findings:  Two physician reviewers found that in the medical literature, Claassen and colleagues reported that PET and 3-dimensional stereotactic surface projection  provide a useful diagnostic method to support a clinical diagnosis of primary lateral sclerosis. Studies with PET demonstrate predominant primary motor strip involvement. This pattern is illustrative of a stripe of hypometabolism. Thus, the literature does support the use of the requested PET for the evaluation of primary lateral sclerosis, looking for a stripe of hypometabolism. All told, the requested PET scan would be helpful to exclude primary lateral sclerosis in this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee requested 30 sessions of chiropractor care for medical treatment of his degenerative disc disease.   Findings:  The physician reviewer found that this patient reports that his ability to perform activities of daily living are affected due to his pain and worsening condition, and that chiropractic treatment has helped his condition.  However, documentation of subjective and objective pain as well as clinical assessment and evaluation is needed to support an indication for continued chiropractic care. This patients records do not support the medical necessity of the requested chiropractic treatment absent this information.  Thus, the requested 30 sessions of chiropractic care are not medically necessary for treatment of this patients chronic back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested removal of a microchip implanted in the knee for medical treatment of his left knee osteoarthritis.  Findings:  The physician reviewer found that this patients operative report does not document that any device was implanted by the surgeon who performed the  arthroscopic procedure.  In addition, there is a lack of evidence from any imaging study that such a device was present in the knee. Thus, the procedure requested by patient is not clinically indicated and not expected to provide the patient with any medical benefit.  Hence, such a procedure is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee requested occupational therapy/sensory integration therapy for medical treatment of the enrollees delayed milestones and lack of coordination.   Findings:  Two physician reviewers found that sensory based interventions can be helpful for children who are dysregulated, inattentive, or delayed. However, the current evidence is contradictory on whether occupational therapy for sensory integration therapy provides more benefits as compared to other interventions. The American Academy of Pediatrics Section on Complementary and Alternative Interventions stated that occupational therapy for sensory integration may be helpful, but the research is limited in proving that this has benefit. At this time, sensory integration has an evidence level of D which means there is no evidence of harm from occupational therapy for sensory integration, but the evidence is lacking to prove that this is beneficial or better than other interventions. Consistent with these findings, the requested occupational therapy/sensory integration therapy 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 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment options.  This patient has been diagnosed with prostate cancer.  However, the records do not document a repeat biopsy to determine if there has been any progression of disease.  Per the medical evidence, there is a lack of support for the UroLift procedure for patients with known prostate cancer.  At this time, long-term studies are needed to support the safety and efficacy of this procedure.  Thus, the requested UroLift procedure is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 64-year-old male enrollee requested Sovaldi, Olysio and ribavirin for medical treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that based on the available documentation, this patient is a Child-Pugh B patient with 10 points and is decompensated. However, use of Sovaldi, Olysio and ribavirin in patients with decompensated disease should be withheld outside the context of a clinical trial until there is more evidence supporting treatment. There is a paucity of medical literature demonstrating the safety and efficacy in this population of patients. The patient could possibly develop worsening decompensation on treatment. Additionally, there is no data on improvement of overall or disease specific health outcomes with treatment. Consistent with these findings, the requested medication regimen of Sovaldi, Olysio and ribavirin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested Dymista  for medical treatment of his rhinitis.  Findings:  The physician reviewer found that in this patients case,  allergy tests were essentially negative except for a weakly positive intradermal test to dust mites.  Thus, he either has a mild perennial, (not seasonal) component allergy, or a possibility of no allergy due to potential false positives.  The submitted office notes do not substantiate nosebleeds or anxiety from Nasonex.  Furthermore, Dymista is a combination of fluticasone and azelastine.  If this patient tolerated Dymista, he should also tolerate either fluticasone or azelastine individually.  Additionally, Dymista is indicated for patients with seasonal allergic rhinitis, which this patient does not have.  All told, the requested Dymista is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested a wireless capsule endoscopy for medical evaluation of her gastroparesis, abdominal pain, nausea, and vomiting. Findings:  Two physician reviewers found that this patients symptoms are likely due to a functional disorder such as irritable bowel syndrome or perhaps secondary to adhesions in the pelvis. There is no evidence of occult or overt GI bleeding or a small bowel neoplasm by history or radiographs. In this clinical scenario, a wireless capsule endoscopy of the small bowel is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested stem cell fat grafting to the right breast for medical treatment of the enrollees medical condition status post partial mastectomy and radiation therapy.   Findings:  The physician reviewer found that the records indicate that this patients degree of deformity as demonstrated on examination and visualized in photographs should be considered abnormal. In addition, this abnormal condition is the result of treatment for breast cancer. The patients condition and treatment including partial mastectomy and postoperative radiation therapy created an abnormal breast from the tissue removal and changes associated with radiation therapy. Stem cell fat grafting is likely to result in a more than a minimal improvement in the patients appearance. Thus, the requested stem cell fat grafting is supported as reconstructive in nature for treatment of this patients contour deformity of the right breast.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his scalp cutaneous follicular cell non-Hodgkins lymphoma stage T2N0M0.  Findings:  Two physician reviewers found that the complexity of treating scalp lesions is based upon the changing surface contours in two planes as well as the underlying brain and adjacent critical structures such the eyes and lacrimal glands. While the dose delivered in this patient was 30 Gy, which is deemed to minimize risk of late complications, the issue of potentially matching electron fields may lead to under treatment of the target or overlap leading to hot spots. In this clinical setting, IMRT provides a solution to the changing contour of the scalp thereby limiting match lines and the risk of overlap. Given these findings, the use of IMRT was likely to have been more beneficial for treatment of this patients cutaneous follicular cell non-Hodgkins lymphoma than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested laparoscopic adjustable gastric band (lap band) surgery for medical treatment of his obesity. Findings:  The physician reviewer found that based upon the documentation provided, the patient appears to meet National Institutes of Health (NIH) criteria for bariatric surgery based on body mass index and the presence of obesity associated medical co-morbidities including obstructive sleep apnea and hypertension (Jensen, et al.) However, further work-up by a bariatric surgeon is needed to rule out any barriers to surgery, obtain psychiatric clearance, etc. While it was determined that a consultation with a bariatric surgeon to discuss the possibility of weight loss surgery is not indicated unless the patient has undergone a medically supervised weight loss attempt, there is a lack of peer-reviewed literature supporting this requirement. To date, it has not been scientifically validated that participation in pre-surgical medically supervised weight loss programs results in better clinical outcomes.   In accordance with the above, a bariatric surgical consultation is medically necessary for the patient. If following the consultation the bariatric surgeon determines lap band surgery is medically necessary, the patients request for surgery should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 75-year-old female enrollee requested endovenous chemical ablation procedure for medical treatment of her varicose veins.   Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. Typically procedural approaches including endovenous ablation is reserved for patients who fail conservative therapy. The documentation submitted for review fails to provide evidence of treatment of conservative therapy such as the use of prescription of medical grade compression stockings and several months of regular use. In addition, the patient presents with hypertension, diabetes, and hyperlipidemia and it is not possible to attribute leg pain to varicose veins without an assessment of lower extremity arterial perfusion. In sum, there was a lack of assessment provided describing the patients symptoms, a description of the examination, and an attempt to treat with conservative therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested  Sovaldi for medical treatment of the her hepatitis C.  Findings:  Two physician reviewers found that hepatitis C is a chronic disease that can progress to cirrhosis, liver failure, hepatocellular carcinoma and is associated with a multitude of extrahepatic complications.  Screening for hepatitis C is indicated in the setting of chronic liver disease and in patients at risk, and treatment of hepatitis C is indicated when no contraindications exist.  The current medical evidence does not support waiting for advanced fibrosis prior to treatment.  This patient is eligible for interferon-based therapy as prescribed, and the current medical evidence supports the requested treatment in this clinical setting.  Thus, Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested a dopamine transporter single photon emission computed tomography (SPECT-DaT) scan for medical evaluation of her Parkinsons disease.  Findings:  Two physician reviewers found thatSPECT-DaT scans have been shown to be useful in cases where the diagnosis is not definitive on clinical grounds. Such is in this case where the patients neurologist suspected a possible essential tremor (or other tremor disorder). It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are different and the treatments for Parkinsons disease can have significant side effects. In this case, the patients diagnosis was confirmed using this study and the patient was able to be appropriately counseled and placed on Parkinsons disease therapy in a timely fashion. All told, the diagnostic procedure was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee requested intensive outpatient program services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient struggles with cannabis use disorder and co-occurring mood and trauma-based syndromes, in addition strained parental dynamics.  The literature supports aggressive treatment of appropriate duration in this clinical setting.  Based upon the submitted records, this patient has not consolidated the treatment gains necessary to maintain affective harmony and abstinence outside of the intensive outpatient program setting.  The services provided at the intensive outpatient program level of care are consistent with good medical practice and are reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, intensive outpatient program services were and are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested human epididymis protein 4 (HE4) screening for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that this patients records document a long history of close observation, with no evidence of malignant disease, and without any progression of the abnormal tumor marker.  In this setting, the elevated CA-125 was not likely to have been of clinical significance, and did not require additional investigation.  Furthermore, the patient was not considered at higher risk of ovarian malignancy on the basis of her prior diagnosis of ductal carcinoma in situ, as she had been screened for BRCA mutations and tested negative.  The medical evidence does not support the services at issue in this patients case.  Thus, HE4 screening was not likely to have been more effective than other alternatives for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee requested developmental, individual-difference, relationship-based model (DIR)/Floortime services for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. The medical literature strongly supports the treatment of autism with ABA therapy in children. ABA therapy has been documented to significantly improve motor, verbal, and social interactive skills in autistic children. A review of the medical literature reveals a lack of independent studies on DIR/Floortime and clinical evidence to support the efficacy of DIR/Floortime interventions. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of DIR/Floortime interventions, it is not possible to conclude that DIR/Floortime is likely to be more beneficial than standard therapies available in this setting. Therefore, the requested services are not likely to be more beneficial for this patients medical condition than any available standard therapy.