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

A male enrollee requested a powered mobility scooter for medical treatment of the enrollee, who has been diagnosed with multiple sclerosis.  Findings:  The physician reviewer found that there are no indications in the records that the patients mobility related activities of daily living could not be accomplished with a manual wheelchair.  Physical activity is generally encouraged regardless of underlying health conditions that may exist, including multiple sclerosis.  Exercise has been shown to improve fatigue, mobility and quality of life in the setting of multiple sclerosis.  The use of a manual wheelchair would promote physical activity while accomplishing mobility related activities of daily living.  All told, the requested powered mobility scooter is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested dopamine transporter imaging with single photon emission computed tomography (DAT-SPECT for medical evaluation of her medical condition.Findings:  Two physician reviewers found that while a DAT-SPECT study is not required for the diagnosis of all patients suspected to have Parkinsons disease, it has been shown to be useful in cases where the diagnosis is not definitive on clinical grounds, as in this patients case.  All told, the requested DAT-SPECT is likely to be of greater benefit than other methods for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines on treating hepatitis C virus state that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Given this support, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested heat to destroy nerve tissue (CPT code 64636) at levels L3-5 for medical treatment of her lumbar spondylosis.   Findings:  Three physician reviewers found that the records provided for review do not support a clinical indication for the requested procedure at the L3-5 levels. There is a lack of documentation, such as a pain diary for the 312 hours of improvement following medial branch blocks (Derby, et al; Falco, et al). Further, this patient underwent injections at both the level above the fusion and the fusion levels and likely only obtained benefit from the injections at the level above the fusion site. Thus, the requested heat to destroy nerve tissue (CPT code 64636) at levels L3-5 is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the allergen specific IgG test for medical evaluation of her metabolic disorder.   Findings:  Three physician reviewers found that testing for food sensitivities by any one of multiple methodologies including radioallergosorbent (RAST) testing, skin testing, or measurement of serum IgG and IgE has not proven to be useful in this clinical setting. Moreover, this patients provider did not document concern for an allergic gastrointestinal disease such as eosinophilic gastroenteritis or eosinophilic esophagitis, which may have been an indication for testing. Thus, the allergen specific IgG test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested the Quickie Iris SE manual wheelchair and accessories (HCPC E1161 x 1, K0108 x 11 ALL, E0973 x 2, E2213 x 2, E2206 x 1, E2609 x 1, E0978 x 1, E0956 x 4 ALL, E2671 x 1, E1028 x 4 ALL, E0960 x 1, E0955 x 1 and E0957 x 1) for medical treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history of cerebral palsy and developmental delay resulting in severe impairments in self-care and mobility.  The patient requires a specialized seating system on an ongoing basis and a tilt-in-space positioning system in his mobility device to optimize pressure relief and mitigate the risk of pressure sores.  In addition, he has a history of seizure disorder and has had a fall from his wheelchair, which underscores the need for a supportive and stable type of mobility device.  His current wheelchair is in a state of disrepair and no longer fits him adequately.  All told, the requested Quickie Iris SE manual wheelchair and accessories are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested physical therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Compliance with an appropriate home program would have been expected to be a much more significant factor in optimizing outcomes over regular, ongoing formal therapy.  There is a lack of proven significant, sustained benefit of formal passive modalities in the chronic postoperative stage with respect to health or functional outcomes for this patients condition.  Palliative modalities could have been applied independently by the patient at home.  All told, physical therapy was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested semimembranosus tenotomy and exploration of the sciatic nerve for medical treatment of his hamstring tendinosis.   Findings:  The physician reviewer found that the requested semimembranosus tenotomy and exploration of the sciatic nerve is not medically necessary for treatment of this patients medical condition.  There is a lack of clinical justification for exploration of the sciatic nerve or release of the semimembranosus tendon. There is no indication that he has piriformis syndrome or significant hamstring pathology. Thus, the requested semimembranosus tenotomy and exploration of the sciatic nerve is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided during a colonoscopy. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer.  Findings:  The physician reviewer found that the risk of anesthesia is rated according to a grading system developed by the American Society of Anesthesiologists (ASA).  Individuals who have a rating of 3 or greater may require monitored anesthesia care.  There are a number of other conditions or circumstances listed in the policy where a separate provider of anesthesia is considered medically necessary.  This patient did not have any of these conditions or circumstances.  Additionally his physician rated his anesthesia risk level at ASA 2 (low risk.)  Accordingly, the MAC services were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 12 week course of Harvoni for treatment of his hepatitis C virus genotype 1b.  Findings:  Three physician reviewers found that the patient has moderate fibrosis per Fibroscan, but the interpretation between F2 and F3 fibrosis is challenging (Afdhal, et al). This patient has elevated liver function testing with probable significant inflammation and high viral load. In this clinical setting, the requested 12 weeks of Harvoni is supported by the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A female enrollee requested the  EasyStand Evolv Stander (E1399) for medical treatment of her multiple sclerosis.  Findings:  Two physician reviewers found that the current medical literature has not established the superior efficacy of the requested equipmentThe current literature is not adequate to demonstrate its utility, benefit, or safety in this clinical setting.  The studies that have been done have been small, and several of these studies have demonstrated no benefit.  In sum, the requested EasyStand Evolv Stander (E1399) is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a lower back epidural injection for medical treatment of her low back pain syndrome.  Findings:  The physician reviewer found that there is a lack of documentation demonstrating that the patient has failed conservative therapy including physical therapy and weight loss management.  Given the patients lack of conservative therapy, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee equested BRCA genetic testing for medical evaluation of her medical condition.   Findings:  Two physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  In this case, the patient has a family history of breast cancer. Specifically, she has a first-degree relative with breast cancer at any age, who in turn has a first, second, or third-degree relative with breast cancer diagnosed before the age 50. Given the patients family history, BRCA genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested eight hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees behavior disorder.   Findings:  Two physician reviewers found that based on the documentation submitted for review, a diagnosis of autism has not been established.   ABA therapy is not medically necessary for the diagnosis of behavior disorder. In sum, this patient presents with findings consistent with behavior disorder; therefore, the requested services are not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested radiofrequency neurolysis for medical treatment of her back pain. Findings:  Three physician reviewers found that there is a lack of support for the requested radiofrequency neurolysis in this patients case.  There is a lack of documentation demonstrating that the patient underwent recent physical therapy prior to the current request.   Given the above, the requested radiofrequency neurolysis is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested the zoster vaccine for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services. Per the current medical evidence, the use of the zoster vaccine is recommended in people age 50 to 59 due to proven efficacy of the vaccine in this age group.  As noted by Schmader and colleagues, zoster vaccine efficacy for preventing infection was 69.8% in this group.  Zoster vaccine reduced the incidence of herpes zoster.  All told, the zoster vaccine was medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that there is support for the requested Viekira Pak for patients with early stage disease.  According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.  Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Therefore, the requested Viekira Pak is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested eight doses of Perjeta for medical treatment of her breast cancer.   Findings:  Two physician reviewers found that there is a lack of evidence supporting the use of the agent Perjeta in combination with Herceptin, in the adjuvant setting. In the adjuvant setting, the NCCN does not specify the duration of dual-therapy, unlike the recommendation regarding trastuzumab monotherapy where clinical evidence suggests optimal benefit with completion of one year. Accordingly, continuation of Perjeta for an additional eight doses in this patient is not supported by evidence, has not been proven to be safe, and is therefore not likely to be more beneficial for treatment of her medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A male enrollee requested anesthesia (monitored anesthesia care) for an endoscopy procedure for medical treatment of his medical condition.  Findings:  The physician reviewer found that 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. 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 male enrollee requested the attended nocturnal polysomnogram and continuous positive airway pressure (CPAP) titration nocturnal polysomnogram for medical treatment of his mild obstructive sleep apnea.   Findings:  The physician reviewer found that The American Academy of Sleep Medicine guidelines indicate that home testing should be performed on patients with high pretest probability of moderate to severe obstructive sleep apnea. This patients pre-test probability for moderate to severe obstructive sleep apnea is low. As such, this is a case where the sensitivity of in-lab testing was important and indicated. Thus, attended nocturnal polysomnogram was appropriate to assist in this patients diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Qsymia for medical treatment of her obesity.   Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved Qsymia for treatment of patients with a BMI of 35 or greater. This patients records document a BMI that is 34.99; she has complications of obesity as well as arthritis and has made documented efforts to lose weight. As this patients medical condition currently includes neuromuscular complications from obesity, the requested Qsymia is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested residential chemical dependency services for medical treatment of his substance abuse.  Findings:  The physician reviewer found that there is a lack of evidence submitted for review demonstrating that 24-hour supervised care was required to prevent decompensation.  The patient had a sober support system. He had no history of prior treatment and no indication that he would not respond to a lower level of care. 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 male enrollee requested Viekira Pak for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the patient presents with F0-F1 fibrosis and based on this result anti-viral treatment is not clinically indicated at this time. A reasonable approach would be to follow the patient and perform serial measurements of fibrosis non-invasively on a yearly basis. Therefore, Viekira Pak is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Synvisc One for medical treatment of his left knee pain.  Findings:  The physician reviewer found that although the patient was identified as having degenerative changes regarding his left knee, there was no documentation of a formal diagnosis of osteoarthritis. Additionally, the clinical documentation does not demonstrate that the patient has had a previous allergic reaction to Euflexxa or Orthovisc or was intolerant to either of the medications as an injection treatment prior to requesting the Synvisc One.  The clinical documentation does not demonstrate that the patient has been formally diagnosed with osteoarthritis to support the use of viscosupplementation with a Synvisc One injection at this time. Therefore, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested hyaluronate injections for medical treatment of his knee pain.  Findings:  The physician reviewer found that the clinical documentation indicates that the patient continues to be significantly symptomatic and recalcitrant to medications and therapy.  Per the medical records, this patient has tricompartmental osteoarthritis.  The peer-reviewed literature supports the use of hyaluronate injections to assist pain relief and in an attempt to delay surgical intervention.  In this patients case, viscosupplementation would assist with pain control allowing a delay in further surgical treatment.  All told, the requested hyaluronate injections are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested a positron emission tomography/computed tomography (PET/CT) scan for medical evaluation of her pancreatic cancer.  Findings:  Two physician reviewers found that the current data supports the use of up to three PET/CT scans in solid tumors as the most effective test for diagnosis, staging and evaluation of treatment efficacy.  The physiologic characteristics of PET scans allow for the early detection of recurrence particularly due to the baseline and post treatment scans which are available for comparison.  All told, the PET/CT scan was likely to have been of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested hydrocodone/acetaminophen 10/325 up to twice daily for medical treatment of her chronic low back pain and lumbar disc degeneration.  Findings:  The physician reviewer found that the patient has been on hydrocodone long-term without documentation of improved function or attempted weaning. In addition, the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. Consistent with these findings, the requested hydrocodone/acetaminophen 10/325 up to twice daily is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested Afirma testing for medical evaluation of her medical condition. Findings:  Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Afirma testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.   All told, Afirma testing was likely to have been superior over other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested PCA3 testing, (CPT 84999) for medical evaluation of his prostate cancer.  Findings:  Two physician reviewers found that the medical literature indicates that PCA3 testing, (CPT 84999) most useful role is in the context of a negative prostate biopsy, and where a confirmatory repeat biopsy would generally be recommended. Based on the documentation submitted for review, this patient has a confirmed diagnosis of prostate cancer and there is a lack of documentation demonstrating the clinical indication for the PCA3 testing and the information it would provide. In addition, the National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer do not recommend use of PCA3 testing. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  This patient has cirrhosis of the liver based upon APRI score and thrombocytopenia.  Therefore, hepatitis C treatment is medically necessary to prevent further deterioration in his liver function and decompensation of his liver disease.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  In sum, the requested Viekira Pak is medically indicated for the treatment of this patient.