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

A female enrollee requested partial right knee replacement (Uni Knee Arthroplasty) for medical treatment of her osteoarthrosis.  Findings:  The physician reviewer found the current medical evidence supports the requested partial right knee replacement in this clinical setting.  MRI documented mild to moderate tricompartmental osteoarthritis with patella osteophytes. The arthroscopic surgical inspection of the joint through direct visualization documented Outerbridge grade 3 and 4 changes of the medial compartment and Outerbridge grade 2 changes of the distal patella surface.  The arthroscopic findings under direct visualization and probing provide the highest levels of objective documentation.  The requested services are likely to be of benefit in this patients case.  All told, the requested partial right knee replacement (Uni Knee Arthroplasty) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus.  Findings:  Three physician reviewers found that the patient presents with HCV genotype 3 status post liver transplantation. There is a lack of support in the peer-reviewed literature demonstrating the efficacy of Harvoni in the treatment of HCV genotype 3 patients. There is no recommendation from American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines to treat genotype 3 patients with Harvoni in sofosbuvir-experienced patients. Moreover, the patient has very early to no fibrosis after 13 years liver transplantation. In sum, due to the paucity of data demonstrating support for Harvoni in genotype 3 patients, Harvoni is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested residential treatment services for medical treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the standard of care for adolescent depression, alcohol abuse, and eating disordered behaviors is psychotherapy and psychopharmacology. Residential treatment is not considered an appropriate treatment setting for patients with symptoms for less than 10 months, as in this patients case. Overall, the records demonstrate that the patient was a candidate for treatment in a less restrictive setting as she was medically stable. All told, residential treatment services were not medically necessary for treatment of this patients medical condition.
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.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  The patient has chronic hepatitis C and has an advanced stage disease as she has progressed to cirrhosis.  Per the current national guidelines that set the standard of care in managing and treating patients with hepatitis C, immediate treatment is assigned the highest priority for those patients with advanced fibrosis, compensated cirrhosis, liver transplant recipients, and patients with severe extrahepatic hepatitis C.  This patient has hepatitis C, is treatment-naive and has F3-F4 disease, hence bridging fibrosis or cirrhosis.  Per the national guidelines, this patient should be treated urgently with Harvoni.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested a real-time remote heart monitor for medical treatment of her palpitations.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options.  In this circumstance, if further evaluation for dysrhythmias is indicated the off-line self-activated event monitoring would be sufficient in recording cardiac rhythm during palpitation symptoms. In addition, off-line auto-triggered event recorders are effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Based on the documentation submitted for review, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested D4277, free soft tissue graft procedure for medical treatment of the enrollees gingival recession.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The requested services are medically necessary to prevent continued soft and hard tissue loss of the tooth in question.  If not addressed, the tooth could be compromised and eventually lost.  There is sufficient support for the requested services in this clinical setting.  All told, the requested for D4277, free soft tissue graft procedure is 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 (PET) scan for medical evaluation of her Parkinsons disease. Findings:  Two physician reviewers found that his patient had early onset of Parkinsonian features, but had some atypical features such as lack of tremor, neuropathy, and behavioral issues that were not typical. She sought a second opinion and the provider clinically determined this may not be Parkinsons disease, but one of the Parkinsonian syndromes, specifically MSA-P and ordered a PET scan. In this case, the PET showed clear changes that confirm a Parkinsonian syndrome and not idiopathic Parkinsons disease. Therefore, the PET scan at issue was likely to be more beneficial in diagnosing this patients underlying condition than a standard neurologic assessment or other standard testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested laser or surgical removal of keloid for medical treatment of her skin condition.  Findings:  The physician reviewer found that keloid constitutes an abnormal structure of the body resulting from a disease of collagen metabolism in the wound site, and its removal will create a normal appearance to the extent possible, which, in addition to improved appearance, will offer more than a minimal improvement, due to a psychological impact of the disease. Consistent with these findings, the requested laser or surgical removal of keloid is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested nerve block treatment for medical treatment of his bilateral carpal tunnel syndrome.  Findings:  Three physician reviewers found that there is support in the medical literature indicating that steroid injection into the carpal tunnel may be beneficial once conservative treatments have been tried and failed.  In this case, there is a lack of documentation that the patient failed conservative therapies for at least three weeks. There is also a lack of documentation for surgery contraindication to justify the use of median nerve injection. Therefore, the request for nerve block treatment is not clinically indicated and not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested psychiatric services for the enrollee on an emergent basis.  Findings:  The physician reviewer found that based on the documentation submitted for review, at the time of admission this patients screening was negative for suicide, self-harm or aggression. He was classified as a mild safety risk and was assigned to receive routine monitoring.  In sum, the patient was not an immediate danger to himself or others and was able to provide adequate self-care at the time of the services. Based on the documentation provided, the patient did not have a psychiatric emergency medical condition that required services provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.   Findings:  Two physician reviewers found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients HCV. The patient presents with minimal to no fibrosis on liver biopsy. She is asymptomatic with no glomerular disease or extrahepatic manifestation of hepatitis C. In this clinical setting, the patient may be followed periodically with non-invasive fibrosis measurements. Therefore, Harvoni is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 12 week course of Sovaldi 400 mg tablets for medical treatment of his chronic hepatitis C virus genotype 2.   Findings:  Three physician reviewers found that guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Sovaldi in this clinical setting. Thus, the requested 12 week course of Sovaldi is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a magnetic resonance imaging (MRI) of the lumbar spine for medical evaluation of her lumbar radiculopathy.   Findings:  The physician reviewer found that the written notes by the referring provider do not include a thorough neurological exam to support an indication for the requested MRI of the lumbar spine. Plain films of the lumbar spine were reportedly performed, but the results are not in the chart for review. In addition, there has been no documented attempt at conservative management including physical therapy. Absent any red flags, there is no documented medical necessity for MRI of the lumbar spine absent a course of conservative management.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Avastin (bevacizumab) for medical treatment of her colon cancer.  Findings:  The physician reviewer found that  the patient has not been treated with Avastin. Per the National Comprehensive Cancer Network (NCCN) compendium, it is medically necessary for this patient to be treated with Avastin and Xeloda. Per NCCN compendium, a patient is allowed two attempts with an Avastin containing regimen. This appears to be the patients first attempt with Avastin. Therefore, the request for Avastin is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 12-week course of Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that Harvoni is the preferred drug for this patient due to the potential for interactions between Viekira Pak and Atripla.  Patients co-infected with HIV should be prioritized for treatment.  As noted by Rockstroh and colleagues, highest priority patients include those with substantial fibrosis, HIV co-infection, diabetes mellitus and coexisting liver disease.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested panniculectomy and abdominoplasty for medical treatment of her excessive weight loss and rash.  Findings:  The physician reviewer found that the patients functional deficits of chronic rashes and pain appear directly related to the lower abdomen and not the upper abdomen. In this case, the requested abdominoplasty is consistent with aesthetic improvement for this patient based on the overall medical record and review of the photographs. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested panniculectomy is medically necessary for treatment of the patients medical condition. However, the requested abdominoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Rituxan for medical treatment of her immune thrombocytopenic purpura. Findings:  The physician reviewer found that Rituxan is medically appropriate in this clinical setting.  Per the current medical evidence, Rituxan is the standard next option in this patients case.  Other interventions could potentially cause disruption of her chronic myeloid leukemia therapy, causing relapse.  All told, the requested medication Rituxan is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested a sinus endoscopy with balloon dilation for medical treatment of her medical condition.  Findings:  Two physician reviewers found that at this point, medical therapy and work-up have not been sufficient to plan surgical therapy.  All told, the requested sinus endoscopy with balloon dilation is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Jublia for medical treatment of his onychomycosis.  Findings:  The physician reviewer found that this patients medical condition, onychomycosis, would be most safely treated with a topical anti-fungal medication, because the patients liver problem precludes from using systemic anti-fungal therapies. The relative efficacy and safety profiles of Jublia, compared to other topical antifungal drugs, support its use in this case as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 12 week course of Harvoni for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Harvoni in this clinical setting. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. Thus, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested for Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has minimal liver disease based upon the records.  At this time, the patient is asymptomatic without extrahepatic manifestations of hepatitis C.  There are no other liver diseases occurring, such as nonalcoholic steatohepatitis, and the patient is not immunosuppressed.  The current medial evidence supports serial monitoring in this clinical setting.  Therefore, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested or Harvoni 84 tablets for treatment of her hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients who have failed treatment with pegylated interferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks.  Based on published evidence of safety and efficacy and current guidelines, the requested Harvoni 84 tablets are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested physical therapy, twice per week, for medical treatment of his medical condition.  Findings:  The physician reviewer found that evidence-based medical literature recommends conservative management for plantar fasciitis, which includes relative rest, activity modification, stretching of the plantar fascia, other various exercises, physical therapy, weight loss, insoles, night splints and walking casts.  In this case, the patient has undergone sufficient therapy to be fully independent with a home exercise and modality program for both his plantar fasciitis and his earlier peroneal tendinopathy.  Although the patient remains symptomatic, no significant benefit would be expected with further formal physical therapy over an independent program.  All told, the requested physical therapy, twice per week, is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested anti-tumor necrosis factor (TNF) antibodies/TNF levels tests for medical treatment of his Crohns disease.  Findings:  Two physician reviewers found that the effectiveness of anti-TNF antibodies/TNF levels tests compared with conventional courses of action remains unproven. Patients treated with adalimumab may experience loss of response. However, loss of response can be due to a multitude of factors and the appropriate method for determination of the cause for loss of response is not clear. The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. In sum, there is a lack of sufficient medical evidence to support anti-TNF antibodies/TNF levels tests as more beneficial than conventional standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested the EZ Ride Stroller for medical treatment of the enrollees Pitt-Hopkins syndrome and cerebral palsy.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with Pitt-Hopkins syndrome, cerebral palsy and epilepsy. The requested stroller is clinically indicated as the patient is an unsafe ambulator who is only able to walk for up to 20 minutes, is a fall risk, has poor safety awareness, and has seizures. Based on the medical literature cited above and the documentation submitted for review, the request for the EZ Rider Stroller is medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A male enrollee requested emergency room medical services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention. According to the documentation submitted for review, there was no wheezing and no apparent threat to normal bodily function. There was no significant pain and no sign of systemic allergic reaction.  All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
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 1a.   Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to nonliver-related comorbid conditions. Patients who have failed treatment with peginterferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks. Based on published evidence of safety and efficacy in the medical literature, and clinical guidelines, the requested treatment consisting of Harvoni for 12 weeks should be considered medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Harvoni for 12 weeks; or Viekira Pak for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the patient presents with minimal hepatic fibrosis, no extrahepatic manifestations, and he is not immunosuppressed. There is no evidence of F3 fibrosis related to chronic hepatitis C infection. In this clinical setting, the patient has a good prognosis and should be followed with non-invasive fibrosis measurements serially. Therefore, Harvoni for 12 weeks or Viekira Pak is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested chiropractic services for medical treatment of her sprain/strain of neck, nonallopathic lesion of ribcage, sprain and strain of ribs, spasm of muscle, and lumbar sprain and strain. Findings:  The physician reviewer found that the patients diagnoses are not clearly supported by the patients complaints or examination history. In addition, the x-ray report does not correlate with the patients symptoms. Further, the providers notes lack a thorough initial examination, consultation, formulation of a diagnosis and treatment plan with specific goals. Therefore, the chiropractic treatment visits at issue were not medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested allogeneic stem cell/bone marrow transplant for medical treatment of her multiple myeloma and history of chronic lymphocytic lymphoma.  Findings:  Three physician reviewers found that her disease appears to be a highly aggressive variant that is refractory to two modern regimens, both of which have typically resulted in very high response rates. Thus, available standard therapies, such as high-dose chemotherapy followed by autologous stem cell rescue, are unlikely to be of benefit. Consistent with these findings, the requested allogeneic stem cell/bone marrow transplant 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 female enrollee requested Percocet and embolization of pelvic varices for medical treatment of her abdominal pain.  The physician reviewer found that according to the documentation submitted for review, the patients abdominal symptoms may be related to chronic opioid use which was initiated for the treatment of knee pain.  The clinical picture of her severe abdominal pain began after a period of chronic and escalating opiate use status post knee surgery, and the opioids given for pain treatment may be a contributor to her pain. All told, the request for the embolization of pelvic varices and Percocet is not supported as medically necessary.