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

The parent of a 15-year-old female enrollee has requested residential treatment center (RTC) mental health services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient does continue to meet criteria for treatment at the RTC level of care. The patient has poor-to-fair motivation, she is preoccupied with intrusive repetitive thoughts 4-6 hours a day and she is cooperative with highly structured treatment. Moreover, she needs supervision at all meals or she will restrict her eating. Some degree of external structure beyond self-control is required to prevent the patient from compulsive exercising. She is able to ask for and use support from others. In addition, she has severe family conflict that prevents her from receiving structured treatment in the home. For the reasons provided above, the RTC level of care provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee requested intravenous immune globulin (IVIG) therapy for medical treatment of her pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS).  Findings:  The physician reviewer found that presently, the clinical trial for IVIG for PANDAS is closed to enrollment, but ongoing evaluation of IVIG efficacy in children diagnosed with PANDAS, has a 3 year follow-up window.  Until these results are published and after the appropriate peer review, no conclusion, favorable or unfavorable can be made. Moreover, the association of streptococcal infection with basal ganglia disease, in particular, obsessive compulsive disorder and movement disorders such as Tourette syndrome, remains controversial. While neuroimmune abnormalities may or may not be present in children that carry a diagnosis of tic disorder, OCD and history of streptococcal infections, systematic studies that have addressed this find no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. All told, the medical necessity of the requested therapy has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested Sovaldi and ribavirin for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that at this time there is a lack of clinical documentation that shows the patient has significant liver disease. The clinical documentation provided shows that the patient has minimal to no liver fibrosis. In addition, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi and ribavirin is not medically necessary. Therefore, the medical necessity of the requested medications has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested proton beam radiation therapy for treatment of his  prostate cancer.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state: Proton beams can be used as an alternative radiation source. Other treatment approaches such as IMRT are highly effective and well tolerated. There is a lack of compelling data that suggests that PBRT affords a benefit over standard approaches, such as IMRT for prostate cancer. In addition, there is data in the peer-reviewed literature that shows worse outcomes with PBRT therapy. According to a study by Sheets and colleagues, proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT). For the reasons provided above, the requested services are not medically necessary for treatment of the patients prostate cancer.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee requested MiniMed 530G with Enlite (E0784 Insulin pump; A9277 continuous glucose monitoring (CGM) transmitter; A9276 x 3 CGM sensors) for medical treatment of his type 1 diabetes.  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient is using an insulin pump and is still having low blood sugar levels in the 30-50s. He is checking blood sugars four times per day. Thus, the use of the new MiniMed 530G with Enlite system with the threshold suspend feature is likely to be beneficial for this patient and will likely lower the frequency of severe low blood sugars (Bergenstal, et al).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested deep brain stimulation surgery for medical treatment of her obsessive compulsive disorder (OCD).  Findings:  Three physician reviewers found that based on the documentation provided, this patient has treatment-refractory OCD. She attended a prominent residential treatment program that specializes in treatment for OCD and she has been treated in the outpatient setting at a facility with a stellar international reputation. She has trialed cognitive behavioral therapy and has been treated with multiple psychotropic medications. Despite these evidence-based interventions, the patient remains debilitated by her OCD. All told, the requested deep brain stimulation is 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 female enrollee requested interlaminar lumbar instrumented fusion (ILIF) procedure for medical treatment of her ruptured L4-5 with radiculopathy.  Findings:  Three physician reviewers found that this patients records do not document any motor, sensory, reflex findings, or accompanying symptoms to warrant a diagnosis of a lumbar radiculopathy (Tarulli and Raynor). Her pain generator has not been identified. A single injection anywhere, without a control does not establish a diagnosis or prove the success of an injection. In addition, the ILIF procedure has not received final FDA approval. Further, there is a paucity of studies showing the long-term safety and effectiveness of this device. Given the lack of scientific data demonstrating equivalent or superior clinical outcomes with use of the ILIF procedure, the requested services are 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 51-year-old female enrollee requested intraoperative radiation therapy for medical treatment of the enrollees breast cancer.   Findings:  Three physician reviewers found that the current medical evidence has not established the superior efficacy of intraoperative radiation therapy in this clinical setting.  External beam radiation therapy is the current standard of care.  The American Society for Radiation Oncology (ASTRO) published a consensus statement on accelerated partial breast irradiation.  The ASTRO Task Force noted that a patient belongs in a cautionary group if specific criteria are met.  In this patients case, she meets two criteria.  Specifically, her age is between 50 and 59 and she has a diagnosis of invasive lobular carcinoma.  The consensus noted that these criteria should result in caution when considering accelerated partial breast irradiation.  At this time, the data regarding the use of intraoperative radiation therapy is limited.  Therefore, intraoperative radiation therapy was not likely to be more efficacious than other alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested lactulose free nutritional supplement PediaSure for treatment of the enrollees chronic developmental delay.  Findings:  The physician reviewer found that the records indicate this patient with cerebral palsy is underweight and treated with PediaSure. However, the patients weight appears to be stable and there is no evidence that the patient cannot tolerate a pureed diet. In addition, there is no evidence of a nutritional or specialist consultation. The documentation does not demonstrate that the patient has tried a pureed diet and failed. Therefore, the continued use of PediaSure 5-10 cans per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee requested revision sinonasal surgery for treatment of the his chronic sinusitis.  Findings:  The physician reviewer found that submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. The patient has evidence on CT scan imaging of a persistence of the opacification of the frontal sinus. According to the clinical records, the patient has had at least two consultations with ear, nose and throat specialists who are in agreement that revision sinus surgery is indicated for treatment of his condition.   Based on the documentation submitted for review, the medically necessity for the requested procedure has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested Subsys 600mg sublingual spray for treatment of her intractable migraine headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient reportedly has refractory migraine.  The medical records do not describe headache frequency.  However, the use of opiates on a daily basis implies chronic daily pain, and thus chronic migraine.  Frequent analgesic use is known to result in transformation of episodic to chronic headache.  The medical records indicate prior use of multiple preventive medications. However, there is evidence that response to preventive medications can be hindered by opiate use.  There are preventive medications that do not appear to have been used in this patients case, including oral methylergonovine and Botox.  The latter is U.S. Food and Drug Administration (FDA) approved for chronic migraine, has good tolerability, and may be beneficial as opiates are being weaned.  All told, Subsys 600mg sublingual spray is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested a power wheelchair for medical treatment of his medical condition.  Findings:  The physician reviewer found that overall, the records from the specialized mobility evaluation do not support the medical necessity of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living.  This patient would benefit from increased upper body physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments due to conditions such as spinal cord injury.  There are no documented impairments that would limit or restrict regular manual wheelchair use in a household setting.  All told, the requested power wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested genetic testing (APC gene fam variants, CPT 81202; BRAF gene, CPT 81210; JAK2 gene, CPT-81270; KRAS gene, CPT 81275; and molecular pathology CPT 81479) for evaluation of her medical condition. Findings:  Three physician reviewers found that the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The standard of care for early breast cancer dictates that testing estrogen receptor status and expression of Her2-neu is critical in determining treatment.  A t this time, the requested testing is not considered the standard of care and was not likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee requested an ankle-foot orthotic (L1945) for medical treatment of his cerebral palsy. Findings:  The physician reviewer found that this patients records do not include a thorough evaluation by a specialist to support the requested AFO as medically necessary. A custom or prefabricated AFO may be appropriate for this patient with cerebral palsy. However, the patient needs a more thorough evaluation for this brace, preferably with a physiatrist with expertise in cerebral palsy or other neuromuscular conditions who are familiar with AFO devices. All told, the documentation does not support the medical necessity of the requested AFO device for treatment of this patients cerebral palsy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested a gene test for medical evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that the gene expression classifier (GEC) test is a relatively new method of obtaining additional information on the malignancy potential of thyroid nodules.  GEC is a tool that is best used when an indeterminate result is obtained in the cytology study and the provider is not able to determine whether surgery would be beneficial.  A benign result will favor continued observation and no surgery.  However, in this case, there is no documentation of a prior cytologic study with indeterminate result.  The report of this biopsy indicates that the genetic testing was the sole study performed in the specimen.  Thus, the gene test was not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested three platelet rich plasma injections for medical treatment of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the use of platelet rich plasma injections for the treatment of the tissue injury sustained by this patient.  While platelet rich plasma injections have been utilized in a variety of applications, including lateral epicondylitis, rotator cuff tears and a number of other tendinopathies, the evidence for efficacy is limited.  Specifically, there is an absence of randomized studies with sufficient size to control for unknown variables.  Thus, due to the lack of documentation of efficacy, the requested platelet rich plasma injections are not likely to be of greater benefit for the treatment of this patients condition than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested continued speech therapy/cognitive rehabilitation services for treatment of her medical condition. Findings:  Three physician reviewers found that the medical records indicate that the patient has had prior stroke, with residual deficits and impairments.  The current medical literature supports the requested services in this clinical setting.  The study by Wan and colleagues showed that an intensive rehabilitation program for patients with non-fluent aphasia led to structural changes in the right hemisphere, which correlated with improvements in speech production.  In this patients case, therapy notes show gradual continuing progress towards goals.  Per the medical literature, recovery post stroke occurs at varied paces, and can continue for many months or even years.  Thus, speech therapy/cognitive rehabilitation services were and are likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Soma for treatment of her chronic pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. 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; therefore long-term administration is not recommended (Fishman). Baron and McDonald reported that high dose opiates and centrally acting muscle relaxants might contribute to sensitization via hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of opioids and other medications such as Soma for a chronic medical condition reported a significant decrease in pain at the end of the study, further supporting the theory of hyperalgesia. It would therefore, be in the best interest of the patient to wean off the Soma. Moreover, centrally-acting and addictive muscle relaxants such as Soma are more likely to cause adverse outcomes and therefore the patients request for the Soma is not indicated. Ballantyne and Mao reported that prolonged use of centrally-acting medications might induce tolerance, and abnormal pain sensitivity. 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. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee requested an epidural steroid injection (ESI) (cortisone injection) for medical treatment of the enrollees left sided disc protrusion at L5-S1. Findings:  The physician reviewer found that based on a review of the available records, the ESI at issue were and are medically necessary for treatment of this patients chronic back and leg pain. The patient has a documented lumbar MRI consistent with his pain. In addition, he has tried and failed to receive relief with anti-inflammatory and opioid medications. The patient has participated in physical therapy and a home exercise program. However, the patient experienced significant reduction in his pain lasting greater than three months at a time following previous ESI treatments. All told, the ESI provided are medically necessary, for no more than four per year, as long as they provide relief for this patients symptoms of lumbar radiculitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested an electric scooter for medical treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the records indicate that this patient has no neurological deficits and no significant impairments in upper or lower limb strength or range of motion. In addition, there are no documented objective indications that she has cardiopulmonary or other organ system impairments that would preclude short periods of ambulation with a walker or manual wheelchair in the home setting to perform daily activities. There are no objective indications that the patient has impairments that would preclude community mobility using a manual wheelchair. Moreover, this patient has multiple chronic health conditions, including COPD, obesity, diabetes, hyperlipidemia and hypertension, which would generally benefit from increased physical activity and exercise (Brook, et al; Gloeckl, et al). Regular use of a power mobility device would likely further decrease her physical activity levels and would be expected to worsen her health conditions. Conversely, manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for patients with mobility impairments (Keyser, et al; Hastings, et al). Use of a powered mobility device, with its likely concurrent decrease in physical activity, is likely to exacerbate her risks for untoward outcomes. All told, a power mobility device is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested a computed tomography (CT) scan of the chest (thorax without dye, 71250) for medical evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found thatthe services were not likely to be more effective for this patient than other available options. Although patients with earlier stages of lung cancer have an improved survival, studies comparing populations of patients who received screening with sputum cytology and chest x-rays revealed no improvement in survival over those patients who did not receive screening. The study performed by the International Early Lung Cancer Action Program Investigators screened 31,567 asymptomatic persons at risk for lung cancer using low-dose CT. The study found that screening resulted in a diagnosis of lung cancer in 484 participants. However this study did not have a control group. Thus, it has not been documented that routine screening improves survival. Although in this case the patient has a history of smoking, the medical records submitted for review did not document hemoptysis, productive cough or chest pain. Therefore, the CT scan of the chest is not standard of care and not likely to be more beneficial for evaluation than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested a follow-up colonoscopy for evaluation of the enrollees colon polyps.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the American Gastroenterological Association guidelines, patients with 3 to 10 adenomas should undergo surveillance colonoscopy in 3 years. In this case, the patient had 9 colon polyps, and therefore should undergo surveillance colonoscopy 3 years from the date of the original colonoscopy. In addition, per the American Cancer Society guidelines, surveillance colonoscopy should be done 3 years in  people with 3 to 10 adenomas, or a large (1 cm +) adenoma, or any adenomas with high-grade dysplasia or villous features. Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested colonoscopy has not been established in this clinical setting.