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

A 56-year-old male enrollee has requested Harvoni (sofosbuvir in combination with ledipasvir (90/400mg)) for 12 weeks for treatment of his hepatitis C, genotype 4. Findings:  Two physician reviewers found that in this case, the requested medication is likely to be more effective than other treatment options.  The patient has cirrhosis of the liver and therefore is not a candidate for interferon-based therapy.  The requested medication has been demonstrated to be safe and effective in this clinical setting.  The SYNERGY trial studied 21 patients with hepatitis C, genotype 4 who were treated for 12 weeks with the combination of sofosbuvir and ledipasvir.  The results indicated a sustained virologic response of 95%.  In sum, the requested Harvoni (sofosbuvir in combination with ledipasvir (90/400mg)) for 12 weeks is likely to be superior over other treatment regimens.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee requested substance abuse residential treatment services for medical treatment of his substance abuse.  Findings:  The physician reviewer found that the patients symptoms were not life threatening and could have been managed at a lower level of care. Medically and psychiatrically his management was stable and did not require 24-hour supervision in a restricted setting. He was engaged and participated in his treatment. He had no prior history of treatment at a lower level of care.  His living situation did not undermine his treatment. His substance abuse did not cause significant impairment that could not be managed safely at 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 59-year-old male enrollee requested Orthovisc injections for medical treatment of his osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation.  The authors concluded that viscosupplementation is associated with a clinically irrelevant benefit and an increased risk of serious adverse effects.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee requested genetic testing for medical evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case, the finding by this standard technique was atypia of undetermined significance. This patient was facing total thyroidectomy if malignancy was present, and only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted for gene expression analysis. The overall conclusions by both Alexander and colleagues and Chudova and colleagues are that unnecessary thyroid surgeries may be prevented by implementation of the gene expression test. Based on the peer-reviewed literature cited above, the testing at issue was 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

The parent of a 14-year-old male enrollee requested speech therapy and ongoing occupational therapy (OT) for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that a portion of the requested services are medically necessary for treatment of the patients medical condition.  According to a speech-language evaluation, the patients communication goals are being addressed in his comprehensive ABA program. Given that his speech therapy is being addressed through ABA, additional speech therapy is not medically necessary.  Occupational therapy has been requested to address the patients coping strategies when overwhelmed. The record demonstrates that the patient has fears that lead to his avoidance of elevators/escalators and long car rides. Sensory processing abnormalities, anxiety and restricted and repetitive behavior frequently co-occur in autism spectrum disorders. According to Barton and colleagues, Sensory-based therapies are designed to address sensory processing difficulties by helping to organize and control the regulation of environmental sensory inputs. As such, using an OT sensory processing technique to address the patients anxieties is clinically appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested continued skilled nursing facility services, including physical therapy for treatment of his medical conditions. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of continued skilled nursing facility services, including physical therapy has not been established. In this case, the patient has a severe myopathy of unknown cause that has led to profound functional impairment. Physical therapy reportedly worsens his symptoms, thus additional physical therapy is not medically necessary. In addition, extensive exercise therapies are not part of treatment in this clinical setting. Stretching to reduce the risk of contracture is important; however this does not require skilled therapists. Therefore, the continuation of skilled nursing facility services, including physical therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested residential treatment center (RTC) services and partial hospitalization program (PHP) services for medical treatment of her anorexia nervosa and anxiety.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the patient meets admission and continued stay criteria for a PHP level of care. However, the records do not support the medical necessity of RTC level of care services. In this case, the patient appears to have motivation for treatment as judged by her cooperation and openness in treatment. Due to her failure of outpatient treatment, it appears that more structured treatment is warranted in order to stop her rapid weight loss. She has no documented episodes of orthostasis and her bradycardia is also not problematic. In addition, the patients problems with purging behaviors, over exercising, and anxiety support the continued need for treatment at the PHP level of care. All told, RTC services were not medically necessary, while PHP services  were and are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested 40 hours per week of applied behavioral analysis (ABA) services for medical treatment of the enrollees Rett syndrome and autism spectrum disorder.  Findings:  Two physician reviewers found that there is a lack of medical literature supporting the use of ABA or other behavioral therapies for the treatment of Rett syndrome. However, ABA therapy is the standard of care in the therapeutic intervention of autistic children. According to Myers and Johnson, Educational interventions, including behavioral strategies and habilitative therapies, are the cornerstones of management of ASDs. These interventions address communication, social skills, daily-living skills, play and leisure skills, academic achievement, and maladaptive behaviors. In this case, the Health Plan has authorized 25 hours per week of direct ABA services. This frequency of therapy is sufficient to address the patients behavior excesses and deficits. Therefore, the request for 40 hours per week of ABA services is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested cervical total disc arthroplasty (artificial disc) for treatment of her parasthesias with moderate to severe central spinal stenosis.  Findings:  Two physician reviewers found that there is an increasing interest in spinal arthroplasty as an alternative to fusion in conjunction with cervical discectomy. However, there are currently no comparative studies of artificial disc replacement with other treatment modalities besides fusion. In addition, the durability of this procedure is unknown, which is important based on the age of most patients who fit the current criteria for treatment. Further, there is limited data in terms of mechanical failure and aseptic loosening. There is also limited evidence as to the long-term effect on index-level facet arthrosis and/or adjacent level degeneration. Moreover, the devices utilized in artificial disc appear to yield results equal to or only incrementally better than fusion for the same indications (Resnick and Watters). Finally, the consequences of failure of an implant in close proximity to the spinal cord, the esophagus, and the trachea are of concern. The available peer-reviewed medical literature suggests that an analysis of these types of questions will take from five to 10 years. The suggested surgery is a three-level construct, yet the literature review shows greater than two levels to be contraindicated. Given the lack of scientific data demonstrating improved health outcomes with artificial disc replacement in the spine, the requested cervical total disc arthroplasty (artificial disc) is not 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

A 40-year-old female enrollee requested Copaxone 40mg prefilled syringes, 12 per box (equals one month supply for medical treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has been diagnosed with relapsing-remitting multiple sclerosis.  She has had difficulty with self-injection on a daily basis, and has limited injection locations.  Per the current medical evidence, patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and should help foster adherence.  The requested dosage has been demonstrated to be safe and well-tolerated.  All told, the requested Copaxone 40mg prefilled syringes, 12 per box (equals one month supply) are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested inpatient hospital services for medical treatment of his dyspnea with exertion/chest pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records note atypical chest discomfort after exercise and a negative initial evaluation.  In this case of a clinically stable patient with no objective evidence of ischemia, it would have been safe and effective to manage the patient at an observational level of care as opposed to a hospital admission.  Several studies have demonstrated the safety and efficacy of treating stable patients with chest discomfort in an observational setting as opposed to a hospital admission.  All told, inpatient hospital services were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 A male enrollee requested an implantable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  Three physician reviewers found that the services at issue were likely to have been superior over other treatment options.  The medical records noted left ventricular dysfunction and a recent ejection fraction of 30 to 35%.  The current medical evidence supports an implantable cardioverter defibrillator in this clinical setting.  Given this patients history, the device at issue was indicated for primary prevention of sudden cardiac death.  All told, an implantable cardioverter defibrillator was likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested  neuropsychological testing for evaluation of her memory issues, dexterity problems, trembling and clumsiness.  Findings:  The physician reviewer found that this patient presented to her provider with reported memory problems.  The records indicate that the provider took a very brief history of the problem, did not perform neurologic testing or simple memory testing, and subsequently ordered an MRI and neuropsychological testing.  Memory complaints in the peri-menopausal period are very common and typically improve once menopause has started.  While hormonal changes may be one cause, anxiety, sleep disorder and depression are also common causes of memory issues in midlife.  There is a lack of support for the services at issue in this clinical setting.  The usual work-up would include a much more detailed history, a complete neurologic examination, and screening memory testing.  The medical records do not document objective findings to suggest early onset dementia or encephalopathy.  All told, the neuropsychological testing performed was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested Harvoni (90/400 mg tablets for 12 weeks) for treatment of the enrollees hepatitis C genotype 1a.  Findings:  Three physician reviewers found that in a recent study, Flamm and colleagues presented findings from the SOLAR study testing an all-oral regimen of direct-acting antivirals that have minimal side effects and cure most people with less advanced liver disease. Overall, 87% of patients treated for 12 weeks and 89% treated for 24 weeks achieved sustained virologic response, or continued undetectable hepatitis C virus viral load 12 weeks after completing therapy, which is considered a cure. The patients were randomly assigned to receive therapy for 12 or 24 weeks. Successful treatment not only eradicated hepatitis C virus, but was also associated with improvement in liver function. All told, the medical literature supports the use of Harvoni (90/400 mg tablets for 12 weeks) for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested  hyaluronate (Orthovisc) injections for treatment of the enrollees osteoarthritis.  Findings:  Two physician reviewers found that the evidence based guidelines provide adequate evidence to support the use of intra-articular knee injections, as a valuable intervention in the continuum of management of arthritis between conservative treatments and knee surgeries, as in this patients case. Administration of these injections have demonstrated anti-inflammatory analgesic effects. The injections that this patient has undergone have been beneficial in both increasing function and decreasing pain. The patient has shown to have benefited with 18 months of pain relief from the previous injection. As such, the requested Orthovisc injections are 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

A 56-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of her cervical pain with radiculopathy down the right arm.  Findings:  The physician reviewer found that while there was no clinical evaluation documented, the patient exhibited symptoms at that visit which would support an indication for MRI of the cervical spine per the National Imaging Associates (NIA) clinical guidelines. Specifically, the patient demonstrated decreased upper extremity reflexes and hypersensitivity of the right upper extremity as well as pain distribution in the C7 root distribution. These abnormal neurological findings qualify for MRI of the cervical spine based upon the information provided. Thus, the requested MRI of the cervical spine is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 77-year-old male enrollee has requested skilled nursing facility services and a swallow test for treatment of his medical condition.  Findings:  The physician reviewer found that the patient did not sustain an acute stroke.  He had deconditioning related to pneumonia.  He was treated with antibiotics with empiric coverage for aspiration and was placed on a modified texture diet.  Thus, the requested swallowing study is medically indicated and can be provided on an outpatient basis.  However, the patient was not making significant progress and was not meaningfully participating in therapies to substantiate a need for inpatient rehabilitation services.  Further therapy services could have been provided on a less intensive basis in the community setting.  There are no documented ongoing skilled nursing needs in this patients case.  All told, the requested swallow test is medically indicated in this patients case.  However, the records fail to demonstrate the medical necessity of the requested skilled nursing facility services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested hydrocodone/acetaminophen 5-325 mg oral tablets #30 for medical treatment of her chronic pain syndrome, acquired kyphosis, and acquired spondylolisthesis. Findings:  The physician reviewer found that the peer-reviewed medical literature indicates there is a lack of evidence supporting the benefits of opioids for the treatment of chronic pain (Warner). There is no evidence of a recent comprehensive examination having been performed to verify the patient has an ongoing need for an opioid analgesic to treat her symptoms. Moreover, the patient is noted to have had an inconsistent urine drug screen, and there is no evidence of a recent urine drug screen, which is required for ongoing treatment with opioids. Based on the available documentation and the medical literature, the requested hydrocodone/acetaminophen 5-325 mg oral tablets #30 are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee requested a 12-week course of Harvoni 90/400 mg tablets for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that in treatment-naive patients, therapy is recommended with Harvoni for 12 weeks. In addition, Harvoni is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. According to the article by Younossi and colleagues, the initiation of HCV therapy at an earlier disease stage yielded substantially fewer cases of decompensated cirrhosis, hepatocellular carcinoma, liver transplant and HCV-related death. Based on the medical literature and clinical guidelines, Harvoni is medically necessary for treatment of this patients medical condition of HCV.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.   Findings:  The physician reviewer found that some patients do fail to lose or maintain weight loss following sleeve gastrectomy. Based on the documentation provided, it is not clear that this patient has been compliant with diet and activity requirements following surgery. Overall, the patient specific causes that might lead to a failure of a second operation with durable weight loss have not been addressed. Given the absence of a more thorough assessment and documentation of compliance with a diet and exercise regimen, the requested revision of the gastric sleeve is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic studies. According to Chou and colleagues, Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition. The clinical documentation provided for review did not indicate that the patient had any kind of nerve pressure or worsening pain prior to the diagnostic study being performed. There was no indication that the patient had attempted conservative therapy prior to the diagnostic study. There was no documentation that the patient had any severe or progressive neurologic deficits that would warrant the need for an MRI study. All told, the medical necessity for the MRI of the lumbar spine performed has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested air and ground ambulance services for treatment of his metastatic colon cancer.  Findings:  The physician reviewer found that air ambulances are appropriately used in situations of medical emergency, where a patient emergently requires a specific intervention, available only at a geographically distant location. Typically, the intervention or medical service required is not available at a closer location amenable to ground transport, and the delay in reaching the destination if transported by ground ambulance, would jeopardize the patients care. This patients records do not document that the patient required transportation by either ground or air ambulance. Further, there is no documented contraindication for travel on a commercial airline with appropriate precautions and supervision. All told, the air and ground ambulance services provided were not medically necessary for treatment of this patients medical condition.