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

A 25-year-old female enrollee requested occupational therapy of the hand for medical treatment of her myotonic dystrophy.  Findings:  The physician reviewer found that the requested therapy is medically necessary for treatment of the patients medical condition. The medical literature supports the requested therapy in this clinical setting. Aldehag and colleagues (2013) demonstrated that a hand training program had positive effects on strength, self-perception of occupational performance, and of satisfaction with performance. In addition, Brady and colleagues found that patients who participate in regular physical activity for at least one year had greater grip strength than those who were not active. Based on the medical literature and documentation submitted for review, additional occupational therapy of the hand is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested immune globulin intravenous (IVIG) for medical treatment of his neuromuscular hyperexcitability syndrome (cramp fasciculation syndrome.) Findings:  The physician reviewer found that in the medical literature, Liewluck and colleagues indicate that most patients with positive antibodies can be treated with oral neuromuscular stabilizing agents such as carbamazepine, phenytoin, gabapentin, or Lyrica, and that most do not require immunosuppression. The authors also state that there is no role for use of immunosuppressant therapies in patients without evidence of autoantibodies. In this patient, no autoantibodies have been documented. Overall, there is a lack of data that identifies IVIG as a specific treatment for muscle hyperexcitability syndromes including cramp-fasciculation syndrome. For these reasons, the use of IVIG is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee requested a Courtney Bed, fully enclosed hospital grade bed, as a medical necessity of the enrollee, who has global developmental delay.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  The Courtney Bed is a fully enclosed hospital grade bed which is likely to be of benefit in this patients case.  Any type of open bed, hospital grade or community grade, poses a risk to this patient.  He has limited safe mobility, yet is highly active and lacks safety awareness and protective reflexes.  The patients current sleeping situation, with the mattress inside the crib frame but on the floor, is unacceptable because of the risk of entrapment and collapse of the crib.  A toddler bed is an open system from which he can fall or injure himself while trying to stand.  The ideal system encases him in such a way that he cannot get entrapped, become injured by the frame, or fall out.  The Courtney Bed provides a sleep environment that is safe for this patient.  All told, the requested Courtney Bed, fully enclosed hospital grade bed, is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested the Flexi-Touch lymphatic pump, suction-assisted lipectomy and double-blind study for medical treatment of her lymphedema.  Findings:  The physician reviewer found that the patient has had CDT, used compression garments, had massage and physical therapy and used exercise for the treatment of lymphedema.  She continues to have recurrent cellulitis and pain with ongoing lymphedema.  The use of Flexi-Touch lymphatic pump (IPC) is a medically appropriate addition to her ongoing treatment regimen.  However, the requested double-blind study using anti-inflammatories is not standard of care and is not medically necessary for the treatment of this patient.  This patient has not failed use of a combined program of CDT, compression garments and IPC.  Furthermore, the surgical intervention is often not permanently effective.  Thus, the surgical procedure of suction-assisted lipectomy is not medically necessary.  All told, the requested Flexi-Touch lymphatic pump is medically indicated for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessity of the requested suction-assisted lipectomy and double-blind study.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee requested a pediatric wheelchair (Convaid Cruiser for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment.   The documentation submitted for review indicates the patients activities of daily living were not dependent on the use of a wheelchair.  Given that the patient was noted to have no significant functional limitations in regards to the lower extremities and she was not using the wheelchair on a regular basis because she is ambulatory and that the proposed wheelchair is for the purpose of fatigue, feedings and behavioral modification, the medical necessity of the requested wheelchair has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested  intravenous antibiotic Rocephin (ceftriaxone) for treatment of his medical condition.  Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with cerebral vasculitis and a borderline positive Lyme titer. However, there is no documentation showing that cerebrospinal fluid analysis has been performed. In this case, although the patient may have neuroborreliosis, the differential diagnosis of cerebral vasculitis is varied and long. Finally, the medical literature does not support the use of repeat and long courses, beyond four weeks, of antibiotics for the treatment of Lyme disease. Thus, Rocephin was not and is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested the AmniSure test (evaluate amniotic fluid protein for medical evaluation of her pregnancy. Findings:  Three physician reviewers found that most cases of premature rupture of membranes can be diagnosed on the basis of the patients history and physical examination consisting of visualization of amniotic fluid passing from the cervical canal and pooling in the vagina. First-line testing includes a basic pH test of vaginal fluid (Nitrazine) or arborization of dried vaginal fluid. Based on the records reviewed, this patient underwent AmniSure testing in lieu of standard testing. Therefore, the AmniSure test (evaluate amniotic fluid protein) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee requested emergency services and an MRI on an emergent basis. Findings:  The physician reviewer found that the patient was experiencing pain, numbness and cold sensation in her right foot and ankle.  A prudent layperson with these symptoms would reasonably expect that the absence of immediate medical attention could result in serious harm.  Possible etiologies in this setting include infection, venous thrombosis and fracture.  Given the patients vascular/neurological complaints, it was appropriate for her to seek immediate medical attention.   As the patient presented to the emergency department with signs and symptoms consistent with an emergency medical condition, all of the services, including the MRI, met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested endovenous laser ablation (CPT code 36478 x 2 for both greater saphenous veins) for medical treatment of the enrollees varicose veins.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested services in this clinical setting. The patient has significant long-standing symptoms and a CEAP classification of level 3 venous disease of the left leg. Her symptoms of edema, varicosities, and dilatation of the greater saphenous vein suggest long-standing venous reflux in this left leg. She also has significant reflux and dilatation of the bilateral lesser saphenous veins. Given these findings the requested services are clinically indicated. The patient also meets the Society for Vascular Surgery and the American Venus Forum guideline criteria for ablation of the greater saphenous veins. For the reasons provided, the requested services are likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested  magnetic resonance imaging (MRI) with contrast of the breasts for medical evaluation of her breast pain and left breast axillary mass.  Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature and this patients records, the requested breast MRI is not likely to provide additional helpful information relevant to this patients evaluation and treatment. There is no indication for the requested diagnostic procedure given the negative findings on breast mammogram and ultrasound. Further, there is a lack of scientific evidence supporting the clinical utility of breast MRI in this setting. All told, the requested bilateral breast MRI with contrast is not likely to be more beneficial for evaluation of the patients breast pain than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested Gilenya 0.5mg capsules for 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 relapsing remitting multiple sclerosis, with weakness and cognitive involvement. She requires disease-modifying therapy.  Injection therapies are uncomfortable, and lack of adherence to treatment reduces clinical benefits.  Gilenya has been well-studied and has been shown to be safe and effective for the treatment of relapsing-remitting multiple sclerosis.  Per the current medical evidence, Gilenya is accepted as a first-line therapy for relapsing-remitting multiple sclerosis.  Bergvall and colleagues noted that patients with multiple sclerosis who switched from interferon therapy to fingolimod (Gilenya) were less likely to experience relapses as compared to patients who switched to glatiramer acetate.  All told, Gilenya 0.5mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee requested adalimumab (Humira) injections for treatment of his panuveitis.  Findings:  Three physician reviewers found that tumor necrosis factor (TNF) inhibitors such as Humira are being used increasingly more often in the management of severe ocular inflammation that is not responsive to standard treatments (Gupta, et al; Soheilian, et al). The records indicate that this patient has been receiving the standard of care treatment including high-dose steroids, T-cell inhibitors and anti-proliferative agents. The only two remaining options for this patient are to use alkylating agents or TNF inhibitors. Given the better safety profile, TNF inhibitors are the preferred treatment for this patient. As such, the requested Humira is supported as likely to be more beneficial for treatment of this patients panuveitis than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested the morrow procedure (septal myectomy) for treatment of his obstructive hypertrophic cardiomyopathy.  Findings:  The physician reviewer found that although hypertrophic obstructive cardiomyopathy may be initially treated with medical therapy, the current indication for surgery includes symptoms unrelieved by intensive medical treatment in a patient with a ventricular outflow gradient of at least 50 mmHg. This patients echocardiogram while on medical therapy demonstrates a peak gradient of 55 mmHg with mild-to-moderate mitral regurgitation. However, the patients cardiac catheterization report documents a peak gradient of greater than 100 mmHg. Given these findings, the requested morrow procedure (septal myectomy) is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee requested a wearable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  Two physician reviewers found that a wearable cardioverter defibrillator offers a potential prophylactic strategy for patients considered at high-risk for sudden cardiac death due to ventricular tachycardia or ventricular fibrillation, but who are not defined to be immediate candidates for permanent automatic cardioverter defibrillator devices.  Currently accepted considerations for use of this device include as a bridge to automatic cardioverter defibrillator devices implantation or until the arrhythmic risk is felt to have subsided.  This patient presented with new onset of non-ischemic cardiomyopathy and marked impairment of left ventricular systolic function.  In this clinical setting, utilization of a wearable cardioverter defibrillator was 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 64-year-old female enrollee has requested the combination of Sovaldi and Olysio for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that in this patients case, the requested medication combination is not likely to be more effective than other treatment options.  She has minimal hepatic fibrosis per her biopsy.  There is no updated pathology or non-invasive fibrosis marker such as FibroSure or transient elastography.  Although she is likely to eradicate the virus on the combination of Olysio and Sovaldi, the actual benefit to her is negligible based on her level of fibrosis.  Per the medical records, she has no evidence of extrahepatic manifestations of hepatitis C such as cryoglobulinemia.  All told, the superior efficacy of the requested combination of Sovaldi and Olysio has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Lyrica for treatment of her back pain, neuralgia, neuritis, and radiculitis.  Findings:  The physician reviewer found that Lyrica is not medically necessary treatment for treatment of this patients chronic low back pain. Gabapentin (Neurontin) and Lyrica have similar safety and efficacy in the medical literature for chronic neuropathic pain. In the medical literature, Jeffrey published a multi-center trial including 137 spinal injury patients who were randomized to receive a flexible dose of Lyrica 150 to 600 mg per day or placebo on top of existing stable pain therapy. The purpose of the study was to assess the efficacy and safety of Lyrica in this patient population. After 12 weeks, patients in the Lyrica group had a significantly lower mean pain score than those in the placebo group. Efficacy was seen as early as the first week for some patients and was maintained through the duration of the study. The author concluded that Lyrica is being used routinely in people with neuropathic pain following spinal cord injury. Gilron reviewed the evidence-based literature supporting the use of Neurontin and Lyrica use for chronic neuropathic and early post-surgical pain. The author found that multiple, large, high quality trials have demonstrated the safety and efficacy of Neurontin and Lyrica in neuropathic pain. The review concluded that Neurontin and Lyrica are efficacious treatments for neuropathic and post-surgical pain. This patients medical records document a negative straight leg raise on physical exam and she does not seem to be exhibiting neuropathic or radicular pain. In addition, there is a lack of documentation that the patient has failed treatment with other anticonvulsant medications in the same class. Based on these findings, the requested Lyrica is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested laminotomy for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of support for the requested laminotomy, as the current medical evidence supports nonoperative management in this clinical setting.  This patient has a history of low back pain and leg pain, and the records note multiple significant comorbidities, including cirrhosis of the liver, pancreatitis and ongoing opiate use.  The patients examinations and anatomical studies suggest a diagnosis of complex regional pain syndrome.  In this patients case, the likelihood of a favorable outcome after a surgical intervention for the lumbosacral spine is limited by her comorbidities and a lack of specificity in diagnosis.  In sum, the requested laminotomy is not medically necessary given her multiple comorbidities and lack of specificity in anatomical diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested intravenous (IV) tocilizumab (Actemra) for treatment of her Takayasu arteritis. Findings:  Three physician reviewers found that Takayasu arteritis is a rare vasculitis, thus it is unlikely that any randomized placebo controlled phase III clinical trials will become available. This patient has been responding to treatment with Actemra. Ceasing treatment that has improved her condition will likely result in clinical deterioration of her condition given her history of aortic aneurysms requiring surgery. Treatment of Takayasu arteritis with Actemra has been shown to be effective in several case series. All told, the requested Actemra is supported as likely to provide this patient with an improved health outcome as compared to expected results with standard available alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested  magnetic resonance imaging (MRI) of the lumbar spine for medical evaluation of her back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure.  This patient continues to have low back pain with radicular symptoms despite completing 22 physical therapy visits in 2012.  In this case, the patients persistent symptoms despite extensive physical therapy are indications for further imaging.  National Imaging Associates, Inc. guidelines do not specify a timeframe for conservative management when there is exacerbation of chronic low back pain.  In addition, while surgery is not contemplated at this time, the request for pain management intervention is reasonable and such consultation routinely requires MRI scan prior to seeing the patient.  Often, MRI serves as a roadmap for intervention via injection by the pain management specialist.  All told, the requested MRI of the lumbar spine is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested genetic testing (BRAF Mutation Analysis  CPT 81210 and KRAS Mutation Analysis  CPT 81275) for medical evaluation of her thyroid nodule. Findings:  Two physician reviewers found that In the peer-reviewed medical literature, Alexander and colleagues concluded of their study that a gene-expression classifier can be used to identify a subpopulation of patients with a low likelihood of cancer in a population of patients for whom diagnostic surgery is otherwise recommended. Since each clinical decision must be individualized, these data suggest consideration of a more conservative clinical approach for patients who have nodules with indeterminate cytologic features on fine needle aspiration and a benign result on gene expression classifier testing. Given this clinical support, genetic testing (BRAF Mutation Analysis  CPT 81210 and KRAS Mutation Analysis  CPT 81275) was appropriate and likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested a single Mohs procedure to remove all of his facial basal cell carcinoma lesions for treatment of his medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The treatment of choice for basal cell carcinomas of the face, particularly a recurrent basal cell carcinoma, is Mohs micrographic surgery.  However, the submitted records fail to demonstrate the medical indication for treating all lesions in a single day.  If a lesion is particularly large or the closure is expected to be complicated or encroach on the border of another lesion, performing the procedure at separate visits may be indicated.  It is at the determination of the surgeon as to the best way to proceed with removal of the lesions and how many lesions can be safely treated at one time.  The recommendation that each lesion be treated at a separate visit is medically appropriate.  All told, the requested for a single Mohs procedure to remove all of the patients facial basal cell carcinoma lesions is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old female enrollee requested sensory integration therapy for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the patient has significant fine motor and sensory processing delays. Occupational therapy incorporating sensory integration therapy is a medically reasonable and appropriate modality to address these issues. All told, sensory integration therapy was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.