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

A 60-year-old male enrollee has requested skin grafts (Acell MatriStem) for treatment of his neck and thigh wounds. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the use of Acell MatriStem in this clinical setting. The patient presented with chronic non-healing wounds, which had failed to fully close with grafting. The treatment of Acell MatriStem was minimally burdensome with healing in a short amount of time. Moreover, a study by Lecheminant and Field conducted on patients who received urinary bladder matrix extracellular matrix (UBM) (MatriStem) concluded that UBM is effective in the treatment of acute and recalcitrant ulcerations when applied correctly with an appropriate dressing. In addition, of the 34 patients evaluated all patients treated with UBM progressed to full healing (Lecheminant and Field). All told, the use of Acell MatriStem was likely to be more beneficial for the treatment of the patients medical condition than other available options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested inpatient psychiatric hospitalization level of care for treatment of his psychosis. Findings:  The physician reviewer found that on the date indicated, the patient had a reassuring presentation.  Per nursing, he was still isolative, but receptive to guidance.  He was engaging the therapeutic milieu, sleeping and eating well, and appropriately maintaining his activities of daily living.  The physician mental status examination reported no suicidal ideation, homicidality, recent aggressive behavior or hallucinations.  There had been no recent or proposed changes to the antipsychotic medication regimen.  Thus, transition to a less restrictive setting would have been appropriate on the date indicated.  All told, inpatient psychiatric hospitalization level of care from the time frame specified was medically indicated.  Per the medical records, the medical necessity of inpatient psychiatric hospitalization level of care from the subsequent time frame has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has been diagnosed with relapsing-remitting multiple sclerosis, and she has been on disease modifying therapy with Avonex.  There has been limited efficacy, with progression despite therapy.  She is JCV seropositive.  Thus, Tysabri is relatively contraindicated.  Patient compliance is important in long-term therapeutics.  Generally, patients prefer oral treatments and are more likely to be compliant when compared to injectable therapies.  The current medical literature supports Gilenya in this clinical setting.  There is adequate evidence supporting the efficacy of Gilenya as oral therapy.  All told, Gilenya is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested radiofrequency ablation of the lumbosacral joint x 2 (CPT 64635) and the lumbar spine x 4 (CPT 64636) for treatment of her axial pain in the lower back.  Findings:  Two physician reviewers found that the requested radiofrequency ablation of the lumbosacral joint and lumbar spine is supported as likely to be more beneficial than standard therapies on the patients left side. The records do not provide an indication for this procedure on the right side as no diagnostic injections have been performed to confirm the right sacroiliac joint as a possible pain generator. In addition, the requested L4-5 and L5-S1 facet joint/medial branch bilateral radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The records indicate that this was helpful for almost a year for the patient previously. For these reasons, bilateral radiofrequency ablation of the lumbosacral joint (CPT 64635) and left side lumbar spine (CPT 64636) are likely to provide this patient with an improved health outcome when compared with standard therapies. Therefore, a portion of the requested services should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested sclerotherapy for treatment of her spider telangiectasis.  Findings:  The physician reviewer found that based on the records provided for review, the requested procedure is not reconstructive in nature and not medically necessary for this patient. The patients condition does not constitute an abnormal structure of the body. In addition, the documentation does not support that the proposed procedure is directed at relieving the patients severe symptoms. The patient is having 10/10 pain with burning and limitation of her walking distance. The records do not indicate that more serious conditions have been ruled out. Additionally, the compression stockings provided no relief, which is evidence that treatment of the patients spider veins would not address the described symptoms. The requested treatment of the spider veins would primarily have a cosmetic benefit and are not to treat a functional impairment or severe symptoms. All told, the requested procedure is not reconstructive in nature and not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested acupuncture for treatment of the enrollees lateral epicondylitis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The medical records document lateral epicondylitis.  There is sufficient support for acupuncture in this clinical setting.  Trinh and colleagues performed a systematic review of the efficacy of acupuncture for the treatment of lateral epicondylitis.  The authors noted that the reviewed studies suggest that acupuncture was effective for the short-term relief of lateral epicondyle pain.  Trudel and colleagues conducted a systematic review to evaluate the efficacy of conservative treatments for lateral epicondylitis.  The authors noted that several treatments, including acupuncture, show positive effect in pain reduction or improvement in function.  All told, acupuncture is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested acupuncture for treatment of her spasmodic dysphonia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The patient underwent multiple series of acupuncture care for treatment of her spasmodic dysphonia and according to the patient the acupuncture has been beneficial. However, upon review of the treatment notes from the patients most recent course of acupuncture, there was no documentation of any significant, objective improvement. As this patient has already undergone several courses of acupuncture care without any significant, measurable outcomes it is unlikely that she will benefit from continued therapy. Therefore, in the absence of evidence of gains in significant, sustained functional activities of daily living (ADLs) with previous acupuncture, additional acupuncture is not supported and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services in this clinical setting.  Rutjes and colleagues performed a systematic review and meta-analysis to assess the benefits and risks of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults.  The authors concluded that viscosupplementation is associated with an increased risk of adverse events and a clinically irrelevant benefit.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  All told, a third series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested platelet rich plasma treatments for treatment of his hip osteoarthritis.  Findings:  The physician reviewer found that prolotherapy is noted to be used in treating ligaments, tendons, muscles, and joints. In the article authored by Sheth and colleagues, a meta-analysis of 23 different randomized trials and 10 prospective cohort studies were reviewed. The authors found a lack of consistency in outcome measures across all studies. Visual analog scores were used in many of the studies comparing platelet rich plasma with alternative injection therapies. These authors concluded that platelet rich plasma provided no significant benefit up to and including 24 months across the randomized trial. In this case, the patient presents with bilateral degenerative osteoarthritis of the hips. There is little consensus that platelet rich plasma would be effective and beneficial in management of the patients bilateral degenerative osteoarthritis of the hips. All told, it is not medically necessary for the patient to undergo the proposed series of platelet rich plasma injections.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested anakinra (Kineret) for treatment of the enrollees systemic juvenile idiopathic arthritis.   Findings:  Two physician reviewers found that there is adequate evidence in the peer-reviewed medical literature including appropriately designed studies, case series, and case reports to support the safety and efficacy of Kineret in the treatment of patients with soJIA. This patient has already been started on Kineret and has responded with symptomatic improvement and ability to reduce his need for steroids. All told, the requested medication is supported as likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary frequency.  Findings:  Three physician reviewers found that review of the submitted documentation fails to demonstrate that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than standard therapies. This patient has overactive bladder symptoms and was provided PTNS for treatment of her symptoms. Based on a review of current medical literature there is a lack of adequate studies which distinguish PTNS as a superior form of therapy over conventional therapies such as pelvic floor relaxation exercises or medications like Vesicare and oxybutynin. Thus, percutaneous tibial nerve stimulation was not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested the brand name drug Neurontin, the brand name drug Ultram, and medicinal marijuana for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this clinical setting.  The current standard of care for chronic back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  In regards to medication, the peer-reviewed literature advocates non-steroidal anti-inflammatory medications as the gold standard for non-radicular and non-neuropathic axial pain.  Ultram is a mild opioid which has the potential for dependence and abuse.  In a retrospective study by Baron and McDonald, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Further, although gabapentin (Neurontin) is efficacious for treatment of neuropathic and post-surgical pain, non-steroidal anti-inflammatory medications are superior for the treatment of chronic axial back pain, such as is involved in this case. Moreover, there is a lack of evidence demonstrating that medicinal marijuana is more effective in this setting than non-steroidal anti-inflammatory medications. The current medical evidence does not support the requested medications for the treatment of this patient.  All told, the brand name drug Neurontin, the brand name drug Ultram and medicinal marijuana are not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested an implantable cardioverter defibrillator for treatment of her long QT syndrome and Class I mutation for long QT syndrome.  Findings:  Three physician reviewers found that in this patients clinical circumstance, even though she has not had syncope or sudden cardiac death, prophylactic ICD placement is appropriate due to the high risk of developing such an event based on her strong family history and identified gene mutation. Current guidelines endorsed by several national organizations also consider a prophylactic ICD placement reasonable in this setting. Specifically, the guidelines state that in patients with prolonged QT the use of the ICD for primary prevention of sudden cardiac death may be considered when there is a strong family history of sudden cardiac death or when compliance or intolerance to drugs is a concern (Epstein, et al). Other studies also support the use of primary prevention ICD devices in high-risk patients with a strong family history of sudden cardiac death and the same deleterious gene mutation as the proband identified in this patient (Zareba, et al; Monnig, et al). All told, the requested ICD is 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 52-year-old female enrollee has requested high intensity ultrasound using magnetic resonance imaging (MRI) guidance for treatment of her uterine fibroids and menorrhagia. Findings:  Three physician reviewers found that the FDA approved the use of this modality in the treatment of uterine fibroids following the completion of a multicenter trial. One study concluded that high intensity ultrasound using MRI guidance demonstrated promise for a non-invasive method of fibroid treatment but cautioned that a randomized clinical trial was necessary to confirm whether this treatment has a role in the available treatment options for fibroids. In addition, there are no adequate peer-reviewed studies directly comparing the efficacy and safety of this treatment with available standard alternatives. Although initial results are promising, the long-term results are currently unknown. Consistent with these findings, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested Norco 10mg (3 times per day as needed) and Soma 350mg (3 weeks on and 1 week off as needed) for treatment of his chronic pain syndrome.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medications. The clinical documentation lacked evidence of a thorough physical exam of the patient, documentation of the patients average rate of pain on a visual analog scale (VAS) and documentation of other conservative treatment modalities the patient has utilized for his pain complaints. The clinical notes also evidence the patient was advised to utilize active treatment modalities for his pain complaints, which the patient declined. Standard of care would indicate the patients medication regimen is not supported at this time as there is lack of documentation evidencing efficacy of the patients medication regimen, such as a decrease in rate of pain on a VAS, increase in objective functional improvement, and utilization of active treatment modalities. Given the reasons provided above, the requested medications are not medically necessary for the treatment of the patients chronic pain syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested Xifaxan for treatment of his small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the benefit of rifaximin (Xifaxan) in treating small intestinal bacterial overgrowth (SIBO) is well-recognized. Scarpellini and colleagues assessed the effects of Xifaxan treatment on 50 children with irritable bowel syndrome (IBS). All patients underwent lactulose hydrogen/methane breath test to assess SIBO before and one month after the treatment with Xifaxan 600 mg daily for one week. Compliance was excellent, and no relevant side-effects were observed during treatment. In addition, Farrell noted that, Xifaxan is a member of the rifamycin class of antibiotics which are currently used to treat serious human diseases including tuberculosis, meningococcal disease, methicillin-resistant Staphylococcus aureus and Clostridium difficile infections and development of resistance to antibiotics with long-term use is a concern. The author concluded that it is advisable that the use of rifaximin as a therapy for IBS should be limited to single, acute, short-term treatment. In this patients case, a post-Xifaxan breath test was not performed to document objective response particularly given the equivocal results seen on his pre-treatment breath test. All told, Xifaxan was not medically necessary for treatment of this patients medical condition when provided on the dates specified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested left lower eyelid blepharoplasty for treatment of her dermatochalasis.  Findings:  The physician reviewer found that the medical literature consistent describes lower blepharoplasty as a cosmetic procedure. In this patients case, the requested blepharoplasty is not going to resolve any functional problems although it will provide a cosmetic improvement. The patients symptoms of tearing and eye redness may require alternative medical or surgical therapies. However, blepharoplasty is not indicated for either of these symptoms. All told, the requested surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested radiofrequency ablation (RFA) for treatment of his Barretts esophagus.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services. The patient has a relatively short segment of non-dysplastic Barretts esophagus. The patients overall risk of developing esophageal cancer is low, with the risk between 2-10%. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested radiofrequency ablation is not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment services the enrollees polysubstance dependence, major depressive disorder, and parent-child relational problem.  Findings:  The physician reviewer found that this patient had extreme risks factors for relapse, which was recognized by the treatment team. However, she was prematurely discharged and relapsed. Her history is that of extreme maladaptive behavior, severe substance abuse, feelings of alienation from her family and very poor compliance with treatment. Her lack of a supportive home environment coupled with her history of poor compliance with treatment demonstrate the medical necessity of the close monitoring and supervision provided in a 24-hour RTC facility. Consistent with these findings, the services provided during the said timeframe were medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested a standing frame for treatment of the enrollees cerebral palsy. Findings:  Three physician reviewers found that the submitted documentation and relevant literature supports the use of a standing frame in this clinical setting. This patient has cerebral palsy and cannot stand or attempt ambulation unless a supportive system is in place. This patient is also fitted with ankle foot orthosis (AFO) to aid in prevention of ankle foot contractures. According to Gibson and colleagues standing frames in non-mobile children significantly improved ankle contractures. Moreover, within the rehabilitation medical community it is well-accepted that the standing position in immobile children will improve cardiac tone, help prevent vasovagal syncope, reduce loss of bone density and improve pulmonary hygiene. Thus, the standing frame is likely to be more beneficial for the treatment of the patients medical condition than other available options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested partial hospitalization program (PHP) level of care services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that based on review of the available records, this patient has continued to struggle with omissions and restrictions of her insulin. She also continued to binge and restrict. The patient reported that she has binged every night since the said date, which is important because she was in PHP level of care, and was not supervised at night. This indicates that she was still in need of a considerable amount of supervision to stay safe. According to the American Psychiatric Association (APA) level of care guidelines for eating disorders, PHP is indicated when the patient has partial motivation and still needs some structure beyond self-control to prevent purging and compulsive exercising. This patient has the additional burden of diabetes mellitus I and misuse of her insulin, adding further complications to her health. For these reasons, the patient met the APA guidelines for PHP services provided during the said time frame. Therefore, the PHP services at issue were medically necessary for treatment of this patients medical condition.