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

The parent of a male enrollee has requested the addition of a new speech goal of K and G articulation to the enrollees speech therapy treatment plan for treatment of the enrollees autism spectrum disorder and speech delay.  Findings:  The physician reviewer found that a study by Lousada and colleagues showed that only focusing on articulation goals did not produce the same results on intelligibility as focusing on speech strategies to improve phonologic processing and overall intelligibility. In this case, the patient is receiving an appropriate amount of speech therapy with adequate treatment goals to address his intelligibility and his pragmatic language deficits. As such, the addition of a new speech goal of K and G articulation to the patients speech therapy treatment plan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an immediate release (short-acting) opioid including Norco, Percocet or Dilaudid, for treatment of her pain.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Short-acting opioids such as Norco, Percocet or Dilaudid are associated with a high risk of dependence and tolerance.  All told, the requested immediate release (short-acting) opioid including Norco, Percocet or Dilaudid is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested an epidural injection for medical treatment of his pain.  Findings:  The physician reviewer found that this patient was noted to have chronic cervical pain complaints, and he reported 15% pain relief from the previous epidural injection.  However, there was a lack of documentation indicating the patient had at least 50% pain reduction, had objective functional improvement, or had a decrease in medication use.  Moreover, the physical examination submitted for review failed to provide evidence of consistent radiculopathy to include abnormal sensation, motor strength, or reflexes along with a positive straight leg raise in a specific dermatomal or myotomal distribution to corroborate diagnostic studies.  Based on the clinical documentation, the epidural injection was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Orthovisc (hyaluronate) injections for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the peer-reviewed literature indicates that the injections may provide short-term relief.  However, the literature noted that treatments are not available to halt the degeneration process once it has begun.  In this patients case, continuation of the injections will not alter the need for surgical intervention.  All told, the requested Orthovisc (hyaluronate) injections are not likely to be superior over other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the patient had multiple prior mammograms which were negative, and the records note fatty breasts.  The records do not indicate that breast tomosynthesis would provide additional information which would improve outcome.  Therefore, breast tomosynthesis was not likely to have been of greater benefit than other options for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested radiofrequency neurolysis for medical treatment of his pain. Findings:  Two physician reviewers found that the services at issue were not likely to be of greater benefit than other treatment options.  According to the peer-reviewed literature, further standardization of radiofrequency ablation of lesion techniques needs to be established, coupled with prospective randomized controlled trials.  Primary conservative treatment for sacroiliac joint pain includes rest, ice therapy, heat therapy, massage, medication, and injections.  All told, radiofrequency neurolysis was not likely to be superior over other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested genetic testing (CPT 81228, 81321, and 81323) for medical evaluation of her malignant breast cancer.   Findings:  Two physician reviewers found thatgiven the extensive history of breast cancer in the patients family and her personal history of both breast and endometrial cancer, this testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Sovaldi for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that the medical records demonstrate low-stage fibrosis, however her fibrosis score does not diminish the medical necessity of her genotype 2 treatment. Sovaldi and ribavirin, is the only treatment option available to her and this regimen is medically necessary to prevent worsening of HCV condition such as liver malfunction. As such, Sovaldi is medically necessary to treat of the patients HCV genotype 2.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Celebrex for medical treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical notes, it is unlikely that pharmacological benefit will be obtained through continued use of anti-inflammatories in an effort to relieve the patients reported shoulder pain.  All told, the requested medication Celebrex is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90/400 mg for medical treatment of his hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  The requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested massage therapy services for medical treatment of her lumbosacral radiculopathy status post decompressive lumbar laminectomy. Findings:  The physician reviewer found that formal massage therapy has not been proven in the medical literature to provide marginally significant health or functional benefits in the setting of back pain due to sciatica or radiculopathy over a program of independent exercise and self-administered palliative interventions such as massage using rollers, or passive palliative modalities such as local ice/heat (Furlan, et al). Consistent with these findings, the requested massage therapy services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested genetic testing for arrhythmogenic right ventricular cardiomyopathy for medical evaluation of her medical condition.  Findings:  The physician reviewer found that this patient has an established diagnosis of arrhythmic right ventricular dysplasia/cardiomyopathy.  In this circumstance, genetic testing would not be of benefit for the patient since the diagnosis is not in question and treatment would not change regardless of results.  All told, genetic testing for arrhythmogenic right ventricular cardiomyopathy was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested 18 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that children with autism with or without intellectual disability have challenging behaviors such as elopement and aggression that are very difficult to treat and often require intensive behavioral interventions. Hutchins and Prelock found that improving communication is one of the best ways to address challenging behaviors. In this clinical setting a reduction of ABA services is not indicated until the maladaptive behaviors are resolved. Thus, it is medically necessary for this patient to receive 18 hours per week of ABA therapy for treatment of his autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested laser spine surgery for medical treatment of her low back pain.,  Findings:  The physician reviewer found that the medical evidence supports a trial of conservative care emphasizing patient education, modality physical therapies and pain clinic care.  The lack of precise localization as to index level will limit the efficacy of any surgical intervention.  All told, the requested laser spine surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a Quantum Edge power wheelchair for medical treatment of her hereditary spastic paraplegia.  Findings:  The physician reviewer found thatThis patient has mobility impairments due to her various conditions, but she has sufficient upper limb strength, coordination, and range of motion to propel an optimally fit manual wheelchair.  Additionally, the patient has multiple chronic conditions that would benefit from increased physical activity and exercise.  All told, the requested Quantum Edge power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested the wearable cardioverter defibrillator (LifeVest) for medical evaluation of the enrollees newly diagnosed non-ischemic dilated cardiomyopathy.  Findings:  Two physician reviewers found that the placement of a wearable cardioverter defibrillator was clinically indicated as the patient presented with non-ischemic cardiomyopathy with recurrent episodes of non-sustained ventricular tachycardia at up to 18 beats. Given his presentation of severely depressed left ventricular function and recurrent episodes of non-sustained ventricular tachycardia it was clinically indicated for the patient to be placed with a LifeVest while awaiting recovery of left ventricular function. Therefore, based on the peer-reviewed literature and the patients symptoms, the wearable cardioverter defibrillator was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested feeding therapy paired with behavioral therapy for medical treatment of the enrollees oral aversion.  Findings:  The physician reviewer found that this patient has severe oral aversion and feeding anxiety, and has failed monotherapy with a speech therapist trained in pediatric feeding disorders. Because of the severity of his anxiety and his extremely limited diet, he requires a team approach to adequately address all facets of his disordered eating.  It is the standard of care to provide such a multidisciplinary approach, and it is thus medically necessary for this patient to receive feeding therapy paired with behavioral therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that according to the most recent guidelines issued by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  For treatment-naive patients, a 12 week course of Harvoni is recommended.  Based on published evidence of safety and efficacy, the requested medication Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested inpatient rehabilitation services for medical treatment of his behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented with moderate withdrawal symptoms. Subsequently, the patient did not require 24-hour supervision in an inpatient rehabilitation facility. The patients treatment and medication changes could have been rendered 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested total disc arthroplasty with discectomy (CPT code 22856) for medical treatment of her medical condition.  Findings:  Three physician reviewers found that the patients physical examination revealed 5/5 motor strength, intact sensation, a steady gait, and normal deep tendon reflexes.  There was no documentation of a significant musculoskeletal or neurological deficit upon examination.  There was no mention of an attempt at any recent conservative management to include active rehabilitation.  There is a lack of support for the requested services in this clinical setting.  Therefore, the requested total disc arthroplasty with discectomy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 The parent of a female enrollee mental health residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  The Health Plan documented discussion with the attending physician.  Discharge, based on that discussion, was not medically reasonable, as a hasty discharge would have more than likely overwhelmed the patient, overburdened the fragile family dynamic and undermined a successful transition to a less restrictive setting.  Subsequently, a family session evidenced the formidable struggles facing the family.  However, that same session also demonstrated many positive elements and improved communication.  Following this, the patient did well in group.  Based on the medical records, discharge at this time, with transition to a partial hospitalization program, would have been appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90/400 mg for 12 weeks for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, treatment with Harvoni is recommended for treatment-naive patients with HCV genotype 1 infection. AASLD/IDSA state Daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1a infection. All told, Harvoni 90/400 mg for 12 weeks is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Sovaldi 400 mg tablets for medical treatment of the her hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Sovaldi in this clinical setting. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. Consistent with these findings, the requested Sovaldi 400 mg tablets are medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested stereotactic body radiotherapy (SBRT) for medical treatment of his prostate cancer.   Findings:  Three physician reviewers found that there is a paucity of data demonstrating that SBRT is superior to standard treatment with IMRT or image guided radiation therapy.  All told, the requested SBRT is not likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested breast reduction surgery for medical treatment of her medical condition.  Findings:  The physician reviewer found that this patient has significantly enlarged breasts and has typical symptoms of back and breast pain likely related to her enlarged breast size.  Based on these symptoms and signs likely related to macromastia, further evaluation by a plastic surgeon is medically indicated.  All told, the submitted documentation demonstrates the medical necessity of a consultation with a plastic surgeon.  However, the medical necessity of the requested breast reduction surgery has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Botox injections for medical treatment of her migraine headaches.  Findings:  The physician reviewer found that the medical records submitted for review do not adequately document a history of chronic migraine or a history of adequate trials of three classes of anti-migraine medications. In addition, there is no mention of headache diaries, or documentation of previous use of other medications. Based on the clinical records submitted, there is a lack of documentation to establish the medical necessity for the requested Botox injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Norco 10-12 per day, #240 pills every 20 days for medical treatment of his chronic pain.  Findings: The physician reviewer found that current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. It would therefore, be in the best interest of the patient to participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. All told, the medical necessity of the requested mediation dosage has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the breast for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested MRI of the breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Leung and Sickles, Developing asymmetry is an uncommon finding. When this sign is identified on screening and diagnostic mammography, the likelihood of malignancy is sufficiently high to justify recall and biopsy. Thus, the use of breast MRI to further evaluate the patients left breast mammographic focal asymmetry is supported by the peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Treatment of patients with HIV is assigned high priority by the AASLD/IDSA guidelines due to high risk of complications.  Treatment-naive patients are recommended to be treated with Harvoni for 12 weeks (Class I, Level A recommendation). In this case, Viekira Pak is contraindicated. AASLD/IDSA guidelines have a Red Box warning stating that Viekira should not be used with efavirenz, which is a component of Atripla. For the reasons provided, Harvoni is medically necessary for treatment of this patients HCV.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the Zio Patch for medical evaluation of her premature ventricular complexes (PVCs).  Findings:  Two physician reviewers found that currently, there is a lack of randomized clinical trial data addressing the Zio Patch for PVC quantification. As this patient had a sensation of single skipped beats, and had previously been documented to have PVCs on monitoring and on treadmill testing, it was suspected that she had PVCs. Thus, the monitor was being used to quantify the PVC burden. It is not established that the Zio Patch is more effective than a standard 24-hour Holter monitoring for quantification of PVCs. Accordingly, the Zio Patch at issue was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Cialis (30 tablets for a 30 day supply) for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication dosage. Coward and Carson report recent studies show a significant treatment benefit from once-daily, low-dose tadalafil. This requires at least 30 tablets per month to be effective.  Therefore, the medical necessity of the requested medication dosage has been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a computed tomography (CT) scan of the abdomen and pelvis (CPT 74177 for medical evaluation of the enrollees Swiss cheese incarcerated ventral hernia along with nonreducible left inguinal hernia.   Findings:  The physician reviewer found that radiologic literature indicates that CT is the best choice for imaging in the evaluation of abdominal wall hernias. Considering the patients history, recent negative colonoscopy and request from the surgeon for CT imaging prior to surgery, the requested CT scan of the abdomen and pelvis (CPT 74177) is medically necessary for evaluation of this patients medical condition.