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

A 41-year-old female enrollee requested the LINX procedure for medical treatment of her gastroesophageal reflux disease.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  The LINX procedure may be beneficial for select patients with gastroesophageal reflux disease symptoms despite maximal medical therapy.  However, there is a lack of support for the requested services in this clinical setting.  Per the submitted documentation, this patients gastroesophageal reflux disease symptoms do not correlate with her reflux episodes.  Therefore, her symptoms may be more functional in nature, and the LINX procedure is not likely to be beneficial.  All told, the superior efficacy of the requested LINX procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested whole body positron emission tomography (PET) scan (CPT code 78813) for medical evaluation of her left choroidal spindle cell melanoma.  Findings:  Three physician reviewers found that this patient has a rare disease, ocular melanoma. The Collaborative Melanoma Study (COMS) demonstrated equivalent survival in patients treated with brachytherapy versus enucleation (Diener-West, et al). Thus, this patient was appropriately treated for a small choroidal tumor. The COMS trial showed that 47% of patients will develop metastatic disease even after enucleation or brachytherapy in 11 years of follow-up and about one-half of these patients develop liver metastases. This patient had a molecular profile that suggested the patient is at high risk for the development of metastatic disease. Accordingly, her providers have recommended performance of a whole body PET to evaluate for additional lesions. Thus, the requested follow-up PET scan (CPT code 78813) is clinically indicated and likely to be more beneficial than any available alternative for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested continued acute inpatient psychiatric services provided for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that considering the patients diagnoses, history and symptom burden upon presentation, treatment at the acute level of care was initially indicated.  However, the medical records do not support the medical necessity for continued inpatient care as the patient was complying with rules and structure.  Despite her anxiety and pain, she was not demonstrating any unsafe behavior.  The patient was independent in her activities of daily living.  The patients antidepressant medication was increased.  She had been stable on her other medicines, which included a second generation antipsychotic.  Subsequently, the patient had a brighter disposition with decreased paranoia and thought blocking.  She was not suicidal or homicidal.  The discharge plan focused on placement, and there were no changes to the treatment plan.  Although the patient had chronic symptomatologies consistent with a formal thought disorder, there was no evidence of an acute psychiatric syndrome.  The services being provided were no longer expected to significantly improve her condition or prevent a more serious episode of illness.  Her delusional complex and paranoia was not impairing her independent functionality, resulting in disruptive behavior or posing an imminent risk to the patient or others in the community.  All told, continued acute inpatient psychiatric services were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested BRCA1 and BRCA2 genetic testing for medical evaluation of her family history of breast cancer.  Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance since it mandates the adoption of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. As per the guidelines, testing is not warranted in the patient. Since the patient does not meet the standard criteria, the requested BRCA1 and BRCA2 genetic testing is not 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

A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested regimen in this clinical setting.  It is medically appropriate to treat the patient before complications of liver disease occur.  Current national guidelines support treatment in this patients case.  Thus, Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested Xifaxan 550 mg three times per day for 14 days for medical treatment of her medical condition.   Findings:  The physician reviewer found that the efficacy of Xifaxan in treating non-constipated IBS is well documented in the peer-reviewed literature. Accordingly, Xifaxan is considered to represent a viable treatment option for this subset population and is under U.S. Food and Drug Administration (FDA) review for the indication of SIBO management. Menees and colleagues noted that Xifaxan proved more effective than placebo for global symptoms and bloating in IBS patients. Similarly, Pimentel and colleagues reported that treatment with rifaximin for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. However, in this patients case, SIBO has not been demonstrated. In addition, her symptoms have shown diminishing response to repeated courses of Xifaxan. All told, the medical necessity for another 14-day trial of Xifaxan in this patient is not supported by the available medical records.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested Orthovisc injections for medical treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. In addition, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee requested inpatient hospitalization stay for medical treatment of the enrollees ulcerative colitis flare-up.  Findings:  The physician reviewer found that the patient was admitted with a diagnosis of an acute exacerbation of ulcerative colitis (UC). She had failed outpatient treatment with oral steroids. Upon admission she was treated with IV steroids and antibiotics and did improve. During her hospitalization her labs improved and she remained afebrile. She was tolerating an oral diet and had non-bloody stools. For the management of severe UC, Peppercorn and Farrell state, In patients who respond, intravenous glucocorticoids should be converted to equivalent dose of oral glucocorticoids in three to five days. The patient was treated appropriately and remained stable. She could have been converted to oral steroids and  discharged.  Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested inpatient psychiatric hospitalization services for medical treatment of her bipolar disorder, depression, and anxiety.  Findings:  The physician reviewer found that the medical records demonstrate that inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition.  At admission, the patient continued to state that she was very depressed and reported suicidal ideation. Given the patients research for weeks and suicide attempt in the few days prior to admission, and her history of impulsivity, continued observation for her safety was clinically appropriate. Applying the American Psychiatric Association (APA) guidelines, hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient was severely depressed with suicidal ideation throughout her admission. All told, acute inpatient hospitalization was appropriate to treat the patients condition, which could not have been provided safely in a less restrictive treatment setting, and it was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee requested cancer gene testing (CPT codes 81211 BRCA 1 and 2, 81210 BRAF gene, 81213 BRCA 1 and 2, 81235 EGFR gene, 81275 KRAS gene, and 81292 MLH1 gene) for medical evaluation of the enrollee, who has a family history of cancer.  Findings:  Two physician reviewers found that screening for BRCA mutations is indicated for individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  Per the current guidelines, an individual with a first-degree or second-degree relative diagnosed with breast cancer at age 50 or younger is considered high risk and is eligible for testing.  Since this patients grandmother was diagnosed at age 45, testing is indicated.  Cancer-relevant mutations in the genes KRAS, BRAF, and EGFR are not germline, meaning that testing for them is not appropriate in individuals with no history of cancer.  The MLH1 gene is relevant in families suspected of a predisposition to the Lynch syndrome, in which affected families are at increased risk of developing colon cancer.  Given the patients history of only a brother with colon cancer at age 67, testing for the Lynch syndrome is not warranted.  All told, a portion of the services at issue (BRCA 1 and BRCA 2 testing) was likely to have been more effective than other methods of evaluation.  However, the current medical evidence has not demonstrated the superior efficacy of the remainder of the gene testing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested bronchial thermoplasty for medical treatment of her severe persistent asthma. Findings:  Three physician reviewers found that the studies performed to date demonstrate the benefit of bronchial thermoplasty for poorly controlled asthma. Patients who require and benefit from it are poorly controlled, severe persistent asthmatics who have failed all manner of aggressive control of both asthma and any associated problems that can exacerbate it such as allergies, reflux and sinus disease. With regard to this patient, she is poorly controlled despite frequent physician visits and an aggressive medical regimen. However, prior to performing an invasive procedure such as bronchial thermoplasty, she requires a trial of omalizumab given the allergic nature of her asthma. The patient should receive an adequate treatment with omalizumab prior to consideration for bronchial thermoplasty, or her provider should provide documentation of trial and failure or intolerance to omalizumab prior to consideration for bronchial thermoplasty. Accordingly, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee requested LINX Anti-Reflux Management System for medical treatment of the enrollees gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX is approved by the U.S. Food and Drug Administration (FDA) for the treatment of GERD and there is growing support in the medical literature demonstrating the efficacy and safety of the requested procedure (Lipham, et al; Reynolds, et al). In this case, LINX is clinically indicated as the patient has had partial relief of symptoms from proton pump inhibitors and does have documented objective evidence of GERD and Barretts esophagus. Based on the documentation submitted for review and the medical literature, the requested services 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 64-year-old male enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of the enrollees depression.   Findings:  The physician reviewer found that the records document that treatment with antidepressants and augmentation strategies have not successfully brought on remission in this patients condition. In the medical literature, Schutter and colleagues reported that TMS had a moderate effect on treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) guidelines state that the acute phase treatment may include TMS. Thus, although relatively new, TMS is an effective treatment that has been granted a category I CPT code by the American Medical Association (AMA) and is U.S. Food and Drug Administration (FDA) approved for patients with treatment resistant major depressive disorder. All told, TMS is medically necessary for treatment of this patients depression.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested a computed tomography (CT) angiogram of the heart for medical evaluation of her dyspnea on exertion and family history of coronary artery disease (CAD). Findings:  Three physician reviewers found that based on gender, age, symptoms and modest risk factors, this patient had a low to intermediate pre-test probability of coronary artery disease. Her treadmill testing showed discordant results with abnormal ECG findings and normal stress ECHO images. In the medical literature, Taylor and colleagues reported on the appropriate criteria for cardiac CT imaging. According to the authors, the appropriateness of sequential cardiac CT imaging in this clinical setting is 8 on a scale of 1-10. This is therefore an appropriate use of this technology based on the guidelines established and recognized by the major specialty organizations including the American Heart Association and the American College of Cardiology. Consistent with this support, the requested CT angiogram of the heart is likely to be 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 53-year-old male enrollee requested a mandibular repositioning device for medical treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that based on the medical records submitted for review, the patient has known obstructive sleep apnea (OSA). He has been successfully treated with a mandibular advancement appliance since that time. The mandibular repositioning device is effective in treating some instances of OSA, especially in mild to moderate severe cases. Most appliances wear out after two years. Based on the evidence of clinical efficacy, the replacement mandibular repositioning device was medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee requested inpatient residential treatment for medical treatment of his anxiety, depression, substance use, and agoraphobia.   Findings:  The physician reviewer found that the patient willingly attended and participated in groups, he had support systems in place with his family and friends, and he had a sponsor. There was no evidence of suicidality or homicidality, or threats of harm to others. His symptoms of anxiety and depression fluctuated and were reported as moderate in nature, which did not require treatment at the inpatient rehabilitation level of care. He was medically stable and was not at imminent risk of relapse due to comorbidity, nor were there acute changes in his condition that would indicate an imminent risk of relapse. All told, the patient did not require 24-hour inpatient supervision and did not meet the medical necessity criteria for inpatient rehabilitation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 92-year-old female enrollee requested a Hoyer sling.Findings:  The physician reviewer found that mechanical transfer devices are well-accepted instruments in the care of patients who are dependent for mobility, both for patients and caregiver safety (Edlich, et al; Collins, et al). This patient is chronically dependent for transfers and has been transferred, appropriately, using a Hoyer lift patient transfer system. However, the medical records do not establish the need for an additional Hoyer sling that is being requested in this case. The records from the patients treating providers do establish that the patient is dependent for transfers, but do not establish that the patients current slings are in disrepair or in need of replacement. Based on the available documentation, the requested additional sling for the patients Hoyer lift is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee requested services required on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patients decision to seek care was consistent with the actions of a prudent layperson in this setting. The record demonstrates that the patient required emergent care for urinary retention.   Although travel with an indwelling catheter would not have been prohibited, one would not expect a layperson to understand that an emergent/urgent issue did not exist, particularly since the patient had recently required urethrocystoscopy to reinsert the catheter after it was removed inadvertently.  In light of these circumstances, the services  meet prudent layperson criteria for emergent care/urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee requested dyadic developmental psychotherapy for treatment of the enrollees reactive attachment disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are a multitude of approaches used to treat reactive attachment disorder.  The current medical evidence does not support the necessity of dyadic developmental psychotherapy as opposed to other available treatment approaches.  While this patient needs treatment for reactive attachment disorder, the specific treatment of dyadic developmental psychotherapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested hydrocodone 5 mg/acetaminophen 325 mg #30 for medical treatment of her chronic pain syndrome, acquired kyphosis, and acquired spondylolisthesis.   Findings:  The physician reviewer found that the patient was encouraged to attend physical medicine and rehabilitation by her primary treating provider. In addition, she has been on hydrocodone long-term without documentation of improved function or attempted weaning. Further, the records indicate that the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  Thus, it is in this patients best interest to wean down or off all opiates and 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 requested hydrocodone 5 mg/acetaminophen 325 mg #30 is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee requested positron emission tomography (PET) scan for medical evaluation of her follicular lymphoma.  Findings:  Two physician reviewers found that there is support in the medical literature for the requested services in this clinical setting. According to Trotman and colleagues, PET-CT rather than contrast enhanced CT scanning should be considered as a new standard for response assessment of follicular lymphoma in clinical practice, and could help guide response adapted therapy.  In this particular case, the patient has developed symptoms. Her fatigue and weight loss are B symptoms and she has already had a CT scan. Furthermore, she has developed an elevated lactate dehydrogenase (LDH) level which can be one of the indicators of recurrent disease. In conclusion, given the patients symptoms of fatigue and weight loss and the medical literature cited above, the requested PET scan is likely to be more beneficial for evaluation than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested Percocet 10-325 mg #90 for medical treatment of her chronic pain syndrome due to treatment for invasive breast cancer.   Findings:  The physician reviewer found that based on the available medical documentation provided for review, the requested Percocet 10-325 mg #90 is not medically necessary. The patient was encouraged to attend pain management and has received morphine to help wean her off Percocet. Additionally, she has been on Percocet long-term without documentation of improved function or attempted weaning. According to the medical records, the patient is receiving treatment for invasive breast cancer in situ. However, there is no documentation that the patient is terminal. The 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. It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain.