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

The parent of a male enrollee requested Prometheus Anser IFX blood test (84999) for medical evaluation of the enrollees Crohns disease.  Findings:  Three physician reviewers found that this patient has a history of Crohns disease and is being effectively managed on Remicade.  The standard dosing of Remicade is 5mg/kg every eight weeks during maintenance, but it has been widely recognized that the need to dose modify in certain situations arises and is effective.    In this patients case, the test was used to prolong and not shorten the drug interval, in order to limit potential toxicity related to supratherapeutic drug levels.  All told, Prometheus Anser IFX blood test was likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Serostim for medical treatment of his human immunodeficiency virus (HIV) associated wasting.  Findings:  The physician reviewer found that Serostim is recombinant human growth hormone.  Per the current medical evidence, growth hormone should be reserved for those patients with severe wasting when other treatments have not been effective.  In this case, the patient has a normal body mass index of 23.1.  The documentation states he has failed treatment with Megace for HIV associated wasting syndrome.  However, the records do not document that he has been advised on the importance of exercise, had a testosterone level checked or been tried on alternative medications besides Megace.  There is a lack of support for the requested medication in this clinical setting.  All told, Serostim is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested genetic testing for Brugada syndrome (CPT code 81281) for medical evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that Brugada syndrome is a rare autosomal dominant cardiac genetic disorder caused predominantly by SCN5A genetic mutations and resultant channelopathy.  Complications include ventricular fibrillation and sudden cardiac death in structurally normal hearts.  The treatment is implantation of a pacemaker.  The indications for genetic testing include family members following identification of the mutation.  In the case, the patients father has both a clinical and genetic diagnosis of Brugada syndrome.  Based on the current literature, it is necessary to perform appropriate genetic testing to identify the SCN5A mutation.  All told, genetic testing for Brugada syndrome was likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus genotype 1. Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines state that, immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Based on current data, 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. Thus, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested the brand name medication Vicodin and the brand name medication CellCept for medical treatment of her optic neuritis and chronic pain.  Findings:  The physician reviewer found that the medical records do not demonstrate any ongoing history of reaction to generic versions of CellCept or Vicodin medication that supports the medical necessity of brand name CellCept or Vicodin.  Further, the medical records do not provide rationale from the patients provider as to the medical necessity for brand name CellCept or Vicodin.   All told, the request for the brand name medication Vicodin and CellCept is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested octreotide (Sandostatin) 40 mg injections for medical treatment of her polycystic liver disease.   Findings:  The physician reviewer found that the requested Sandostatin is supported as medically necessary. In the medical literature, Gevers and colleagues reported that in patients with polycystic disease, young female patients appear to have the greatest benefit from treatment which might avert the progressive course of the disease in this specific group. All told, the requested octreotide (Sandostatin) 40 mg injections are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Harvoni for 24 weeks for medical treatment of the enrollees hepatitis C.  Findings:  Two physician reviewers found that in treatment-naive patients with cirrhosis, therapy is recommended with Harvoni for 12 weeks.  According to the current guidelines, the significance of a positive hepatitis C RNA test result at four, six or eight weeks remains unknown.  There is no recommendation to stop therapy or extend therapy at this time.  Based on published evidence of safety and efficacy in the literature and clinical guidelines, 12 weeks of Harvoni is medically necessary.  However, there is a lack of support for the extension to 24 weeks of Harvoni based upon the provided records.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested  acute inpatient rehabilitation for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that notes document the patients pain and tone control are both good, and he has functionally made continued gains in all areas. In addition, his impairment with problem solving and higher subjective reasoning skills are improving. Thus, continued stay in acute rehabilitation is not medically necessary. Based on the clinical documentation provided including digital videos, the request for acute inpatient rehabilitation stay is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Aranesp 300 mcg subcutaneous (SQ) every three weeks, or in the alternative, Procrit 40,000 units SQ daily for two weeks for medical treatment of his anemia in end stage renal disease with chronic kidney disease.  Findings:  The physician reviewer found that erythropoiesis stimulating agents are generally not recommended for patients with hemoglobin levels above 10, since they can increase the risk of thromboses. In addition, there is a lack of documentation that this patient has any significant angina that requires maintaining hemoglobin or has chemotherapy exposure or cancer. All told, the requested Aranesp 300 mcg subcutaneous (SQ) every three weeks, or Procrit 40,000 units SQ daily for two weeks, is not medically indicated and necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested continued post-acute inpatient rehabilitation services for medical treatment of his medical conditions.  Findings:  The physician reviewer found thatthe patient was documented to have made improvements in various areas of his treatment that include improvements with cognitive and behavioral components, and independence with wheelchair propulsion and stair negotiation. Although several areas of concern remain as to his ability to return to independent care and participation in his daily activities, his overall condition was determined to be stable. Based on the clinical documentation demonstrating improvements in multiple areas, the services at issue were not medically necessary and the patient could have been treated at a lower level of care. Therefore, continuation of post-acute inpatient rehabilitation services was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested psychiatric inpatient hospitalization services for medical treatment of the enrollees major depressive disorder and generalized anxiety disorder.   Findings:  The physician reviewer found that the notes indicate that the patient was accepting of the idea of transfer to aresidential treatment center (RTC) after discharge from acute care. She was compliant with her treatment and no longer expressed any thoughts of hurting herself or others. Overall, there is a lack of documentation supporting continued treatment at an inpatient level of care while waiting for transfer to a RTC. Thus, she would have been safe for transfer to a lower level of care and the psychiatric inpatient hospitalization services were therefore not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested an intensive inpatient feeding program (with a one year authorization period) for medical treatment of the enrollees feeding problem.  Findings:  Two physician reviewers found that  the patient has severe feeding aversions as well as gagging with certain foods and vomiting. He has tried outpatient therapy which has not advanced his ability to take foods by mouth. Inpatient feeding programs have been shown to be successful in patients such as this that have not responded to other therapies. Therefore, an intensive inpatient feeding program (with a one year authorization period) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested an ultrasound guided caudal epidural corticosteroid injection for medical treatment of his back pain.  Findings:  The physician reviewer found that the patients physical examination and lumbar MRI do not show evidence of lumbar radiculopathy/radiculitis. The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis. The patients chronic pain condition is not consistent with such a diagnosis. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested residential behavioral health services for medical treatment of her opioid dependence.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient was not at risk for imminent withdrawals. Her medical conditions were stable. Although in need of structure for recovery from her substance abuse, she did not require 24-hour supervision at residential level of care. Suboxone induction and maintenance is routinely performed on an outpatient basis. She had no significant impairments that could not be managed at a lower level of care such as intensive outpatient or outpatient levels of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Acthar HP 80 units/mL for medical treatment of his rheumatoid arthritis. Findings:  The physician reviewer found that there is a lack of evidenced based medical literature that supports the use of Acthar HP injections over the use of conventional oral prednisone during a flare of rheumatoid arthritis. The requesting provider does not provide a medical rationale supporting this medication to replace the use of oral prednisone. On the basis of the available medical records and the available evidenced based medical literature, Acthar HP 80 units/mL is not medically necessary for treatment of this patients rheumatoid arthritis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Xenical 120 mg three times daily for treatment of his obesity and hypertension.  Findings:  The physician reviewer found that the patient has complications of his obesity including hypertension treated with emergency department visits, and has made previous efforts to lose weight. Moreover, the patients provider noted recent increased BMI of 38, which meets the criteria for treatment with the requested weight loss agent. Thus, the requested Xenical 120 mg three times per day is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested cerebral perfusion imaging for medical evaluation of the enrollees cerebrovascular accident (CVA). Findings:  Two physician reviewers found that while the role of perfusion imaging has been established for acute neurologic event, it has been less regarded in terms of the role in chronic ischemia, as in this case. The American College of Radiology (ACR) lists primary and secondary roles of CT perfusion imaging which suggest the role in this patient would be a secondary indication, not a primary indication. Although perfusion imaging may be able to differentiate at risk tissue, it has not yet been shown in peer-reviewed medical literature, to affect outcome outside of acute ischemia. Therefore, cerebral perfusion imaging 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 female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America noted the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Initiation of treatment may avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C.  Therefore, Harvoni is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested bilateral sacroiliac joint fusion surgery for medical treatment of her medical condition.  Findings:  Three physician reviewers found that while it is noted that the patient has failed multiple conservative treatment options, there is a lack of imaging provided for review to validate that there is a dysfunction within the patients sacroiliac joint that would support the requested services.  Without clear evidence that the patient has objective findings per an imaging study of a deficit within the bilateral sacroiliac joints, the requested procedure would not be supported.  All told, the requested bilateral sacroiliac joint fusion surgery is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the diagnostic procedure at issue in this clinical setting. In this case, the patient has a family history of breast cancer in her mother. In this particular case, the patient does not meet criteria for breast magnetic resonance imaging (MRI) screening, however given the patients high risk of developing cancer, breast tomosynthesis was clinically indicated and was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested the medication Hysingla ER 40mg for medical treatment of her chronic pain.  Findings:  The physician reviewer found that this patient has been on chronic opioids without documentation of improved function or attempted weaning.  The records document non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Hysingla ER 40mg is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A female enrollee requested medical services provided on an emergent or urgently needed basis.  Findings:  The physician reviewer found that nonsurgical management of metacarpal fractures includes buddy strapping of the injured digit to the neighboring digit and splinting or casting.  There was no documentation of a significant functional deficit or acute or severe pain. In sum, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. Therefore, the patients symptoms did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met. The services could have been delayed until the patient returned to her Health Plans service area. Based on the medical records submitted for review, there was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that her condition was deteriorating. In sum, based on the patients clinical presentation, she did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested residential treatment center substance abuse with detoxification and residential treatment center substance abuse services for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that this patient was at high-risk for both complicated alcohol withdrawal and potential for relapse.  Clinically supervised detoxification was safe, appropriate and consistent with good medical practice.  Further, the diazepam taper was reasonably expected to improve his condition and prevent a more serious episode of illness.  Thus, the detoxification services were medically necessary.  Per the submitted documentation, the patients alcohol use dominated his daily routine, negatively impacted his health and caused significant impairment across multiple domains of functionality.  In this patients case, the residential treatment provided was medically indicated.  Additionally, the services provided were for active treatment, and reasonably expected to improve his condition and prevent a more serious episode of illness.  Therefore, the residential treatment center substance abuse services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested speech therapy for medical treatment of his medical condition status post ischemic stroke. Findings:  Two physician reviewers found that there is adequate support for speech therapy in treating cognitive/linguistic deficits after cerebrovascular accidents. This patients documentation describes a cognitive deficit secondary to an ischemic stroke which bled, which is known as an acquired brain injury. The records noted that the patient had potential for measurable improvement within a reasonable time. Further, there is no other treatment that would be considered the standard of care over this type of therapy for this particular type of cognitive deficit. Thus, speech therapy services were likely to have provided this patient with greater benefit than any available intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that the medical records do not document baseline headache frequency or characteristics to indicate the patient has chronic migraine. Botox has been established to be beneficial for chronic migraine with a specific treatment protocol, which entails injection of 5 units in 31 specific locations including frontal, temporal, occipital, paraspinal, and trapezius, with concentration of 5/0.1, at 12 week intervals. This patient appears to have been injected at cosmetic dosing and locations, and may have been injected with Botox cosmetic, as notes indicate a vial size of 50 units, while Botox therapeutic comes in vials of 100 and 200 units. In sum, the clinical records submitted for review do not confirm a diagnosis of chronic migraine. Based on the peer-reviewed literature and clinical documentation provided, Botox injections were not and are not 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 male enrollee requested artificial disc replacement C6 and C7 for medical treatment of his medical condition.  Findings:  Three physician reviewers found that there is lack of information regarding significant neurological deficits to include decreased motor strength, decreased deep tendon reflexes, and a positive Spurlings test.  Additional studies are needed to support the long-term efficacy of the services at issue.  In sum, artificial disc replacement C6 and C7 was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested a Prime super stander chair (E0641) for medical treatment of the enrollees spastic quadriplegic cerebral palsy.  Findings:  Two physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with spastic quadriplegic cerebral palsy, a severe form of cerebral palsy which is characterized by neurological impairment of all four extremities. This patient cannot stand or attempt ambulation unless a supportive system is in place. In general, the standing position is vital to maintain vasovagal sympathetic/parasympathetic responsiveness to prevent hypotension and to maintain varying cardiac tone for circulation.  In sum, the requested Prime super stander chair is widely utilized in the treatment of children with cerebral palsy and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.