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

A female enrollee requested three-dimensional x-ray (digital breast tomosynthesis for medical evaluation of the enrollee, who has a family history of breast cancer.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The scientific data has shown the advantage of adding three-dimensional breast tomosynthesis to the usual two-dimensional full field digital mammographic images.  This technique has been particularly useful in patients with dense breast tissue, and the current data shows a decrease in recall rate and increased sensitivity to the early detection of cancer.  Thus, the three-dimensional x-ray (digital breast tomosynthesis) was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested facet block injections using monitored anesthesia care for medical treatment of this chronic back pain.  Findings:  The physician reviewer found that the physical exam was not evident of facet pain. In addition, facet injections with monitored anesthesia care are not medically necessary because the sedation interferes with the results of the injection. Moreover, there is no clinical indication for monitored anesthesia with the requested procedure such as extreme anxiety or severe conditions requiring monitored anesthesia. The evidence obtained from the literature review suggests that controlled comparative local anesthetic blocks of facet joints without intravenous sedation are reproducible, reasonably accurate and safe. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Nuvigil 150mg for medical treatment of her multiple sclerosis-related fatigue.  Findings:  Two physician reviewers found that multiple sclerosis-related fatigue is very common, and may be a disabling feature of the disease. There is a typical algorithm for treating fatigue which includes ruling out a primary sleep disorder and eliminating medications that may be contributing to fatigue.  Commonly used medications for fatigue include amantadine, modafinil, armodafinil, methylphenidate, pemoline, and amphetamine.  In this patients case, the records do not indicate that amantadine has been tried.  Several recent comparator studies suggest amantadine is more effective than modafinil for the treatment of fatigue.  Armodafinil (Nuvigil) is the enantiomer of modafinil which is more pharmacologically active and requires daily dosing, but otherwise is nearly identical to modafinil as far as its action.  All told, the requested Nuvigil 150mg is not likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni 90/400mg tablets for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America recommendations, patients with chronic active hepatitis C should be treated with approved antiviral therapy regardless of fibrosis score.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, Harvoni 90/400mg tablets are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested laboratory testing of adalimumab levels in the blood for medical evaluation of his ulcerative colitis.  Findings:  Three physician reviewers found that the target level of adalimumab necessary to achieve clinical benefit remains unknown.  There is a lack of randomized prospective trials demonstrating that treatment guided by trough adalimumab levels is superior to optimal clinical care.  All told, laboratory testing of adalimumab levels in the blood was not likely to have been superior over other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Oasis graft product for medical treatment of her third-degree burns.  Findings:  Three physician reviewers found that this patient underwent tangential excision with temporary wound coverage with homograft and xenograft to some sites before coverage with autograft.  There is a lack of support for the use of Oasis graft product in this clinical setting.  The Oasis product is not indicated for patients with third-degree burns.  All told, the use of Oasis graft procedure was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested the Vest Airway Clearance System for medical treatment of hiss congenital myotonic dystrophy and asthma.  Findings:  The physician reviewer found that in this case, the patient presents with congenital myotonic muscular dystrophy, asthma and autism. Although the majority of studies of HFCWO systems have involved patients with cystic fibrosis, these systems were developed for any patient with poor airway clearance and the inability to perform other clearance maneuvers. Aggressive pulmonary care is essential for this population of patients because of the risk of morbidity from respiratory complications. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested Vest Airway Clearance System is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested residential mental health treatment center services for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that residential treatment services were medically necessary for treatment of the patients medical condition. This patient could not have been managed at a lower level of care. 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 female enrollee requested monitored anesthesia during endoscopy for medical evaluation of her gastric mucosa-associated lymphoid tissue (MALT) lymphoma.  Findings:  The physician reviewer found that there are advantages with MAC versus benzodiazepines and narcotics for patients with risk factors for sedation-related complications and for patients undergoing prolonged procedures. Conscious sedation and MAC are often used interchangeably for those undergoing gastrointestinal procedures, however the most invasive and prolonged procedural settings, such as endoscopy with EUS with multiple biopsies warrant monitored anesthesia care. In sum, MAC was medically necessary for evaluation of the patients gastric MALT lymphoma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested bilateral hip and back panniculectomy and bilateral medial thigh lift for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records and photographs do not demonstrate that a significant functional deficit is present to warrant surgical intervention.  All told, the requested bilateral hip and back panniculectomy and bilateral medial thigh lift are not medically indicated for the treatment of this patient and are not reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested autonomic nerve testing (CPT code 95924) for medical evaluation of his idiopathic peripheral autonomic neuropathy. Findings:  Two physician reviewers found that the records provided for review suggest this patient underwent a screening evaluation in the absence of any documented symptoms or medical disorder. Moreover, in the testing baseline information it indicates the patient has no symptoms. In the absence of clear cut autonomic neuropathic symptoms such as orthostatic hypotension, anhydrosis, or gastroparesis, automate autonomy nervous system testing 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: Upheld Decision of Health Plan

A 63-year-old female enrollee requested rectus diastasis repair for medical treatment of the enrollees rectus diastasis and abdominal pain.  Findings:  The physician reviewer found that the requested procedure is not medically necessary for treatment of the patients medical condition. The surgeon recommended weight loss and has not provided additional justification for intervention on a functional basis. There are no photographs to document an extraordinary condition. In addition, there does not appear to be a significant pannus to suggest that there is a functional deficit such as chronic intertrigo, ulcerations and/or lower back pain related to the size of an overhanging pannus. Thus, diastasis rectus repair is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested radiofrequency ablation for medical treatment of her symptomatic uterine fibroids. Findings:  Three physician reviewers found that Ultrasound guided radiofrequency ablation is a promising procedure for the treatment of uterine fibroids. Short-term studies suggest its effectiveness with minimal side effects. However, studies with extended follow-up are still underway, so long-term effectiveness and side effects have not yet been established. Overall, there is a lack of evidence that the requested radiofrequency ablation is likely to be more beneficial for the treatment of this patients symptomatic fibroids than standard therapies such as uterine artery embolization, myomectomy, and hysterectomy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested parathyroid imaging with single photon emission computed tomography (SPECT) and CT (CPT code 78072) for medical evaluation of her hyperparathyroidism.  Findings:  Two physician reviewers found that in patients with suspected parathyroid adenoma, identification of the tumor is necessary for surgical planning. Moreover, the exact anatomic location is crucial to minimize the extent of surgery and to actually pinpoint the site of the tumor. Up to 25% of parathyroid adenomas are found in an ectopic location or outside of the usual parathyroid bed and may even occur in the mediastinum. While dual phase planar imaging with SPECT is an accepted way to search for the adenoma, the fused CT scan allows for the exact anatomic location to be pinpointed for the surgeon. Without the cross sectional anatomic detail available via CT, this crucial step in the pre-operative work-up would not be as complete as possible. Therefore, the diagnostic procedure at issue was 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 tumescent liposuction for medical treatment of her lipedema.  Findings:  The physician reviewer found that the proposed tumescent liposuction meets reconstructive surgery criteria, the patient presents with lipedema, which is considered an abnormal condition. Her condition is a result of disease of fat accumulation. The documentation provided demonstrates that there is an abnormal appearance present and more than a minimal improvement can be expected from surgical treatment. Therefore, the requested tumescent liposuction does meet reconstructive surgery criteria.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested Provent nasal expiratory positive airway pressure (EPAP) for treatment of his obstructive sleep apnea (OSA).  Findings:  Two physician reviewers found that this patient has mild positional OSA. However, he only has mild changes when sleeping supine. This is positional sleep apnea and the standard of care is a vest with a tennis ball in it, which is worn so the ball prevents supine sleep. All told, the requested Provent device is not likely to be more beneficial for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee requested substance abuse residential treatment center services (RTC) for medical treatment of his substance abuse. Findings:  The physician reviewer found that according to the documentation submitted for review, this patient represents a high risk for relapse. He required the high degree of structure of a 24-hour residential setting in order to help him start to build and solidify coping skills towards relapse prevention. The patient met American Society of Addiction Medicine (ASAM) placement criteria for residential level of care.  Subsequently, 30-minute checks were discontinued, he endorsed decreased auditory and visual hallucinations, and he was attending groups, demonstrating motivation for change. Thus, he could have been stepped down to a lower level of care. Therefore, residential treatment services provided initially were medically necessary for treatment of the patients medical condition and 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 31-year-old female enrollee requested magnetic resonance imaging (MRI) of the thoracic and lumbar spine without dye for medical evaluation of her right-sided sciatica with radiation to anterior and posterior thigh. Findings:  The physician reviewer found that while this patient previously underwent lumbar surgery, the symptoms of bilateral hip weakness and unilateral genital numbness are concerning and support further investigation with the requested MRI of the lumbar spine. However, there is no history of thoracic spine trauma or abnormality on plain x-rays and no symptoms or physical findings referable to a thoracic dermatome in order to support the requested thoracic spine MRI. All told, the requested MRI of the lumbar spine is medically necessary while the MRI of the thoracic spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested modafinil (Provigil) 200 mg tablets for medical treatment of his obstructive sleep apnea with excessive daytime sleepiness.  Findings:  The physician reviewer found that the records document that this patient has both bipolar disorder and severe obstructive sleep apnea (OSA). The patient has taken Provigil for six years, and has found it helpful for his low energy levels. Although this patient reports symptomatic improvement with Provigil his sleep apnea remains untreated. Provigil is not an adequate treatment for OSA alone and is only indicated for treatment of residual sleepiness in cases of treated OSA such as patients already on CPAP. Moreover, the patients diagnosis of bipolar disorder is not an FDA approved indication for Provigil. All told, this patient does not meet the current criteria for treatment with Provigil and its use is not medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested revisional bariatric surgery for medical treatment of her medical condition status post Roux-en-Y.  Findings:  The physician reviewer found thatgastrogastric fistulas are a known complication of gastric bypass that do not always require surgical repair. When small, they may or may not lead to any consequence and are generally repaired only when large with wide disruption of the staple line or if the gastrogastric fistula is the cause of a marginal ulcer/stenosis. The upper gastrointestinal study did not document a large gastric pouch/outlet or any other anatomic complication. In addition, a very small amount of contrast was seen in the remnant stomach and this alone would not be an indication for surgical repair. Further, there is no documented evidence of a marginal ulcer. All told, the medical records do not support the requested revisional surgery as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Vyvanse for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical record does not substantiate the medical necessity of lisdexamfetamine. The patient was prescribed opiate and benzodiazepine medications that, in addition to being susceptible to tolerance and dependence, commonly result in cognitive impairment. Furthermore, the patient was not diagnosed with ADHD by the treating provider. Based on the documentation provided including the diagnostic uncertainty of ADHD, the prescription of lisdexamfetamine for this patient is not medically necessary. As such, the requested medication is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested for AndroGel for medical treatment his hypogonadism. Findings:  The physician reviewer found that low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). This treatment should therefore help to prevent potential complications from untreated hypogonadism.  All told, the requested AndroGel is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested intra-operative radiation therapy (IORT) for medical treatment of her malignant neoplasm of the breast.  Findings:  Three physician reviewers found that IORT is not likely to be more effective for this patient than other available options. IORT is a decades-long technology, used primarily for gastrointestinal cancers in the 1980s and more recently for breast cancer. The most recent National Comprehensive Cancer Network guidelines do not explicitly address IORT. Moreover, IORT is not the standard approach in this clinical setting as there is a paucity of long-term outcome data. In sum, there is a lack of data to suggesting IORT is superior to standard approaches of delivering breast radiotherapy. Thus, IORT is 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 male enrollee requested sumatriptan (Imitrex) 100 mg twice per day for treatment of his cluster headaches. Findings:  The physician reviewer found that there is a lack of documentation on the medications that have been previously used and the duration. Given the lack of evidence for the daily use of oral triptans in cluster headache, the potential for harm caused by daily high dose triptan usage, and the presence of medication overuse headache in cluster patients who use frequent triptans, the request for sumatriptan (Imitrex) 100 mg twice per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the medication Nuvigil for medical treatment of her multiple sclerosis-related fatigue. Findings:  Two physician reviewers found that although Nuvigil is not considered a first-line therapy for fatigue in multiple sclerosis, there is support for the requested medication in this clinical setting.  The patient reported that Nuvigil has been beneficial.  She is unable to take more standard medications due to prior adverse effects.  Undertreated fatigue can potentially cause significant morbidity.  All told, the requested medication Nuvigil is likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. These new guideline recommendations are based on multiple randomized clinical trials.  Based on evidence of safety and efficacy in the published literature, Harvoni is 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 12 weeks for medical treatment of his chronic hepatitis C virus genotype 4.   Findings:  Three physician reviewers found that patients with genotype 4 are recommended to be treated with Harvoni for 12 weeks. These new guideline recommendations are based on the SYNERGY trial, an open-label study evaluating 12 weeks of ledipasvir/sofosbuvir in 21 hepatitis C virus genotype 4 infected patients who were either treatment-naive or had advanced fibrosis (Kapoor, et al). Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni 90-400 mg for 12 weeks is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Botox injections for medical treatment of her jaw pain and headaches.  Findings:  Two physician reviewers found that this patient has been diagnosed with TMJ disorder and migraine headache. Treatment of chronic migraine with Botox injections is supported in the peer-reviewed literature. However, the record does not document the patient has chronic migraine headaches. In addition, there is a lack of adequate medical studies for the treatment of TMJ disorder with Botox injections. Moreover, there are numerous management strategies for the treatment of TMJ disorder, such as physical therapy, oral devices and intra-articular injection. In this case, prior treatments for the patients TMJ disorder are not provided in the documentation submitted. As such, the records do not substantiate that Botox injection to the masseters were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.