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

A 55-year-old male enrollee has requested Rituxan 1000mg intravenous therapy given one week apart for treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested therapy.  The clinical documentation indicates that the patient had a disruption in IVIG treatment that caused an increase in symptoms.  However, there is a lack of support for the requested therapy in this clinical setting.  Per the current medical evidence, there is a lack of scientific evidence supporting the long-term safety and efficacy of the requested therapy for the treatment of this patients condition.  As such, the superior efficacy of Rituxan 1000mg intravenous therapy given one week apart has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that this patient is more likely to benefit from the requested LINX procedure over standard treatment consisting of fundoplication. The patients physical history and clinical findings support an indication for either procedure. However, he has the presence of Barretts at a young age. There is concern that if he undergoes fundoplication, then surveillance for dysplasia would not be possible. All told, the requested LINX procedure is likely to provide this patient with an improved health outcome as compared to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested a 12-week course of Sovaldi 400mg for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The current medical evidence supports the requested medication in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  This patient has no contraindications to interferon-based treatment and is motivated to begin therapy before his liver disease progresses.  Allowing the patient to develop advanced fibrosis before the proposed treatment regimen will substantially reduce the efficacy of the proposed drug treatment and lower the patients chance of virologic response.  All told, the requested 12-week course of Sovaldi 400mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested posterior tibial nerve stimulation (PTNS) treatments and  resumption of weekly PTNS treatments (up to 12 weeks) and/or monthly maintenance of PTNS for treatment of her urinary incontinence.  Findings:  Two physician reviewers found that lower urinary tract symptoms make up a large percentage of the complaints encountered by urologists.  These complaints include urinary frequency, urgency with and without incontinence and occasionally nocturia.  Patients are initially instructed in lifestyle changes that may improve their symptoms.   If these techniques fail, second-line, non-invasive treatment options include pelvic floor muscle therapy, bladder retraining and anticholinergic therapy.  Although there are numerous medical therapy options available, not all patients are candidates secondary to other concomitant medical conditions.  In these instances, more invasive techniques may be required.  However, there is a lack of support for PTNS in this clinical setting.  In this case, there are multiple anticholinergics that are still available for trial by this patient.  Additionally, there is a lack of documentation regarding behavioral techniques trialed such as eliminating caffeine, timed voiding and fluid restriction.  The records do not indicate that pelvic floor muscle therapy has been trialed.  In sum, the superior efficacy of PTNS has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested outpatient program (IOP) services for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the IOP services provided to this patient from was medically necessary for treatment of her medical condition. The treatment team documented that she was resistant to treatment and felt coerced by her family. Although her family was supportive, they presented a significant barrier to her recovery. The combination of the patients resistance to treatment and a non-supportive environment supports the medical necessity of the IOP level of care provided to this patient from the time period specified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested partial hospitalization program services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support partial hospitalization program services in this clinical setting.  The medical records do not document prior treatment at a lower level of care.  There is no evidence that she would have required a higher level of care if she had not received partial hospitalization at that time.  Per the medical records, she had no medical comorbidities.  The patient was not suicidal or homicidal, and she was not a danger to self or others.  All told, partial hospitalization program services from the date indicated forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested eating disorder intensive outpatient program (IOP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, as of the date indicated the patient is of normal body weight with a weight of 142 pounds, a height of 66 inches resulting in a body mass index (BMI) of 23. Her ideal body weight (IBW) is noted to be 130 pounds. She has no significant medical comorbidities. She is not currently an imminent threat to self or others and has a stable home environment. The patient does not demonstrate any aggressive behaviors that require containment in an intensive outpatient program. In addition, although the patient reportedly has suicidal ideation, this can be safely managed at a less restrictive level of care. Thus, the request for eating disorder intensive outpatient treatment program services is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested  percutaneous tibial nerve stimulation (PTNS) and future PTNS treatments for treatment of his overactive bladder. Findings:  Two physician reviewers found that in this patients case, the services at issue were not and are not likely to be more effective than other treatment modalities.  The submitted documentation does not support the services at issue in this clinical setting.  The records do not include details regarding prior medications.  Additionally, details regarding dietary restrictions or attempts at bladder retraining were not provided.  The current medical literature does not support the long-term utilization of this modality.  All told, the superior efficacy of PTNS treatment provided from the time frame specified and future PTNS treatments has not been established.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested services she received in Singapore for treatment of her low back pain.   Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. According to Mattu and Goyal, patients with lumbar motor radiculopathy may require early surgical treatment and the most important determining factor is the presence of significant weakness. If the weakness is substantial, delaying surgery could result in a permanent deficit. Thus, urgent magnetic resonance imaging (MRI) is needed to ensure optimal outcomes. In this case, there are no records provided for review demonstrating an MRI or physical exam findings to determine if this was an urgent or emergent case. Thus, there is no clinical evidence that shows the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, given the lack of medical documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested radiofrequency ablation of the 3rd median branch and occipital nerve (procedure codes 64634 and 64633) for treatment of the enrollees cervical back pain.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. Based on the medical records provided for review, the patient has been treated with two diagnostic blocks involving the third occipital and C3 medial branch nerves with demonstrated relief of her pain. Her physical examination is consistent with facet mediated pain for which these diagnostic procedures are supported in order to evaluate for condition. Given that the patient has had two diagnostic blocks performed with improvement in her pain and the physical exam findings consistent with facet mediated pain, the requested radiofrequency ablation of the 3rd median branch and occipital nerve is medically indicated and likely be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested a power wheelchair (HCPCS code K0825) for treatment of her history of osteoarthritis of the knees. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records forwarded for review do not establish that the patient would be confined to a bed or chair without a power mobility device.  The records indicate that she is requesting the power mobility device so that she can travel about her school campus.  Otherwise, she ambulates with a cane.  There is no documentation of physical examination findings, imaging findings or other objective findings that establish upper limb, cardiovascular or other pertinent organ system impairment that would preclude manual wheelchair propulsion for accomplishing mobility-related activities of daily living in the home.  This patient would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested posterior tibial nerve stimulation for treatment of her overactive bladder.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of long-term follow-up data in the peer-reviewed literature to validate the sustained benefit of nerve stimulation in the treatment of lower urinary symptoms. The medical literature in regards to PTNS in this clinical setting remains controversial. Therefore the requested services are not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 8-year-old male enrollee has requested one-on-one occupational therapy (OT) (3 times per week); and for make-up occupational therapy sessions to be scheduled for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that according to Weinman and colleagues, successful OT should permanently improve the childs motor and self-skills as the child matures. In this case, based on the documentation submitted for review this patient has made limited progress in the reported OT sessions. Despite OT services at the frequency of 3 hours per week , an assessment indicated serious and multiple difficulties in self-help skills. In addition, the patients treating occupational therapist stated on the date indicated that 1 hour of OT is sufficient for the patient. Although the patients parent reports his regression since OT sessions were reduced from 3 hours per week to 1 hour per week, acquired OT skills should be fixed and permanent in patients who are responsive to OT. Finally, the number of goals recommended in the  assessment is excessive given the patients prior experience and limited improvement from extensive OT. In this case, the patients goals should be limited to an achievable number of goals. As such, one hour of OT per week as authorized by the Health Plan is adequate and medically reasonable. Moreover, increasing OT hours through make-up sessions is not medically indicated. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested  psychiatric services for treatment of his psychiatric emergency medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the documentation submitted for review, this patient presented with an acute psychotic episode with paranoia and persecutory delusions. The patients psychiatrist described an individual that posed an immediate danger to himself and others who was unable to provide adequate self-care at the time. Based on the documentation provided including the longitudinal history, the patient did have a psychiatric emergency medical condition that required the services provided from the time period specified.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested weekly mental health individual therapy sessions for treatment of her depression.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) practice guidelines for major depressive illness, it is appropriate to consider a change in treatment approach when little to no improvement is noted. The National Alliance on Mental Illness (NAMI) also suggests that if a patient with major depression does not respond to medication management and psychotherapy within a short period of time, the diagnosis of major depression should be questioned. Based on the records reviewed, patients condition has had little to no improvement after what appears to be over eight months of treatment in PHP, IOP, individual counseling and medication management. The provider indicated that the patient had not shown any improvement and recommended ECT. The patient preferred to continue with the individual counseling. The patient was not comfortable with the group counseling in the IOP setting. Further, there are no clear goals stated within the medical records. Therefore, continuation of weekly psychotherapy visits will not benefit this patient, and will not provide improvement in her symptoms. A reevaluation of patients medication regimen in its entirety is appropriate, given this patients complex medical history. All told, continuation of weekly individual counseling sessions is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  psychiatric emergency services for treatment of the enrollee's post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the medical records submitted for review, although the patient had a history of suicidal attempts there is no clinical documentation demonstrating that the patient was actively suicidal upon admission to the treatment program. Further, the patients master treatment plan on the date specified does not indicate that the patient was homicidal or psychotic or a threat to others. Moreover, the submitted clinical records do not demonstrate that the patient was unable to attend to his daily needs. If the patient was experiencing a psychiatric emergency medical condition as defined above, he would have required treatment in acute inpatient hospital setting and would not have been an appropriate candidate for participation in a wilderness therapy program. Given that the patient did not meet the above definition of a psychiatric emergency medical condition, the services at issue were not required on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Trigeminal neuralgia is a painful nerve syndrome of the face.  Treatment of trigeminal neuralgia includes surgical decompression as well as medication management.  Pregabalin (Lyrica) is a gamma-aminobutyric acid (GABA) analogue with structural similarity and actions similar to gabapentin.  Like gabapentin, Lyrica has antiepileptic, analgesic and anxiolytic activity.  There is sufficient support for the requested medication in this clinical setting.  Perez and colleagues reported on the effects of Lyrica in 65 patients with trigeminal neuralgia refractory to analgesic therapy.  Per the authors, 59.4% of these patients experienced pain reduction of 50% or more.  In this case, the patient has tried a number of interventions, including surgery and medications.  The records document continued pain and burning of the face.  There is a lack of treatment options in this patients case.  All told, Lyrica is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested SoundBite prosthetic hearing system for treatment of his unilateral hearing loss. Findings:  Two physician reviewers found that the requested device is likely to be more effective for this patient than other available options. The medical records submitted for review indicates that the patient has single-sided deafness. The SoundBite device has been U.S. Food and Drug Administration (FDA) approved for the treatment of single-sided deafness. According to the medical literature cited above, a number of clinical trials have shown its effectiveness and long-term safety. Given the support in the medical literature cited above and the documentation submitted for review, SoundBite prosthetic hearing system is likely to be more beneficial than any standard treatments for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested early repeat course of Orthovisc (hyaluronan) injections for treatment of her right knee pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). 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 request for an early repeat course of hyaluronan injections in the form of Orthovisc for treatment of the patients right knee pain is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a breast ultrasound of the right/left breast for evaluation of her abnormal mammogram. Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. Bilateral automated whole breast ultrasound is not considered a standard medical therapy. Moreover, the medical literature cited above does not show a significant difference between whole breast ultrasound and hand-held examinations. Thus, the request for whole breast ultrasound of the right/left breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested intensive post acute neurological rehabilitation services for treatment of his anoxic encephalopathy secondary to massive hemorrhage during heart transplant surgery.  Findings:  The physician reviewer found that the records indicate this patients medical and functional rehabilitation needs can be addressed in a skilled nursing facility (SNF). He needs some rehabilitation as well as careful attention to his daily care needs as he continues to experience neurological recovery. There is a substantial body of evidence suggesting that SNF based rehabilitation is an appropriate treatment setting to achieve these goals. All told, the requested intensive post acute neurological rehabilitation services are not medically necessary for treatment of this patients medical condition.