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

A 63-year-old female enrollee has requested Sovaldi and Olysio for treatment of her hepatitis C virus (HCV). Findings:  Three physician reviewers found that HCV treatment is medically necessary for treatment of the patients medical condition. While HCV treatment is necessary, the requested treatment of Sovaldi and Olysio is class B, and not class A per the latest American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines. Newer treatment options exist for this patient with similar efficacy recommended for patients with HCV genotype 1a infection who do not have cirrhosis, in whom prior peg-interferon and ribavirin treatment has failed. The first treatment option is the fixed-dose combination of ledipasvir/sofosbuvir for 12 weeks. The second option is treatment with daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dasabuvir and weight-based ribavirin for 12 weeks. Although the requested treatment is appropriate, it should be considered after either one of the two newer options has been considered. Given that there is no documentation provided indicating that the newer treatment options have been considered, the requested medication combination is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The medical records document multiple medical problems, including a recent myocardial infarction and chronic abdominal/groin pain.  The documentation notes that the patient has been using medical marijuana.  There is a lack of support for Norco in this clinical setting.  Reisfield and colleagues noted cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse.  This patient has been appropriately screened with Opioid Risk Tool (ORT), and this revealed high risk.  Per the records, there are adjunctive pain medications which have not been tried.  All told, the requested Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested Xiaflex for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Peyronies disease is a diagnosis that is made by physical examination and supported by appropriate symptoms.  Intralesional injection therapies seeking to reduce plaque production, contracture, recurrence rate and progression have been used for decades.  At this time, the gold standard for improved symptoms and low recurrence is surgery.  The current medical evidence has not demonstrated the long-term efficacy of intralesional injections with Xiaflex, and complications from injections may limit repeat treatments.  The use of intralesional injections of Xiaflex is currently under investigation with results regarding the multiple aspects of efficacy pending.  All told, the requested Xiaflex is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested sacroiliac joint fusion surgery for medical treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that this patient had objective findings upon examination and had undergone multiple injections with a positive reduction in pain.  However, there is a lack of documentation indicating the patient has exhausted alternate treatment methods.  The peer-reviewed literature indicates that more studies are needed to support the efficacy of the requested surgical intervention.  As such, the requested sacroiliac joint fusion surgery is not likely to be more effective for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested DaT scan (CPT code 78607) for evaluation of his medical condition. Findings:  Three physician reviewers found that the requested DaT scan is likely to be more beneficial for evaluation of the patients medical condition than any standard diagnostic tool for the patients medical condition. The medical literature demonstrates the utility of the requested diagnostic procedure in this clinical setting. Although a DaT scan is not recommended for every patient with a tremor, it does have excellent utility in discriminating between patients with suspected essential tremor versus Parkinsonism, such as in this case. It is important to obtain the correct diagnosis to select the most appropriate treatment as the treatments for essential tremor and PD are very different. In this case, the patient has had side effects to prior trials of medications and if the DaT scan does not suggest PD, the patient would be spared a potential trial of a dopamine medication. Therefore, based on the peer-reviewed literature and medical records submitted the requested diagnostic procedure is likely to be more beneficial than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her chronic interstitial cystitis and urinary frequency. Findings:  Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. The medical literature in regards to PTNS in this clinical setting remains controversial, and there are a variety of treatments that are readily available and that have wide acceptance as to the efficacy. Moreover, there is a lack of peer-reviewed literature supporting treatment of interstitial cystitis and related symptoms with PTNS. For the reasons provided, the services at issue were not likely to be more beneficial than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. EMDR is a therapy in which patients generate exposure to trauma via imagery while performing horizontal saccadic eye movements. A skilled therapist assists the patient in decompressing the anxiety burden stemming from the traumatic image or memory. EMDR is not recommended for the treatment of obsessive-compulsive disorder or psychosis (Koran, et al), but it is a well-accepted treatment for post-traumatic stress disorder (PTSD) (McNally). In this case, the record does not substantiate the diagnosis of PTSD. Thus, the disputed service is neither appropriate nor reasonably expected to improve the patients condition based on the data provided. Therefore, 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 33-year-old male enrollee has requested urgent care services for treatment of his rash.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented to an urgent care facility  with complaints of a rash and was assessed with cellulitis and abscess. Cellulitis can cause serious medical problems if not treated promptly and effectively with antibiotics and recommendations for local care.  In addition, abscess and cellulitis can also spread locally and systemically causing additional illness. Cellulitis can range from mild to severe.  Mild cellulitis if untreated can progress to moderate or severe and may require hospital admission or cause more serious systemic complications. This condition does not require abnormal vital signs for the diagnosis. Moreover, this patient also had a history of regional enteritis which may have systemic immune consequences. In this case, the patients condition of cellulitis and abscess could have potentially led to serious dysfunction to bodily functions and serious dysfunction of any bodily organ or part. In sum, the services provided did meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested intrapulmonary percussive ventilation (IPV) machine for treatment of her cystic fibrosis.  Findings:  Three physician reviewers found that this patient has cystic fibrosis, and airway clearance therapy is considered one of the cornerstones of treatment in the management of this disease.  However, there is a lack of evidence demonstrating that use of IPV machine is superior to other airway clearance methods that are available and routinely used in treatment.  The standard of care is chest physiotherapy, which requires another trained caregiver to administer on a regular basis.  Flutter valves can be used without assistance.  External chest compression therapy is generally used for patients without the availability of another caregiver, for whom the flutter devices are ineffective.  In this patients case, the records do not demonstrate failure of other standard methods of airway clearance.  Thus, the requested IPV machine is not likely to be of greater benefit than other treatment options.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee requested ambulance transportation services for emergency services as well as to and from regularly scheduled hemodialysis medical treatments.  Findings:  The physician reviewer found that review of the submitted medical records demonstrates that the patient was transported to the hospital on more than one occasion as he was experiencing an acute change in his medical condition that warranted immediate medical attention. Thus, ambulance transport services on those occasions met criteria for ambulance transportation. A prudent layperson would seek immediate medical attention under these circumstances.  On other occasions, the patient utilized ambulance transportation services to and from routine, scheduled, outpatient hemodialysis treatments. The patient was not bedridden and in most instances was able to ambulate to the gurney. During the first transport the patients systolic blood pressure was in the 90s. He was not tachycardic or symptomatic. The remainder of the transport logs all record normal blood pressures with systolic blood pressures above 100. The patient did not require any medical intervention by paramedics. He was not oxygen dependent. In none of the cases was the 911 system activated to transport the patient to the nearest hospital for acute symptoms of such severity that a prudent layperson would believe his life to be in jeopardy. All told, not all ambulance transportation services met prudent layperson criteria for emergency care and the patient could have been safely transported to and from hemodialysis treatment by other means.  Thus, a portion of the services at issue met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested food sensitivity testing for evaluation of her collagenous colitis.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Patients with suspected food allergies are commonly seen in clinical practice. The most common foods that produce allergic symptoms are milk, eggs, seafood, peanuts, and tree nuts.  According to Yawn and Fenton Although skin testing and in vitro serum immunoglobulin E assays may help in the evaluation of suspected food allergies, they should not be performed unless the clinical history suggests a specific food allergen to which testing can be targeted. Furthermore, these tests do not confirm food allergy. Confirmation requires a positive food challenge or a clear history of an allergic reaction to a food and resolution of symptoms after eliminating that food from the diet. These and other recommendations are derived from the guidelines for the diagnosis and management of food allergy in the United States, published by the National Institute of Allergy and Infectious Diseases. Moreover, there is a lack of peer-reviewed literature regarding a link between collagenous colitis and food allergies. Accordingly, the testing at issue was 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 55-year-old male enrollee has requested Harvoni (ledipasvir-sofosbuvir) tablet 90/400 mg for treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the guidelines further indicate that Harvoni is recommended for treatment- naive patients with HCV genotype 1a infection. In this case, the patient has a HCV genotype 1a and is treatment-naive. Therefore, treatment with Harvoni is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested the real time heart monitor study for evaluation of her heart palpitations.  Findings:  Two physician reviewers found that when a patient is being evaluated for syncope or presyncope, extending the period of monitoring can increase the incidence of symptomatic events to approximately 50% at three days and 75% at 5 to 21 days. The diagnostic value of ambulatory monitoring depends on a number of variables. As an example, attention has been drawn to the differences between hospital inpatients and outpatients with ventricular arrhythmias. One study found that 6.3% of 306 hospitalized patients complained of symptoms of ventricular arrhythmias (Zeldis, et al). These complaints correlated with causal arrhythmias detected by 24-hour ambulatory electrocardiography in 95% of patients. Complaints occurred more frequently in 278 outpatients, but these symptoms were less likely to correlate with a causal arrhythmia. Given this patients symptoms, it was reasonable to place a cardiac event monitor. Thus, the real time heart monitor study provided from the time period specified was 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 20-year-old female enrollee has requested weekly individual therapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this case the documentation submitted for review does not support the medical necessity for weekly individual therapy sessions. The documentation does not include a clinical report of current status. Such a report would provide information such as patient goals, chief complaint, barriers to care, symptom complex, mental status examination, sequential objective rating scales, physical examination, medication list, assessment, interpretative summary and plan. In addition, absent is a comprehensive treatment plan, which develops and organizes interventions. One of the many products of a treatment plan in this case would be the specification of the type, setting and frequency of therapy, in addition to the plan for monitoring progress. Further, the patient has done well with the structure of IOP in the past. With a chronic severe mental illness that impairs multiple domains of functionality, a setting such as IOP or partial hospital, both of which offer the full range of biopsychosocial interventions, might provide the most appropriate comprehensive treatment in a complex case such as this. In sum, although comprehensive, specialty treatment services are indicated there is no medical justification for individual psychotherapy at a frequency of once per week. Moreover, an updated psychiatric evaluation is indicated to determine the patients current clinical status and her subsequent treatment needs. As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested  C4-5, C5-6 anterior cervical discectomy and fusion with allograft  for treatment of her cervical spondylosis with myelopathy. Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  This patient was noted to have an assessment of cervical spondylosis with myelopathy.  However, there was a lack of physical examination findings noted for the patient to warrant the surgical request.  The only objective finding noted for the patient was bilateral hand numbness.  She was noted to have a diagnosis of multiple sclerosis.  The records indicated that the patient had not failed conservative treatment prior to the request for a surgical intervention to the cervical spine.  The medical evidence does not support the use of recombinant human bone morphogenetic protein for the treatment of this patient.  Therefore, the requested C4-5, C5-6 anterior cervical discectomy and fusion with allograft is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested MyRisk gene panel testing (CPT code 81479-59) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical records noted a personal history of ovarian cancer.  Per the current guidelines, BRCA testing is warranted due to this patients history of ovarian cancer.  The MyRisk gene panel is a 25-gene panel which includes BRCA testing.  Although the documentation supports the BRCA testing portion of this panel, the records fail to demonstrate the superior efficacy of the remaining tests of the MyRisk gene panel testing.  Thus, a portion of the MyRisk gene panel testing performed was likely to have been more effective than other options for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested nerve blocks (CPT codes 64505, 64405 and 20553) for treatment of her temporomandibular joint disorder. Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available options. Blumenfeld and colleagues conducted a meta-analysis of published peer reviewed literature and concluded that with the exception of cluster headache, there is a paucity of evidence supporting the performance of peripheral nerve blocks in the treatment of headache disorders. In this case, the medical records provided for review report a condition of oromandibular dystonia with associated mixed headaches, and not cluster headache. The physical examinations report occipital tenderness but do not indicate any specific occipital neuralgia, specific trigger points or indicate any signs and/or symptoms related to sympathetic mediated pain. As such based on the medical records provided for review, the nerve blocks provided from the time period specified were not likely to be more beneficial for treatment for the medical condition of oromandibular dystonia and mixed headaches than any other available standard therapy. Furthermore, future nerve blocks are not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old male enrollee requested inpatient hospitalization services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a systemic developmental disorder coupled with concerning cognitive impairment and disruptive behavior with prominent self-injurious behavior that dominate all domains of functionality. In reviewing the clinical documentation, the patient had not consolidated the treatment gains needed to succeed in a less restrictive setting and that discharge would have resulted in undue morbidity and likely readmission.  The multidisciplinary and evidence-based services provided were for active treatment that was delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The services were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, the services at issue were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested gene testing (BRCA1 and BRCA2) for medical evaluation of her history of breast cancer. Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  This patient reports no family history of cancer, and her personal history of breast cancer entails a diagnosis that occurred above the age of 50.  The tumor was unilateral, and not triple-negative. She is not reported to be of Ashkenazi heritage.  Based on the above history, her risk of carrying a deleterious BRCA mutation is not sufficiently high to justify screening.  All told, the requested BRCA1 and BRCA2 testing is not likely to be of greater benefit than other methods of evaluating this patient.