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

A 35-year-old male enrollee requested genetic testing for evaluation of the enrollee, whose spouse is a carrier of spinal muscular atrophy. Findings:  Two physician reviewers found that prenatal carrier screening for either targeted populations or pan-ethnic screening for specific conditions with relatively high carrier frequencies in the general population has existed for many years.  Screening is recommended to allow for guidance of reproductive decision making.  The current medical evidence supports spinal muscular atrophy screening in this patients case.  This patients spouse is a carrier for spinal muscular atrophy.  Thus, the spinal muscular atrophy screening was likely to have been more efficacious than other options.  However, the medical records fail to establish the necessity of the remainder of the genetic testing provided.  In sum, a portion of the services at issue was likely to have been of greater benefit than other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee requested a computed tomography (CT) scan of the abdomen and pelvis for treatment of his abdominal pain.  Findings:  The physician reviewer found that the patient does not meet the American College of Radiology indications for abdominal or pelvic CT scans. The preliminary evaluation prior to CT scanning was limited, the patients physical examination was unrevealing, and there was no clinical sign or indication, or suspicion, of abdominal or pelvic masses or fluid collections, malignancies, inflammatory processes, infections, bowel obstruction or documented weight loss. In sum, there is a lack of clinical justification to warrant the CT scan of the abdomen and pelvis performed during the course of emergency treatment. Therefore, the medical necessity of the services at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested Avastin for medical treatment of his rectal cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Avastin has been approved for use, along with chemotherapy, in metastatic colorectal cancer.  However, the current medical evidence does not support the continuation of Avastin alone in this clinical setting.  There is a lack of data indicating that Avastin alone as maintenance therapy is likely to beneficial in this patients case.  Further, it is not clear that this patients clinical status is a maintenance situation.  This patient would be more likely to derive benefit from a new line of chemotherapy rather than continuation of Avastin alone.  All told, the requested Avastin is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested Norco 10/325, 1-2 every 4-6 hours; Xanax 0.1 mg twice daily; and Flexeril 10 mg for medical treatment of her medical conditions.  Findings:  The physician reviewer found that a portion of the requested medications are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is being treated for headaches and neck pain radiating into the left upper extremity. She appears to have a combination of myofascial pain and rotator cuff impingement. In this clinical setting, the request for Norco 10/325, 1-2 every 4-6 hours and Xanax 0.1 mg twice daily are not medically necessary for treatment of the patients medical condition. The continued use of Norco carries the risk of medication overuse as well as rebound headache. In addition, Xanax (alprazolam) is a benzodiazepine which is not recommended for long-term use. Long-term efficacy has not been proven and there is a risk of dependence. Tolerance to anxiolytic effects occurs within months and long-term use may actually increase anxiety which may be occurring in this case.  The request for Flexeril 10 mg is medically necessary for treatment of the patients medical condition. Flexeril (cyclobenzaprine) is closely related to the tricyclic antidepressants. It is recommended as a second-line option for the treatment of acute exacerbations in patients with muscle spasms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Tarceva for treatment of her lung cancer.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient presented with inoperable advanced non-small cell lung cancer, an adenocarcinoma.  In this patients case, the EGFR mutation was an alteration in exon 18, which is most likely a missense mutation.  Some of the more common mutations detected are within exons 18 or 21 or deletions in exon 19.  All of these mutations correlate with response to tyrosine kinase inhibitors.  Exon 18 mutations, such as G719X, confer a 53% to 60% response rate to Tarceva or gefitinib.  Thus, the current medical evidence supports the use of Tarceva as medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Soma 350 mg two pills three times per day, Percocet 10-325 mg two pills two times per day, and removal of a spinal cyst for treatment of her diagnosis of spinal cyst status post two spinal surgeries.  Findings:  The physician reviewer found that based on the available medical records, this patient has post-operative seroma posterior to the spinal canal, not connected to the spinal canal and not compressing the dura. There is no evidence of a change in size of the seroma on magnetic resonance imaging (MRI) scans and the spinal canal is wide open. Although there is a small amount of an enhancing epidural scar at one level, additional surgery is not indicated or likely to improve her condition as the scar has not been determined to be the cause of her symptoms. Given the patients continued need for narcotic pain medications and muscle relaxants, she should be planned to undergo detoxification with assistance from pain management. All told, the requested Soma 350 mg two pills three times per day, Percocet 10-325 mg two pills two times per day, and removal of a spinal cyst are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested intensive outpatient program (IOP) services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) practice guideline states that IOP may be helpful for patients with severe treatment resistant OCD. The records indicate that this patient is doing well at the IOP level of care and is only just beginning to identify her paranoid ideations. The patient remains at the stage where social anxiety, OCD, and paranoia still impede her ability to perform activities of daily living. Thus, she needs more time in the therapeutic milieu that the IOP offers so that she can continue challenging these thoughts in a safe environment. All told, continued treatment at the IOP level of care from the date indicated forward is appropriate to treat the patients condition, could not be managed effectively at a lower level of care, and is thus medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested Erbitux or Vectibix, in combination with irinotecan for treatment of his colon cancer.  Findings:  Two physician reviewers found that in this patients case, the requested medications are likely to be more effective than other available alternatives.  This patient has metastatic colorectal cancer that has progressed on the combination of Xeloda and Avastin.  At this time, changing his treatment to a regimen of single agent irinotecan in combination with an EGFR-inhibitor, either Vectibix or Erbitux is medically appropriate.  Erbitux or Vectibix is not recommended when the patient has progressed on either of these agents in the past.  In this case, the patient was briefly treated with Erbitux, but progression of disease while on this agent was not documented.  Therefore, use of Erbitux at this time would be considered a continuation of treatment and not re-treatment.  In sum, Erbitux or Vectibix, in combination with irinotecan is likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested computed tomography (CT) angiography (CPT code 75574) for evaluation of his abnormal cardiac study and an iliac artery aneurysm.  Findings:  Three physician reviewers found that performance of coronary CT angiography in this patient is not consistent with current standard medical practice or likely to be more beneficial than any available therapy. An exercise stress test with imaging is considered the first-line diagnostic study given this patients history and the time that has elapsed since the previous study (Miller, et al). According to the Health Quality Ontario review on the utility of CT angiography, the diagnostic procedure is almost as good as coronary angiography in detecting true positives but poorer in the rate of false positives, which may lead to further unnecessary testing. Consistent with the available data, the requested CT angiography (CPT code 75574) is not 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 53-year-old female enrollee has requested Orencia infusions with an initial loading dose (three infusions over four weeks) followed by a maintenance dose of 750 mg intravenously (IV) every four weeks for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that there is a lack of guidance provided in the peer-reviewed literature, the American College of Rheumatology guidelines and the manufacturers prescribing highlights of how to dose Orencia when there a break in treatment.  According to Orencias packaging insert, the half-life of Orencia is 8-25 days with a terminal half-life of 13 days. Typical pharmacodynamics would suggest that this medication would be eliminated within 4-5 half-lives which could be from 32-125 days with an average of 52-65 days. Given that the patient has not reached the 65 days, there may still be Orencia in her body putting her at risk of overdosing and infections if she were to be re-loaded. Westhovens and colleagues evaluated the safety and efficacy of abatacept plus methotrexate (MTX) over five years in patients with rheumatoid arthritis. The authors found long term safety allowed interruptions of up to two infusions (12 weeks) between treatments without re-loading the patients for safety issues. Since it has been only eight weeks since her last infusion, she does not require re-loading. Moreover, given that according to her most recent exam, Orencia has not put her in remission and there is discussion of stopping it, the risk of re-loading outweighs the risk of restarting at her current monthly dose as approved by the Health Plan. In sum, the request for re-loading may place the patient at risk of overdosing or serious infections, making the requested Orencia infusions with an initial loading dose (three infusions over four weeks) followed by a maintenance dose of 750 mg IV every four weeks as not medically necessary. 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: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his stage IV colon cancer.  Findings:  Three physician reviewers found that current guidelines state that patients with oligometastatic colon cancer should be treated aggressively including local treatment to each liver lesion in the form of surgery or radiation (Benson, et al). The records indicate that this patient underwent surgery for the hepatic lesions and the surgeon determined that the third lesion could not be completely resected. Therefore, SBRT is considered appropriate in this clinical setting because the remaining hepatic lesion cannot be entirely removed by surgery. There are adequate prospective studies demonstrating the efficacy of stereotactic body radiotherapy in this setting (Schefter, et al; Katz, et al). Thus, the requested services are likely to be more beneficial for treatment of the patients condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the patient was not suicidal. The latest medication, bupropion, was prescribed at a reasonable dose and remained well-tolerated.  The treatment team decided to taper the selective serotonin reuptake inhibitor and replace the medicine with a dual-acting antidepressant. This type of change does not necessitate an inpatient setting. Although the patient demonstrates chronic underlying issues of significance including a serious affective mental illness with chronic suicidality that will necessitate on-going comprehensive specialty care, there was no acute psychiatric syndrome or grave disability. Thus, transition to a less restrictive setting, such as a residential program or partial hospitalization with supportive housing if discharge home to her family was not conducive to recovery, was indicated and the disputed service was no longer medically necessary. All told, the acute inpatient psychiatric services provided from the time period specified were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for genetic testing (whole exome sequencing) for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the request for genetic testing (whole exome sequencing) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with a complex medical history with biochemical testing results suspicious for a complex metabolic/mitochondrial disease. Whole genome sequencing allows for a comprehensive, ultimately time saving modality to approach complex medical cases. In addition, this patients phenotype and biochemical testing overlap many possible genes which makes him a good candidate for this technology. Moreover, whole exome sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy given that there are too many genes in consideration to do them in a sequential manner.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lower extremity joint without dye for evaluation of her left knee pain.  Findings:  The physician reviewer found that based on the available medical records, this patient has clinical evidence to justify MRI exam of the left knee as mentioned in the National Imaging Associates (NIA) guidelines. Specifically, there is evidence of swelling, likely a joint effusion and there is a note in the records concerning knee instability. These symptoms and physical findings qualify as appropriate indications for MRI according to the 2014 NIA guidelines for MRI imaging. Moreover, the records document joint swelling and a recent history of fever and chills. Although these symptoms are non-specific they could also be consistent with a joint space infection. As such, the requested MRI of the lower extremity without dye is medically necessary without the requirement of a course of physical therapy beforehand.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Transcranial magnetic stimulation is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical course of transcranial magnetic stimulation falls between 30 to 40 sessions.  There is a lack of adequately-powered, well-designed studies demonstrating the long-term clinical utility of transcranial magnetic stimulation maintenance therapy or its ability to prevent relapse.  In this patients case, she completed 35 transcranial magnetic stimulation treatments.  She had a positive response.  She was experiencing anticipatory anxiety with the transcranial magnetic stimulation tapering which came to fruition in her symptom report.  The extent of non-pharmacological, community-based interventions was not reported.  In sum, the medical evidence does not support continuing transcranial magnetic stimulation therapy, and the medical records indicate that standard therapies had not been exhausted.  Thus, transcranial magnetic stimulation from the date indicated forward was not and is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that Harvoni is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir (90 mg/400 mg) is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. In this case, the medical necessity for Harvoni has not been established due to the lack of information of the patients HCV viral load, genotype and fibrosis score. Harvoni is approved for genotype 1 patients only and duration of HCV therapy is determined on HCV viral load. Given the lack of documentation demonstrating the patients HCV viral load, genotype, and fibrosis score the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested arthroscopy of the hip for treatment of her hip pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  According to Yazbek and colleagues, patients with clinical evidence of an acetabular labral tear confirmed with MRI can show meaningful improvement with nonsurgical intervention.  The patient experienced a negative response to an intra-articular hip injection of Marcaine and Kenalog.  The records do not demonstrate that the patients clinical symptoms are resulting from a labral tear.  The patient has tenderness to palpation about the L4-5 region of the spine with painful range of motion and radiation into the lower extremities.  Given the patients positive findings on CT scan of the lumbar spine and physical examination findings, the patient was appropriately referred to a spine specialist.  The current medical evidence does not support the requested arthroscopy of the hip in this clinical setting.  All told, the requested arthroscopy of the hip is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested the LINX Reflux Management System for treatment of her gastroesophageal reflux disease. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment alternatives.  The LINX device has been approved for patients with chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  Appropriate patient selection is crucial before anti-reflux procedures.  This patient has gastroesophageal reflux disease based on her pH recordings.  However, it appears she has benefitted to a significant degree from acid suppression treatment.  Thus, the records do not demonstrate that she is refractory to acid blocker drugs.  Additionally, the documentation does not show that the patient has worsening bone mineral loss due to medical management of her gastroesophageal reflux disease.  Available records do not document by serial DEXA scanning progressive osteopenia/osteoporosis.  Therefore, the LINX Reflux Management System is not likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested intravenous antibiotic therapy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Outpatient therapy of diabetic foot infections is provided via the oral or intravenous route.  Intravenous therapy is preferred in cases in which there is significant infection and potential risk for amputation.  Generally, this therapy is provided on an outpatient basis unless the patient has very significant comorbid disease, such as severe cardiac or pulmonary disease, or is septic.  In this case, the documentation indicates that the patient refused a PICC line.  However, there is no clinical documentation indicating that the patient was at high-risk for a PICC line associated infection.  Additionally, PICC lines are used on a regular basis in patients at high-risk for infection.  All told, hospitalization from the time period specified for completion of intravenous antibiotic therapy was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested skilled nursing facility (SNF) services (including physical therapy and occupational therapy) for treatment of his chronic obstructive pulmonary disease (COPD), diabetes, nephrolithiasis, and arterial hypertension.  Findings:  The physician reviewer found that based on the available medical records, this patient has multiple chronic health conditions, such as obesity, diabetes and hypertension that would benefit from increased physical activity and exercise (Brook, et al; Hagen, et al). He has been undergoing inpatient therapy for deconditioning but plateaued at the end of the year indicated performing transfers and ambulating very short distances with significant levels of assistance. Thus, further therapy for improving self-care and mobility can be provided on an outpatient basis. Additional inpatient physical and occupational therapy at the SNF level of care would not be expected to provide predictable, marginally significant functional gains that could not be attained in the outpatient therapy setting. For these reasons, the requested SNF services (including physical therapy and occupational therapy) are not medically necessary for treatment of this patients medical condition.