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

A 61-year-old male enrollee requested transcranial magnetic stimulation services for medical treatment of his bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association for the acute phase treatment of major depressive disorder.  However, the recommendation does not extend to bipolar disorder.  Although some preliminary positivism can be found in the medical literature regarding the application of transcranial magnetic stimulation therapy for patients with bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  Thus, the safety and appropriateness of transcranial magnetic stimulation for this indication has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested facet joint injections, CPT codes 64490 x 2, 64491 x 2, and 64492 x 2 for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested facet joint injections in this clinical setting.  In this patients case, physical examination did not indicate whether her pain was derived from the facets.  Additionally, there was a lack of imaging studies demonstrating facet pathology.  Based upon review of the clinical notes, there is a lack of documentation indicating that the patient has tried and failed conservative therapy, including physical therapy.  All told, the requested facet joint injections, CPT codes 64490 x 2, 64491 x 2, and 64492 x 2 are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested Sovaldi 400 mg and Olysio 150 mg capsules for 12 weeks for medical treatment of her Hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested medication combination. The requested combination of Sovaldi and Olysio has not been approved by the U.S. Food and Drug Administration (FDA). Although the requested treatment of simeprevir and sofosbuvir has been suggested by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines it has not been studied in a large phase III trial. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested PCA3 testing for medical evaluation of his prostate cancer.  Findings:  Three physician reviewers found that the testing performed was not likely to be more effective for this patient than other available treatment options. The PCA3 test is not established as a unique therapeutic aid. Although, according to a few studies it may have more sensitivity than the prostate-specific antigen (PSA). However, the PSA is used as the definitive laboratory test for evaluating prostate cancer per National Comprehensive Cancer Network (NCCN) guidelines. Therefore, 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: Upheld Decision of Health Plan

A 35-year-old female enrollee requested a laparoscopic hysterectomy for medical treatment of the enrollees pelvic pain and menorrhagia.  Findings:  The physician reviewer found that there is no indication for any surgery at this time based on her cervical issues.  This patient underwent endometrial ablation previously, and the records following the procedure noted that the patient was doing well.  The current medical evidence does not support laparoscopic hysterectomy in this clinical setting.  It is likely that this patients symptoms will respond to endometrial ablation, and if her symptoms do not resolve, there are other options for management prior to proceeding with hysterectomy.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested inpatient hospitalization stay for treatment of her elevated blood pressure during pregnancy.  Findings:  The physician reviewer found that the inpatient hospitalization stay was not medically necessary for treatment of the patients medical condition.In this case, according to the medical records submitted for review, at the time of admission her blood pressure (BP) was 142/85. There is no evidence that the patient had consistent hypertension after the initial BP reading. In addition, the FHTs were normal. There is a lack of evidence demonstrating that the patient required hospitalization for stabilization of BP or for reasons of possible or impending fetal compromise. Moreover, the discharge summary indicates that the patients blood pressures and vital signs were normal throughout the hospitalization. The patient could have been observed in a triage setting prior to consideration of the inpatient hospitalization. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) for medical treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the services were likely to be more beneficial for treatment of the patients medical condition any available standard therapy. The patient presents with oligometastatic disease, and this particular type of disease has a long interval to progression and limited sites of disease.  While the standard therapy for metastatic disease is chemotherapy there is an emerging body of literature which suggests that patients with oligometastatic disease benefit from aggressive local therapy including stereotactic radiation (Palma, et al.). Given the disease process has a relatively indolent course and that she was not a candidate for surgical resection of the lesion, stereotactic body radiotherapy to the liver metastases was likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested an electric scooter for medical treatment of her back pain with right lower extremity radiculopathy and diabetes. Findings:  The physician reviewer found that the patient has impairments, but none that would preclude the use of a gait aide such as a cane or walker, or an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion, for accomplishing her mobility-related activities of daily living. In addition, this patient has multiple chronic health conditions including diabetes and arthritis that would benefit from increased physical activity and exercise (Hagen, et al; Samson and Garber). All told, the requested electric scooter is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested bilateral knee Orthovisc injections for medical treatment of his osteoarthritis.  Findings:  Two physician reviewers found that there have been carefully conducted double-blinded studies, which do not document any clinical effect from repeated hyaluronan injections. This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. 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. Given the paucity of well-designed, double-blinded studies demonstrating improved health outcomes with repeated viscosupplementation, it is not likely to be beneficial for this patient to receive the repeated injection protocol recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested Sovaldi with Pegasys and ribavirin (Sovaldi+PEG+RBV) for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that Sovaldi has been shown to be effective and tolerable to patients with chronic hepatitis C virus. In addition, the treatment duration is decreased. Also, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines support the use of the recommended regimen in this treatment naive patient. The patient has no contraindication to interferon-based treatment and is motivated to begin re-therapy to prevent further progression of disease. Consistent with the AASLD/IDSA guidelines, the requested combination therapy consisting of Sovaldi with Pegasys and ribavirin (Sovaldi+PEG+RBV) is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested Prolia (denosumab) injections for treatment of her osteopenia.  Findings:  Two physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient is being considered for treatment of osteopenia with the goal of preventing the progression to osteoporosis. She has documented osteopenia on the most recent bone mineral density test with a corresponding fracture risk below the threshold suggested for starting anti-resorptive therapy (Levis and Theodore). Although denosumab is an effective and approved medication for the treatment of both postmenopausal and steroid-induced osteoporosis (Cosman), this patient does not have clinical evidence of either condition. Anti-resorptive therapy is not indicated for the treatment of osteopenia, and has not been studied for osteoporosis prevention. As such, the request for denosumab is not likely to be a more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested acute inpatient mental health services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that acute psychiatric hospitalization was initially indicated and consistent with good medical practice. However, based on the medical records, the acute level of care was necessary only until the patients antipsychotic medication had been increased, the patient had an improved appearance and was doing better. The trend continued as the patients thought processing was notably improved, his affect was appropriate and, although he disagreed for the need for a conservator, the patient was stable.  His thoughts were more organized and his behavior was cooperative. He was not suicidal or homicidal. He was adherent with his medications which were both well tolerated and efficacious. In sum, this patient has severe mental illness. His illness responds well to pharmacotherapy.   However, the patient has history of discontinuing his psychotropic medications and subsequently decompensating. Thus, a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee requested intensive psychodynamic psychotherapy 4-5 times per week for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that psychodynamic therapy is not endorsed by the American Academy of Child and Adolescent Psychiatry for treatment of autism spectrum disorder, which is a highly recognizable, and often comorbid, developmental condition firmly steeped in biological etiology. The most effective treatment strategies involve behaviorally based therapies such as applied behavioral analysis. Second, the patients psychiatrist commented that the patient has just recently achieved therapeutic doses of her medication and the results have been very good. Thus, it appears that the patient has the potential to benefit from appropriate pharmacotherapy. Further, there are other standard interventions available in this setting including treatment in a multidisciplinary mental health program, which it appears was recommended for the patient earlier. Based upon the documentation provided, there is limited evidence supporting the therapeutic effectiveness of intensive psychodynamic psychotherapy in this setting and the patient has not exhausted the standard therapeutic options commonly relied upon for the treatment of her condition. 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 59-year-old female enrollee requested posterior tibial nerve stimulation (PTNS for medical treatment of the enrollees overactive bladder.  Findings:  Two physician reviewers found that PTNS treatments were not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the long-term efficacy of PTNS compared to standard therapies, both medical and interventional. Also, the patients confounding conditions of uterine prolapse requiring pessary, depression, overweight, antihistamine use and Ambien use do not make it possible to assess the efficacy of PTNS in isolation amongst this constellation of potential contributors to the outcome of therapy. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 20-month-old male enrollee requested special wound product, ACell for medical treatment of the enrollees burns.  Findings:  Three physician reviewers found that there is a lack of case reports in the medical literature on the use of Matristem ACell in acute burns. In the absence of support from peer-reviewed medical literature on the use of Matristem ACell on acute burns, the services at issue were not likely to be more beneficial for treatment than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested genetic screening (Counsyl Panel) for medical evaluation of her risk for genetic diseases.  Findings:  Three physician reviewers found that based on the current medical literature, carrier screening is recommended for selected disorders even without a previously affected individual in the family. These are autosomal recessive disorders amenable to prenatal diagnosis. Screening for a panel of mutation with no family risk and no availability of prenatal diagnosis is not recommended and has not been shown to be beneficial. The Counsyl Panel is not risk based and is therefore not more beneficial than targeted screening. All told, the use of the Counsyl Panel genetic testing in this clinical setting 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: Overturned Decision of Health Plan

A 34-year-old male enrollee requested acute inpatient psychiatric hospital services for medical treatment of his bipolar disorder.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the acute inpatient psychiatric hospital services provided were medically necessary for treatment of this patients bipolar disorder and borderline personality disorder. The records indicate the patient was plagued with the most serious of affective disorders. Further, the hospitalization enabled the patient to start dialectical behavior therapy while the inpatient team prepared the patient for transition to an appropriate aftercare treatment program. The services provided were for active treatment that was appropriate and reasonably expected to improve the patients condition as well as prevent a more serious episode of illness. In sum, considering the patients records, relevant peer-reviewed literature, and current practice guidelines, the acute inpatient psychiatric hospital services were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested skilled nursing facility services for medical treatment of her medical condition.   Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient sustained a left hip fracture and was treated with surgery. She has improved functionally to the point that she is set up to be independent for most of her basic activities of daily living and transfers. There are no documented impairments that would preclude her from propelling a manual wheelchair for household distances. Thus, rehabilitative care could have been provided at a less intensive level of care such as home care with custodial level assistance and community-based home, then outpatient rehabilitation. Care at a skilled nursing facility is custodial in nature and not medically necessary. Therefore, skilled nursing facility services, was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee requested labial reduction for medical treatment of her enlarged labia.  Findings:  The physician reviewer found that labial reduction surgery reshapes the labia minora to decrease the length of the labia or create symmetry.  The traditional aim of the surgery is to decrease discomfort from chaffing or irritation.  The submitted documentation supports the medical necessity of the requested services in this clinical setting.  The medical records document that the patient has symptoms and findings of significant and symptomatic labial hypertrophy, including chronic irritation.  Therefore, the proposed procedure is within the standard of care for the indication of labial hypertrophy and is medically indicated.  The condition constitutes an abnormal condition of the body caused by a developmental abnormality.  The requested surgery is proposed to improve the symptoms associated with the abnormality.  All told, the requested labial reduction is reconstructive in nature and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 85-year-old male enrollee requested Lyrica for medical treatment of his sciatica.   Findings:  The physician reviewer found that  per prescribing information, Lyrica is indicated for patients with epilepsy or seizure, diabetic peripheral neuropathy, post herpetic neuralgia, neuropathic pain due to spinal injury, or fibromyalgia. This patients records do not include documentation that this patient has any of these approved indications for Lyrica. Consistent with the prescribing information and without significant studies in response of Lyrica in low back pain, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 54-year-old female enrollee requested the use of real-time intra-fraction target tracking during radiation therapy for treatment of her right breast infiltrating ductal carcinoma.  Findings:  Three physician reviewers found that the use of real-time intra-fraction target tracking techniques may allow for a reduction in margins and thus has the potential to reduce the morbidity associated with unnecessary dose to surrounding normal tissues. Using this technology in the treatment of left-sided breast cancers in conjunction with respiratory management has been shown to reduce the dose of radiation to the lung and heart (DAmbrosio, et al; Cervino, et al). However, in right-sided breast cancer there is no documented benefit to real-time intra-fraction target tracking. Consistent with these findings, the use of real-time intra-fraction target tracking during radiation therapy was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested bronchial thermoplasty for medical treatment of her asthma.  Findings:  Two physician reviewers found that bronchial thermoplasty may be considered as a treatment option for patients with uncontrolled severe asthma despite maximal medical therapy.  Although this patient may have asthma, other diagnoses, such as vocal cord dysfunction or lisinopril-induced cough, have not been excluded.  She is not on maximum medical therapy because her regimen does not include a long-acting beta-agonist.  The current medical evidence does not support bronchial thermoplasty because the diagnosis of asthma is uncertain and she is not on maximal medical therapy.  All told, the requested bronchial thermoplasty is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested lumbar spine magnetic resonance imaging (MRI) with and without contrast for medical evaluation of her low back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure in this patients case.  She has received epidural injections for back pain.  The patient presents with severe low back pain, and there is reference in the chart to a complete blood count showing high white blood cell count.  Given the history of injections, severe pain and high white blood cell count, there may be the possibility of epidural abscess or osteomyelitis.  As such, MRI of the lumbar spine without and with contrast would be the procedure of choice to rule out a post-procedure infectious process or hematoma which could be dangerous if left undetected.  All told, the requested lumbar spine MRI with and without contrast is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested positron emission tomography (PET) scan of the brain for medical evaluation of her Parkinsons disease.   Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of a PET scan in this clinical setting. The diagnosis of Parkinson disease is mainly based on clinical criteria characterized by motor symptoms including bradykinesia, rigidity, resting tremor, and postural instability (Hsiao, et al). In this case, the provider recommended the diagnostic procedure to further confirm the patients diagnosis of Parkinsons disease. There is a lack of controlled studies supporting the use of PET scan for the diagnosis of Parkinsons disease. Therefore, based on the peer-reviewed literature and medical evidence submitted the PET scan at issue was not likely to be more beneficial than standard medical therapy.