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

A 52-year-old male enrollee has requested skilled nursing facility (SNF) services including physical therapy and occupational therapy for treatment of his left-sided paralysis due to history of tumor.  Findings:  The physician reviewer found that the patient has chronic paralysis not from stroke but from neurological injury. However, the neurological response in rehabilitation parallels that of stroke. Physical therapy and occupational therapy do not improve neurological function but improve function at a given neurological state. When neurological status is stable, further recovery with formal rehabilitation services cannot be expected. The records indicate that this patient has chronic fixed neurological deficit and has reached maximal recovery. Continued daily therapy will not produce significant changes. The patient has reached a level of function that is not expected to respond to daily skilled therapy to restore or maintain function. Moreover, the patient has no daily skilled nursing needs. All told, the SNF services including physical therapy and occupational therapy are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested reimbursement Avastin injection for treatment of his choroidal neovascularization (CNV).  Findings:  Three physician reviewers found that there are numerous case series reports of improvement in vision and retinal structure with Avastin for treatment of idiopathic choroidal neovascularization. Moreover, in most diseases causing choroidal neovascularization, Avastin injection has been shown to be beneficial. Since idiopathic choroidal neovascularization is a rare condition, there are not likely to be any prospective studies evaluating this treatment. All told, the Avastin injection at issue was likely to have been more beneficial than any other available treatment for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female enrollee has requested doxycycline injections for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that a biopsy confirmed pathology consistent with a giant cell reparative granuloma/aneurysmal bone cyst.  The patient has been treated with extensive cortisone injections.  However, the mass has continued to grow in size.  There is a lack of support for the requested services in this clinical setting.  Per the current medical evidence, doxycycline is not generally accepted as a standard treatment in this clinical setting.  Additionally, as the patients tumor is noted to be growing rapidly, continued conservative treatment is not indicated. As such, the requested doxycycline injections for treatment of giant cell reparative granuloma with aneurysmal bone cyst characteristics are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested gastric electrical stimulator for treatment of her diabetic gastroparesis. Findings:  Two physician reviewers found that the requested device is not likely to be more effective than other treatment options.  There is a lack of support for the requested gastric electrical stimulator in this clinical setting.  Per the current medical literature, there is a paucity of evidence supporting this device.  The gastric electrical stimulator has not been shown to consistently improve gastric emptying.  All told, the requested gastric electrical stimulator is not likely to be more efficacious than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee has requested acute inpatient eating disorder services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, discharge on the date indicated would have been inconsistent with good medical practice.  The patient had a body mass index of 15.8 upon admission.  Per the medical records, he had only gained 3 ounces.  This calls into question the success of the critically important re-feeding stage.  He began treatment with a serotonergic enhancing medication upon admission and an antipsychotic medication was added due at least in part to persistent loose associations, thought blocking and tangential speech.  In addition to psychopharmacotherapy, the patient received comprehensive services including nutritional counseling, individual therapy, and occupational therapy.   However, the patient continued to have symptoms of cognitive disarray, anxiety and eating disordered schemas until his transition to the residential level of care.  In sum, the services were reasonably expected to improve his condition and prevent a more serious episode of illness.  All told, acute inpatient eating disorder services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested percutaneous skeletal fixation of tarsometatarsal joint dislocation for treatment of her plantar calcaneal spur. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The medical records show that the radiology report does not confirm the diagnosis of fracture, subluxation or dislocation. Skeletal fixation is indicated for fracture and manipulation is indicated for a displaced fracture or subluxation of the joint, which there are no radiographic findings for. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested platelet rich plasma injections for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other available treatment options.  The current medical evidence has not established the superior efficacy of the requested services in this clinical setting.  Cerciello and colleagues noted that while reports regarding the use of platelet rich plasma injections in in-vitro models are promising, further research is needed to establish the efficacy of platelet rich plasma injections and to adopt standardized protocols.  Additional studies are needed to demonstrate the overall efficacy and safety of platelet rich plasma injections versus standard therapy.  Thus, the requested platelet rich plasma injections are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Sovaldi for treatment of her hepatitis C virus genotype 2b.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) indicates that an interferon regimen is the preferred treatment for hepatitis C virus genotype 1. However, the standard of care for hepatitis C virus genotype 2 includes combination therapy with Sovaldi and ribavirin. In addition, three high quality trials support the combination of a polymerase inhibitor with ribavirin for treatment of hepatitis C virus genotype 2. Consistent with these findings, the requested medication regimen with Sovaldi and ribavirin is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Norco, Vicodin, and a pain patch for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. Long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. It is in the patients best interest to wean off all these opioids and continue in a multidisciplinary program. All told, the requested Norco, Vicodin and pain patch are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested cone beam tomography for evaluation of her history of temporomandibular joint pain and stiffness. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, physical therapy has been prescribed.  The medical records note clicking in the temporomandibular joint upon opening.  Cone beam tomography may be used to diagnose disc displacement, a condition which would produce the temporomandibular clicking on opening, or arthritic changes, which are often a cause of the crepitus observed in the joints.  However, there is no treatment plan provided other than the description of temporomandibular joint discomfort, and there is no rationale given for cone beam tomography.  The requested cone beam tomography would typically be used to confirm the working diagnosis given.  There is no indication that results of the tomographic imaging requested would alter the course of treatment.  All told, the requested cone beam tomography is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that at the time of admission the patient presented with significant anger management and physical aggression issues that placed her sister at high level of risk or harm and also placed the family home at risk of destruction. The patient had already received outpatient, inpatient and PHP with no improvement. In addition, she had already failed treatment with multiple medications. Therefore, the admission to residential level of care was appropriate and medically necessary. Her recent dangerous behaviors and especially physical aggression toward her sister as well as the chronic nature of her impairments did make RTC the most reasonable level of care. Additionally, having failed prior treatments, she did require admission for a coordinated assessment with follow up to determine the cause of her problems and an appropriate treatment plan. The medical records indicate that by the date indicated, the patient reported feeling much better and was getting along better with the family and beginning to consent to meet with her sister to work on their relationship. Therefore, she could have been stepped down to PHP level of care to safely continue her treatment. As such, the residential treatment center services were medically necessary for treatment of the patients medical condition, however from the specified date and forward the services in dispute were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Subsys for treatment of her interstitial cystitis.  Findings:  The physician reviewer found that Subsys is not medically necessary for the patients medical condition. Subsys is indicated for breakthrough cancer pain in patients who are opioid tolerant or otherwise with a limited life expectancy. In addition, the patient reportedly failed previous trials of multiple opioids including fentanyl citrate, which is the same opioid known as Subsys. Opioids are considered adjunctive to this therapy and short-release medications with a high risk of dependence and tolerance such as Subsys is not recommended. High dose opioids may also cause adverse outcomes. Ballantyne and Mao reported on studies indicating that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. Baron and McDonald reported that high dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. All told, it is in this patients best interest to wean off opioids and be provided adjunctive therapy such as physical therapy, massage therapy, aqua therapy or cognitive behavioral therapy, in order to address the patients chronic pain. Therefore, the requested Subsys is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested a computed tomography (CT) scan of the sinuses for evaluation of the enrollees sinusitis and ocular pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the diagnostic procedure at issue. In this case, the patients symptoms included eye pain, with no other associated findings compatible with the diagnosis of sinusitis. If the patient had other associated symptoms such as nasal discharge or postnasal drip then the diagnosis would be more obvious and one could conclude without the use of imaging that he actually has sinusitis and begin treating empirically. However, the patient had isolated eye pain without any other symptoms of sinusitis and therefore one could not have made the diagnosis of sinusitis without the CT scan. Based on the medical literature cited above and the documentation submitted, the CT scan of the sinuses was medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested radiofrequency neurolysis for treatment of her back pain with sciatica and lumbar radiculitis.  Findings:  Three physician reviewers found that pulsed radiofrequency, a modification of the conventional radiofrequency ablation treatment, has been utilized in managing chronic pain. Generally radiofrequency neurotomy is applied for facet joint pain. Epidural steroid injections are commonly performed for managing lumbar radiculitis. Although pulse radiofrequency of the dorsal root ganglion may be a potential alternative to epidural injections in treating chronic lumbar radicular pain, there is a paucity of peer-reviewed medical literature demonstrating the efficacy of pulsed radiofrequency for dorsal root ganglia. Shanthanna and colleagues published a report showing no difference in pain ratings at four weeks or three months following pre-operative assessment. Simopoulos and colleagues retrospective report included 76 patients. The authors reported improvement in 75% of the patients in the short-term, but all of them lost any benefit at eight months. All told, there is a lack of scientific data supporting the use of radiofrequency neurolysis in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a surgical procedure to remove a growth (right eye) for treatment of her pterygium of the right eye.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. Pterygium is an abnormal growth of the conjunctiva onto the corneal surface. It is associated with chronic sun exposure, dust exposure and dry climates. Pterygium surgery is indicated when the pterygium impinges on the visual axis, interfering with vision. In this patients case, the provider noted the growth to be 1.75 mm, which is not extensive enough to interfere with the visual axis. As such, the requested surgery is not clinically indicated. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested continued use of methadone HCl for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The records noted aberrant behavior with opioid medications, including a urine toxicology positive for cocaine.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The medical evidence does not support the requested medication in this clinical setting.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high-dose opiates might induce abnormal pain sensitivity and tolerance.  All told, continued use of methadone HCl is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested proton beam therapy treatments for treatment of his prostate cancer. Findings:  The physician reviewer found that although there is an increased risk of stricture after radiation post transurethral resection of the prostate, this is a manageable toxicity.  It is not clear from the literature that dose to the transurethral resection of the prostate deficit impacts this risk, and there is a lack of evidence indicating that proton therapy can reduce this risk.  Due to the dosimetric uncertainties with proton therapy, particularly if image-guided radiation therapy is not being used for this patient, it is possible that toxicity could be worse with proton therapy versus intensity modulated radiation therapy/image-guided radiation therapy.  All told, proton beam therapy treatments were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Actiq lollipop for treatment of his brachial neuritis.  Findings:  The physician reviewer found that in the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. Consisting with these findings, it is in this patients best interest to wean off Actiq and be treated with adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. All told, the requested Actiq is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested power wheelchair repairs for treatment of his arthrogryposis multiplex congenita (AMC).  Findings:  The physician reviewer found that wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario (Cherubini and Melchiorri; Dicianno and Tovey; Johnson and Fitzsimmons). In the current case, the patient was assessed in the community by a physical therapist and noted to be able to use a manual wheelchair for all of his home mobility needs. He was assessed to have the capacity to self-propel a manual wheelchair. His power wheelchair was being used for community mobility only. The homes entry/egress was not accessible to a power mobility device. Overall, the records from the specialized mobility evaluation do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living in the home. The current manual wheelchair was in excellent condition. Therefore, the requested repairs of this patients current wheelchair are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medications. Prior to the introduction of Sovaldi, treatment options for interferon ineligible HCV patients have been very limited. Compared to previously conventional agents, Sovaldi provides improved efficacy and tolerability, oral route of administration, and a shortened treatment duration requirement. For patients with HCV genotype 1 infection who cannot take interferon, the use of Sovaldi plus ribavirin may be considered as an alternative (Osinusi, et al). In addition, the joint treatment guidelines of the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend the proposed regimen of daily Sovaldi and weight-based ribavirin for the retreatment of HCV genotype 1 infection in this clinical setting. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi and ribavirin is medically necessary. Therefore, the medical necessity of the requested medications has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested binge eating disorder (BED) group for treatment of his behavioral health conditions.   Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has been attending binge eating disorder group for a couple of years without much improvement. Given the patients primary diagnosis is narcissistic personality disorder, it is not medically necessary for him to be attending a binge eating group. Moreover, it is likely that the reason the patient is not progressing in the binge eating group is that it is not treating his primary diagnosis. Therefore, it is not medically indicated for him to continue receiving treatment in the BED group. The treatment team has provided a reasonable alternative treatment to this patient, to continue individual therapy with a new therapist. 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.