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

A female enrollee requested individual therapy with a psychologist every two weeks for medical treatment of her depression and anxiety. Findings:  The physician reviewer found that the records do not demonstrate that this patient has regularly followed up with the psychologists recommendations of anxiety skills group and DBT, which is the gold-standard treatment for patients struggling with interpersonal boundaries, character pathology and emotional dysregulation. All told, the medical records do not support the requested individual therapy with a psychologist every two weeks.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested breast tomosynthesis (CPT 77063) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found there is a lack of peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis is a promising tool in breast imaging, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Therefore, the breast tomosynthesis was not likely to be more beneficial for evaluation of this patient than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested wireless capsule endoscopy of the gastrointestinal tract for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the American Gastroenterological Association guidelines recommend video capsule endoscopy to investigate patients with occult blood in stool and negative esophagogastroduodenoscopy and colonoscopy, such as in this patients case.  In appropriately selected patients, the technology has a high yield and can avoid more invasive procedures. Therefore, the requested wireless capsule endoscopy of the gastrointestinal tract is likely to be more effective than other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested epidural spinal injections for medical treatment of her thoracic radiculitis.  Findings:  Three physician reviewers found that given that the patient has not responded with definitive relief from facet joint injections, with evidence of osteophyte complex and pain in the ribs with nerve cysts, epidural spinal injections are appropriate in this clinical setting. As such, epidural spinal injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested real-time intra-fraction target tracking (CPT 77387) for medical treatment of her stage III clinical group 3 embryonal rhabdomyosarcoma. Findings:  Two physician reviewers found that real-time intra-fraction target tracking is not likely to be more beneficial to facilitate delivery of proton beam radiation therapy than standard available approaches. At this time, there is a lack of scientific data demonstrating that the use of real-time intra-fraction target tracking results in improved safety and efficacy in the treatment of skull base lesions.  The requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Benlysta injections for medical treatment of her systemic lupus erythematosus (SLE).   Findings:  The physician reviewer found that since approval, Benlysta has been demonstrated to be useful in the treatment of arthralgias and fatigue. Moreover, Benlysta has been shown to increase the interval between lupus flares. This patient continues to experience severe arthralgias and myalgias, failed methotrexate, and has been unable to tolerate hydroxychloroquine. Benlysta is therefore reasonable and medically necessary treatment for this patients disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Norco for medical treatment of her chronic neck and back pain. Findings:  The physician reviewer found that there was no documentation of a significant functional deficit to support the necessity for ongoing opioid therapy. There was also no mention of a failure of non-opioid analgesics prior to the initiation of Norco. Based on the clinical information received, the requested Norco is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested water assisted lymph node saving liposuction for medical treatment of her bilateral lymphedema. Findings:  The physician reviewer found that although the patient has undergone some traditional conservative management of her lower extremity enlargement, she does not appear to have undergone significant weight loss to possibly improve her condition and lessen any possible risk for surgical intervention. This patient should consider further weight loss to help treat her condition and to possibly become a better surgical candidate prior to consideration for surgical intervention. Thus, the requested water assisted lymph node saving liposuction is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested the LINX surgery with an esophageal sphincter augmentation device (CPT 43289 and 43280) for medical treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that overall, the currently available peer-reviewed literature and the FDA requirement for additional data do not indicate that LINX is more likely to be beneficial in this case than standard treatment such as surgical fundoplication (Sheu, et al). Accordingly, the requested LINX surgery with an esophageal sphincter augmentation device (CPT 43289 and 43280) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested psychotherapy, once or twice a week for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the Health Plans recommendation of weekly group and twice monthly individual sessions adequately meets evidence-based treatment recommendations.  Further, the Health Plan has suggested augmentation with an intensive outpatient program which would further bolster the non-pharmacologic interventions in this case. As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that in this case, the patient would likely be non-compliant in an IOP/PHP program, as already determined by the staff at the program to which she applied. She has chronic, serious symptoms that require an intensive, coordinated treatment approach. Thus, RTC level of care is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested eribulin intravenous (IV) (mesylate 0.1 mg) therapy for medical treatment of her metastatic leiomyosarcoma.  Findings:  Two physician reviewers found that.  The patients provider recommended eribulin in the hope of rendering the patient more surgically operable.  There is sufficient support for the requested medication in this clinical setting.  Therefore, eribulin IV (mesylate 0.1 mg) therapy is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Xyrem for medical treatment of her excessive daytime sleepiness.    Findings:  The physician reviewer found that  Xyrem is U.S. Food and Drug Administration (FDA) approved for the treatment of narcolepsy. According to the documentation submitted for review, the patient does not have a diagnosis of narcolepsy. Based on the clinical documentation submitted for review, Xyrem is not medically necessary for treatment of the patients excessive daytime sleepiness.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested admission into a skilled nursing rehabilitation facility for intensive physical therapy for medical treatment of her myasthenia gravis.  Findings:  The physician reviewer found that the patient has already undergone an extended stay in inpatient rehabilitation, where she had plateaued functionally. She did not tolerate more intensive therapies, primarily due to pain. Another stay at an inpatient rehabilitation facility would not be expected to produce significantly different results. Notably, she has not functionally ambulated for about a year, and her physician and physical therapist are recommending a power wheelchair for her mobility. For the reasons provided, admission into a skilled nursing rehabilitation facility is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested growth hormone (GH) therapy Nutropin 0.5 mg daily for medical treatment of the enrollees Turner syndrome.  Findings:  The physician reviewer found that Turner syndrome is a well-established indication for GH treatment, and GH has been shown to be safe and effective in improving adult height in girls with Turner syndrome treated with GH. Consistent with these findings, the requested GH therapy Nutropin 0.5 mg daily is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a Quantum Q6 Edge power wheelchair for medical treatment of her quadriplegic cerebral palsy.  Findings:  The physician reviewer found that  Livingstone and Paleg studied the use of power mobility in children with cerebral palsy and found that Without efficient, independent mobility, young children are at risk of developing passive, dependent behavior and older children are at risk of decreased participation and isolation. In this case, the patient has very limited mobility and is fully dependent on other people for movement. She has demonstrated that she can safely use a power wheelchair. As such, a power wheelchair is reasonable and medically necessary for functional mobility. Based on the medical literature and documentation submitted for review, the request for the Quantum Q6 Edge power wheelchair is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested posterior tibial nerve stimulation (PTNS) for medical treatment of her urinary incontinence. Findings:  Three physician reviewers found that the records provided for review indicate that this patient has nocturia and nocturnal incontinence. Based on the current peer-reviewed medical literature, PTNS is not indicated and unlikely to be effective for this patients symptoms. Thus, the requested PTNS is not likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested Botox treatment for treatment of her chronic migraines.  Findings:  Two physician reviewers found that  This patient has documented chronic migraine and had previously failed beta blockers, topiramate, and Cymbalta. In addition, she was previously treated with Botox for chronic migraine with some improvement. In the medical literature, Aurora and colleagues concluded that Botox for treatment of chronic migraine resulted in fewer headache and migraine days per month, which in turn reduced the burden of illness in adults with disabling chronic migraine. Given these findings, the Botox treatment was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The spouse of a male enrollee requested molecular profiling for evaluation of the enrollees acute myeloid leukemia (AML).  Findings:  Two physician reviewers found that the services at issue were likely to be more effective for this patient than other available treatment options. The medical literature supports the services at issue in this clinical setting. The use of molecular markers to enable risk stratification is encouraged by National Comprehensive Cancer Network (NCCN) guidelines. Based on the records provided and medical literature cited, molecular profiling was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested a 3D mammogram (breast tomosynthesis) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found there is a lack of peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, the 3D mammogram (breast tomosynthesis) was not likely to be more beneficial for evaluation of this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested a blood pressure monitor for medical treatment of his high blood pressure.  Findings:  The physician reviewer found that the documentation submitted for review indicates the patient is being treated with a low dose of Cardizem. However, there is a lack of clinical documentation demonstrating the patient has poor control of his blood pressure. All told, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested substance abuse residential treatment for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found thatthe patient had concerning comorbidities and severe addictive illness.  Further, he previously failed a residential placement during the episode of illness.  Prior to admission, he was consuming benzodiazepines in dangerous amounts.  He was having relationship distress and lacked a sober support network.  Based on these factors, discharging the patient early would have more than likely resulted in relapse.  The duration of the service was within typical community standards.  The residential level of care was reasonably expected to improve his condition while preventing a more serious episode of illness.  All told, substance abuse residential treatment was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested repetitive transcranial magnetic stimulation (TMS) for medical treatment of her depression.  Findings:  The physician reviewer found that in the medical literature, TMS is supported in this clinical setting.  TMS is an effective treatment, has been granted a category I CPT code by the American Medical Association and, is U.S. Food and Drug Administration (FDA) approved for the patients with treatment resistant major depressive disorder. All told, the requested repetitive TMS is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested head magnetic resonance imaging (MRI) and abdominal MRI for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the patient has no history of malignancy, abnormal physical examination or other indications for an abdominal MRI.  Based upon current guidelines, MRI of the brain may be indicated when there is a history of blurred vision with headache but only after a detailed and complete neurological evaluation.  All told, the requested head MRI and abdominal MRI are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested six months of individual mental health therapy sessions for medical treatment of her depression and anxiety.   Findings:  The physician reviewer found that according to the current medical literature, behavioral interventions, not individual therapy is recommended in this clinical setting. All told, the medical records do not support the medical necessity of the requested six months of individual mental health therapy sessions for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested for Harvoni 90/400 mg tablets for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis scoreIn this case, Harvoni is indicated to potentially clear hepatitis C infection in this patient and prevent further deterioration of cirrhosis leading to decompensation and liver failure.  Therefore, the requested Harvoni 90/400 mg tablets are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested breast reconstruction using autologous fat grafting and adipose-derived stem cells for medical treatment of the enrollee, who is status post bilateral breast reconstruction revision.  Findings:  Two physician reviewers found that the requested services are supported by the current medical evidence and are specifically used for contour defects, including ones associated with breast reconstruction.  Additionally, fat grafting is considered standard treatment in this clinical setting.  All told, the requested autologous fat grafting and adipose-derived stem cells are likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested residential treatment services for medical treatment of the enrollees polysubstance abuse.  Findings:  The physician reviewer found that the records available for review do not show that criteria were met for admission to the residential level of care. The patient was not a danger to herself or others. She had not failed substance abuse treatment at a lower level of care. She was medically stable and did not receive any further changes in her psychiatric care. She did not receive any medical or nursing care that required 24-hour monitoring. All told, RTC services were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested genetic testing for predisposition for breast cancer (BRCA1, BRCA2, or BRCA analysis rearrangement test (BART)) for medical evaluation of her breast pain and family history of breast cancer.  Findings:  The physician reviewer found that the records do not include documentation of a consultation with a genetic counselor to support the requested testing at this time. According to the U.S. Preventive Services Task Force recommendations, women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Thus, the requested genetic testing for predisposition for breast cancer (BRCA1, BRCA2, or BRCA analysis rearrangement test (BART)) is not supported as medically necessary for evaluation of this patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested lysis of epidural adhesion procedures for treatment of her medical condition.  Findings:  Two physician reviewers found that the lysis of epidural adhesion procedures billed with CPT code 62311 were likely to be more beneficial for treatment of the patients medical condition than other modalities. However, the lysis of epidural adhesion procedure billed with CPT code 62319 (epidural catheter placement) was not clinically indicated. In this clinical setting CPT 62311 was appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A transgender female enrollee has requested facial feminization surgery for medical treatment of her gender identity disorder.  In this patients case, the submitted documentation supports a diagnosis of gender identity disorder. Photographs of the patient demonstrate the presence of masculine facial features. Moreover, the patients therapist notes the patient suffer[s] from significant dysphoria in relation to her facial features. In fact, anxiety and depression related to the patients masculine facial features is well documented in the records provided. Therefore, based upon the above cited evidence and the patients clinical history and current presentation, rhinoplasty (30410), frontal bossing and orbital reshaping (21209), jaw/chin contouring (21198) and tracheoplasty (31750) are medically necessary for treatment of the patients gender identity disorder. These procedures also meet reconstructive surgery criteria, as the presence of the patients masculine facial features represent an abnormal structure of the body as a result of her gender identity disorder and these procedures would be expected to create a normal appearance as well as provide more than minimal improvement in the patients appearance.  With regard to the requested septoplasty (30520), this procedure appears to have been requested for the condition of acquired or congenital septal deviation and, as such, would be considered medically necessary for treatment of the patients deviated septum.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The requested Harvoni is medically necessary for treatment of this patients medical condition.