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

A 59-year-old male enrollee requested transcranial magnetic stimulation for medical treatment of his major depressive disorder.  Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other treatment options.  He has already undergone antidepressant treatment with maximum dosages for adequate periods of time with antidepressants of several different mechanisms.  The patient has had augmentation with Abilify and lithium.  The patient has undergone treatment with cognitive therapy and electroconvulsive therapy.  There is sufficient support for transcranial magnetic stimulation in this clinical setting.  All told, transcranial magnetic stimulation is likely to be of greater benefit than other alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested lumbar spinal fusion at L3-4 and L4-5 for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested lumbar spinal fusion in this clinical setting.  Although the records document that she had pain that had not responded to conservative treatment and a positive lumbar discogram at L3-4 and L4-5, there is lack of evidence of moderate to severe degeneration of the disc with modic changes at the L3-4 level.  Per the submitted documentation, she had some noted discogenic marrow changes on MRI at L4-5.  However, there is lack of evidence that these changes were moderate to severe in intensity.  Moreover, the request is for a two-level lumbar fusion which is not currently supported by the medical literature for discogenic low back pain.  All told, the requested lumbar spinal fusion at L3-4 and L4-5 is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT 72141) for medical evaluation of the enrollees neck and back pain.  Findings:  The physician reviewer found that the neurological exam is normal and plain films have been negative through C6. However, the records show no evidence of a trial of conservative therapy including physical therapy. Overall, there is a lack of neurological findings and no history of tumor or infection. The requested cervical spine MRI is not medically necessary for evaluation of his medical condition absent an adequate trial of conservative therapy including physical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested lumbar epidural injections (CPT 62311) for medical treatment of his lumbar pain.  Findings:  The physician reviewer found that the request for lumbar epidural injections (CPT 62311) is not medically necessary.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy.  The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.  The peer-reviewed medical literature supports epidural steroid injections in documented cases of nerve root compression or radiculitis.  However, the patients chronic pain condition is not consistent with such a diagnosis.  In this case, the patients physical exam and lumbar spine MRI do not show evidence of lumbar radiculopathy/radiculitis.  In sum, 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee requested Acthar gel for medical treatment of the enrollees multiple sclerosis.  Findings:  The physician reviewer found that this patient has documented significant side effects with intravenous Solu-Medrol. Subsequently the patient tried Acthar gel and had a better response and fewer side effects. She also has intravenous access problems per her treating physician and Acthar is given intramuscular, so intravenous access is not an issue. Acthar gel is U.S. Food and Drug Administration (FDA) approved for treatment of multiple sclerosis exacerbations. It has previously been shown to be as effective as intravenous Solu-Medrol. While intravenous Solu-Medrol is the standard of care, Acthar gel is an option for those patients with no intravenous access, poor response to intravenous Solu-Medrol, and significant tolerability issues with Solu-Medrol. Given this patients documented intolerance to intravenous steroids and the documented response to Acthar Gel previously, Acthar gel is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested disc arthroplasty (Mobi-C Disc replacement for medical treatment of her cervical degenerative disc disease.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. In this case, the patient presents with neck pain with a normal physical exam, other than positive for Hoffmans reflex. In addition, her pain generator has not been identified and she has no defined symptoms or signs of myelopathy with spasticity, weakness or gait problems. Her MRI has not shown cord compression nor signal changes. In addition, the U.S. Food and Drug Administration (FDA) has required a seven year post approval study to determine the long term safety and effectiveness of the Mobi-C device. Thus, the long-term safety and effectiveness of this product has not been substantiated. For the reasons provided, 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 44-year-old female enrollee requested the combination of pertuzumab, trastuzumab and tamoxifen, for use without chemotherapy for medical treatment of her metastatic breast cancer.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination in this patients case.  Newly approved biologic and chemotherapy agents have improved overall survival and quality of life for patients with metastatic breast cancer.  The combination of pertuzumab, trastuzumab and tamoxifen, for use without chemotherapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested ultrasound therapy for medical treatment of her temporomandibular joint pain.Findings:  Two physician reviewers found that the requested services are likely to be more beneficial than other available treatment options.   This patient has undergone both surgical and non-surgical modalities to treat her ongoing temporomandibular joint pain.  Per the current medical evidence, ultrasound therapy used in conjunction with physical therapy is an important adjunct in pain relief.  The requested ultrasound therapy can be utilized in the management and treatment of this patients temporomandibular joint pain as an adjunct with combined modalities.  Thus, the requested ultrasound therapy is likely to be more effective than other alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee requested Ensure enteral formula and enteral feeding supplies (syringes, Ensure, extensions and tubes for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that  submitted documentation fails to demonstrate the medical necessity of the requested formula and supplies.  Historically, this patient apparently had issues with feeding orally, because he required gastrostomy tube placement for nutrition.  Currently, no documentation has been submitted to support or refute ongoing need for gastrostomy tube feedings.  Although he is taking some nutrition by mouth, there is no mention of whether this is adequate to sustain him.  In summary, the submitted information is not sufficient to justify medical necessity for ongoing Ensure supplementation.  All told, the requested Ensure enteral formula and enteral feeding supplies (syringes, Ensure, extensions and tubes) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested Lyrica for medical treatment of his neuropathic pain. Findings:  The physician reviewer found that Lyrica is not medically necessary for treatment of this patients chronic low back pain. Gabapentin and Lyrica have similar safety and efficacy in the medical literature for chronic neuropathic pain (Siddall, et al). Gilron reviewed evidence based literature supporting the use of gabapentin and Lyrica for chronic neuropathic and early post-surgical pain. The author found that multiple, large, high quality trials have demonstrated the safety and efficacy of gabapentin and Lyrica in neuropathic pain. The review concluded that gabapentin and Lyrica are efficacious treatments for neuropathic and post-surgical pain. However, this patients medical records document that the physical exam revealed a negative straight leg raise and sensory testing was intact. In addition, the patient reportedly had depression with gabapentin. Since the patient does not seem to be exhibiting neuropathic or radicular pain, and the records do not document trials with other anti-convulsant medications in the same class, Lyrica is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee requested 40 hours per week of licensed vocational nurse (LVN) services and two hours per month of registered nurse (RN) supervisory services for medical treatment of the enrollees feeding difficulties, gastrostomy tube (G-tube), and failure to thrive.   Findings:  The physician reviewer found that this patient has multiple medical and developmental problems including feeding intolerance and reliance on gastrostomy tube feedings for nutrition. He is not on home monitoring, there is no indication that he has uncontrolled seizures, his respiratory status appears to be stable, and his gastrostomy tube feedings appear to be stable. Although he has been under evaluation for failure to ambulate, there is no indication that this introduces skilled nursing needs. There is no indication that the patients parent is not competent or is not available to provide for his care for the requested 40 hours per week.  Based on the submitted documentation, the request for 40 hours per week of LVN services and two hours per month of RN supervisory services is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested Copaxone 40 mg/ml, 3 times per week injections for medical treatment of her relapsing multiple sclerosis.  Findings:  The physician reviewer found that a change in multiple sclerosis disease modifying medication is typically made in cases in which there is active disease, increase in disability or new MRI activity. Data suggests that 3 times per week Copaxone is as effective as daily injections (Khan, et al.), with less long-term lipoatrophy and higher patient satisfaction.   Current standard of care among multiple sclerosis specialists is to prescribe 3 times weekly Copaxone 40mg/ml rather than daily therapy, as the former is associated with better compliance, less injection site reactions and less long-term lipoatrophy.   Therefore, the requested medication is medically necessary for treatment of the patients relapsing multiple sclerosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee requested rituximab 1 gm x 2, 15 days apart for medical treatment of her C1q nephropathy with arteriolar sclerosis.  Findings:  The physician reviewer found that C1q deposits in the mesangium occur with minimal change disease, focal segmental sclerosis, and immune complex glomerular nephropathy. There is currently a lack of randomized controlled clinical trials to guide therapy, which is usually directed at the light microscopic pattern of injury. However, there is data demonstrating successful outcomes with use of rituximab in this clinical setting. Further, rituximab does not appear to be inferior to steroids and cyclophosphamide in terms of safety and efficacy for treatment of C1q nephropathy. Given these findings, the requested rituximab 1 gm x 2, 15 days apart is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 22-month-old female enrollee requested bilateral reverse last shoes  open toe (custom orthopedic shoes for medical treatment of the enrollees bilateral metatarsus adductus.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There is a lack of support for the requested custom orthopedic shoes in this clinical setting.  The medical literature has shown that shoe therapy may produce a negative impact on future foot posture in patients.  Williams and colleagues noted there was strong evidence supporting no treatment in the case of flexible metatarsus adductus.  The medical literature has shown that most cases of metatarsus adductus resolve spontaneously and without treatment.  Therefore, the requested custom orthopedic shoes are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee requested residential treatment center services for medical treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and bipolar disorder.  Findings:  The physician reviewer found that the weekly progress notes do not support the medical necessity of the RTC services provided to this patient. The patient was making progress and learning coping skills. Additionally, each weekly progress note documented that the patient had just completed a successful weekend pass with his family. The main issue for almost all the notes is that he became upset upon having to return to the facility after his pass. Only after was there mention of the patient requiring seclusion prompted by refusing to follow staff directions. There was no mention of his trying to harm himself or others. Based on the providers notes, the patient was stable for treatment at a less restrictive treatment setting. The patient could be safely and adequately treated with dialectical behavioral therapy (DBT) and medication management in this setting. Thus, the RTC services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested gastric sleeve revision to gastric bypass for treatment of her obesity, sleep apnea, dilated cardiomyopathy, asthma, and chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the patient has undergone two previous bariatric surgical procedures that have both failed from a weight loss perspective. She is now seeking a third bariatric surgical procedure for persistent morbid obesity. There is published literature to suggest that the potential complication rate is higher with repeat procedures (Coblijn, et al). Without a thorough assessment by a multidisciplinary team including a dietician and a health psychologist, and without evidence of compliance with an exercise regimen including recommended eating behaviors, it is likely the patient will experience a poor weight loss outcome once again. In the absence of a clinical indication or evidence-based rationale for the requested surgery, this patient should undergo counseling, education, and non-surgical weight management for treatment of her continued obesity. Thus, the requested gastric sleeve revision to gastric bypass surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that in this patients case, Harvoni is likely to be of greater benefit than other treatment alternatives.  The proposed treatment is appropriate for this patients hepatitis C.  The use of this medication is likely to result in eradication of this virus and prevention of further progression of liver disease and its complications.  The current medical evidence supports Harvoni in this clinical setting.  Harvoni has been approved for the treatment of chronic hepatitis C, genotype 1 in both treatment-naive and treatment-experienced patients regardless of the fibrosis stage of the liver disease.  Therefore, the requested medication is likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested Humira for medical treatment of her hidradenitis suppurativa.  Findings:  The physician reviewer found that in this patients case, the requested medication is likely to be more effective than other treatment options.  This patient has failed multiple therapies, including oral antibiotics, topical antibiotics and intralesional steroids.  Effective treatment of hidradenitis is very challenging.  Given that the patient has already failed typical first-line therapies, treatment with Humira is appropriate.  Thus, Humira is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested removal of a cyst for medical treatment of the 2 cm cyst on her anterior chest wall.  Findings:  The physician reviewer found that excision and closure can be very difficult with inflamed cysts, and it may be preferable to postpone the surgical procedure until the inflammation has subsided to operate on a non-inflamed cyst (Zuber). The standard of care for this case is to surgically remove the cyst while it is not inflamed in order to avoid complications. This patient has an enlarging epidermal inclusion cyst that can get inflamed and rupture. This could lead to infection and even antibiotic-resistant bacteria leading to sepsis. Consistent with these findings, removal of the cyst as requested by this patient is supported as medically necessary and reconstructive in nature for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee requested mental health residential treatment center (RTC) for treatment of the enrollees substance use disorder, anxiety disorder, and unspecified trauma and stressor related disorder.  Findings:  The physician reviewer found that the treatment plan and therapy notes describe her as working with her parents in therapy. Further, she was described as having made a few good relationships and doing very well. She had no health problems and was not receiving any medications. Therefore, this patient would not have met the American Society of Addiction Medicine (ASAM) criteria for RTC level of care on the basis of her alcohol abuse. Moreover, she did not meet the RTC level of care criteria for any comorbid medical condition. There is no evidence that she was a risk to herself or to others, her thoughts were described as linear, her mood was euthymic, and she was not aggressive. The treatment plan does not indicate any medical or nursing care that is being provided. All told, the patient could have been treated at a lower level of care and did not require the intensity or monitoring provided at the RTC level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested Xifaxan (rifaximin) for medical treatment of her small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that the submitted documentation established the medical necessity of the medication. The efficacy of Xifaxan in treating non-constipated irritable bowel syndrome (IBS) is well documented in peer-reviewed literature. Accordingly, the drug is a viable treatment option for the population with SIBO.  In this case, SIBO has been objectively demonstrated and the patients longstanding subjective complaints responded to Xifaxan. The drug was appropriately prescribed as a one-time course, is supported by evidence-based literature, and it proved efficacious. Therefore, the medical necessity of the medication at issue has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee requested Mepron 750mg/5ml oral suspension for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The diagnosis of Babesia duncani appears to be based on a single serology.  Specifically, Babesia duncani (WA-1) IFA IgG was reported to be 1:256.  A normal value is less than 1:256.  This is not a significant result absent repeat testing or other clinical information that would suggest Babesia duncani infection was present.  Per the current medical evidence, patients with non-specific symptoms, such as this patient, are not likely to have infection with Babesia.  There is a lack of support for the requested medication in this clinical setting.  All told, Mepron 750mg/5ml oral suspension is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested a wireless capsule endoscopy for medical evaluation of her abdominal pain, swelling, constipation, gas, and nausea.  Findings:  Three physician reviewers found that this patient presents with multiple GI complaints that have been extensively evaluated by multiple procedures including EGD, colonoscopy, wireless capsule endoscopy, and MRI, all of which were unremarkable. Based on the available peer-reviewed medical literature, wireless capsule endoscopy is not appropriate in this clinical setting due to negative endoscopies and the previously performed wireless capsule endoscopy. All told, the requested wireless capsuled endoscopy is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.