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

An 18-year-old male enrollee has requested a cartilage transplant (CPT 24999) for treatment of his right elbow pain. Findings:  Two physician reviewers found that the requested cartilage transplant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review indicates the patient has documented osteochondritis dissecans of the elbow. The use of osteochondral allograft or autograft is an established procedure in orthopedic surgery with the primary criteria being a discrete lesion surrounded by normal cartilage. This patient meets that definition with a 0.8 cm lesion of the radial condyle of the capitellum. The efficacy of osteochondral allograft or autograft transplantation has been demonstrated in many joints including the knee, talus, femoral head, and in limited series in the elbow. Moreover, Bojanic and colleagues note that OCD of the elbow can cause permanent elbow disability if left untreated. For the reasons provided above, the requested services are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested Tysabri injections for treatment of her multiple sclerosis.   Findings:  The physician reviewer found that although the patient has a diagnosis of multiple sclerosis, the submitted records do not include confirmatory evidence to support the diagnosis. Based upon the information submitted, the patient is not currently assessed with a relapsing form of multiple sclerosis. The patients neurologist ordered several tests, the results of which have not been provided. Before it can be determined if a change in therapy is indicated, the diagnosis of multiple sclerosis must be confirmed, neuromyelitis optica should be ruled out and documentation of recent relapse should be provided. In the absence of such evidence, Tysabri 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 17-year-old female enrollee has requested applied behavioral analysis (ABA) therapy and ABA supervision for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is currently 17-years-old and presents with significantly delayed language, daily living and socialization skills. Based upon the documentation provided, it appears she has been receiving at least one hour daily of ABA therapy for approximately the specified timeframe. The submitted progress reports do not demonstrate the patient has made significant functional progress with ABA therapy. There is a lack of evidence that the patients behaviors or social skills have improved beyond the level that would be anticipated by maturation despite the specified timeframe of ABA therapy. Individuals who benefit from ABA therapy generally exhibit gains in behavior within a two-year period. Therefore, continuation of ABA therapy at a frequency of 8 hours of therapy per week and 4 hours of supervision per month is not medically necessary. Two hours of ABA therapy per week and 1 hour per month of supervision is sufficient to maintain the patients current performance level and therefore is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested the LINX reflux management system for treatment of her gastroesophageal reflux disease. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  There is a lack of support for the requested services in this clinical setting.  The data regarding the LINX procedure remains premature.  A randomized controlled trial with fundoplication as the comparator arm is needed in order to support the superior efficacy of the LINX procedure over standard treatment.  Therefore, the requested LINX reflux management system is not likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Restasis eye drops (cyclosporine) in the amount of two vials per day for treatment of her chronic dry eyes.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity.  Restasis is a fungus-derived medication that has been demonstrated to be safe and efficacious in the treatment of dry eye.   Restasis is prescribed as twice daily therapy and is dispensed in preservative-free disposable single-use vials.  According to the manufacturer, a full months supply is sixty vials, or two disposable single-use vials per day.  This patient has been instructed to reuse a single disposable single-use vial of Restasis twice daily rather than using two single-dose vials per day.  The American Academy of Ophthalmology is silent regarding this practice in their preferred practice guidelines on dry eye syndrome.  However, single-dose vials such as Restasis lack an antimicrobial agent, increasing the risk of harmful bacterial growth and subsequent infection should they be reused.  All told, the requested two vials per day of Restasis eye drops (cyclosporine) are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found this patient has an element of chronicity based in part on his stunted ability to self soothe and delay gratification combined with other biological, psychological and characterological influences. Considering the formidability of the symptom complex, clinical recommendations and past treatment history, it was reasonable to expect that the residential placement would improve his situation and prevent a more serious condition.  The residential treatment services were a safe and appropriate disposition consistent with good practice. However, it became evident that the patient was progressing towards discharge. He had improved on his medications.  He was responding to redirection. He was less invested in the setting and desiring to return to home. This phase shift is quite important as a sound treatment foundation and therapeutic momentum can be generated in a residential setting, but enduring treatment gains are optimized in community settings. In the absence of any additional documentation, the patient was suitable for transition to a less-restrictive treatment setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested a single photon emission computed tomography (SPECT) scan for evaluation of his diagnosis with hepatitis B. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to be superior over other available modalities.  There is a lack of support in the current medical literature for the services at issue in this clinical setting.  Current guidelines do not support the SPECT scan for the evaluation of this patient.  The records do not demonstrate that the SPECT scan would have changed medical management in this patient with liver disease.  Thus, the SPECT scan performed on the specified date was not likely to be of greater benefit than other alternatives for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested magnetic resonance imaging (MRI) of the spine for evaluation of his back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure in this patients case.  The current medical evidence supports the requested MRI in this clinical setting.  This patient continues to have right lower extremity radicular symptoms, including right thigh atrophy. While there has been some improvement, he continues to have intermittent burning, and abnormal right patellar reflex persists.  MRI is medically necessary in order to assess the cause of his symptoms and to determine whether any interventions may be beneficial.  All told, the requested MRI of the spine is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested tumor treatment fields therapy (TTF) with NovoTTF-100A system for treatment of the enrollees recurrent glioblastoma. Findings:  Three physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Following progression of disease in patients with glioblastoma multiforme, who have already received optimal initial therapy with surgery followed by radiation with temozolomide, there is a lack of reliably effective options for further therapy. The National Comprehensive Cancer Network (NCCN) guidelines list several chemotherapy agents that have been shown to have some activity as second-line therapies, but also indicate that palliative care alone is an acceptable option.  In this context, the NCCN guidelines propose use of NovoTTF as a treatment option, with a grade 2B level of evidence. This is in recognition of results of a Phase III trial that showed this therapy to be as efficacious as chemotherapy, in terms of survival parameters, but less toxic. Based on the above considerations, most notably the paucity of effective treatment options in this context, the requested services are 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

The parent of a two-year-old male enrollee has requested a battery operated nebulizer  for treatment of the enrollees asthma. Findings:  The physician reviewer found that that asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment (Helfaer, et al). Fu and Tsai noted that acute exacerbations continue to be a major problem in patients. The authors reported that early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations. Inpatient admission is indicated for patients with mild to moderate status asthmaticus, and intensive care unit (ICU) admission is necessary for patients with history of ICU admissions or rapid deterioration, severe distress with air hunger despite bronchodilator therapy, respiratory arrest, or rising CO2 with clinical signs of fatigue. Critically ill children require fluid resuscitation, aggressive bronchodilator therapy, corticosteroids, and occasionally mechanical ventilation. In an effort to control this patients asthma, the requested battery operated nebulizer is supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested  oxycodone 5mg tablets; and butalbital-APAP-CAFF 60-32 (Fioricet); and Dilaudid injections for treatment of her chronic pain syndrome.  Findings:  The physician reviewer found that the requested medications are not medically necessary for the patients medical condition. The standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then surgery should be considered. Short release/acting opioids such as oxycodone, Fioricet, and Dilaudid are associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman). 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. 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. Therefore, it would be in the best interest of the patient to wean off opioids and continue in a multidisciplinary program. Finally, short-acting 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. Thus, the request for oxycodone, Fioricet and Dilaudid, would be contradictory to providing safe and effective treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested endoscopic reduction of gastric stoma for treatment of her complication of gastric bypass.  Findings:  Three physician reviewers found that Gastrogastric fistulas are a known complication of gastric bypass, but found to occur in a much higher percentage with open and non-divided gastric bypass techniques. As many as 15% of patients with gastrogastric fistulas are from open gastric bypass surgery. Endoscopic repair techniques have not been shown to have durable weight loss or durable repair of fistulas. This patients small disruption is unlikely the cause of her weight regain, which occurred over a seven year period. In addition, this patient has documented poor dietary habits and did not undergo any form of multidisciplinary evaluation for endoscopic revision. All told, the requested services are not supported as 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

A 52-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that the records provided for review note a positive family history of breast cancer, but there is no Gail risk assessment and there is no history of positive BRCA 1 genetic mutation. The patients heterogeneously dense breast tissue decreases the utility of mammography. Applying the American College of Radiology (ACR) guidelines, since MRI is the most sensitive method with which to screen for breast cancer in this clinical setting, the MRI exam at issue was likely to have been more beneficial for evaluation of this patients medical condition than any other imaging modality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided from the specified date forward were not and are not medically necessary for continued treatment of the patients medical condition. The progress notes indicate that the patients mood is stable and any possible psychosis she may have suffered at the time of admission has resolved. She was documented to be social with peers and has been able to go on outings without noted difficulty. A majority of her treatment goals are behavioral in nature and can be worked on and accomplished safely and effectively in a less restrictive setting. Her treatment goals are mostly related to routine activities of daily living that she struggles with due to ritualistic impulses and contamination fears.  She is receiving exposure therapy along with CBT.  Both of these treatments are evidence based, effective treatments for OCD and other anxiety disorders.  The therapy notes indicate that she is involved in exposure therapy in a group setting. This therapy could also occur in a less restrictive setting. Her individual therapy could also occur in a less restrictive setting, such as a partial hospital program. There is little evidence base to support that residential treatment center treatment is superior to less restrictive forms of treatment (McCurdy and McIntyre). Moreover, there is no indication that the patient has any severe, unstable psychiatric symptoms that necessitate a 24-hour placement. Considering the patients status as of the specified date, continued residential treatment center services were no longer medically necessary and transition to a less restrictive setting would have been appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Bepreve eye drops for treatment of his  eye allergies.  Findings:  The physician reviewer found that Bepreve eye drops are medically necessary for treatment of the patients medical condition. Chronic allergic conjunctivitis is often responsive to over-the-counter antihistamine drops such as Pataday. When these become ineffective, use of low-strength steroid preparations are indicated. The problem with long-duration steroid drops is the chance of developing glaucoma and/or cataracts. Therefore, if no relief is achieved with any of the aforementioned drops, Bepreve eye drops are reasonable and medically necessary. Therefore, the medical necessity for the requested medication has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested residential treatment services for treatment of his alcohol dependence. Findings:  The physician reviewer found that based on review of the available records, this patient meets the continued stay criteria for residential services provided from the timeframe indicated. According to the American Society of Addiction Medicine (ASAM) guidelines for inpatient rehabilitation services for substance abuse, continued stay is appropriate if the patient identifies with the severity of the alcohol problem and manifests insight, yet does not demonstrate behaviors suggestive that he has developed the problem solving skills necessary to cope with the problem and would likely relapse if transitioned to a lesser level of care. The records demonstrate that this patient remained at high risk for relapse although he had made some progress toward identification of the severity of his alcohol problem.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Supartz injections for treatment her bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested Supartz injections for treatment of this patients bilateral knee osteoarthritis. Carefully conducted double-blinded studies have demonstrated a lack of any clinical effect from hyaluronan injection. In addition, there is a documented incidence of aseptic inflammatory reactions due to allergic response. Further, there is also a low but present risk of iatrogenic infection within the joint. Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint after multiple injections. Given the limited benefit demonstrated in well designed, double blinded studies and the documented incidence of acute local reactions, it is not medically necessary for this patient to receive the repeated injection protocol recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested mental health outpatient services for treatment of her major depressive disorder. Findings:  The physician reviewer found that the mental health outpatient services provided on the specified dates were medically necessary for treatment of the patients medical condition. The patient received psychotherapy previously for mood symptoms with good effect. In the month and year indicated, the provider diagnosed the patient with adjustment disorder and rule out major depressive disorder. In the month and year specified, the reported diagnosis was persistent mood disorder with anxious distress. The patient was experiencing significant affective impairment which is expected as depression is a recurrent illness. Additionally, at the time, the patient was enduring psychosocial stressors. She was negotiating a job change and consolidating health concerns while two days prior to the first of the disputed sessions she had a relationship break up. The patient was depressed, irritable and anxious, with impaired insight, judgment and thought processing. Effective psychotherapy is a trusted intervention in the treatment for patients with depression and anxiety. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Further a study by Cuijpers and colleagues identified that at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. Thus a treatment course of seven sessions is well within accepted practice standards. Based on the patients history, including past success with therapy, and her psychosocial stressors at the time, the services provided were reasonably expected to improve her situation, and prevent a more serious illness and the need for more intensive treatment. Therefore, the two sessions provided on the dates indicated were safe, appropriate and consistent with good medical care. Thus, the services at issue were medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested the LINX procedure for treatment of his gastroesophageal reflux disease (GERD), atrophic gastritis, and esophagitis. Findings: Two physician reviewers found that based on the patients records provided for review, there is a lack of information regarding the patients treatment with proton pump inhibitor (PPI) therapy. In addition, the peer-reviewed medical literature suggests that in patients whose GERD symptoms are refractory to medical therapy, surgical intervention is available with fundoplication. There is a paucity of clinical data that LINX is superior to fundoplication. In a multicenter study, Ganz and colleagues noted a substantial rate of dysphagia as a recognized complication. Thus, until a randomized control trial with fundoplication as the comparator arm is performed, LINX is not likely to provide this patient with a superior health outcome when compared to standard available therapies.