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

The parent of a five-year-old female enrollee requested the medication Tarceva for medical treatment of the enrollees neurofibromatosis type 1 with extensive metastatic peripheral nerve sheath tumor.  Findings:  Two physician reviewers found that the requested medication is likely to be of greater benefit than other treatment alternatives.  This patient has a rare malignancy, and because the disease is rare, there is not an evidence base upon which to make firm, data-based management decisions.  Per the current medical evidence, there is biologic rationale for the proposed therapy.  This patients tumor is EGFR positive, and there are preclinical data that suggest EGFR positive tumors might respond to targeted therapy.  As this patient has exhausted standard therapies, the requested medication Tarceva is likely to be more efficacious than other alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. The standard of care for early stage prostate cancer includes prostatectomy, interstitial brachytherapy and IMRT delivered over seven weeks. SBRT, delivering high fractional doses to the prostate in 3-5 fractions is an emerging approach to the treatment of prostate cancer. However, longer-term follow-up and randomized controlled phase III clinical trials are needed before SBRT becomes a standard treatment method. Moreover, SBRT for the treatment of prostate cancer encompasses an entire gland while generally only a few TRUS biopsy cores are positive for prostate cancer. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 24-year-old male enrollee requested residential treatment center services for medical treatment of his bipolar disorder and substance abuse.  Findings:  The physician reviewer found that this patient did not meet the American Society of Addiction Medicine (ASAM) criteria for residential substance abuse treatment. The records indicate the patient did not meet criteria of moderate withdrawal and had no co-occurring biomedical conditions. The patient had ceased using all substances one month prior to admission, except for alcohol which was not consumed daily. In addition, the patient demonstrated readiness to change according to the admitting psychiatrist. Further, the provider noted the patient did not have any documented impairment in social functioning, self-care, or a history suggestive of destabilization without residential treatment. Therefore, the residential substance abuse treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested the brand name Synthroid for treatment of her hypothyroidism. Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has critical aortic stenosis and there is concern that her levels of thyroid hormone may change. Any change in levels may impact contractility of the heart and potentially cause significant cardiovascular symptoms. This is likely to occur if a new brand is used. The thyroid hormone content of different thyroid medications is not the same and a change in brand can be clinically significant and cause changes in thyroid hormone levels. Therefore, the changing of this patients brand name is not appropriate and may be potentially harmful. The standard of care in this clinical setting is to continue the use of brand name Synthroid. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested hormone pellet implantation and continued hormone pellet implantation every three to four months for medical treatment of her medical condition.  Findings:  Two physician reviewers found that Vestibulodynia is typically a multifactor disease, and is conventionally treated with a combination of vulvar care measures, topical, oral and injectable medications, biofeedback, physical therapy, sexual counseling and, as a last resort, surgery.  Testosterone pellet implantation is not a recommended therapy at this time.  The current medical evidence does not support the requested hormone pellet implantation in this patients case.  The risks of testosterone therapy include acne, liver dysfunction, hirsutism and adverse lipid changes.  There is insufficient scientific evidence supporting the safety and efficacy of testosterone therapy in this setting. Therefore, hormone pellet implantation and continued hormone pellet implantation every three to four months is not likely to be more effective than other treatment alternatives.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee requested medical services on an emergent or urgent basis.   Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient presented with knee pain and swelling that had been ongoing for two weeks. These symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part. All told, based on the documentation submitted for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested methylphenidate (40 mg in the morning) and Daytrana (60 mg per day), or methylphenidate 120 mg per day (40-40-20-20 mg), and methylphenidate 120 mg per day (40-40-20-20 mg) for treatment of her attention-deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that this patient is diagnosed with ADHD combined type, a highly comorbid psychiatric condition with poor long-term outcome measures for those receiving inadequate treatment. The patient has a long-term, clinical relationship with her psychiatrist. She has trialed other medications. The current dose of methylphenidate was achieved after a systematic titration. The medication dose is both efficacious and well-tolerated, with no evidence of safety concern, side effect or misuse. The treatment is optimizing functionality and minimizing the disease burden. It is the recommendation of the treating provider to continue the medication at the current dose. All told, the request for methylphenidate (40 mg in the morning) and Daytrana (60 mg per day) and methylphenidate 120 mg per day (40-40-20-20 mg) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested adult eating disorder partial hospitalization program services for treatment of her eating disorder. Findings:  The physician reviewer found that the services at issue were and are medically necessary for treatment of the patients medical condition. This patient has several diagnoses including major depressive disorder and eating disorder NOS. According to the documentation submitted for review, her depression began many months prior to her eating disorder and has been poorly managed. Her depression progressed to the point that she did not eat and lost sufficient weight, which developed into an eating disorder. In addition, the presence of her gastroparesis presents a unique challenge that does not seem to be amenable to treatment in a standard PHP in which the patients are only treated for 6 or 7 hours daily on weekdays. It is likely that the patient will not improve in her depressive symptoms until she is able to tolerate nutritious food and can get into a positive nutritional balance. In order for this to occur, she will need the support of the structure and skills found only in a specialized eating disorders unit. Therefore, based upon the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee requested coverage for 4 hours per week of direct applied behavioral analysis (ABA); 4 hours per week of ABA parent training and 2 hours per week of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Three physician reviewers found that based on the documentation submitted for review, the request for 4 hours per week of direct ABA; 4 hours per week of ABA parent training and 2 hours per week of ABA supervision is medically necessary for treatment of the patients ASD. Applied behavioral analysis is an effective modality for many patients with autism.  In addition, there is evidence that supports the efficacy of ABA parent training.  Parental participation in therapy is associated with better outcomes.  As such, parent training at the frequency of 4 hours per week is clinically indicated and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested the medication Relistor for treatment of his chronic pseudo-obstruction. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  There is sufficient support for the use of Relistor in this clinical setting.  Relistor is indicated for patients with opioid-induced constipation who are receiving palliative care and fail to adequately respond to laxative therapy.  Per the submitted documentation, this patients constipation is of functional origin, largely opiate-induced, and he has not responded to conventional therapy.  The available records do not demonstrate that aggressive treatment for his cancer is planned, and limited treatment options are available.  All told, Relistor is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of the enrollee, who is status post knee surgery.  Findings:  Three physician reviewers found the current medical evidence has not demonstrated that simple methods of applying cold in the postoperative period are less effective than circulating cold pads with and without alternate compression.  While cryotherapy in the immediate postoperative period has been demonstrated to be beneficial in terms of pain control, it is not necessary to utilize a water circulating cold pad with pumps to provide cold therapy.  Thus, the water circulating cold pad with pump was not likely to have been of greater benefit than other available alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee requested adolescent mental health residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center (RTC) services were medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, this patient has an extremely severe case of obsessive-compulsive disorder that has made him unable to function outside a regulated and highly structured environment.  The record further documents that he has deteriorated previously when he was discharged from this structured environment to a less structured one.  Based on documentation submitted for review,  RTC level of care is  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested gene testing (BRAF mutation analysis, CPT code 81210 and KRAS mutation analysis, CPT code 81275) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other methods of evaluation.  Molecular testing has been developed which utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy.  Because the testing is very sensitive and has a high negative predictive value, a negative result is suggestive of a benign nodule and can therefore preclude surgical procedures.  All told, gene testing (BRAF mutation analysis, CPT code 81210 and KRAS mutation analysis, CPT code 81275) was likely to have been more efficacious than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested codeine/butalbital/aspirin/caffeine (Fiorinal with Codeine #3), quantity #90/30 days for treatment of her headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The patient has a longstanding headache history and has been using the requested medication for at least four years.  However, no specific diagnosis is identified by the submitted records.  Further, details regarding headache characteristics, diagnosis and frequency were not reported.  Per the medical literature, patients with primary headaches such as migraine are prone to increase of headaches related to pain medication usage.  The use of opiates for more than eight days per month, or barbiturates more than five days per month has been associated with progression of headaches.  Per the current medical evidence, the use of barbiturates and opiates are not recommended for headache care.  Thus, the requested additional quantity of codeine/butalbital/aspirin/caffeine (Fiorinal with Codeine #3) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested magnetic resonance imaging (MRI) of the right foot for medical evaluation of the enrollees right foot pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  There is a lack of support for the requested MRI of the right foot in this patients case.  This patient has no red flags such has a history of trauma, malignancy or infection, which would necessitate MRI without a trial of conservative therapy.  The current medical evidence supports a trial of conservative therapy in this clinical setting.  All told, the requested MRI of the right foot is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested debulking surgery for treatment of her brain astrocytoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. Oligodendroglial tumors constitute between 5 and 20 percent of all glial tumors and typically present in the fourth to sixth decades, with low-grade tumors occurring at an earlier age than anaplastic tumors. Historically, the management of patients with anaplastic oligodendroglial tumors was based upon results from studies in patients with malignant gliomas, carried out prior to the recognition of the molecular and prognostic differences between oligodendroglial and other glial tumors. Compared with astrocytic tumors, oligodendroglial tumors are more likely to harbor certain favorable molecular markers, which are specifically relevant to treatment planning and prognosis.Surgery is utilized to relieve symptoms due to mass effect in patients with suspected anaplastic oligodendroglial tumors, with maximal resection being the preferred approach.  As in the current case, partial resection is required based upon the location and extent of the tumor. There is a lack of randomized trials that have established the benefit of maximal surgical resection compared with a more limited resection. In this case, the patient has received primary and secondary in-Plan neurosurgical opinions and both opinions suggest that the patient is not a surgical candidate and recommend hospice care. However, an out-of-Plan neurosurgeon has recommended surgical debulking based upon the patient's current exam, tumor type and prior history. Moreover, the out-of-Plan neurosurgeon has performed most of her neurosurgical procedures (with the exception of her initial craniotomy) and has been following the patient for many years. The medical records indicate surgical debulking would be in the patient's best interest and is medically necessary. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee requested Humira for medical treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. This patient should be treated with a tumor necrosis factor (TNF) antagonist as initial therapy based upon the severity of his disease. In this clinical setting, a TNF antagonist is clinically indicated to prevent any additional long-term damage.  As such, the request for Humira is appropriate and clinically indicated for treatment of the patients psoriatic arthritis. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee requested medical treatment at the acute level of care for his sepsis, anemia, tachycardia, and acute renal failure.  Findings:  The physician reviewer found that the records indicate the patient is presently at the skilled nursing level of care. Based on the available records, the skilled nursing level of care is appropriate and transfer to inpatient acute care is not medically necessary. All of the patients problems are chronic. In addition, restorative physical therapy can also be provided at the skilled nursing level of care. Should the patient become acutely ill, then transfer to an inpatient acute facility would be indicated. However, there is insufficient documentation to substantiate the medical necessity of transferring this patient to inpatient acute care based on the documentation provided for review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested periodontal scaling and root planing (dental procedure code D4342 for teeth numbers 18, 19, 30, 31, 14, 15, 2 and 3) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the dental necessity of the services. According to the American Academy of Periodontologys Position Paper on the diagnosis of periodontal diseases, initial treatment includes debridement of the plaque/calculus with subsequent re-evaluation to gauge response to this initial therapy. Many patients with no evidence of bone loss or loss of attachment respond favorably to routine debridement and oral prophylaxis. Only after subsequent re-evaluation to gauge response to initial therapy should assessment be made if further treatment such as quadrant scaling and root planing is dentally indicated. In this case, the radiographs document alveolar bone levels near the cementoenamel junction, an indication that this patient has not suffered a loss of periodontal attachment consistent with the periodontal charting of probe depths provided. In addition, the patients provider did not indicate the date of the patients last routine oral prophylaxis. As there is no notation of routine dental care and no evidence of loss of bone or tissue attachment probe depths shown, the scaling and root planning performed was not dentally necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested iStent for medical treatment of his medical condition.   Findings:  Three physician reviewers found that current medical evidence supports the services in this clinical setting.  There is sufficient support for the use of iStent to lower intraocular pressure in this patients case.  This patient was an appropriate candidate for the procedure, which had the potential to reduce the intraocular pressure and potentially reduce or eliminate the need for ocular antihypertensive medication. Other therapies have been tried, including medications, without adequate pressure control.  Therefore, the iStent was likely to have been more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee requested partial hospitalization program for medical treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that this patient evidenced significant psychiatric impairment stemming from an eating disorder with co-occurring anxiety and mood symptomatologies.  In reviewing the clinical documentation, partial hospitalization services were safe, appropriate and aimed at optimizing the skills needed to succeed in the outpatient setting.  Further, the services provided were for both purposes of diagnosis and active treatment.  Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, partial hospitalization program services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical and thoracic spine for medical evaluation of the enrollees unspecified spine lesion.  Findings:  The physician reviewer found that there is lack of evidence provided that shows the patient has chronic neck pain. In addition, there is lack of evidence that demonstrates the patient has clear objective neurological examination findings that would warrant a cervical MRI. The requested MRI of the thoracic spine is being requested due to problems associated with bladder incontinence. Bladder incontinence is associated with S3, S4, and S5 myotomes. A lumbar MRI would be more appropriate. However, the patient has already had numerous lumbar MRIs to date that have been unremarkable expect for the known lesion at L4. Therefore, the request for MRI of the cervical and thoracic spine is not medically necessary.