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

A 24-year-old male enrollee has requested Adderall XR 20 mg per day for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. In the psychiatric practice the standard of care indicates that a patient returning for treatment of adolescent ADHD must be completely re-evaluated. According to the documentation submitted for review, there are no recent evaluations provided, either in-Plan or with the treating psychiatrist, that demonstrates the patient still meets the criteria for ADHD. In addition, this patient has many co-morbid diagnoses, including depression, substance abuse and anxiety. All of these co-morbid conditions can cause problems with attention and concentration. Given the absence of testing to validate the patients diagnosis, such as Conners CPT testing or a psychological evaluation the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Olysio in combination with Sovaldi for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  The treatment of hepatitis C is undergoing rapid evolution.  This patient is not a candidate for interferon-based therapy because of her multiple relapses.  The request for Olysio and Sovaldi is based on phase II data which is encouraging.  However, the patient has relatively minimal fibrosis and does not require immediate therapy.  In this patients case, the requested medication combination is not indicated at this time.  All told, Olysio in combination with Sovaldi is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Botox injections for treatment of her medical condition.  Findings:  Two physician reviewers found that the requested Botox injections are not likely to provide significant benefit over other standard treatment.  There is a lack of support for the requested services in this patients case.  Scientific data suggests that Botox injections may reduce the frequency and severity of migraine headaches.  However, the clinical documentation submitted for review does not support Botox injections in this setting.  Specifically, the clinical documentation did not clearly identify a reduction in the number of headaches per month, nor did the documentation provide evidence that the previous Botox injection reduced the severity of the migraine headaches.  Thus, Botox injections are not likely to be more efficacious than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested Acthar gel for treatment of his nephrotic syndrome.  Findings:  The physician reviewer found that the medical literature supports use of Acthar gel therapy in patients with idiopathic nephrotic syndrome. However, Acthar gel is not recommended for treatment of patients with nephrotic syndrome occurring due to transplant glomerulopathy, recurrent, or de novo glomerulonephritis in renal allografts. The records do not indicate the patients native renal disease, whether the patient had nephrotic range proteinuria or nephrotic syndrome, or if the patient was treated with an ACE inhibitor. All told, the requested Acthar gel has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested acute psychiatric inpatient services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patient presented with suicidal ideation described as 3.5/10 with plan to overdose on prescription medication. He had no prior history of suicide attempts at the time of the admission under review. The records indicate that patient was not a danger to himself or others. He also presented with a current and past history of self harm, apparently associated with a personal relationship. His major depressive disorder was single episode, moderate. Although the patient engaged in self harm behaviors, he attested that these injurious behaviors were not suicidal in nature. During the course of his hospitalization the patient participated in all available services. He was described as insightful and utilized healthy coping mechanisms. Medication changes were not of a nature that required 24-hour nursing supervision on an acute inpatient psychiatric setting. He steadily gained weight each week and his eating disorder was not described to be of a severity that required 24-hour nursing supervision on an acute psychiatric setting. For these reasons, the patient did not require continued stay in an acute psychiatric inpatient level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested Lap band removal for treatment of her status post Lap band placement. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  A Lap band can induce pseudoachalasia, and this may be reversible in some patients following removal of the band.  This does not appear to be due to any constrictive effect of the band, but instead alterations of lower esophageal sphincter function and esophageal peristalsis.  For patients with achalasia, the band needs to be removed to be able to technically conduct a Heller myotomy and carry the myotomy satisfactorily onto the stomach.  Therefore, it is medically necessary to remove the Lap band to determine if the patient has pseudoachalasia, and if no resolution of symptoms, then perform a Heller myotomy.  All told, the requested Lap band removal is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested magnetic resonance guided high-intensity focused ultrasound (MRgFUS) for treatment of her desmoid tumor. Findings:  Two physician reviewers found that MRgFUS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a desmoid tumor that has demonstrated interval growth. Given the rarity of her tumor, there is no generally accepted standard of care demonstrated in the peer-reviewed literature. Moreover, possible treatment options with the exception of the requested MRgFUS have significant downsides with respect to recurrence, side-effects and poor clinical response.  Thus, given the rarity of this disease, as well as the lack of standard of care treatment, the requested services are likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Supartz injections for treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that there is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested unlimited injections of viscosupplementation for treatment of her bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of support for the requested services in this patients case.  There have been carefully conducted double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection there is an increased risk of allergic response. There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a recent meta-analysis of the efficacy of viscosupplementation.  This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a clinically irrelevant benefit and an increased risk of serious adverse effects.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint.  All told, unlimited injections of viscosupplementation are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The representative of a deceased male enrollee has requested reimbursement for uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) testing for evaluation of the enrollees metastatic adenocarcinoma. Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other methods of evaluation.  UGT1A1 is an enzyme involved in the metabolism of CPT-11, a commonly used chemotherapeutic agent, particularly in metastatic colon cancer.  It has been proposed that certain genotypes of this enzyme are associated with increased toxicity of CPT-11, and that dose modification in these patients should be considered.  However, there is a lack of support for the services at issue at this time.  Palomaki and colleagues noted that there is a paucity of evidence to assess the benefits and risks of modifying irinotecan regimens for patients with colorectal cancer based on this genotyping.  All told, the superior efficacy of UGT1A1 genotyping has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a portable oxygen concentrator (as opposed to an oxygen tank and portable tanks) for treatment of her chronic obstructive pulmonary disease. 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 equipment in this clinical setting.  Per the submitted records, the patient has a portable system.  As noted in the submitted documentation, a portable system was being used during the office visits in the months specified.  The records do not show that the requested portable oxygen concentrator is needed in this case.  All told, the requested portable oxygen concentrator (as opposed to an oxygen tank and portable tanks) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested L5973 X1-microprocessor controlled feature, dorsiflexion and/or plantar flexion control includes power source and prosthetic device called an Endoskeletal ankle and foot system (coded as L5973)  for treatment of his status post knee amputation.  Findings:  The physician reviewer found that the requested device is not medically necessary for treatment of the patients medical condition. This patient has lung and peripheral vascular disease with chronic stump pain since an amputation. Multiple configurations of socket and feet have been tried to see if any combination can relieve stump pain and improve functioning. A trial of the Proprio Foot showed that the patient had reduced pain with it. However, it is not clear if his functioning improved. Moreover, he has had only a brief trial of the requested device which is not adequate to determine if it will ultimately reduce his pain and improve function when used regularly. Furthermore, the patient has shown to have poor psychological adjustment to his pain condition, which indicates his treatment is not a matter of prosthetic prescription but rather one requiring a multidisciplinary team to manage and cohesively address his psychological, emotional and medical needs. For these reasons the Proprio Foot has not been shown in his case to be a medically necessary device as there is insufficient evidence that demonstrates the Proprio Foot will improve his pain or function. For the reasons provided, the requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested radiofrequency neurolysis for treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis has been reported in the peer-reviewed medical literature as a treatment option for patients with a diagnosis of SI joint pain who have failed conservative treatment. There is a lack of documentation of specific SI joint pain on examination. In addition, the providers notes do not include a targeted history, physical examination, and treatment plan to support an indication for the requested radiofrequency neurolysis. Thus, the requested services are not likely to provide this patient with greater benefit for treatment of her medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of his cervical disc disorder with radiculopathy.   Findings:  The physician reviewer found that based on a review of the available records, this patient has had cervical spine pain for at least a couple years following a motor vehicle accident. Plain film x-rays are referenced in the physical exam but no report is in the records provided for review. There is no neurological deficit noted on exam and no atrophy or weakness is described in the providers notes. In addition, the patients deep tendon reflexes are normal. There are no red flags to provide an indication for a cervical spine MRI. Thus, the requested MRI of the cervical spine is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested magnetic resonance imaging (MRI) of the pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the diagnostic procedure at issue. Endometriosis is a chronic gynecological disorder whose principal manifestations are chronic pain and infertility. The pain associated with endometriosis may not correlate with the stage of the disease, but there may be some associations with the depth of infiltration of endometrial lesions. Painful defecation during menses and severe dyspareunia are the most predictable symptoms of deeply infiltrating endometriosis (Fauconnier, et al). According to the medical records submitted for review, the patient does not complain of these symptoms. In addition, the diagnosis of endometriosis can only be made by the histology of lesions removed at surgery and neither serum markers nor imaging studies have been able to supplant diagnostic laparoscopy for the diagnosis of endometriosis or the extent of the disease (Practice No.114). MRI should be reserved for equivocal ultrasound results in cases of rectovaginal or bladder endometriosis (Practice Bulletin No.114). All told, the medical necessity of the diagnostic procedure at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested morphine sulfate immediate release (MSIR) and MS Contin for treatment of his paraplegia with neuropathic pain syndrome.  Findings:  The physician reviewer found that the requested opioid treatment regimen is not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has neuropathic pain. However, there is no documentation that the patient has tried and failed a comprehensive trial of neuropathic pain medication. The current treatment guidelines do not recommend opioid medications for treatment of chronic neuropathic pain. Further, the patients quality of life has not improved with use of opioid medications given his request for hospice treatment. An interdisciplinary pain management evaluation would address the neurological, neuropathic, and mental health aspects of this patients pain. Thus, the recommendation by the provider for an integrated or interdisciplinary pain management program is appropriate and the requested continued opioid treatment outside of this setting is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested a follow-up ultrasound for evaluation of her medical conditions. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. Although this pregnancy is complicated by advanced maternal age and uterine fibroids, there is no specific suspicion for abnormal fetal growth from the clinical exams. The finding of an enlarged fetal abdominal circumference at 31 weeks is suggestive of potential fetal macrosomia. According to the American Institute of Ultrasound in Medicine (AIUM) obstetrical ultrasound guidelines, The abdominal circumference or average abdominal diameter measurement is used with other biometric parameters to estimate fetal weight and may allow detection of intrauterine growth restriction or macrosomia. This finding, however, does not necessitate further ultrasounds unless fundal height measurements are more than 2 weeks ahead of expected or if the estimated fetal weight is more than 4,000 g or 4,500 g (ACOG Practice Bulletin No. 101). Since the estimated fetal weight at 31 weeks was normal, this degree of excess fetal growth does not warrant an additional ultrasound. Given these factors, the request for the follow-up ultrasound is not medically indicated. All told, the medical necessity of the requested diagnostic procedure has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested Xiaflex injections (clostridial collagenase histolyticum) for treatment of his Peyronies disease.  Findings:  Two physician reviewers found that Non-surgical treatments for Peyronies disease include oral medications vitamin E and Potaba, and injectable verapamil and interferon. The peer-reviewed medical literature does not support these therapies as effective for patients with Peyronies disease. Xiaflex has been shown to have modest efficacy in clinical trials and has been approved by the U.S. Food and Drug Administration (FDA) for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. For these reasons, the requested Xiaflex injections 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

A 34-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. According to the American Psychiatric Publishing Textbook of Psychiatry, TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. In this case, the patient is described as enduring an acute major depressive episode that was causing significant morbidity and functional impairment despite appropriate psychotropic medications and evidence-based psychotherapies for the treatment of depression.  Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented an appropriate treatment consistent with good medical practice. Although TMS is not indicated for maintenance or preventative treatment, the patient did not complete her initial treatment course.  Thus, it is reasonable to expect that the additional sessions would complete the treatment course, improve the patients condition and prevent a more serious episode of illness. Thus, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested triamcinolone injections for treatment of his allergic rhinitis.  Findings:  The physician reviewer found that the treatment of both asthma and allergies are considered a stepwise approach to achieve control with the least risk. Steroids are not immediate acting and may take 12 hours or more to take effect. When an asthmatic patient has an exacerbation fails to respond to oral steroids, the patient is treated with intravenous steroids as the standard of care. Although this patient is allergic to grass, his skin testing showed he had other allergens including trees and perennial allergens. The patients presentation to his provider corresponds to the same time last year, which is tree season. When it was tree season, the patients peak flow was marginally subpar at 78. Moreover, despite treatment with medications, he is not improving. Given the potential side effects associated with chronic, continual use of steroids, the requested triamcinolone injections are supported as medically necessary for treatment of this patients medical condition.