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

A 45-year-old male enrollee requested radiofrequency neurolysis for medical treatment of his back and neck pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has undergone facet joint injections in multiple regions with steroid and normal saline. Radiofrequency neurolysis is clinically indicated for patients with an established diagnosis with controlled diagnostic blocks based on symptomatology. However, the patient has not undergone any type of diagnostic interventions to delineate the presence of facet joint pain in a complex patient. All told, the requested treatment is not appropriate for this patient. Therefore, based on the reasons provided above, 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: Upheld Decision of Health Plan

A 33-year-old male enrollee requested biweekly individual cognitive behavioral therapy (CBT). for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical documentation submitted for review does not support the medical necessity of biweekly individual CBT appointments as the patient has not optimized the therapeutic interventions currently available to him. In addition the documentation provided did not include a treatment plan, interpretative summary and progress notes that would allow for assessing if the specific intervention and requested frequency of sessions was actively bolstering autonomy and resilience while mobilizing the patient towards enduring remission and averting treatment at a higher level of care.  As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee requested Vyvanse 80 mg for medical treatment of his attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that there is a lack of data supporting the medical necessity of Vyvanse dosing in excess of the U.S. Food and Drug Administration (FDA) recommended limit of 70 mg per day.  The literature does not support the request for Vyvanse 80 mg per day as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested a computed tomography (CT) scan, electrocardiogram (EKG) and bacterial (BACT) testing for medical treatment of her abdominal pain and urinary tract infection. Findings:  The physician reviewer found that given the lack of exact definitions or criteria for non-ST elevation acute coronary syndrome, particularly in middle-age women such as this patient, who often present atypically, the EKG was clinically indicated. In addition, per the American College of Radiology, the disputed CT scan was indicated for the patients presenting symptoms of a three-day history of abdominal pain.  Also, in the case of urinary tract infection, bacterial testing is critical in determining the choice and appropriateness of antibiotic treatment (Schmiemann, et al). In sum, the services provided to the patient at the time of her ED presentation were clinically warranted and medically necessary. Therefore, the medical necessity of the services at issue has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested hospital admission for medical treatment of her vomiting and dehydration during pregnancy.  Findings:  The physician reviewer found that the patient presented to the ER and was found to be dehydrated from protracted nausea and vomiting. The patient had an electrolyte imbalance as well as a markedly elevated urine specific gravity and ketonuria which is consistent with severe dehydration. In addition, she presented with an elevated temperature of 100.4 F and bandemia (immature white blood cells) on the manual differential, suggesting a possible underlying infection. An attempt at IV hydration in the ER with two liters of fluid was undertaken with the patient still symptomatic. The patient was admitted to the hospital for further observation with documentation of administration of IV fluids with electrolyte replacement and IV antiemetics. In this clinical setting the patient could not have been managed at a lower level of care. The patient was evaluated and diagnosed with dehydration in the ER and to have transferred the patent home with home IV therapy at that point, even if it could have been arranged would have been outside the standard of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested revision surgery, replacing the Lap-band with the gastric sleeve for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient has a known complication of the Lap-band procedure, which includes slip with partial outlet obstruction.  In this clinical setting, removal of the Lap-band and port is medically necessary to relieve this obstruction and prevent secondary complications such as erosion and gastric necrosis.  However, the medical records do not support the medical necessity of the requested gastric sleeve procedure.  There is a lack of any updated behavioral evaluation documenting clear understanding of the risks, benefits of revisional surgery, discussion regarding her general compliance after the Lap-band procedure and any barriers to candidacy for revision.  All told, the submitted records support the medical necessity of removal of the Lap-band and port.  However, the medical necessity of the requested gastric sleeve procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested substance abuse residential level of care for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that in this case, the patients substance abuse necessitated specialty services.  However, the patient had not failed any less restrictive interventions, such as intensive outpatient programming or partial hospitalization with supportive sober living in the community, during the episode of illness.  Additionally, the documentation provided did not include a treatment plan, progress notes or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, substance abuse residential level of care was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the LINX anti-reflux procedure for medical treatment of her gastroesophageal reflux disease.  Findings:  Two physician reviewers found that In this patients case, the superior efficacy of the requested services has not been established.  The LINX Reflux Management System has been approved for lower esophageal sphincter augmentation for patients with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Per the current medical evidence, results from early studies at four years are encouraging.  However, the long-term durability has not been assessed.  Anti-reflux surgery is designed to provide benefit for many years, and this has not been demonstrated. Moreover, there is a lack of controlled data comparing this technology to continued proton pump inhibitor therapy or fundoplication.  All told, the requested LINX anti-reflux procedure is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested hydrotherapy for medical treatment of her psoriatic arthritis. Findings:  The physician reviewer found that the records do not establish that a formal aquatic therapy program is medically necessary. Formal aquatic therapy, as opposed to generalized water-based exercise, is medically necessary only for patients who require therapy in a partially body weight unloaded environment. There are no documented clinical findings or notes indicating her impairments, functional deficits, and specific therapy goals to establish that formal therapy is necessary. All told, the request for hydrotherapy with or without an exercise coach is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee requested the fentanyl patch for medical treatment of his chronic headaches. Findings:  The physician reviewer found that based on the available medical literature, there is no role for chronic narcotics in the management of chronic headache disorders. Moreover, it has been demonstrated that chronic narcotic use causes chronic headache and opiate withdraw as well (De Marinis, et al; Creach, et al). This is known as medication overuse headache. For these reasons, this patient should undergo treatment with the goal of narcotic elimination (Scher, et al). All told, the requested fentanyl patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested weekly individual psychotherapy, monthly psychiatry medication management appointments, full panel hormone testing, testing for Addisons disease, and testing for adrenal gland dysfunction for medical treatment of her depression and anxiety.  Findings:  The physician reviewer found that the records indicate the patients current medication regimen is not yet controlling symptoms and she continues to require ongoing regular psychotherapy visits. Weekly psychotherapy is appropriate to treat the patients condition, consistent with standards of good medical practice in the United States and is thus medically necessary. In addition, medications need to be prescribed by a psychiatrist, which supports the request for monthly psychiatric visits for medication management. However, it is not medically necessary to perform full hormone panel testing, testing for Addisons disease, or additional adrenal gland dysfunction testing based on the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee requested the Medtronics MiniMed with Enlite for medical treatment of her type I diabetes. Findings:  The physician reviewer found that based on the current medical literature, clinical studies, and evidence that insulin pump therapy with continuous glucose monitoring is beneficial for adult patients with diabetes type 1, the requested insulin pump therapy with continuous glucose monitoring is medically necessary. The patients control will be better, with less risk of hypoglycemia, and she will experience improved quality of life. All told, the requested Medtronics MiniMed with Enlite continuous glucose monitoring system is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee requested predictive genetic testing for non-malignant diseases, for medical evaluation of the enrollees obesity and impaired fasting glucose. Findings:  Three physician reviewers found that although testing for MODY does not need to be routinely performed on most children with diabetes mellitus, the recommended genetic testing was appropriate to help guide the patients lifestyle choices and medical treatment given his history and presentation. Thus, the predictive genetic testing for non-malignant diseases was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested Harvoni 90-400 mg x 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the patient has failed sofosbuvir and simeprevir hepatitis C virus treatment. However, there is currently inadequate data to support retreatment with Harvoni especially given the absence of documented cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state that patients who failed sofosbuvir/simeprevir should await further data supporting treatment or enroll in a clinical trial. Consistent with these findings, the requested Harvoni 90-400 mg x 12 weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested Eylea injections for medical treatment of her diabetic macular edema.  Findings:  Two physician reviewers found that the Eylea injections were not and are not likely to be more effective for this patient than other available options. At the time of the patients treatment, there were two other treatment options available, bevacizumab (Avastin) and ranibizumab (Lucentis) intravitreal injections. Eylea is no more effective that Lucentis for a patient with good visual acuity. For this patient, Eylea and Lucentis would both be equally effective, and both are slightly superior to Avastin. In sum, there is a lack of evidence in the medical literature indicating that for patients with good visual acuity treatment with Eylea is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee requested Harvoni for medical treatment of his chronic hepatitis C genotype 1b.  Findings:  Two physician reviewers found that given this patients advanced stage disease with evidence of cirrhosis, the requested Harvoni is supported as medically necessary. In addition, the U.S. Food and Drug Administration (FDA) recommend treatment for patients with advanced stage of disease. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Consistent with these findings, the requested Harvoni is medically necessary for treatment of this patients advanced stage chronic hepatitis C virus with cirrhosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee requested Norco (hydrocodone/acetaminophen) for medical treatment of his migraine headaches.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has chronic migraine headaches with limited prior preventive trials and medication-overuse headache (MOH). Treatment of MOH consists of combining prophylaxis, 100% wean of overused acute medications, and provision of new acute medications, strictly limiting use to 2 or fewer days per week (Tepper). As opiates have poor evidence for management of migraine, with evidence of potential harm, they should not be continued except as rare rescue therapy. Therefore, a prescription for opiates (Norco) is not clinically indicated. All told, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee requested removal of cysts and black bumps from skin for medical treatment of his skin condition. Findings:  The physician reviewer found that this patient has an erythematous epidermal inclusion cyst that can get inflamed and rupture and place the patient at risk for sepsis. Therefore, the standard of care for this case is to surgically remove the cyst and black bumps from the skin while not infected, fully inflamed and ruptured, to avoid complications. For these reasons, the requested surgery is supported as reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee requested psychiatric residential treatment level of care for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that, per the medical records, initial discharge would have been premature as the patient was still engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness.  In sum, the services consisted of evidence-based treatment and family involvement aimed at facilitating a seamless discharge to a less restrictive setting.  Subsequently, the patient had made significant improvement and demonstrated the consolidation of treatment gains needed to succeed in a less restrictive setting.  All told, initial psychiatric residential treatment level of care was medically necessary, while the records fail to demonstrate the medical necessity of subsequent psychiatric residential treatment level of care.  I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested skin surgery (CPT codes 11404 and 13101) for medical treatment of his medical condition.  Findings:  The physician reviewer found that in this patients case, the records indicate that the dermatofibroma on the chest is asymptomatic.  There is no indication from the record that the provider is concerned about malignancy as a possibility for the chest lesion.  If there is concern for possible malignancy, a biopsy could be performed to determine whether the lesion was benign or malignant.  Given that the dermatofibroma has been asymptomatic and there is no apparent concern for malignancy, removal is not medically indicated.  All told, the requested skin surgery (CPT codes 11404 and 13101) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested physical therapy for treatment of his spinal stenosis/degenerative spondylolisthesis.   Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of physical therapy has not been established. In this case, the patient has diabetes with peripheral neuropathy and chronic nerve injury.  He has bilateral lower limb weakness impairing his functional mobility. Treatment to improve his function has included a skilled nursing facility stay, provision of adaptive devices, and outpatient physical therapy. He has a home exercise program and he is able to perform it. Continued skilled physical therapy services are not medically necessary given the intensive instruction he has had to date.  He lacks sufficient strength in his ankle dorsiflexors for it to be a safe to ambulate without AFOs and using a cane. He currently uses a walker and but stopped using the AFOs. The medical literature cited above does not include physical therapy as an efficacious treatment modality for regeneration of peripheral nerves. As such, additional physical therapy to ambulate with a cane is not reasonable or medically necessary. Therefore, the requested physical therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested proton beam radiation therapy for treatment of her lung cancer. Findings:  Three physician reviewers found that proton beam radiation therapy is not likely to be more effective for this patient than other available options. Proton beam radiation therapy has been used to treat several cancers including lung cancer in last several years. However, most of the published reports are retrospective studies with small number of patients or single institution phase II studies. There is a lack of published reports on the long term outcome of proton beam radiation therapy for the treatment of lung cancer from randomized controlled trials or cohort trials in peer reviewed literature. There are several ongoing phase II trials evaluating responses and toxicities of proton beam radiation therapy for lung cancer. In sum, there is a lack of long term clinical outcome data available demonstrating 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: Upheld Decision of Health Plan

A 48-year-old male enrollee requested the LifeVest wearable cardioverter for medical treatment of his medical condition.  Findings:  The physician reviewer found that based on the medical records provided for review, this patient had an acute myocardial infarction, complicated by arrhythmias requiring defibrillation. However, there was no documentation of arrhythmias beyond 24 hours from the acute infarction and no documentation of syncope, sustained or inducible ventricular tachycardia or aborted sudden cardiac arrest.  In this circumstance arrhythmias during the first 24-48 hours of an acute myocardial infarction are generally not predictive of subsequent sudden cardiac arrest. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed or needed to be significantly delayed, such as due to infection or required explantation. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee requested the single photon emission computed tomography (SPECT) scans (CPT code 78205) for evaluation of his chronic hepatitis C genotype 1. Findings:  Two physician reviewers found that this patient has known cirrhosis due to hepatitis C virus and has undergone extensive therapy with new pharmacologic agents. The SPECT scans have allowed the treating providers to monitor the success or failure of drug agents by quantifying the uptake in the liver and spleen. Such quantification is not possible with standard planar liver spleen scans or with static imaging such as computed tomography (CT), ultrasound, or magnetic resonance imaging (MRI). All told, the SPECT scans (CPT code 78205) were likely to have been more beneficial for evaluation of this patients medical condition than any available modality.