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

A 43-year-old female enrollee requested wireless capsule endoscopy for medical evaluation of her medical condition.Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more efficacious than other methods of evaluation.  This patient presented with dysphagia and gastroesophageal reflux disease symptoms.  Wireless capsule endoscopy does not have a role in this clinical settingThis patient already had esophageal manometry, which is the gold standard esophageal motility study.  Therefore, wireless capsule endoscopy was not likely to have been of greater benefit than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee requested social skills group therapy (nine hours per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient is currently receiving 10 hours per week of ABA therapy. The Health Plan has recommended the patient work with his ABA provider to address his social deficits. Given the lack of support in the medical literature demonstrating the efficacy of social group therapies for autistic children with social deficits, the Health Plans recommendation is reasonable and appropriate to treat the patients social deficits. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee requested single photon emission computed tomography (SPECT) imaging of the liver for medical evaluation of his hepatitis B and cirrhosis.  Findings:  Three physician reviewers found that SPECT is used to quantify the degree of cirrhotic changes in the liver and the physiologic congestion of the spleen as it relates to cirrhosis. The SPECT scan allows for such physiologic analysis and this evaluation is not available on standard liver scans which only allow for static imaging. The determination of the degree of cirrhosis is useful for therapeutic management including surveillance. All told, the SPECT imaging of the liver was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee requested  pharmacogenomic testing for medical evaluation of the enrollees behavioral health condition.  Findings:  Three physician reviewers found that pharmacogenomic testing is not likely to be more effective for this patient than other available options. The patients primary diagnosis is eating disorder with symptoms of restriction and purging. The treatment for this condition is psychotherapy including individual, group and family therapy.  The therapist appears to be appropriately working with this patient and has discussed a more intensive level of care.  The patient has also been seen by a psychiatrist who has utilized fluoxetine and venlafaxine.  Pharmacogenomic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee requested sinus endoscopy with balloon dilation (CPT 31295) for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other available options.  Per the clinical records, this patient had nasal congestion and blockage.  The records do not support the diagnosis of chronic sinusitis.  In this clinical setting, sinus surgery was not indicated.  The CT scan does not demonstrate the need for sinus surgery in this patients case.  Thus, sinus endoscopy with balloon dilation was not likely to have been superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his malignant neoplasm of thymus.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the diagnostic study.  The documentation indicates that the patient had CT/PET performed as an initial staging exam and after chemotherapy was completed.   Given that there are prior studies to compare the scan to, the use of this technology is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested a scooter for medical treatment of her medical condition.  Findings:  The physician reviewer found that the patient was assessed by a physical therapist and it was noted that her home was not accessible to powered mobility.  There are no more recent therapy evaluations.  Later documentation noted that she could get up, dress and move around the house if pain was sufficiently controlled.  Although this patient has some mobility impairments, the records indicate that she is a household ambulator when pain is sufficiently controlled.  Additionally, the patient has chronic health conditions, such as arthropathy, that would benefit from increased physical activity and exercise.  All told, the requested scooter is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee requested Xifaxan 550mg, twice daily for seven days for treatment of the enrollees small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication.  The medication represents a viable treatment option for patients with small intestinal bacterial overgrowth.  In this patients case, there is a lack of corroborative evidence to support an etiologic role of small intestinal bacterial overgrowth in his symptoms.  Also, the benefit of Xifaxan per medical literature appears to be for non-constipated patients, but this patient had constipation with scybalous stool and anorectal dysfunction.  All told, Xifaxan 550mg, twice daily for seven days was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee requested growth hormone (GH) therapy (Norditropin) for medical treatment of his GH deficiency.   Findings:  The physician reviewer found that the patients medical records substantiate the diagnosis of GH deficiency. The patient has been treated with human GH (Norditropin) since the diagnosis of growth hormone deficiency, with good results. The treatment is in progress and has not been determined to be completed. The patient has continued to grow at a rate of 2.5 cm per year. It is indicated in the literature that treatment may be withdrawn when this rate falls below 2.5 cm per year. Thus, continued treatment is medically necessary not just because of the final height goal, but also for the benefits related to metabolic health and psychosocial implications of appropriate growth for age (Drake, et al; Rogol). Consistent with these findings, the requested GH therapy (Norditropin) is supported as medically necessary for treatment of this patients GH deficiency.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested Prometheus Anser IFX diagnostic testing for medical treatment of her Crohns disease.   Findings:  Two physician reviewers found that the records indicate a baseline of quiescent Crohns disease, so that consideration was given to stopping Remicade. The Anser IFX resulted in a positive net health outcome, supporting the indication for the assay in this case. Without the guidance that Anser IFX provided, the alternative approach of empirically stopping the drug and assessing her response off Remicade carried significant risk of precipitating a disease flare. As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee requested ambulance services provided on an emergent, or urgent in nature, basis.  Findings:  The physician reviewer found that there was no indication that this patients health was in serious jeopardy. His 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; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, based on the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for emergency care and the patient did not meet the above-stated criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested brand name medication, Vytorin for medical treatment of her hyperlipidemia.  Findings:  The physician reviewer found that based on the current data demonstrating Vytorins clinical effectiveness; there are circumstances where the use of this medication is indicated, such as in this case. This patient had been on Vytorin for the past seven years with good LDL and glucose control, as the ezetimibe had allowed for a lower dose of statin to be used. The patient has had issues with glucose control on both higher doses of some statins and with more potent statins (atorvastatin), and had previously demonstrated good control with Vytorin. Therefore, in this clinical setting, in light of current efficacy data, the use of the combination drug Vytorin (simvastatin/ezetimibe) is medically necessary for keeping her LDL at goal while maintaining tight glucose control.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested eating disorder intensive outpatient program (IOP) services for medical treatment of her eating disorder.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, in determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight.  From the submitted records regarding the patients progress, the patient could have been safely and adequately treated at a lower level of care. The patient was highly motivated and wanting to recover after many years of addictive patterns with alcohol, food and co-dependent behavior. All told, the IOP services cannot be supported as medically necessary based on the available documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested hyperthermia treatment (CPT 77600) for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. Hyperthermia is generally used to treat cancers which are progressive or recurrent despite conventional therapy. In this case, the patient has localized prostate cancer which can be treated with several well-established treatments such as surgery and radiation. Moreover, there is a lack of support in the medical literature for the use of hyperthermia for the treatment of prostate cancer. Thus, in the absence of support in the published clinical data, the services at issue were not likely to be more beneficial than any available standard treatment for this clinical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested pharmacogenetic testing for medical evaluation of her difficulty sleeping.  Findings:  Three physician reviewers found that there is a lack of exploratory and confirmatory studies demonstrating that pharmacogenetic testing is superior to standard testing in this patients evaluation and treatment.  As presented, the records do not document that the patient had failed contemporary medication or non-pharmacologic interventions for sleep disturbance prior to consideration for pharmacogenetic testing.  For these reasons, the pharmacogenetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee requested scar revision of the left abdomen and fat transfer into the left abdomen for medical treatment of her late effect of surgery, painful lesion and scar condition.  Findings:  The physician reviewer found that the patient has complications related to performance of a medically necessary procedure. This is producing a functional deficit that has failed conservative management. Thus, reasonable treatments aimed at correcting complications related to a medically necessary procedure should be considered medically necessary as well.  The patient has failed conservative management and has an abnormal appearance.  This is not cosmetic surgery, as cosmetic surgery is aimed at improvement of normal structures, not abnormal ones. In sum, the patient has complications related to a medically necessary procedure and she has failed typical conservative management. Therefore, the planned surgical treatment is consistent with reconstructive surgery and is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested laparoscopic gastric sleeve surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the requested laparoscopic gastric sleeve surgery is medically necessary for treatment of the patients medical condition.  She has been appropriately screened and cleared for bariatric surgery by numerous providers including a bariatric surgeon and a psychiatrist.  She meets generally accepted criteria for bariatric surgery (Buchwald, et al). As such, the requested procedure is medically necessary for treatment of the patients clinically severe obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested a referral to an ear, nose and throat (ENT) specialist and a referral to a cardiologist for medical treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has been diagnosed with post-nasal drip, allergic rhinitis, multiple somatic complaints and anxiety.  The neurological examination and cardiovascular examination have been normal.  The patient has not been reported to have any concerning cardiovascular symptoms, and imaging of the brain and partial sinus was normal.  All told, the requested referral to an ear, nose and throat (ENT) specialist and a referral to a cardiologist are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee requested residential treatment for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  This patients social environment would not have undermined his treatment, and the records do not demonstrate that his level of function or condition would be stabilized, improved, or benefitted from residential treatment.  In this patients case, treatment could have safely occurred at a lower level of care in conjunction with family therapy.  All told, residential treatment was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested the eRapid Nebulizer System for medical treatment of her chronic obstructive pulmonary disease (COPD), asthma, and factor V Leiden.  Findings:  The physician reviewer found that there is a lack of evidence in the medical literature that supports the use of the eRapid Nebulizer System over a standard nebulizer in patients with chronic obstructive pulmonary disease. Both are portable systems, deliver medications rapidly, and have similar nebulizer particle characteristics. Thus, the requested the eRapid Nebulizer System is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested laboratory testing (immune cell function assay) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that in this case, the services at issue were not likely to have been more effective than other modalities for evaluating this patient.  The use of immune cell function assay for assessing the immunosuppressive status of patients who have received solid organ transplants has not been accepted as standard of care.  The existing studies do not support a sufficient diagnostic accuracy to identify patients at risk of rejection.  The International Society of Heart and Lung Transplantation guidelines have not recommended this test for routine clinical use until larger, randomized trials are available.  Therefore, the superior efficacy of immune cell function assay has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.  Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, the requested Rituxan is not likely to provide this patient with an improved health outcome beyond that expected with standard available therapies. This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms. Rituxan has been shown of potential benefit with treatment of conditions such as chronic inflammatory demyelinating polyneuropathy (CIDP), multiple sclerosis, and myasthenia gravis. Data regarding treatment of Crohns disease with Rituxan is mixed, with some patients experiencing an exacerbation with treatment. Rituxan has also been associated with the development of progressive multifocal leukoencephalopathy. All told, the request for Rituxan is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee requested inpatient psychiatric hospitalization for medical treatment of her traumatic brain injury (TBI) and bipolar disorder.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines note that hospitalization should be considered for patients who are severely ill and lack adequate social support outside a hospital setting or demonstrate significantly impaired judgment. Applying this recommendation to this patients case, the inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition. The patient continued to have impaired insight and judgment regarding her family until the final day. Given her ongoing persecutory delusions, mood liability, cognitive impairment, her history of aggressive behavior directed to self and others, she required the intensity of services provided at the inpatient psychiatric hospitalization level of care. The patient required more insight and a cohesive plan to be in place before she could be safely discharged. Consistent with these findings, continued inpatient psychiatric hospitalization was the appropriate level of care to treat this patients condition, could not have been provided safely in a less restrictive setting, and was medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested radiofrequency ablation of multiple uterine leiomyomata, Acessa procedure for medical treatment of her uterine fibroids.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested service.  This patient was noted to have an enlarged uterus with multiple fibroids for an extended duration of time.  There was a lack of documentation of other therapies that had been considered.  The current medical evidence has not established the superior effectiveness of the requested service in this clinical setting.  All told, radiofrequency ablation of multiple uterine leiomyomata was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee requested sensory integration occupational therapy services for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that sensory interventions can be effective for many children with ASD, especially with self-regulation and teaching self-control. Sensory integration therapy often makes the OT more effective in teaching self-regulation while teaching ADLs. Occupational therapists who are knowledgeable in sensory interventions can provide parents with tools to help them relate to autistic children and to teach effective tools to help them in difficult situations. Moreover, sensory strategies can be useful tools for children with ASD to address anxieties, self-regulation delays or hyperactivity. In this case, the use of sensory intervention techniques provided has improved the patients ADLs and compliance with requests. The documentation submitted for review indicates that the patient responds and has benefited from sensory integration occupational therapy services. Given the support for sensory based therapies in this clinical setting, the medical necessity for the requested therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested abdominoplasty; abdominal panniculectomy; and bilateral thighplasty for treatment of her massive weight loss. Findings:  The physician reviewer found thatIn this case, the patients massive weight loss led to a significant deformity that had previously been treated with surgical correction. However, at this time there is insufficient medical documentation to warrant further surgical resection. Thus, the medical necessity for the requested services has not been established.  Furthermore, the requested services do not meet reconstructive surgery criteria. Based on the photographic documentation and the medical documentation submitted for review, there is insufficient evidence that a significantly abnormal condition is present. Therefore, as supported by the peer-reviewed literature, the requested services are not reconstructive in nature and not medically necessary in this clinical setting.