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

A female enrollee requested lab testing including serum adalimumab (Humira) levels and antibiotics to adalimumab for medical evaluation of her Crohns disease. Findings:  Two physician reviewers found that monitoring patients on adalimumab with measurement of levels and antibodies to adalimumab continues to be an area of intense investigation. In general, adalimumab levels correlate inversely with disease activity. The presence of antibodies may explain loss of response. However, use of the test is problematic since antibodies can be transient and may not be biologically significant in an individual patient. Moreover, the target level of adalimumab necessary to achieve clinical benefit remains unknown. Overall, there is a lack of randomized prospective trials demonstrating that treatment guided by trough adalimumab levels is superior to optimal clinical care. Thus, lab testing including serum adalimumab (Humira) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee requested substance abuse residential treatment services for medical treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, the treatment provided was for active treatment and was reasonably expected to improve his condition and prevent a more serious episode of illness.  Further, the duration of services was consistent with community practice standards.  Considering the clinical presentation and the peer-reviewed literature, substance abuse residential treatment services were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested physical therapy for medical treatment of his lower back and neck pain status post motor vehicle accident.  Findings:  The physician reviewer found that in the medical literature, Gellhorn and colleagues reported a lower risk of subsequent medical service usage among patients who received physical therapy early after an episode of acute low back pain relative to those who received physical therapy at later times. It was reported the patient had undergone pain management in the form of pain medication and heat and remained with pain and deficits related to whiplash injury and low back sprain/strain. Therefore, the requested physical therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested fetal gene testing for medical evaluation of her recurrent miscarriages. Findings:  Two physician reviewers found that according to the American Society for Reproductive Medicine, while early miscarriage is associated with random chromosomal abnormalities in the embryo in up to 60% of cases, inherited genetic causes occur in less than 5% of couples. The standard testing is karyotype of the fetal tissue. The American College of Obstetricians and Gynecologists (ACOG) reports that limited data are available on the clinical utility of chromosomal microarray analysis to evaluate first-trimester and second-trimester pregnancy losses. Thus, fetal gene testing is not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the allograft placement for medical treatment of her burns on the bilateral feet and lower extremities. Findings:  Two physician reviewers found that the patient sustained wounds which would be considered not only serious but potentially life threatening. Excision and coverage of the devitalized tissue was appropriate to reduce the risk of infection. When skin grafting is either not possible or is not an option, an allograft is a reasonable and recognized treatment option in attempts to prevent sepsis. The allograft placement was likely to have been more beneficial for treatment of this patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni 90-400 mg for 24 weeks for medical treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Three physician reviewers found that the patient has hepatitis C virus cirrhosis which places her in the category of patients who need hepatitis C virus urgently, as classified by the national guidelines on treating hepatitis C virus published by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The patient has relapsed after a prior sofosbuvir, peg interferon and ribavirin regimen. In this clinical scenario, the guidelines support retreating patients who failed a prior sofosbuvir-containing regimen with Harvoni with or without ribavirin for 24 weeks, especially in the presence of cirrhosis. This patient satisfies these criteria and should be treated with the requested Harvoni 90-400 mg, which is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee requested Sovaldi 400mg and ribavirin 200mg for 24 weeks for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Based upon the medical records, it is likely that this patient has cirrhosis with portal hypertension.  He has a nodular liver on MRI with splenomegaly.  In this case, FibroSure most likely underestimated the degree of fibrosis. This patient is likely to benefit from viral eradication.  Therefore, Sovaldi 400mg and ribavirin 200mg for 24 weeks are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Harvoni 90-400mg for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to support the requested medication in this patients case.  Per the current medical evidence, Harvoni has been shown to be effective for patients with hepatitis C, genotype 1.    However, this patient does not have advanced liver disease and fails to meet American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for highest priority, high priority, or even at elevated risk.  In sum, the requested Harvoni 90-400mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested the LINX Reflux Management System for medical treatment of his severe gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the requested procedure is a minimally invasive procedure, with support of safety and efficacy data in multiple studies. LINX procedure is a treatment option for patients with medically refractory GERD who have not yet progressed to end-stage reflux disease with associated complications. Given that the procedure is supported as safe and effective in patients with medically refractory GERD, it is clinically indicated for this patient. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested a wearable cardiac defibrillator (LifeVest) for treatment of his severe congestive heart failure with coronary and valvular disease.  Findings:  Two physician reviewers found that the placement of a wearable cardioverter defibrillator was and is clinically indicated as the patient has severe coronary artery disease including severe left main disease. In patients felt to be at high risk of sudden cardiac death (SCD) while undergoing a trial of optimal medical therapy, the wearable cardioverter defibrillator (WCD) provides protection against SCD while awaiting improvement in left ventricular function. Therefore, based on the peer-reviewed literature cited above and the patients symptoms, the wearable cardioverter defibrillator was and is likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested inpatient hospital admission for medical treatment of his coronary artery disease (CAD) with angina status post multiple interventional procedures.   Findings:  The physician reviewer found that this patients clinical picture did not support same day discharge given his significant history of CAD, his presentation and also his angiographic findings. Given the complexity of the procedure, it was prudent to keep him in the hospital for observation. Thus, the inpatient hospital admission was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 24-week course of Harvoni 90/400 mg for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, patients with advanced fibrosis or cirrhosis in whom a previous sofosbuvir-containing regimen has failed should be treated with daily Harvoni with or without ribavirin for 24 weeks. This is based on studies, such as the randomized COSMOS trial, in which sofosbuvir resistance-associated variants were not observed (Lawitz, et al). In addition, high rates of sustained virologic response have been observed with Harvoni treatment in patients with prior failure of Sovaldi and ribavirin (Osinusi, et al). Based on clinical literature and clinical guidelines, Harvoni for 24 weeks is medically necessary for patients with sofosbuvir failure, such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Sovaldi 400 mg tablet formedical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the AASLD and IDSA guidelines recommendation for patients with hepatitis C genotype 2 is treatment with daily Sovaldi and weight-based ribavirin for 12 weeks. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested treatment is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested valsartan for medical treatment of his hypertension. Findings:  The physician reviewer found that the records note a history of hypertension.  However, there is no documented coexisting condition that would provide an indication for a specific class of antihypertensive medication.  In this clinical setting, the current guidelines recommend that initial antihypertensive treatment should include a thiazide-type diuretic, a calcium channel blocker, an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.  Each of these four drug classes has yielded comparable outcome effects with respect to overall mortality, cardiovascular disease and renal disease.  Since there is no documented compelling indication for an angiotensin receptor blocker, such as valsartan, and no documented intolerance to other antihypertensive medications, the requested medication valsartan is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the Bioness functional electrical stimulation device H200 (arm) and the Bioness functional electrical stimulation device L300 Plus (leg) for medical treatment of her medical condition. Findings:  Two physician reviewers found that in this patients case, the requested devices are likely to be superior over other treatment options.  Although a functional electrical stimulation is not indicated for all patients with stroke and hemiparesis, there is medical literature supporting its use in this clinical setting.  In this case, the patient has documented hemibody weakness secondary to a stroke.  In the past, she had a suboptimal response to bracing.  Therefore, the Bioness functional electrical stimulation device H200 (arm) and Bioness functional electrical stimulation device L300 Plus (leg) are likely to be of greater benefit than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni (ledipasvir/sofosbuvir) 90/400 mg for medical treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD and IDSA guidelines further state, 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.  Therefore, the requested Harvoni medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested chiropractic services for medical treatment of his medical condition.  Findings:  The physician reviewer found that the patient presented for treatment of low back pain which began while lifting weights.  However, the records do not document an examination or evaluation to the lumbar spine which is essential for diagnosing this patient.  The assessments do not discuss the low back, but note medial high ankle sprain and Achilles strain.  In this patients case, there is a lack of documentation regarding the lumbar spine in the office visits to support the services at issue.  All told, chiropractic services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested the wearable cardioverter defibrillator for medical treatment of her congestive heart failure. Findings:  The physician reviewer found that given this patients presentation with severe cardiomyopathy and recurrent episodes of sustained ventricular tachycardia, it was reasonable to place the wearable cardioverter defibrillator while awaiting the recovery of the heart function. The efficacy of the wearable cardioverter defibrillator has been tested for induced ventricular tachyarrhythmias as well as for spontaneous events in clinical trials and post-market study. Consistent with these findings, the wearable cardioverter defibrillator was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested intensive outpatient treatment, psychiatric child and adolescent treatment services for medical treatment of the enrollees obsessive-compulsive disorder.  Findings:  The physician reviewer found that the patients obsessive-compulsive disorder was causing functional impairment in her social and academic spheres, which represent critical domains for adolescents negotiating their second individuation and identity formation.  Her provider recommended intensive outpatient services, which is a level of care endorsed by the American Psychiatric Association for the treatment of obsessive-compulsive disorder.  The patient had been making progress with the active treatment.  However, she had difficulty decompressing her psychiatric burden outside of the therapeutic setting, and thus continued to struggle.  In this patients case, the services at issue were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, intensive outpatient treatment, psychiatric child and adolescent treatment services, were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested custom made foot orthotics for medical treatment of her plantar fasciitis. Findings:  The physician reviewer found that this patients prior treatment has included shoe modifications, oral anti-inflammatory medications, and oral pain medications.  Per the medical records, she continues experience pain.  The current literature demonstrates the effectiveness of custom functional orthotics in the treatment of arch pain, heel pain, and painful plantar fasciitis.  Custom functional orthotics for treatment of painful plantar fasciitis are standard of care in this clinical setting.  All told, the requested custom made foot orthotics are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Orthovisc injections to the right knee for medical treatment of her right knee arthritis.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. All told, the requested Orthovisc injections to the right knee are not supported as medically necessary for treatment of this patients right knee pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested genetic testing (CPT 81225, 81226, 81227 and 81479) for medical evaluation of her myalgia.  Findings:  Three physician reviewers found that genotype testing was not appropriate or clinically indicated for the patients chronic condition as it does not demonstrate contribution towards improving or adding to treatment of the patients condition. Jannetto and Bratanow performed a study to evaluate the clinical effectiveness of genotyping chronic pain patients on analgesic therapy. The authors found a positive association between the geneotypes of chronic pain patients and adverse reactions to opioid therapy; however, the results were not statistically significant. Finally, the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. For the reasons provided, the testing at issue was not 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 female enrollee requested a panniculectomy  for medical treatment of her abdominal pannus.  Findings:  The physician reviewer found that this clinical picture is one of recurrent infection and periodic open sores that has failed reasonable conservative treatment.  Based on the entirety of the medical record, the patient has a well-defined functional deficit related to excess abdominal soft tissue from her abdominal pannus.  Surgical resection of the excess soft tissue would directly address the functional deficit. Thus, the requested panniculectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested ketamine infusion therapy for treatment of her complex regional pain syndrome (CRPS).  Findings:  Two physician reviewers found that the records do not document the patient has exhausted available standard treatment options (Yampolsky, et al). In addition, Patil and Anitescu reported that the outpatient setting is a good treatment option for ketamine infusion and the doses recommended in the research is less than the dose this patient received in the outpatient setting. In addition, this patients provider indicated that a higher dose of ketamine was planned for the next infusion. All told, the requested inpatient ketamine infusion is 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 female enrollee requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her mastalgia.   Findings:  The physician reviewer found that the most recent American College of Radiology (ACR) practice guidelines for the performance of breast MRI outline 12 indications for dynamic contrast-enhanced breast MRI, and this patients records do not include evidence of any of these indications. Thus, evaluation with a mammogram should be performed to determine if further imaging with breast MRI as an adjunct is clinically indicated. However, based on the available documentation, the requested bilateral breast MRI is not medically necessary for evaluation of this patients breast tenderness.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested radiofrequency ablation for medical treatment of her fibroid tumor.  Findings:  Two physician reviewers found that ultrasound guided radiofrequency ablation is a promising procedure for the treatment of uterine fibroids. Short-term studies suggest its effectiveness with minimal side effects. However, studies with longer follow-up are still underway, so the long-term effectiveness and side effects have not yet been established. Overall, there is a lack of peer-reviewed medical evidence that radiofrequency ablation is likely to be more beneficial for the treatment of this patients symptomatic fibroids than standard therapies such as uterine artery embolization, myomectomy, or hysterectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested eating disorder intensive outpatient programming (IOP) treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. According to the American Psychiatric Association (APA) practice guidelines for patients with eating disorders, IOP is recommended when some degree of external structure beyond self-control is required to prevent the patient from compulsive exercising. According to the medical records submitted for review, this patient has problems controlling her self-exercise. sum, the recommendations by her treatment team who have direct knowledge of this patient and her needs are reasonable, appropriate and medically necessary. Thus, based upon the documentation provided, the medical necessity of IOP treatment has been established.