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

A 25-year-old female enrollee has requested inpatient treatment and pain monitoring at a dual diagnosis treatment facility for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient evidences dramatic symptoms of parasuicidality and affective illness interwoven with her underlying characterological organization and polysubstance use in context of unrelenting pain. She has been unable to generate any therapeutic momentum with her current treatment regimen. Based on the most recent notes, the patient did not require acute psychiatric level of care services. She indicated that her pain was the primary issue of concern. Her recent bouts of attention-seeking self-injurious behavior were the result of desperation and poorly refined defenses consistent with the borderline personality organization. Considering the patients tenuous home environment and formidable symptom complex that has not responded to an array of multidisciplinary interventions, a residential admission focusing on her addictions and chronic pain would be safe, appropriate and reasonably expected to improve her condition while preventing a more serious episode of illness. All told, the records support the medical necessity of residential treatment services for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested physical therapy and occupational therapy at a skilled rehabilitation facility for treatment of her peripheral edema, peripheral vascular disease, and hepatic encephalopathy.  Findings:  The physician reviewer found that the records indicate this patient reached a functional status with ability to walk with use of a walker and ability to dress and perform self-care without hands on support. The patient does not currently require daily inpatient skilled therapy (Ward, et al). She will continue to improve in functional status if she is able to refrain from consuming alcohol. The key for her return to her previous status and improvement in her liver indices is not continued daily skilled therapy as she can receive quite adequate therapy as an outpatient (Alvarez, et al). She has no daily skilled therapy or skilled nursing needs. Continued daily skilled services are not necessary to restore or maintain function. Thus, the requested physical therapy and occupational therapy at a skilled rehabilitation facility is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested spinal fusion surgery for treatment of her low back pain with radiation down the right leg. Findings:  The physician reviewer found that in the medical literature, Parker and colleagues caution against fusion surgery as a first-line surgical intervention due to the significant follow-up surgical interventions that generally result from spinal fusion. Additionally, Deyo and colleagues noted that long-term benefit of spinal fusion surgery in the absence of instability is not supported due to long-term complications that oftentimes require further surgical intervention. All told, this patient has progressive neurological deficits that would benefit from surgical intervention. However, the clinical documentation submitted for review does not support the requested fusion surgery at L5-S1 as a medically necessary first-line surgical intervention for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested inpatient psychiatric services and hospital stay for treatment of the enrollees anxiety and depression.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) practice guideline states that hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patients records demonstrate that she was severely depressed with ongoing suicidal ideation throughout her admission. The treating providers were not confident that the patient would not intentionally overdose once discharged and thus gave her family the medications, which is an indication that patient was at risk of suicide until the last day of admission. Her risk factors for suicide included depressive disorder, anxiety disorder, chronic pain and social isolation. All told, acute inpatient hospitalization from the time frame specified was medically necessary to treat this patients condition, was consistent with standards of good medical practice, and could not have been provided safely in a less restrictive treatment setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. In this case, the patients large breasts hang down touching her pants which constitutes an abnormal structure of the body caused by a developmental abnormality. The surgery proposed would create a normal appearance to the extent possible. It would also likely improve function as breasts that large likely interfere with function. The breast reduction surgery offers more than a minimal improvement in the appearance of the patient. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a three-month course of Sovaldi 400mg tablets, Pegasys Pro Click 180mcg/0.5mL solution and Ribapak 600mg tablets for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication combination.  The current medical evidence supports the requested medication combination in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  Per the medical records, this patient has no contraindications to interferon-based treatment.  Allowing for the development of advanced fibrosis prior to initiating the proposed treatment regimen is likely to reduce the efficacy of the proposed treatment and lower the patients chance of virologic response.  All told, the requested three-month course of Sovaldi 400mg tablets, Pegasys Pro Click 180mcg/0.5mL solution and Ribapak 600mg tablets is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested a xiphoidectomy for treatment of her xiphodynia.  Findings:  The physician reviewer found that this patient is an example of an infrequently diagnosed condition of xiphodynia. This can occur after repeated trauma, direct injury, or without explanation. In the medical literature, xiphoid deformities have been associated with pain. In the Tack Hammer Deformity, the tip of the xiphoid is acutely angled and this pressure causes pain. Referred pain is also possible given the involvement of the lower intercostal nerves, anterior branches of the iliohypogastric and ilioinguinal nerves, and the phrenic nerve (Simpson and Hawken). The standard treatment for this condition includes anti-inflammatory medications, ice, and injections. In the rare patient who fails medical treatment, xiphoidectomy is recommended (Lipkin, et al; Hanlon and Miller). All told, this patient meets the criteria for the requested surgical procedure. Therefore, the requested xiphoidectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Novo-TTF-100 (electric tumor treatment field) for treatment of his  recurrent glioblastoma. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other treatment alternatives.  The medical evidence supports the requested services in this clinical setting.  Turner and colleagues noted that combining chemotherapy with Novo-TTF therapy may improve efficacy without added toxicity.  This patient has undergone recurrent craniotomy and maximal radiation, as well as chemotherapy. All other chemotherapy options are likely to carry greater hazard, and no evidence of better outcome, than the requested services.  Therefore, Novo-TTF-100 (electric tumor treatment field) is likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested epidural steroid injections for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. According to the American Academy of Neurology, epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection. DePalma and colleagues critically reviewed trials of the utility of epidural steroid injections to treat lumbosacral radiculopathy. In this case, there was no documentation of a comprehensive physical examination of the lumbar spine. The medical records indicate that the patient did not demonstrate any focal neurologic deficits. In addition, there were no imaging studies or electrodiagnostic reports submitted for review to demonstrate a diagnosis of radiculopathy. Based on the clinical information received for this review, the requested epidural steroid injections are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Sovaldi 400mg daily with Olysio 150mg daily concurrently for 24 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that in this patients case, the requested medication combination is not likely to be of greater benefit than other treatment options.  This patient meets the definition by the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) for interferon-ineligibility.  Once-daily treatment with Olysio and Sovaldi, with or without ribavirin, has been shown to be effective in both treatment-naive patients and prior  responders infected with hepatitis C, genotype 1.  However, AASLD/IDSA guidelines caution that the efficacy and safety of Olysio have not been studied in patients with hepatitis C and moderate or severe hepatic impairment.   Thus, Olysio is not recommended in patients with moderate to severe hepatic impairment, as in this patients case.  All told, the superior efficacy of Sovaldi 400mg daily with Olysio 150mg daily concurrently for 24 weeks has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested radiation therapy for treatment of his Merkel cell carcinoma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested radiation therapy.  Standard treatment options for Merkel cell carcinoma include surgical resection, radiation therapy, chemotherapy, and multimodality combinations of these treatments approaches.  Generally, radiation is considered a standard approach as adjuvant therapy for resected Merkel cell cancer, for palliation of symptoms and for aggressive treatment of disease confined to volume that is safely encompassed within a radiation field.  One disadvantage of concurrent chemotherapy and radiation is the exacerbating of radiation and chemotherapy toxicities.  In this patients case, his provider has more recently advised against radiation due to the extent of disease.  Per the submitted documentation, adding radiation to chemotherapy would not be medically necessary as the radiation field would be extensive and the likelihood of toxicity would be high, with low likelihood of benefit.  There is a lack of support for the requested services in this clinical setting.  All told, the requested radiation therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested coverage for acupuncture services for treatment of his shoulder, arm, leg and entire back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. According to the documentation submitted for review, the patient has had an unknown number acupuncture sessions for the treatment of his condition. The medical records fail to document a pre-care baseline in order to assess the benefits of an acupuncture trial. In addition, there are no measurable, objective symptoms, functional deficits improvements documented in order to support the medical necessity of the acupuncture services. Furthermore, the peer review literature cited above indicates that the use of acupuncture for the treatment of the patients condition is modest at best, suggesting that further research for is needed. Johansson and colleagues studied the effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation. The authors concluded, When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Sovaldi (sofosbuvir) 400 mg tablets and Olysio (simeprevir) 150 mg capsules for 12 weeks for treatment of his hepatitis C virus. Findings:  Two physician reviewers found that the requested medication combination of Sovaldi and Olysio are not likely to be more effective for this patient than other available options. The proposed combination treatment of simeprevir and sofosbuvir is not approved by the U.S. Food and Drug Administration (FDA) for treatment of the patients medical condition. Although the requested treatment of simeprevir and sofosbuvir has been suggested by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines it has not been studied in a large phase III trial. As such, the request for Sovaldi (sofosbuvir) 400 mg tablets and Olysio (simeprevir) 150 mg capsules for 12 weeks is not likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. A lumbar MRI may be performed to evaluate low back pain that does not get better after treatment, or lower leg weakness, numbness, and other symptoms that do not improve. A physician may also order a lumbar MRI if the patient has back pain and fever, birth defects of the lower spine, injury or trauma to the lower spine, low back pain with a history of cancer, multiple sclerosis, problems controlling or emptying the bladder, or disc herniation. In this case, the patient does not exhibit any signs or symptoms suggestive of significant spinal pathology. The patient demonstrates normal range of motion with normal strength, normal gait, and normal reflexes. The medical necessity for a lumbar MRI scan has not been established. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a LifeVest wearable cardioverter defibrillator for treatment of his myocardial infarction.  Findings:  Two physician reviewers found that based on the records provided, the patient presented with an acute myocardial infarction associated with severely reduced LVEF of less than 35%. In this circumstance of newly diagnosed severe left ventricular (LV) dysfunction in the setting of an acute myocardial infarction, there is potential for recovery of LV function after revascularization, time and medical therapy. There is no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until 40 days after myocardial infarction where continued severe LV dysfunction is documented to persist in spite of appropriate treatment (Epstein, et al). Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced LVEF of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Consistent with these findings, the LifeVest device provided to this patient from the time frame specified was not likely to have been more beneficial than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested surgery involving the lip for treatment of his medical condition. Findings:  The physician reviewer found that in this patients case, the requested services are not medically necessary.  The medical records do not support the requested services in this clinical setting.  Photographs  show normal symmetric lip movement on smiling and lip pursing. There is no visible deformity or functional abnormality of the right or left upper lip.  The alleged abnormality does not constitute an abnormal structure of the body as there is no visible deformity in the included photographs.  The requested services will not improve function as it is currently normal.  It will also not create a normal appearance as the appearance is currently normal.  The proposed surgery would not provide any improvement in the appearance of the patient.  All told, the requested surgery involving the lip is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested spinal fusion surgery at L4-S1, extreme lateral interbody fusion for treatment of her lumbar pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. A review of the medical records demonstrates that the patient has chronic back pain which she attributes to a motor vehicle accident. Based on the documentation submitted for review including her neurological examinations, lumbar radiculopathy has not been established in this clinical setting as there is no evidence of defined symptoms matching a lumbar root distribution or motor, sensory, reflex findings (Tarulli and Raynor). Furthermore, the patient fails to meet Milliman Care Guidelines (MCG) and National Imaging Associates, Inc. (NIA) guideline criteria for surgical fusion which includes: spondylolisthesis with more than 4.5 mm instability, scoliosis, infection, tumor, fracture and stenosis with radiculopathy, neurogenic claudication, pseudarthrosis, rapidly progressive or severe neurologic deficits and imaging consistent with medical condition. In this patients case, she does not have any of the accepted criteria listed above. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested platelet rich plasma injection for treatment of his bilateral elbow pain.  Findings:  Three physician reviewers found that in the medical literature, the efficacy of PRP has not been established. Moraes and colleagues reviewed controlled trials and concluded that there is currently inadequate evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. The authors also stated that the lack of standardization in PRP preparation methods needs to be addressed in the design of future studies. In the article by Sheth and colleagues, a meta-analysis of 23 different randomized trials and 10 prospective cohort studies were reviewed. The authors reported that PRP provided no significant benefit up to and including 24 months across the randomized trial. Sbakova compared PRP with hyaluronic acid injections but did not present a controlled placebo group for comparison. The studies of the use of PRP in a matrix form for rotator cuff has been followed for an average of three years with apparent improvement in healing. All told, it is not likely to be more beneficial for PRP to be utilized for the treatment of this patients condition of bilateral elbow pain than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested cervical disc replacement surgery for treatment of his degeneration of cervical intervertebral disc. Findings:  Three physician reviewers found that the request for cervical disc replacement surgery is not likely to be more effective for this patient than other available options. The documentation submitted for review fails to demonstrate that the requested surgery is clinically indicated. The patient presents with several unknown factors, including unknown type of prior cervical spine surgery performed and whether there is either iatrogenic or degenerative fusion of the neck. Further, given the patients multilevel foraminal disease, a posterior approach such as laminectomy and fusion plus or minus foraminotomies is likely more beneficial than the proposed surgery. Based on the information provided for review, the request for cervical disc replacement surgery has not been established in this clinical setting and is not likely to be the more beneficial compared to other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested Sovaldi and Olysio for treatment of his hepatitis C genotype 1a.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) recently approved Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor, for treatment of patients with hepatitis C virus infection. However, this patients ultrasound did not demonstrate advanced (F3 or F4) liver fibrosis. Overall, this patient does not have significant liver fibrosis to support an indication for combination therapy with Sovaldi and Olysio. Therefore, the requested Sovaldi and Olysio combination therapy is not supported as medically necessary for treatment of this patients medical condition.