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

A 29-year-old female enrollee has requested  magnetic resonance imaging (MRI) of the brain with contrast (dye) for evaluation of her memory loss, hand tremor, loss of balance, and slurred speech.  Findings:  The physician reviewer found that based on review of the available records, the requested MRI with contrast (dye) is supported as medically necessary to evaluate this patients symptoms for multiple sclerosis (MS). Symptoms of MS include unusual sensations, blurred vision, clumsiness and coordination difficulties, loss of balance, numbness, problems with speech, and muscle spasms. As noted by Ge, conventional MR scanning offers the most sensitive way to detect MS lesions and their changes and plays a dominant role in ruling in or ruling out a diagnosis of MS. Lovblad and colleagues noted that, a gadolinium-containing contrast agent should be used for all diagnostic procedures. All told, the requested MRI of the brain with contrast (dye) is medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be more beneficial than other available standard methods of evaluating this patients medical condition. When used for evaluation of a palpable breast mass with negative traditional imaging, breast MRI offers low yield of cancer diagnosis and low specificity. Moreover, a biopsy is indicated for palpable masses. Although, the patient does not have a palpable finding, her findings on mammogram are similar, and a biopsy should first be performed. In this case, there is no indication a biopsy has been attempted or cannot be attempted. Further, an MRI should not be a substitute for biopsy. Thus, the request for an MRI of the right breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation. Findings:  Two physician reviewers found that the testing at issue was likely to have been superior over other methods of evaluating this patient.  There is support for gene expression profiling using AlloMap testing for acute cellular rejection screening in appropriate low-risk patients who are between six months and five years post transplant.  The current medical evidence supports the testing at issue in this clinical setting.  In this patients case, AlloMap testing was consistent with well-established guidelines for postoperative management and follow-up.  Therefore, AlloMap testing was consistent with current standard of care and was likely to have been more beneficial for this patient than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested substance abuse partial hospitalization treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addictive illness.  The patient had a long history of addiction that had impacted all functional domains of living.  On the date indicated, she had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The patient remained ambivalent and was still experiencing withdrawal symptoms of irritability and insomnia, in addition to craving that was addressed with a naltrexone prescription.  The current medical records support the services at issue in this clinical setting.  The treatment provided was reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, substance abuse partial hospitalization treatment was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested venous angioplasty for treatment of her history of right axillo-subclavian vein thrombosis. Findings:  Two physician reviewers found that the requested services are likely to be of greater benefit than other treatment options.  There is sufficient support for the requested services in this clinical setting.  The requested venous angioplasty is likely to result in better long-term outcome.  Based upon the medical records, venous angioplasty is indicated to decrease the long-term sequelae of venous outflow obstruction.  This patient is status post first rib resection, and the requested venous angioplasty is likely to be superior over other alternatives in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested disc replacement or fusion of disc for treatment of his cervical neck and left upper extremity pain. Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The medical records submitted for review fail to document that a conservative physical therapy program has been tried and failed. In addition, the properties of wear and the resultant patient response to wear debris from bearing surfaces of hip, knee and spinal disc share the same phenomenon (Flynn). Total hip and total knee replacement devices have a predictable rate of the need for revision and secondary procedures over time. Studies of longer duration are needed to assess the longer term potential complications of a methylmethacrylate arthroplasty within the cervical spine. Given the patients age and the potential for complications and lack of documented conservative care, the request for disc replacement or fusion of disc are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested pediatric speech therapy, including but not limited to group therapy for pragmatic communication skills (social skills training) and neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis for treatment of the enrollees pervasive developmental disorder and autism. Findings:  The physician reviewer found given his normal expressive and receptive language, as well as the fact that the patient is receiving other services that improve social language pragmatic delay, the request for pediatric speech therapy, including but not limited to group therapy for pragmatic communication skills (social skills training) was not and is not medically necessary in this clinical setting. The neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis was and is medically necessary for treatment of the patients medical conditions. Sensory integration techniques enable the occupational therapist to assist developmentally delayed children to develop the ability to integrate into normal motor and personal-social patterns to function with their peers. Sensory integration therapy is supported in the medical literature as to its long-term value in autistic children. The study by Miller and colleagues reports significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children. In this case, the patient presents with sensory dysfunction with noted delayed processing and motor planning abilities. Thus, the services at issue were and are medically necessary to assist with remediating his sensory dysfunction. As such, neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis to overcome this unique autistic behavior is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested removal of right breast implant for treatment of her post status breast augmentation. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  If there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant or infection/extrusion of a breast implant, its removal with capsulectomy would be medically necessary.  Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and would prevent migration of the gel to adjacent areas where it could cause additional medical problems.  However, surgery for visible but non-painful capsular contracture (grade III) or palpable but not visible or painful capsules (grade II) is not medically necessary.  In this patients case, the capsular contracture grade is I-II so removal of the right breast implant is not medically necessary.  This patients condition does not constitute an abnormal structure of the body.  All told, the requested removal of right breast implant is not medically necessary and is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested Lo Loestrin Fe for treatment of the enrollees endometriosis and growth of ovarian cysts.   Findings:  The physician reviewer found that although birth control pills are indicated as the first-line use in the medical management of endometriosis, the specific use of Lo Loestrin Fe is not clinically indicated at this time. There is a lack of evidence in the medical literature that supports the benefits in treatment goals of amenorrhea and reduction in pain with Lo Loestrin Fe compared to other low dose monophasic pills. That being the case, it is medically reasonable and appropriate for the patient to trial another pill currently on formulary. Furthermore, in a letter from the patients parent she states that the patient is at higher risk given her familial history of breast cancer. However, the medical records show that BRCA testing was performed and was noted to be negative. In sum, based on the medical records submitted for review and the medical literature cited above, the requested medication is not medically necessary at this time. Therefore, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested binaural hearing aids for treatment of his bilateral hearing loss. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested binaural hearing aids.  There is a lack of support for the requested devices in this clinical setting.  The records do not show that the hearing aids were prescribed by an otolaryngologist after review of an audiological evaluation.   This patient has a severe form of hearing loss, but he has been using hearing aids.  There is no rationale supplied for new hearing aids as the patients current devices already provide as much benefit as can be expected based on the audiograms submitted for review.  All told, the requested binaural hearing aids are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested below the knee amputation using the Ertl (bone bridge) procedure for treatment of his traumatic arthritis of ankle and trauma induced aseptic necrosis of the ankle.  Findings:  Two physician reviewers found that in a study by Lewandowski and colleagues, the authors stated that, symptomatic distal tibiofibular instability is a known complication of trauma-related transtibial amputations. The authors reported that recent studies have suggested an increase in complication and reoperation rates in transtibial amputations that received a bridge synostosis compared with standard transtibial amputations. In a report by Kingsbury and colleagues, the authors stated that, although some evidence indicated that patients with a bone bridge have improved loading at higher speeds, a regression of all patients walking at self-selected speed indicates that as residual limb length increases, loading increases regardless of amputation type. Thus, our data suggest it is important to preserve residual limb length to allow for improved loading in terminal stance. Overall, the requested Ertl bone bridge procedure does not have sufficient long-term studies to demonstrate the overall efficacy and safety of this device. Moreover, the Ertl procedure has not been demonstrated to be equivalent or superior to standard therapies in long-term studies. Therefore, the requested services are 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 49-year-old male enrollee has requested hospitalization services for treatment of his diabetic ketoacidosis.  Findings:  The physician reviewer found that diabetic ketoacidosis is a potentially life-threatening complication in patients with diabetes mellitus. Treatment involves administering intravenous fluids to correct dehydration and insulin to suppress the production of ketone bodies, treatment for any underlying causes such as infections, and close observation to prevent and identify complications (Kitabchi, et al). This patients complications during hospitalization for treatment of diabetic ketoacidosis included anemia and thrombocytopenia. Evidence suggests that patients who develop anemia during the course of hospitalization may be at risk for adverse outcomes (Koch, et al). Hospitalized patients with life-threatening conditions such as diabetic ketoacidosis need to be treated for these blood disorders prior to discharge from the hospital. For these reasons, the hospitalization services were medically necessary for treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Three physician reviewers found that the records indicate this patient has severe persistent asthma and has failed treatment with numerous medical therapies. In the peer-reviewed medical literature, bronchial thermoplasty results in fewer exacerbations and improved quality of life as well as reduced hospitalizations and need for rescue inhalers. The available data has shown that results do not diminish after five years. This patient is a good candidate and would likely benefit from bronchial thermoplasty. All told, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Sovaldi with Olysio for treatment of her chronic hepatitis C genotype 1b.  Findings:  The physician reviewer found that the current standard of care for hepatitis C genotype 1a and 1b treatment includes two directly acting antiviral drugs which typically include a protease inhibitor and polymerase inhibitor directed against non-structural proteins involved in hepatitis C replication. The sustained virologic response rate is greater than 90% in patients with and without cirrhosis. This patient has a diagnosis of cirrhosis which is supported by evidence of portal hypertension on laboratory testing and the results of the hepascore. A liver biopsy is not needed to support an indication for the requested Sovaldi and Olysio combination therapy. Moreover, the patient has already failed interferon based therapy. For these reasons, the requested medications are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The peer-reviewed literature continues to demonstrate positivism for TMS, while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama, et al). In addition, TMS is approved by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. The patient has trialed appropriate psychotropic medications and previously pursued a course of ECT, which was poorly tolerated. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is an appropriate treatment and is consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness, and therefore, medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested dual therapy Sovaldi tablets and RibaPak tablets for treatment of his chronic hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The submitted medical records do not support that the patient is interferon-ineligible as defined by the American Association for the Study of Liver Diseases and the Infectious Disease Society of America.  The lack of interferon-ineligibility broadens the treatment options available to this patient per the current guidelines.  Further, the American Association for the Study of Liver Diseases and the Infectious Disease Society of America recommend delaying treatment for some patients in this clinical setting, as waiting for future highly effective, pan-genotypic, direct acting antiviral combinations in interferon-free regimens may offer potential advantages.  All told, the requested dual therapy Sovaldi tablets and RibaPak tablets are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested repetitive transcranial magnetic stimulation (TMS) services for treatment of her major depressive disorder. Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available treatment options. In this case, the patient presents with a debilitating unilateral depressive disorder with a formidable affective symptom complex that is causing significant morbidity and functional impairment. Despite trialing appropriate psychotropic medications and augmentative strategies, and participation in evidence-based psychotherapies for depression, the patient remains symptomatic. TMS therapy is reasonably expected to improve her condition and prevent a more serious episode of illness. Furthermore, TMS is safe, appropriate and consistent with good medical practice.  Considering the case in its entirety within the context of the most current practice guidelines and relevant peer reviewed literature, repetitive TMS is likely to be more beneficial for treatment of the patients medical condition than any remaining available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested duloxetine (Cymbalta) for treatment of her chemotherapy induced peripheral neuropathy.  Findings:  The physician reviewer found that Cymbalta is medically necessary treatment for treatment of this patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy and depression. Raskin and colleagues performed a multi-center double-blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. The authors concluded that Cymbalta was safe and effective in the management of diabetic peripheral neuropathy. Kajdasz and colleagues performed a post hoc analysis and reported that Cymbalta was effective and well tolerated for the management of peripheral neuropathic pain. Consistent with these findings, the requested Cymbalta is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her diagnosis with breast cancer. Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be superior over other available treatment options.  Per the medical records, this patient has a particularly aggressive form of breast cancer.  MRI is the most sensitive means with which to detect breast cancer.  Given this patients multifocal disease, MRI is appropriate after chemotherapy to determine which site or sites should be excised.  The MRI will be valuable as a surgical and prognostic test and is superior to all other available techniques.  Therefore, the requested MRI is likely to be of greater benefit than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested Sovaldi and Ribapak for treatment of his hepatitis C genotype 3A.  Findings:  The physician reviewer found that based on review of the available records, the treatment plan recommended by the provider is medically necessary for treatment of this patients hepatitis C. The available data indicates that the sustained virologic response (SVR) rate is higher for genotype 3 using regimens that contain the direct antiviral agent Sofosbuvir. Further, the American Association for the Study of Liver Diseases (AASLD) recommends a regimen of Sovaldi and ribavirin over interferon based treatment. For these reasons, the requested Sovaldi and Ribapak are supported as medically necessary for treatment of this patients hepatitis C.