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

A 36-year-old male enrollee requested Percocet 10/325 for treatment of his medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support Percocet 10/325 in this clinical setting.  The standard of care for chronic pain associated with piriformis syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  Baron and McDonald reported that high-dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, Percocet 10/325 is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT 72141), thoracic spine (CPT 72146), and lumbar spine (CPT 72148) for medical evaluation of her progressive paresthesias and dysthesias with ataxia, dyskinesias, and dystonia.  Findings:  The physician reviewer found that based on the available records, the requested MRI of the cervical and thoracic spine to the conus is medically reasonable to assign a cause to this patients ongoing complaints of pain, paresthesias, dysthesias, dyskinesia, and dystonia. The provider noted the differential diagnoses include myelopathy, syrinx, multiple sclerosis and its variants, and spinal cord glioma given the persistent and somewhat variable pattern in the presentation of these symptoms. MRI of the spinal cord with contrast is a sensitive method for evaluating for multiple sclerosis among the other entities given the patients differential diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee requested residential treatment services for treatment of the enrollees cannabis abuse, major depressive disorder, attention deficit hyperactivity disorder (ADHD), and psychotic disorder not otherwise specified (NOS).  Findings:  The physician reviewer found that this patient was admitted to residential level of services because she had already run away from home for many days prior to admission. She was uncooperative with her parents, non-compliant with medications, and was abusing marijuana. After admission to residential treatment, her pattern of lack of cooperation was often noted. Given this patients history and review of the records, she continues to require the intensity and supervision provided at the residential level of care. All told, the records support the medical necessity of residential treatment services for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee requested a five day inpatient stay for ketamine infusion for medical treatment of her complex regional pain syndrome (CRPS).  Findings:  Three physician reviewers found that given the unanswered issues including optimal duration and dosing of ketamine infusions, effectiveness of the setting for the infusion (inpatient versus outpatient), and ketamine usage in diagnosed refractory cases of CRPS, the requested ketamine infusion over a five day inpatient admission is not likely to provide this patient with greater benefits than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee requested occupational therapy (OT) at the frequency of one hour per week for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient presents with mild delays in fine motor and gross motor skills. Moreover, his IEP reports that he is making progress. The patients parents have requested OT to address the patients sensory processing deficits. Given the lack of support for sensory based therapies in the medical literature and the patients delays in both fine and gross motor skills are only mild, the medical necessity for the requested therapy has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee requested applied behavior analysis (ABA) services (35 hours per week of direct care and 16 hours per month of supervision) for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested services.  The submitted documentation indicates that the patient has had an exceptionably favorable response to ABA therapy.  Plasticity in the developing brain exists, and can be utilized to improve overall neurologic health.  ABA therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  All told, the requested ABA services (35 hours per week of direct care and 16 hours per month of supervision) are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested magnetic resonance imaging (MRI) of the shoulder for evaluation of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records noted shoulder pain of three weeks duration.  There is no documentation of an orthopedic consultation.  X-rays have been negative for any skeletal lesion.  While MRI is an important adjunct to clinical assessment, there needs to be a clinical examination and patient history prior to MRI.  Although there is documentation of a prescription for an anti-inflammatory, there is a lack of documentation of other aspects of conservative care.  All told, the requested MRI of the shoulder is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested a neurosurgery consultation for medical treatment of her constant low back pain radiating to the right leg associated with numbness and tingling in the right leg. Findings:  The physician reviewer found that based on the available medical records, the requested neurosurgery consultation is medically necessary for treatment of this patients medical condition. The records indicate she has symptoms including low back pain radiating to the right leg associated with numbness and tingling in the right leg. The patient also has a positive Lasegue on the right to 10 degrees and decreased pinprick and light touch on the right L5-S1 dermatome. Given these findings, the patient should undergo an evaluation by a neurological surgeon as requested.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee requested acute hospitalization care or skilled nursing facility level of care for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that the medical records document a catastrophic traumatic brain injury.  In the past, the patient has received extensive rehabilitation services.  More recently, the patient has been assessed and viewed to have had a plateau in his response to rehabilitation therapy.  In this clinical setting, skilled nursing facility level of care was and is medically appropriate.  There is sufficient support for skilled nursing facility level of care in this clinical setting.  However,  acute hospitalization care was not and is not medically indicated.  Thus, the medical records demonstrate the medical necessity of skilled nursing facility level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis of the thoracic spine. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees lumbosacral spondylosis with neck and back pain with radiation down the upper and lower extremities.   Findings:  Two physician reviewers found that given the documentation of facet arthropathy shown as the pathological cause through the physical exam, MRI and the patients positive response to the cervical facet blocks, the requested radiofrequency neurolysis of the thoracic spine is likely to provide this patient with a greater health benefit than treatment with any available therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested patent foramen ovale (PFO) closure for medical treatment of her medical condition. Findings:  Two physician reviewers found that the request for PFO closure is likely to be more effective for this patient than other available options. The patient is a young, active female who had a transient ischemic attack and subsequent work-up demonstrated PFO with significant right to left shunt. Recent studies and meta-analysis have favored PFO closure especially using the Amplatzer device versus medical therapy, especially in young patients such as in this case (Stortecky, et al). For the reasons provided, the requested closure of a patent foramen ovale is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee requested gastric electric stimulation for medical treatment of his gastroparesis.  Findings:  Three physician reviewers found that a review of available records supports that this patients gastroparesis remains symptomatic despite modest objective improvement and trials over two years of several gastroprokinetic agents.  There is adequate support in the medical literature to indicate that well selected patients with refractory gastroparesis can get significant relief from nausea and vomiting by gastric electrical stimulation. Jayanthi and colleagues conducted a clinical audit of consecutive gastroparesis patients treated with gastric electric stimulation. The authors reported that approximately 71% of patients with intractable gastroparesis had good response to permanent gastric electric stimulation at follow-up of up to two years. Given this support, the requested gastric electric stimulation is 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 48-year-old male enrollee requested continued home intravenous immunoglobulin (IVIG) infusions twice per month for medical treatment of his myasthenia gravis. Findings:  The physician reviewer found that his records do not indicate that he has been treated with standard immunotherapy including oral steroids, azathioprine, or mycophenolate mofetil. In this case specifically, it is unclear from the records whether he is in a long-term remission, which may occur after thymectomy. In order to treat his myasthenia gravis exacerbation and transition him to a more standard therapy, treatment with IVIG twice per month for 90 days is appropriate. For these reasons, a portion of the requested IVIG therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested hyperthermic intraperitoneal chemotherapy (codes 77605 and 96446) for treatment of her ovarian cancer.   Findings:  Two physician reviewers found that The National Comprehensive Cancer Network guidelines do not include the use of hyperthermic intraperitoneal chemotherapy in their recommendations for management of ovarian cancer. Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option, specifically in cases where surgical debulking was suboptimal.  The current medical evidence has not established the superior effectiveness of hyperthermic intraperitoneal chemotherapy in this clinical setting.  Helm and colleagues noted that further research is needed.  There is a lack of high quality prospective trials showing benefit over standard of care.  Thus, hyperthermic intraperitoneal chemotherapy is not likely to be of greater benefit than other alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested Marinol (dronabinol) for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the use of Marinol in this clinical setting.  Marinol is approved for the treatment of chemotherapy-associated nausea and vomiting refractory to other anti-emetics and acquired immune deficiency syndrome (AIDS) related anorexia.  Marinol is not approved for the use of nausea associated with chronic pancreatitis or familial adenomatous polyposis.  There is a lack of support for Marinol for the treatment of this patient.  All told, Marinol is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee requested anterior lumbar fusion surgery for medical treatment of his low back and bilateral leg pain. Findings:  The physician reviewer found that the patients MRI with contrast documented postoperative changes at L5-S1 with minimal enhancing scar tissue surrounding the S1 nerve roots left greater than right. A diagnosis of failed spinal surgery and complex regional pain syndrome is therefore appropriate. However, anterior fusion as a treatment method is not supported by evidence of instability or recurrent intervertebral disc herniation.  A more conservative approach has been recommended including continuing physical, movement and cognitive therapies. For these reasons, the requested anterior lumbar fusion surgery is not medically necessary for treatment of this patients back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A 53-year-old male enrollee requested magnetic resonance imaging (MRI) of the ankle for medical evaluation of his left foot and ankle pain.  Findings:  The physician reviewer found that the submitted documentation supports the requested diagnostic procedure in this patients case.  Per Burge and colleagues, MRI is an optimal modality for imaging evaluation of suspected foot injury.  Cheung and Rosenberg noted that MRI is beneficial in evaluating persistent ankle pain.  In this patients case, the medical records document negative x-rays and continued pain.  Thus, MRI of the ankle may be beneficial in evaluating the soft tissue structures.  Chronic ligamentous injuries can be demonstrated on MRI.  All told, the requested MRI of the ankle is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine and lumbar spine without dye for medical evaluation of his back pain.  Findings:  The physician reviewer found that the patient presents with a history of chronic pain syndrome and has undergone previous MRI scans of the lumbar spine as well as a computed tomography (CT) scan of the cervical spine. There is no evidence of a significant neurological deficit. Moreover, the patients physical examination reveals limited range of motion with diffuse tenderness. There is no evidence of a motor weakness or sensory deficit in the bilateral upper or lower extremities. There is also no evidence of the emergence of any red flags indicating serious spinal pathology. All told, the medical necessity for the requested MRI of the cervical spine and lumbar spine without dye has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction. Findings:  Two physician reviewers found that the clinical information submitted for review provided substantial evidence that lower levels of care intended to treat the patients sacroiliac joint dysfunction have failed to resolve her symptoms.  Per the current medical evidence, when nonoperative treatment fails, sacroiliac joint fusion may be appropriate.  This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.  In this patients case, proceeding with surgical intervention is warranted.  All told, the requested sacroiliac fusion is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested a spinal cord stimulator for medical treatment of her pelvic and buttock pain with a diagnosis of interstitial cystitis.   Findings:  The physician reviewer found that the records document that the patient has failed to receive any reduction in pain or improved quality of life with conservative therapy and medications. Surgery is not considered an appropriate treatment option for chronic interstitial cystitis. In this case, where the patient has intractable pain and urinary frequency despite medication and failed conservative therapy, spinal cord stimulation is supported in the medical literature . Spinal cord stimulation was found to reduce pain, improve quality of life, and reduce analgesic consumption, as well as allow some patients to return to work with minimal significant adverse events. For these reasons, the requested spinal cord stimulator is supported as medically necessary in treating this patients chronic pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee requested Dexilant 60 mg for medical treatment of her chronic gastritis and reflux associated esophagitis with history of helicobacter pylori (H. pylori).  Findings:  The physician reviewer found that in this case, the patient has a documented attempt at modified diet, and documented failure on multiple typical PPIs with need for over-the-counter therapy and significant abdominal pain interfering with sleep. She also has demonstrated success on Dexilant for two years, with recurrence of considerable symptoms after reverting back to typical proton pump inhibitors. In this case, Dexilant is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old enrollee requested inpatient care for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services.  This patient evidenced dramatic affective symptoms characterized by dysphoria, mood dysregulation and suicidality despite outpatient treatment.  Further complicating matters was his anxiety disorder.  Discharge would have been premature and inconsistent with good medical practice.  Per the medical records, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  The hospital services were for active treatment.  The services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, inpatient care was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested medical marijuana for treatment of her anxiety.  Findings:  The physician reviewer found that the use of medical marijuana for the treatment of anxiety is not endorsed by the American Psychiatric Association.  Further, there is a lack of well-designed, adequately powered studies in the peer-reviewed medical literature demonstrating both the safety and efficacy of medical marijuana for treatment of anxiety in human populations.  Finally, regarding this particular patient, there was no mental health documentation provided.  Critical documents such as a psychiatric history, comprehensive treatment plan, serial progress notes with clinical rating scales, and the status and outcomes of prior or concomitant treatments, such as services provided at alternative levels of care, community programming or evidence-based interventions for anxiety such as pharmacotherapy and cognitive behavioral therapy, were not included for review.  In sum, there is a lack of clinical justification supporting the use of medical marijuana as a treatment intervention for an anxiety disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 77-year-old male enrollee requested a knee brace for medical treatment of his knee pain.  Findings:  The physician reviewer found that there is sufficient support for the requested knee brace in this clinical setting.  This patient has documented malalignment.  Given this patients multiple comorbidities and age, the requested knee brace is likely to be beneficial.  Lorbach and colleagues noted that several studies have demonstrated a reduction in pain with the use of unloader braces.  The authors reported that while orthotics such as a medial unloader braces are not likely to alter the long-term effects of osteoarthritis, they are likely to result in short-term benefit.  The literature review by Maleki and colleagues supports the use of the medial unloader valgus brace as a conservative treatment for medial knee osteoarthritis.  All told, the requested knee brace is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee requested antigen leukocyte cellular antibody testing (ALCAT) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that high-quality controlled trials of ALCAT are not available.  The test has been characterized in the literature as lacking scientific and clinical proof of efficacy.  The National Institute of Allergy and Infectious Diseases (NIAID) guidelines for diagnosis of food allergy do not recommend ALCAT testing.  Given the lack of controlled trials and the lack of support from medical society clinical guidelines, the superior effectiveness of ALCAT testing in this clinical setting has not been established.  Therefore, ALCAT testing was not likely to have been of greater benefit than other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee requested a panniculectomy for medical treatment of her excess skin status post bariatric surgery and weight loss.   Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. In this case, the medical documentation supports that the functional deficit is related to the upper and lower abdominal pannus. Manahan and Shermak recommend panniculectomy in this clinical setting. Thus, based on the entirety of the medical record, the patient has a well-defined functional deficit related to excess abdominal soft tissue from previous significant weight loss. Resection of the excess soft tissue is medically necessary to address this specific functional deficit.