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

A male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his Ewings sarcoma. Findings:  Three physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the medical records provided for review, the patient presents with Ewings sarcoma and in this clinical setting IMRT is likely to be the most effective way to treat this patient and spare the surrounding normal tissues. In addition, the scalp is a complex shaped volume for which IMRT is well-suited. IMRT is expected to improve the dose coverage and dose homogeneity. For the reasons provided, IMRT is 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

The parent of a male enrollee requested Avastin for medical treatment of the enrollees malignant spindle cell sarcoma.  Findings:  Two physician reviewers found that Synovial sarcoma is a rare disease and thus, large scale clinical trials for sarcomas have small numbers of patients with synovial sarcoma. According to the current peer-reviewed medical literature, studies have demonstrated that Avastin may benefit and even halt disease progression for a period of time (Palmerini, et al; DAdamo, et al). This patient has received first-, second-, and third-line therapies for synovial sarcoma. Accordingly, the requested Avastin is supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Serostim 4 mg daily for medical treatment of his lipodystrophy secondary to human immunodeficiency virus (HIV) medications. Findings:  The physician reviewer found that as noted by the U.S. Food and Drug Administration (FDA), Serostim is indicated for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. The records indicate that due to documented and stated findings of lipodystrophy previously, this patient began taking Serostim. At the time, he was noted to have significant lipoaccumulation of the abdomen and muscle wasting of the face, arms, legs and buttocks. Based on the documentation, the patient appears to have improved from this status. He reports that his waist size is down significantly and that he has regained appropriate muscle mass. However, the medical documentation provided for this review does not adequately define any current lipodystrophy, including the amount of continued lipoaccumulation or lipoatrophy present or other documentation to warrant continued treatment. Without detailed examination of the patients current lipodystrophy including lipoatrophy or lipoaccumulation, further treatment with the requested Serostim 4 mg daily is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 A male enrollee requested intensity modulated radiation therapy (IMRT) and real-time intra-fraction target tracking for medical treatment of his high-grade retroperitoneal sarcoma.Findings:  Two physician reviewers found that IMRT was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. IMRT is the standard of care in this clinical scenario and was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Retroperitoneal sarcomas are generally fixed to the retroperitoneum and not subject to much respiratory motion.  Real-time intra-fraction target tracking was not likely to be more beneficial for treatment of the patients medical condition than standard therapy.   A portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Herceptin for treatment of her transverse colon adenocarcinoma.  Findings:  Two physician reviewers found that the requested medication is not likely to be superior over other treatment options.  Foundation One assay explores the mutations or gene overexpression of an individuals cancer cells.  However, at this time, there is a lack of evidence demonstrating that the assay adds to decision-making above and beyond the tests which are available conventionally.  There is a lack of data supporting the use of Herceptin in colorectal cancer.  Therefore, the requested medication Herceptin is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested residential treatment center services for treatment of her depression and anorexia nervosa.  Findings:  The physician reviewer found that progress notes from the patients treatment indicate the residential treatment center services at issue were not medically necessary. She was experiencing some depressive and anxious symptoms, but these symptoms were mild-to-moderate, and did not require the intensity of residential treatment level of care. She was very cooperative in treatment, showed insight into her need for treatment and did not demonstrate any dangerous behaviors. The patient was going for visits outside the treatment center and had appropriate behaviors in public. All told, residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Two physician reviewers found that the computed tomography scan of the sinuses showed no disease in the right frontal sinus and mild disease in the left side. The physical examination of the sinuses by the provider using nasal endoscopy shows no evidence of disease. In this case, it is possible that the patient is suffering from a primary headache problem. Prior to proceeding with surgery, a neurology consultation should be obtained. Based on the documentation submitted for review, the requested services are not likely to be more beneficial than any standard treatments for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested prostate artery embolization for medical treatment of his benign prostatic hyperplasia.   Findings:  Two physician reviewers found that there is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of prostatic arterial embolization to treat symptomatic benign prostatic hyperplasia. Limited international studies have demonstrated possible short-term benefits. However, there is also a lack of comparative studies evaluating prostate artery embolization as compared to other methods such as TURP. All told, the requested prostate artery embolization is not 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 female enrollee requested a positional MRI for medical evaluation of her rectocele.  Findings:  Two physician reviewers found that this patient has clinical symptoms which may be related to rectocele or pelvic mass encroaching on the rectum.  In this patients case, the most beneficial modality was the positional MRI of the pelvis which allowed for the evaluation of possible rectocele and evaluation for a potential pelvic/perineal mass.  All told, the positional MRI was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested transcatheter insertion of Amplatzer patent foramen ovale (PFO) closure device for medical treatment of her patent foramen ovale. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  The medical evidence has demonstrated a beneficial effect in the prevention of recurrent neurologic events with PFO closure.  Considering the association of cryptogenic stroke in addition to migraine in this patients case, the requested services are likely to be of greater benefit over standard medical therapy, which would include lifelong systemic anticoagulation.  In sum, transcatheter insertion of Amplatzer PFO closure device is likely to be more effective than other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a vertical sleeve gastrectomy for medical treatment of her status post laparoscopic removal of adjustable gastric band.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient does not meet the standard criteria for bariatric surgery. There is no basis or rationale for proceeding with pre-emptive bariatric surgery. In addition, there is no indication in the medical record that she is actively engaged in non-surgical weight loss program with the goal of avoiding weight gain following removal of the band. For the reasons provided, the requested procedure is not medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested lumbar laminectomy for medical treatment of her progressive degenerative disc disease (DDD). Findings:  The physician reviewer found that the records indicate that this patient has chronic back pain. However, she has no symptoms or signs of lumbar radiculopathy (Tarulli and Raynor). The criteria for fusion from the Milliman Care Guidelines (MCG) and National Imaging Associates (NIA) include lumbar radiculopathy, sciatica, cauda equina syndrome, pseudarthrosis, and spinal stenosis with progressive neurologic condition or neurogenic claudication after failure of six months of conservative care including physical therapy, ESI, chiropractic care, and cognitive behavioral therapy. All told, the requested lumbar laminectomy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested sclerotherapy for medical treatment of her varicose veins.   Findings:  The physician reviewer found that in order for sclerotherapy to be considered appropriate and medically necessary it has to be determined that there is no occlusion of the deep venous system. It has to be determined that there is no significant reflux in the major superficial veins such as at the saphenofemoral junction and greater saphenous vein. Additionally, the patient has to have failed adequate efforts at conservative treatment. In this case, there is no documentation that she recently has been provided a prescription for medical grade compression stockings, instructed in their use, and used them as instructed. If conservative therapy is helpful, it could spare the patient a procedure or procedures and their attendant potential complications. For these reasons, the requested sclerotherapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested rectal sensory testing (91120) for medical evaluation of her slow transit constipation, abdominal pain, non-ulcer dyspepsia, and rectocele.   Findings:  The physician reviewer found that currently, the medical literature does not support an indication for rectal sensory testing in evaluation of this patients symptoms and complaints. Remes-Troche and colleagues performed stepwise graded balloon distensions of the rectum in 30 patients with constipation and rectal hyposensitivity and in 23 healthy controls and evaluated the thresholds for first sensation, desire, and urgency to defecate. The authors reported that constipated subjects with rectal hyposensitivity demonstrated higher thresholds for inducing rectoanal reflexes and abnormal characteristics of sensorimotor response. While testing of rectal sensation appears to be a promising research tool, there is a lack of data demonstrating its utility in clinical practice. All told, the requested rectal sensory testing (91120) is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested a colon motility study (91117, six hour study) for medical evaluation of her slow transit constipation, abdominal pain, non-ulcer dyspepsia, and rectocele.  Findings:  Two physician reviewers found that this patient has evidence of slow colonic transit by defecography and has remained with persistent constipation despite medical management. In this clinical setting, colonic manometry can identify the cause of constipation in well selected patients. Given these findings, the requested colon motility study (91117, six hour study) is likely to be 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 male enrollee requested Harvoni for 12 weeks for medical treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three 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. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Moreover, interferon-based regimens are no longer recommended for first-line therapy. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni for 12 weeks should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested AmniSure testing for medical evaluation of her fetal rupture of membranes. Findings:  Three physician reviewers found that according to the American Congress of Obstetricians and Gynecologists practice bulletin on premature rupture of membranes, The diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation.  AmniSure testing was not likely to be more beneficial than standard therapy. In sum, the testing at issue was not clinically indicated and not likely be 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 male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, 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. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Harvoni has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. In this case, the patient presents with chronic HCV genotype 1a and is treatment-naive. Therefore, Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested acute inpatient psychiatric hospitalization services for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that based on the documentation provided, the inpatient services were medically necessary initially, and discharge to a less restrictive setting would have been appropriate shortly thereafter.  Initially, it was reported that the patient was withdrawn and likely responding to internal stimuli.  Shortly thereafter, the patient was making some improvements; had a family meeting, and he had no physical complaints.    He reported feeling better, and his antipsychotic medication had not changed recently.  There was no evidence of an acute psychiatric syndrome.  Thus, acute inpatient psychiatric hospitalization services were medically necessary initially for the patients medical condition, but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested referral to a provider who completed a burn and critical care fellowship for treatment of her right hip burn. Findings:  The physician reviewer found that second degree burns are commonly treated by primary care physicians and wound physicians at a wound center. In this case, the wound is improving. The eschar can be debrided in an outpatient setting or be allowed to fall off after standard wound care. As noted in the medical literature, thermal burns due to therapeutic appliances can be managed as an outpatient by a family physician. Therefore, the requested referral to a provider who completed a burn and critical care fellowship is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the peroral endoscopic myotomy (POEM) procedureal for treatment of the enrollees esophageal achalasia.  Findings:  Two physician reviewers found that given that the vast preponderance of clinical results have been extremely favorable for the POEM procedure, it is 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 male enrollee requested monitored anesthesia care (MAC) services for medical evaluation of his risk for colon cancer.  Findings:  The physician reviewer found that this patient did not present with a significant history that would require MAC. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office based setting and without the need of MAC services with propofol, as required per American Society of Anesthesiologist (ASA) guidelines. For these reasons, MAC services were not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90/400 mg for 24 weeks for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that in this clinical setting Harvoni is medically necessary for treatment of the patients HCV. The patient has cirrhosis based on imaging, lab work, and non-invasive testing. He has previously failed treatment for genotype 1 disease with an interferon-based regimen. His cirrhosis is well-compensated and renal function is preserved. There is no evidence of hepatocellular carcinoma. In sum, treatment with Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested inpatient mental health services for medical treatment of her major depressive disorder and suicidal ideation. Findings:  The physician reviewer found that the records indicate the patient was assaulted only two weeks before admission and was receiving treatment for the exacerbation of her underlying depression as a result. Further, the notes during the treatment period in dispute show that the patient was continuing to receive appropriate management with training in coping strategies to deal with her depression and thoughts of suicidal ideation and self-harm and the addition of lamotrigine to help her mood. For these reasons, the inpatient mental health services were 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 residential behavioral health services for medical treatment of the enrollees depression, anxiety, and substance abuse. Findings:  The physician reviewer found that progress notes during the treatment period show that the patient was unstable, anxious and depressed. The treatment notes indicate that she is still having a significant problem dealing with stress in an appropriate manner, and being with her family is a major precipitant of that stress. Had she been discharged, she would not have had the coping ability to deal with her anxiety and depression and most likely would have resorted again to using substances for this purpose. Accordingly, residential behavioral health services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested 36 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that the patient attends elementary school five days per week in addition to ABA therapy. There is a lack of documentation submitted for review demonstrating a need to increase ABA services to 36 hours per week. Based on the clinical documentation submitted for review and medical literature, 25 hours per week of ABA services is appropriate and medically necessary for this patient. As such, the request for ABA therapy at the requested frequency of 36 hours per week is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested residential treatment services for medical treatment of her depression and anxiety. Findings:  The physician reviewer found that progress notes from the patients treatment indicate the patients primary problems stemmed from chronic relationship issues. She did present with some depressive and anxious symptoms, but these were mild to moderate in nature, and did not require the intensity of care provided at the residential level of care. She was going for visits outside the treatment center and reportedly had appropriate behaviors in public. For these reasons, the patient could have been safely and adequately treated in a less restrictive setting. Therefore, residential treatment services were not medically necessary for treatment of this patients medical condition.