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

A 64-year-old male enrollee requested a CardioNet Monitor (real time remote heart monitor, CPT 93228 and 93229) for evaluation of his intermittent dizziness.  Findings:  Three physician reviewers found that the real time remote heart monitoring was not likely to either improve or alter patient outcome. In this clinical setting, the deployment of a standard Holter monitoring for 24-48 hours would have been reasonable and appropriate prior to the services at issue. At this time, there is insufficient support in the medical literature demonstrating immediate recognition and reporting through a call center provided by real-time mobile telemetry services results in improved health outcome compared to standard monitoring techniques. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested Ampyra, one tablet twice per day for treatment of her multiple sclerosis.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has multiple sclerosis and has been treated with Ampyra.  There has been reported clinical and functional benefit.  Ampyra has been demonstrated to improve walking in patients with multiple sclerosis.  However, the clinical trial measure of improved gait speed is only one of multiple possible indicators of success.  This patient has noted improvement in spasms and fatigue, and has had a documented improvement in gait speed.  The current medical evidence supports the requested medication in this clinical setting.  All told, the requested Ampyra, one tablet twice per day is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested monitored anesthesia care (MAC) services for the lumbar epidural injection for treatment of his degenerative disc disease.  Findings:  The physician reviewer found that based on the current medical literature and guidelines from the American Society of Anesthesiologists (ASA), the routine use of MAC services for most pain procedures is not supported. In addition, this patients provider did not document any condition that would require the use of MAC services during an epidural steroid injection. Therefore, the requested MAC services for the lumbar epidural steroid injection are not medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee requested removal of excess breast tissue for medical treatment of his gynecomastia. Findings:  The physician reviewer found that per the current medical evidence, surgical treatment of gynecomastia should be reserved for severe and refractory cases.  As noted by Pruthi and Jones, nonsurgical interventions and medical therapies should be considered as initial therapy.  In this case, the clinical documentation submitted for review fails to demonstrate that this patients condition is severe and refractory to nonsurgical treatment.  All told, the requested removal of excess breast tissue is not medically indicated for the treatment of this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested substance abuse residential rehabilitation treatment for treatment of his substance abuse.  Findings:  The physician reviewer found that based on the available medical records, this patient presented with a history of substance abuse but there was no psychiatric admission, evaluation, nursing notes, or any other physicians documentation provided for review. Further, the patients substance abuse history does not support admission to residential treatment. The patient does not have any reported prior treatment at the partial hospitalization program, or outpatient level of care for substance abuse. He had no comorbid psychiatric or medical conditions that would require treatment in a 24-hour setting. In addition, he did not meet the American Society of Addiction Medicine (ASAM) criteria for residential level of care. He could have been treated on an outpatient basis with community based sober support systems such as a 12-step program. All told, the substance abuse residential rehabilitation treatment provided from the time period specified was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee requested a bone allograft (20930) and bone autograft (20936) for medical treatment of his neck fusion surgery.  Findings:  Two physician reviewers found that acute inflammatory reactions to recombinant human bone morphogenetic protein (RHBMP) can occur in the posterior cervical spine and can lead to significant morbidity (Robin, et al). Seroma formation was commonly mentioned where patients with brainstem compression, obstructive hydrocephalus, and neurologic compromise were observed. The report by Anderson and colleagues stated that caution should be used with RHBMP because safe and effective dose and technique in the cervical spine have yet to be determined. Due to these complications the use of RHBMP is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, the medical literature supports the use of bone autograft as the standard of care in adjunct to spine fusion surgery. It provides osteogenic, osteoinductive and osteoconductive elements that aid in creation of a fusion mass. Dagostino and colleagues reported that when compared to RHBMP autograft transplants had an overall decrease in rates of revision fusion procedures. The medical literature supports the use of bone autograft in cervical fusion as the standard compared with RHBMP. Therefore the use of bone autograft (20936) in this case is supported as likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.  It was determined that a portion of the requested services are 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

The parent of a five-year-old female enrollee has requested Pediasure formula for treatment of the enrollees low weight. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient is not known to have a neurological, musculoskeletal, gastrointestinal, cognitive disease, or anatomical abnormality that impairs swallowing or chewing. The patient does not have a medical condition that is considered a significant risk factor for malnutrition, such as an inborn error of metabolism, atopic disease associated with allergy-related formula intolerance, malabsorption syndrome or other severe chronic disease. At this time, her BMI is in the 10th percentile. Moreover it is not clear from the records that the patient requires continued administration of Pediasure to maintain a stable weight trajectory. Given the lack of documentation demonstrating that the patient requires ongoing nutritional supplementation to prevent weight loss and that appropriate caloric intake with standard nutrition is insufficient to maintain energy needs, the requested services are not indicated. Based on the medical literature cited above and the documentation submitted for review, the request for Pediasure formula is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested laser treatment for treatment of his toenail fungus. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The documentation submitted for review fails to provide support for onychomycosis. There are no positive fungal cultures, microscopic examinations or pathology examinations of the toenails to confirm the diagnosis of onychomycosis. There is no documentation to support pain secondary to the onychomycosis to support treatment of this condition. Further, there is no documentation to support the patients nails are causing pain with pressure affecting shoe gear and ambulation. In addition, there is a lack of medical literature supporting the efficacy of laser treatment for onychomycosis. According to Bristow, The evidence pertaining to the effectiveness of laser treatment of onychomycosis is limited and of poor methodological quality. Future studies using a randomised controlled trial designs with larger study populations and clear procedures are required to permit a full evaluation of this emerging technology. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Norco 5-325 (one tablet twice per day) for treatment of his ulcerative colitis, and foot and knee pain.  Findings:  The physician reviewer found that the American Association of Orthopedic Surgeons (AAOS) has recommended against the routine use of opioids for the treatment of pain associated with osteoarthritis of the knee. Trials of NSAIDs, low impact exercises and weight loss for a body mass index (BMI) greater than 25 are all evidence-based recommendations which have not been documented in this patient. Similarly, the American College of Rheumatology (ACR) has recommended the use of opioids conditionally after documenting that the patient had an inadequate response to initial therapy. However, adequate trials of physical therapy and treatment with NSAIDs have not been documented in the records provided for review. Thus, the requested Norco 5-325 (one tablet twice per day) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested eating disorder partial hospitalization program (PHP) services for treatment of his bulimia nervosa.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, in determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. The records document that this patient has been diagnosed with bulimia nervosa and struggled with symptoms of anxiety and eating disordered behaviors including restricting food, binging, purging, negative body image, and body checking daily, which resulted in a 2.8 pound weight loss in a week prior to admission. He continued to struggle with substance abuse issues which resulted in relapses and had an overdose attempt during his course of treatment. On admission, he was restricting 15% of his meal plan daily, or 357 calories, and on discharge was able to reach 100% of meal plan compliance on most days, but still restricting 25% of his meal plan on the weekends, which is about 595 calories per day, and had strong urges to exercise. All told, the PHP services rendered at the facility indicated through the time period specified were medically necessary as the patient was experiencing mood lability, needed substance use monitoring, had the potential for self-harm.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on the available medical records, this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures. Given his age, it is too early to make a prediction of final adult height. It is difficult to distinguish whether the patients short stature and delayed bone age are due to constitutional delay or occult systemic disease. According to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient satisfies only two of these criteria, and no information is provided to document that all other systemic and nutritional causes of short stature have been ruled out. All told, there is inadequate evidence to support the medical necessity of Genotropin GH treatment for treatment of this patients short stature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested Harvoni 90/400 mg. for treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD and IDSA guidelines further state, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. Therefore, regardless of fibrosis score, per guideline recommendations, the requested Harvoni medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Egrifta for treatment of his human immunodeficiency virus (HIV) and lipodystrophy.  Findings:  The physician reviewer found that lipodystrophy is an abnormal accumulation of fat. The abnormal collection may be caused by the treatment of HIV, which is an infection. As stated in the press release from the U.S. Food and Drug Administration (FDA), Egrifta is noted to decrease abdominal fat and some patients reported improvements in their self-image. Falutz and colleagues found that Egrifta might be useful for the treatment of HIV-infected patients who have an increase in abdominal girth and dyslipidemia in the context of receiving antiretroviral therapy. Given the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible. However, there is insufficient medical documentation to define the severity of this patients abnormality that is present. The treating provider did not document a detailed examination that could help define the patients condition. The waist-to-hip ratio and other measurements are documented, but this does not adequately define the condition. Thus, one cannot determine that more than a minimal improvement in the appearance is possible given the information provided for review. All told, the requested Egrifta is not supported as reconstructive in nature for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested AmniSure Rupture of Membranes test for evaluation of her  reported leaking fluid during pregnancy.  Findings:  Two physician reviewers found that the diagnosis of rupture of membranes is made based on patient history and clinical examination, including a speculum evaluation of the vagina and cervix.  Typically, the patients history, with its description of leakage of fluid, can be of help to rule in or rule out the diagnosis.  This is coupled with a sterile speculum examination to evaluate vaginal/cervical secretions, evaluation of the pH of any secretions, and a microscopic examination for cervical ferning.  In this patients case, there was no documentation of a sterile speculum/pelvic examination.  There is no documentation of an evaluation of any vaginal secretions by pH or microscopic examination.  In sum, the AmniSure Rupture of Membranes test performed was not likely to have been more effective than other methods of evaluating this patient for possible rupture of membranes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested  a muscle biopsy for evaluation of her myalgia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient has chronic myalgia and complaints of leg weakness and has had an extensive work-up including neurology and rheumatology consultations. Muscle weakness on examination has not been documented in the medical records submitted for review and laboratory studies have been normal with the exception of an elevated ESR, a non-specific finding. There is no laboratory evidence of muscle injury, with both CK and aldolase reported as normal on multiple occasions. The requested muscle biopsy is not indicated given non-invasive investigations have been normal or negative. The diagnostic yield of muscle biopsy is dependent on selection of a muscle that is weak on exam, but in this case there appears to be no objectively weak muscles. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested intensity modulated radiation therapy (IMRT) for treatment of her Hodgkins disease.  Findings:  Two physician reviewers found that there are emerging data in the medical literature for the use of IMRT for Hodgkins lymphoma. The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, breast and other tissues. IMRT is a useful tool to potentially reduce toxicity and improve the dose distribution. IMRT is likely to be more beneficial for treatment of the medical condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-month-old female enrollee has requested Synagis respiratory syncytial virus (RSV) vaccine for treatment of the enrollees moderate central sleep apnea with mild obstructive sleep apnea. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) issued new guidelines for the administration of Synagis for RSV prophylaxis based on review of current peer-reviewed medical literature. Based on the guidelines, infants with neuromuscular disease or congenital anomaly that impairs the ability to clear secretions from the upper airway because of ineffective cough are known to be at risk for a prolonged hospitalization related to lower respiratory tract infection and, therefore, may be considered for prophylaxis during the first year of life. This patient, with significant hypotonia due to Prader-Willi syndrome and chromosomal deletion, as well as laryngomalacia and central apnea significant enough to require continuous supplemental oxygen therapy, is at risk for severe respiratory disease should she contract RSV infection because of inability to adequately clear secretions. Based on the AAP guidelines and standards of care, the requested Synagis is medically necessary and appropriate for this patient for the duration of the 2014-2015 RSV seasons.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested chemosensitivity and chemoresistance assays for the evaluation of her medical condition.  Findings:  The physician reviewer found thatthe submitted documentation fails to demonstrate the medical necessity of the services at issue.  In vitro drug testing on patients tumor cells prior to applying chemotherapy is difficult to put into clinical use.  An evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  The panel concluded that such in vitro drug testing should be limited to clinical trials.  The current medical evidence does not support the services at issue in this patients case.  All told, chemosensitivity and chemoresistance assays were not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested  hyperthermic extracorporeal applied tumor therapy (HEATT) clinical trial (formerly perfusion induced systemic hyperthermia (PISH)) for treatment of her stage IV ovarian cancer.  Findings:  Two physician reviewers found that in the medical literature, van der Zee and colleagues reported some efficacy on the HEATT method when given with chemotherapy. In 2013, Ahmed and Zaidi reviewed this treatment and reported improved health outcomes when used with radiation therapy and chemotherapy. The proposed treatment is a part of a Phase I clinical trial and is noted to include use of hyperthermia alone. As such, the goals of the protocol are mostly to determine dose, safety, and toxicity. Currently, there is a lack of data suggesting that the requested HEATT clinical trial (formerly perfusion induced systemic hyperthermia (PISH)) conducted by James Lilja, MD of Bay Area Gynecology Oncology Clinic at Good Samaritan Hospital in San Jose is likely to provide this patient with superior results when compared to standard available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested parasympathetic function and sympathetic function heart rate test (CPT 95943) for medical evaluation of his medical condition.  Findings:  Three physician reviewers found that this patient was diagnosed with mild obstructive sleep apnea syndrome.  The etiology of obstructive sleep apnea involves both structural and nonstructural factors, including genetic factors.  The submitted documentation does not demonstrate the indication for the services at issue.  In sum, parasympathetic function and sympathetic function heart rate test was not likely to have been more effective than other options for the evaluation of this patient.