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

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, 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 (See Unique Patient Populations).  Moreover, the recommendation for treatment-naive chronic HCV patients with genotype 1a is daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. Based on the clinical documentation submitted for review and treatment guidelines, the requested medication is medically necessary for treatment of the patients HCV.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested scleral contact lens for the left eye for medical treatment of his irregular astigmatism.  Findings:  The physician reviewer found that the fitting of a scleral contact lens for the left eye is not indicated for this patients medical condition. From the clinical notes provided for review, the patient is already wearing a gas permeable contact lens with vision correction to 20/20 in the left eye. The current medical literature describes the fitting of scleral contact lenses in cases in which a pathologic diagnosis is noted such as the corneal ectasia that this patient has in the right eye. Given the absence of evidence supporting a diagnosis of corneal ectasia in the left eye, the requested scleral contact lens for the left eye is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested shoulder Orthovisc injections for medical treatment of his right shoulder degenerative joint disease (DJD).   Findings:  Three physician reviewers found that there is a paucity of peer-reviewed medical literature supporting the clinical utility and safety of Orthovisc injections in the shoulder for glenohumeral osteoarthrosis. Izquierdo and colleagues noted that treatment of glenohumeral osteoarthritis remains controversial. In addition, the U.S. Food and Drug Administration (FDA) has not approved Orthovisc in the treatment of patients with glenohumeral osteoarthrosis. Given the lack of data demonstrating the efficacy of viscosupplementation in the treatment of this patients advanced degenerative joint disease, Orthovisc injections were not likely to have been 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 female enrollee requested use of a continuous passive motion (CPM) machine for medical treatment of her medical condition status post right hip arthroscopy.  Findings:  The physician reviewer found that based on the available documentation, the CPM device was not medically necessary during this patients recovery from a resection of a CAM lesion and labral repair at the right hip joint. The current data suggests that it is likely that gentle passive and active range of motion will accomplish the same benefits of rehabilitation during a patients recovery from the surgical procedure described. All told, the use of a CPM during this patients recovery status post right hip arthroscopy was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested clostridial collagenase histolyticum (Xiaflex) for medical treatment of his Peyronies disease. Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition, Xiaflex is the only FDA approved drug for Peyronies disease. All told, the requested Xiaflex is supported as medically necessary for treatment of this patients Peyronies disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in reviewing the clinical documentation, the patient had not consolidated the treatment gains needed to succeed in a less restrictive setting and discharge at an early date would have been premature.  He expressed intent to resume cannabis use and demonstrated self-centered and attention-seeking behavior.  This patient was likely to have promptly relapsed in the absence of the residential program services if he had been discharged.  The evidence-based services were delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  The services were reasonably expected to improve his condition and prevent a more serious episode of illness.  All told, residential treatment services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the MammaPrint, TargetPrint, and BluePrint testing for medical evaluation of her history of invasive and in situ ductal carcinoma.  Findings:  Three physician reviewers found that the MammaPrint assay is a fairly reliable predictor of risk of recurrence in women with early breast cancer, following surgical resection. MammaPrint can be used to identify a subset of women in whom risk of recurrence is low, and as such, can be spared adjuvant chemotherapy (Buyse, et al). These were the circumstances that the MammaPrint assay was appropriately utilized in this case, and as such the test was likely to have been more beneficial for evaluation of this patients medical condition than any available therapy.  However, the TargetPrint and BluePrint assays were not likely to have provided additional data relevant to determining whether the patient should be treated with adjuvant chemotherapy. Thus, the MammaPrint, testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the TargetPrint and BluePrint assays were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested Genotropin for treatment of her medical condition.  Findings:  Two physician reviewers found that the patient has short stature and a history of significant weight loss due to inflammatory bowel disease.  Given that this patients bone age is delayed and she is only in early puberty, her adult height prediction has the potential to improve with effective treatment of her underlying inflammatory bowel disease.  In sum, the requested Genotropin is not likely to be more effective than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Subsys for medical treatment of his medical condition.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Subsys is a potent short acting opioid with highly addictive properties.  The medical evidence does not support Subsys in this clinical setting.  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.  All told, the requested medication Subsys is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested a wireless capsule endoscopy for medical evaluation of his history of intestinal tuberculosis and small bowel obstruction.  Findings:  The physician reviewer found that wireless capsule endoscopy of the small bowel may be indicated to diagnose the site of obscure gastrointestinal bleeding in adults, confirm suspected Crohns disease, and evaluate small bowel tumors. This patients records do not include documentation of any of these indications. In addition, the provider noted concern for a possible stricture, which places the patient at risk for capsule retention. Further, a wireless capsule endoscopy will not allow the provider to obtain a culture which is required to support the diagnosis of intestinal tuberculosis. All told, the requested wireless capsule endoscopy is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Subsys for medical treatment of the her chronic daily headaches.  Findings:  The physician reviewer found the patient has been diagnosed with intractable headaches and has been treated with a combination of medications including Subsys. There is a lack of controlled studies supporting the safety and efficacy of Subsys in the treatment of intractable headaches. Therefore, the request for Subsys is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested acute inpatient psychiatric services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has essentially given up and wishes to be left alone. Based on the documentation submitted, this patient has the danger signs of someone who would end his own life if allowed to do so. He is hopeless, apathetic, severely depressed and does not wish to continue to live in this state. Thus, acute inpatient psychiatric services were medically necessary for medical treatment of his behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested the Barnett continent intestinal reservoir for medical treatment of his malfunctioning ileostomy with stomal prolapse. Findings: The physician reviewer found that this patient has chronic problems with stoma dysfunction, colonic dysmotility, and pelvic floor dysfunction. Although a continent ileostomy is not a routine surgical intervention, it has been shown to be highly effective in appropriately selected patients. The evidence supports the procedure in this clinical scenario given this patients stoma dysfunction following exhaustion of all other reasonable means of therapy. All told, the requested Barnett pouch is medically reasonable and necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested exome sequence analysis for medical evaluation of the enrollees ataxia and developmental delays. Findings:  Two physician reviewers found that whole exome sequencing is used as a diagnostic tool for rare genetic diseases as well as ataxia. Sawyer and colleagues noted success rate of 46% with exome sequencing when evaluating pediatric patients with ataxia. The authors note that whole genome sequencing is a powerful clinical tool that has been increasingly used to assist in the diagnosis of Mendelian disorders. For the reasons provided, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested 16 home health visits of skilled nursing for treatment of his medical condition.  Findings:  The physician reviewer found that  according to the documentation submitted for review, the patient was provided with six home health visits, however, there is no mention in the documentation supporting the need for additional home health services. The patient indicates in his application that he needs more nursing help, although there is no medical justification provided for review. Hence, the request for 16 home health visits is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested inpatient hospital services for medical treatment of his chest pain and right arm numbness.  Findings:  The physician reviewer found that this patient presented with atypical chest discomfort at rest with no objective evidence of ischemia on initial evaluation.  In this circumstance of a stable patient with an initial negative evaluation, it is medically safe to manage the patient at an observational level of care.  All told, inpatient hospital services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90/400 mg for 12 weeks 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 Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration approved antiviral therapy regardless of fibrosis score. Therefore, this patient should be approved for Harvoni for 12 weeks in attempt to eradicate HCV infection and prevent further progression of fibrosis in the future and potential complications of advanced liver disease such as liver failure and hepatocellular carcinoma, and extrahepatic complications of HCV such as renal disease, diabetes, vasculitis and lymphoma. For the reasons provided, the request for Harvoni 90/400 mg for 12 weeks is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested a hospital stay for medical treatment of his diverticular bleeding.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this clinical setting, a patient generally would be admitted for acute inpatient care for two days.  Because of the anticoagulation factor, management as an outpatient would have not been standard of care.  However, the prep for colonoscopy could have been given on one day, and the colonoscopy could have been completed the next day.  There is a lack of support for hospital services provided after the completion of the colonoscopy.  All told, the services at issue were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested an additional 12-week course of Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two 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), treatment with Harvoni for 24 weeks is recommended for patients with Child-Turcotte-Pugh class B cirrhosis, and the provided records indicate the patient meets these criteria. Based on the evidence of safety and efficacy in the published literature, and clinical guidelines, the treatment of Harvoni for 24 weeks is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Marinol for medical treatment of her fibromyalgia.  Findings:  The physician reviewer found that the medical literature does not support Marinol for the treatment of this patients condition.  Wang and colleagues performed a systematic review of the medical literature in regards to the therapeutic use of cannabis and cannabis-based medicines.  The authors concluded that the risks associated with long-term use were poorly characterized in published clinical trials and observations studies.  All told, Marinol is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested inpatient stay services for medical treatment of her depression.  Findings:  The physician reviewer found that although inpatient psychiatric care was initially indicated for this patient with severe mental illness and chronic risk for suicide, the medical record does not justify subsequent inpatient care. Records indicated that the patient was having clear and linear conversations, she was adherent with her medication and she was not having side effects.  Based on her condition and treatment history, which included a prior course of ECT, treatment in a less restrictive setting would have been appropriate after initial treatment was completed. Thus, the inpatient psychiatric services provided initially were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Xenical for medical treatment of her morbid obesity.   Findings:  The physician reviewer found that according to American Association of Clinical Endocrinologists and American College of Endocrinology guidelines, pharmacologic therapy is indicated in addition to dietary and exercise therapy in patients with BMI greater than 30. This patient has a BMI of 40.62 and is an appropriate candidate for pharmacologic therapy such as Xenical in addition to dietary and lifestyle changes. Thus, the requested Xenical is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Copaxone 40 mg/mL syringe subcutaneous for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the requested regimen consisting of Copaxone 40 mg has been shown to be effective in clinical trials and the data is nearly identical to the findings supporting dosing at 20 mg. As this patient has a relapsing form of multiple sclerosis, a disease-modifying agent is medically necessary. In addition, the patient has documented injection site reactions that warrant fewer injections per month. All told, the requested Copaxone 40 mg syringe subcutaneous three times weekly is medically necessary for treatment of this patients multiple sclerosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for eight weeks for medical treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per 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. All told, the requested Harvoni for eight weeks is supported as medically necessary for treatment of this patients hepatitis C infection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Otezla 30mg tablets for medical treatment of her Behcets syndrome.  Findings:  Two physician reviewers found that the current medical evidence has not established the superior efficacy of the requested medication.  There is a lack of high-quality studies that support the use of Otezla in the treatment of Behcets Syndrome.  The safety and efficacy of this medication in the treatment of Behcets has not been determined.  In sum, the requested Otezla 30mg tablets are not likely to be of greater benefit than other options in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested implanted hormone pellets for medical treatment of her medical condition.  Findings:  Three physician reviewers found that the issue of testosterone pellet therapy is addressed by several references, often in conjunction with the discussion of bioidentical and/or compounded hormone therapy, as these pellets are compounded products and not produced by a pharmaceutical company.  She is currently being treated with multiple compounded hormones and various herbal remedies, none of which are FDA approved.  If it was decided that hormonal therapy was indicated, there are many FDA approved estrogen preparations, including oral, transdermal and transvaginal routes, as well as an estrogen/testosterone oral preparation that does not appear to have been tried, and could be used as an alternative to the compounded estrogens and testosterone pellet therapy.  In summary, the superior efficacy of implanted hormone pellets has not been demonstrated, and there are potential safety and side effect concerns.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested occupational therapy for medical treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. Based upon the documentation provided, the patient has been receiving occupational therapy utilizing multiple techniques including sensory processing integration. The occupational therapy progress report demonstrates his motor coordination skill is still at the 7th percentile for age. Despite the intensity of his therapy his progressive improvement has been marginal; the patient has had intensive therapy with limited positive effects. Therefore, based on the medical literature cited above and the documentation submitted for review, occupational therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a medication course of three treatment cycles (up to six injections) of Xiaflex for medical treatment of his Peyronies disease.  Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. Xiaflex is the only FDA-approved drug for Peyronies disease. This patient has failed conservative therapy and is an appropriate candidate for Xiaflex. Therefore, the request for a medication course of three treatment cycles (up to six injections) of Xiaflex is medically necessary for treatment of the patients Peyronies disease.