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

A 24-year-old male enrollee has requested treatment in a 28-day residential treatment program or partial hospitalization services for treatment of his hallucinogen dependence. Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  There is a lack of support for residential treatment or partial hospitalization program services in this clinical setting.  The medical records do not indicate current suicidal ideation.  Although the documentation notes significant discord in relationships, the patient demonstrated cooperation in treatment and insight into his need for treatment.  The records indicate overall medical stability and no significant psychiatric symptoms.  In this case, current guidelines support intensive outpatient program services.  The records do not document symptoms that necessitate 24-hour residential services or partial hospitalization program services.  Based upon the records submitted for review, treatment in a 28-day residential treatment program is not medically indicated.  Additionally, partial hospitalization program services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested Norco for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support Norco in this clinical setting.  Per the medical records, this patient has been on Norco long-term without documentation of improved function.  He has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose and short-acting opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an epidural injection for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The peer-reviewed medical literature does not support the requested epidural injection in this clinical setting.  It was noted that the patient was referred to physical therapy.  However, the medical records lack documentation of the patients attempt at physical therapy and her response.  Abdi and colleagues found that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief.  According to the medical records, the patient had multiple epidural steroid injections with variable results.  Per the clinical notes, the patients response to prior epidural steroid injections was not demonstrated by an increase in activity or reduction in pain medication.  All told, the requested epidural injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested abuse subacute residential treatment center level of care for treatment of her alcohol dependence. Findings:  The physician reviewer found that overall, the records do not support the substance abuse subacute residential treatment center services provided. There were unclear withdrawal symptoms reported other than anxiety and insomnia. The patients drinking can only be described as moderate at best, with her maximum reported 34 bottle of wine per night for the month prior to admission. Her last drink was two days prior to admission. She was not described as being in discomfort upon presentation for admission, her vital signs were stable, and she did not appear to be at risk for severe withdrawals. She was medically and psychiatrically stable, managed on Paxil. She had no prior history of any treatment or exposure to AA or other 12-step group. She described herself as motivated, and her family as supportive. Given these findings, the patient did not require 24-hour medical and nursing supervision. She did not meet the American Society of Addiction Medicine (ASAM) criteria for substance abuse subacute residential treatment. She could have been treated at an outpatient level of care with the sober support system of a 12-step group. Thus, the substance abuse subacute residential treatment center level of care was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested corrective eye surgery for treatment of his cataracts.  Findings:  The physician reviewer found that based on the medical records provided for review, the patient had a preoperative refractive error of -2.75 to -4.00 in right eye and -1.25 in the left eye. He elected to receive a monofocal intraocular lens, calibrated for near. Following surgery, his visual acuity improved to 20/25 at distance corrected for a refractive error of -3.00, and J1 (uncorrected) near. After his surgery, the patient decided that he would rather have a multifocal lens, to allow him better distance vision along with his near vision. However, this second surgical procedure to remove his present intraocular lens and replace it with a multifocal intraocular lens is not without substantial risk. The risks are higher for this patient, given his history of obesity, diabetes, and a prior myocardial infarction. This patient has achieved a very good result, with a refractive error almost identical to his preoperative refractive error. Thus, replacing this patients present intraocular lens with a multifocal intraocular lens is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested single photon emission computed tomography (SPECT) scans for evaluation of the enrollees attention deficit/hyperactivity disorder. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other available modalities.  This patients presentation and symptoms were consistent with attention deficit/hyperactive disorder.  The family history also strongly supports this diagnosis.  The evidence base and case presentation indicate that this diagnosis can be made through a clinical interview without the need for further evaluation procedure.  Current American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters do not support the use of SPECT scans to diagnosis or treat attention deficit/hyperactivity disorder in children or adolescents.  The AACAP practice parameters detail the method of diagnosis of attention deficit/hyperactivity disorder as a clinical interview involving the family, patient and school as the standard for diagnosis.  The records indicate that the patient has tried three different stimulant medications.  However, there are no records that indicate the duration or dose for two of the medications, Adderall and Ritalin SR.  Thus, SPECT scans provided were not likely to be more efficacious than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that this patient did well in the context of a structured setting, learning how to communicate with his parents while they learned how to effectively set boundaries.  He eventually learned to accept the boundaries and show respect.  However, he continued to struggle with avoiding blame and accepting responsibility.  In this patients case, residential treatment services provided from the time period specified were medically necessary.  During this time, the patient was still demonstrating anger, bargaining, and making threats when confronted with unpleasant situations.  However, he was able to contain his impulses and show respect for authority and his family relations were on the mend.  All told, the records support the medical necessity of residential treatment services provided from the time period specified, but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested  Nuvigil tablets for treatment of his depression.  Findings:  The physician reviewer found that Nuvigil has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of narcolepsy, work shift sleep disorders and obstructive sleep apnea leading to daytime drowsiness. The records do not demonstrate that this patient has a diagnosis of work shift sleep issues, narcolepsy or obstructive sleep apnea. Nuvigil and other psychostimulants have been used off-label as an adjunct to antidepressant medication in depressed patients, for attention deficit disorder, as well as fatigue in the elderly and for terminally ill patients. However, none of these uses have supportive scientific data to demonstrate the efficacy of Nuvigil in these conditions. All told, the requested Nuvigil is not medically necessary for treatment of this patients fatigue and depression secondary to the hepatitis C infection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested gene testing for drug metabolism for evaluation of her behavioral health conditions.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  The American Psychiatric Association does not endorse the services at issue in this clinical setting.  In this patients case, there was a dearth of case-specific information about psychosocial stressors and past interventions or the specific type, setting and duration of psychotherapy.  Further, the circumstances, dosing and length of previous psychotropic medication trials were not discussed, while the record does not indicate that the patient had exhausted common pharmacologic strategies.  Based upon the peer-reviewed literature and current practice standards, it has not been demonstrated that the services at issue were likely to have yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity.  Thus, gene testing for drug metabolism performed on the date indicated was not likely to have been of greater benefit than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested magnetic resonance imaging (MRI) for evaluation of his left arm pain.  Findings:  The physician reviewer found that MRI of the brachial plexus is a standard test used in assessing brachial plexus pathology. According to Sureka and colleagues, Magnetic resonance imaging (MRI) has become the primary imaging technique in the evaluation of brachial plexus pathology, and plays an important role in the identification, localization, and characterization of the cause. The patients history is suggestive of neuroma formation. A high quality neurogram of the brachial plexus may identify a lesion and its location, allowing the treating physicians to develop an effective treatment plan. Moreover, the requested diagnostic procedure may lead to a definitive diagnosis. In sum, the MRI of the brachial plexus pre and post contrast is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested Harvoni for treatment of her hepatitis C genotype 1a.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) guidelines, 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. Consistent with this support, this patient should be approved for Harvoni as recommended by her provider. Therefore, based upon these findings, the requested Harvoni is medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested a pediatric neuropsychological evaluation for evaluation of the enrollees learning disability. Findings:  The physician reviewer found that according to InterQual criteria, neuropsychological testing is indicated in cases of acute brain insult/pervasive developmental disorder. Examples include traumatic brain injury, anoxic/hypoxic brain injury, intracranial surgery, neurotoxin exposure, confirmed, cerebrovascular accident, encephalitis/meningitis and pervasive developmental disorder. Other appropriate conditions include brain tumor, cerebral palsy, epilepsy with seizures, hydrocephalus with shunt placement, diagnosed language disorder, multiple sclerosis, genetic condition that affects the brain, structural malformation of the brain and prematurity with birth weight below 1500 g. The history of this patient fails to meet any of these criteria. Further, the American Academy of Child and Adolescent Psychiatry (AACAP) in its practice parameters for attention deficit hyperactivity disorder (ADHD), suggests that neuropsychological testing is only appropriate if psychological testing has been completed and suggests that there may be a significant cognitive disorder. However, ADHD was ruled out in this patient. All told, the requested pediatric neuropsychological evaluation is not medically necessary for evaluation of this patients learning disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the inpatient psychiatric services provided were medically necessary for treatment of the patients medical condition. According to the physician progress notes, the patient remained psychotic, unable to take care of himself and continued to have delusions and auditory hallucinations. On the date indicated, the patient was no longer suicidal and agreed to take his medications at discharge. As such, the patient would not have been able to be discharged to a lower level of care without a high risk of relapse and readmission. The days in dispute were medically necessary and meet the standard criteria for inpatient psychiatric services. All told, the acute inpatient psychiatric services provided from the time period specified were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested electronic brachytherapy for treatment of his basal cell carcinoma of the right cheek.  Findings:  Two physician reviewers found that radiation is within accepted standards as an alternative to surgery in this clinical setting. More importantly, there is a rationale as to why electronic brachytherapy was used as opposed to standard radiation, as the superficial nature of the radiation would better protect the underlying tissue in the treatment of this patients disease. While electrons would likely be the most commonly used approach, this would not provide adequate protection to the underlying buccal mucosa. In summary, the records and medical literature indicate that the electronic brachytherapy provided was 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 59-year-old male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that this patient has minimal to no fibrosis despite infection with hepatitis C.  There are no documented systemic manifestations of hepatitis C, such as cryoglobulinemia or leukocytoclastic vasculitis.  Thus, treatment of hepatitis C is not medically necessary at this time.  The current medical evidence supports monitoring fibrosis levels every one to two years, and initiation of therapy if there is evidence of increasing fibrosis.  All told, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee requested the LINX Reflux Management System for medical treatment of his gastroesophageal reflux disease.  Findings:  Three physician reviewers found that there is a lack of support for the requested LINX Reflux Management System in this clinical setting.  The documentation notes a history of gastroesophageal reflux disease.  However, the medical records do not demonstrate that this patients condition has been fully treated with available medications.  Furthermore, the records do not document if the patient has tried and failed different regimens.  All told, the requested LINX Reflux Management System is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested one day subacute detoxification services, subacute rehabilitation for six days, and partial hospitalization program (PHP) services for 32 visits for medical treatment of his opiate withdrawal with diagnosis of chronic pain syndrome.   Findings:  The physician reviewer found that based on the available medical records, the patient was not displaying withdrawal symptoms. His medications were prescribed by his providers and he was not taking them in a manner which would indicate the potential for clinically significant withdrawal that would require inpatient treatment with 24-hour medical and nursing monitoring. The patient did not meet the American Society of Addiction Medicine (ASAM) criteria for PHP or subacute residential treatment. All told, one day subacute detoxification services, subacute rehabilitation for six days, and PHP services for 32 visits were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested partial hospitalization program (PHP) level of care for treatment of her behavioral health condition.  Findings:  The physician reviewer found that, according to the medical records submitted for review, the patient meets the American Psychiatric Association (APA) guideline criteria for treatment at the PHP level of care. In this case, the patient is medically stable, has weight above 80%, has partial motivation, is cooperative but preoccupied with intrusive, repetitive thoughts at least three hours each day, needs some structure for her eating program and has some limited support and structure outside the program. Moreover, the patients complex psychiatric history and diagnosis of post-traumatic stress disorder may have indicated a higher level of care. Therefore, based upon the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested anesthesia (monitored anesthesia care (MAC)) for treatment of his average-risk screening for colon cancer.  Findings:  The physician reviewer found that the documentation submitted for review does not support that the risk factors warranting MAC were present in the patients case, nor did his pre-sedation evaluation raise concern for intolerance to conscious sedation. In sum, the MAC was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested sofosbuvir/ledipasvir (Harvoni) for medical treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the overall positive and negative predictive value for liver biopsy and non-invasive markers of fibrosis for providing an accurate total liver fibrosis score are about 70%. In this case, the biopsy specimen appears to have been inadequate to provide an accurate stage. Thus, the FibroSure study assessment is likely more reliable. Given that this patient likely has significant underlying liver disease, he is likely to benefit from treatment with Harvoni over treatment with standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee requested the medication Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America recommendations, patients with chronic active hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response.  Therefore, regardless of fibrosis score, there is sufficient support for Harvoni in this clinical setting.  Harvoni has been approved for the treatment of hepatitis C, genotype 1 in both treatment-naive and treatment-experienced patients.  All told, Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested 120 tablets of oxycodone 30 mg, 1 every 6 hours; and Oxycontin 80 mg every 12 hours for medical treatment of the enrollees chronic pain syndrome.  Findings:  The physician reviewer found that the current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then surgery should be considered. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Based on the documentation submitted for review, the requested medications are not medically necessary for treatment of the patients medical condition.