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

A female enrollee requested a brain computed tomography (CT) scan for medical evaluation of her narcolepsy without cataplexy.   Findings:  The physician reviewer found that review of the records does not reveal the method by which narcolepsy was diagnosed by the patients provider. The patient has a history of chronic migraines but no history of recent trauma, malignancy, infection or other red flag to support an indication for immediate imaging. The neurological consultation is pending and the neurologists evaluation and recommendation should be helpful. However, on review of the records submitted, there is a lack of findings supporting the requested CT scan of the brain as medically necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A male enrollee requested urgent care services on an emergent or urgent basis. Findings:  The physician reviewer found that based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. The patient could have contacted his primary care physician and been evaluated as a routine medical care visit. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part, and the patient did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested weekly private therapy services for medical treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that this patients records indicate that he is being managed appropriately and is showing a marked improvement in both home and school as a result. The plan is to continue medication management and family therapy. Any further behavior problems that occur at home can be adequately addressed within the family therapy sessions. All told, the requested weekly private therapy services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a magnetic resonance imaging (MRI) of the spine and hip without dye for medical evaluation of her back and hip pain. Findings:  The physician reviewer found that based on the records provided, this patient has no red flags to mandate advanced imaging without first undergoing an adequate course of physical therapy. Moreover, there are no contraindications in the records provided for a conservative course of management prior to consideration for additional imaging with MRI of the spine and hip. For these reasons, the requested MRI of the spine and hip without dye is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested a bone growth stimulator for medical treatment of her medical condition.  Findings:  Three physician reviewers found this patient underwent surgery for a non-union.  However, prior to application of a bone growth stimulator, there should be documentation of serial x-rays in the postoperative timeframe, demonstrative of a nonunion.  Generally, concerns for nonunion would not usually be raised until at least six weeks postoperatively, and standards would require serial imaging demonstrating a lack of healing.  In this patients case, the bone growth stimulator was applied immediately after surgery and there was no radiographic evidence of failed union postoperatively.  Thus, the requested bone growth stimulator is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested lower back spinal fusion surgery for medical treatment of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, flexion extension films have not demonstrated structural instability, and there is no discussion of anticipated likely introduction of instability by a standard laminectomy, foraminotomy and discectomy.  The efficacy of instrumentation and fusion as treatment for complex regional pain syndrome remains controversial and is supported predominantly by level III and level IV case series studies.  The current medical evidence does not support the use of fusion in the management of chronic lumbosacral pain with nonspecific findings.  All told, the requested lower back spinal fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested magnetic resonance imaging (MRI) of the knee for medical evaluation of his knee pain. Findings:  The physician reviewer found that an x-ray of the left knee revealed minimal degenerative changes and physical exam showed mild effusion, but no evidence of joint looseness. Lower extremity MRI is indicated for persistent knee pain unresponsive to 4-6 weeks of conservative treatment followed by a clinical re-evaluation. In this case, the medical records do not document that a trial of conservative treatment such as anti-inflammatory medication and physical therapy has been tried and failed. Based on the clinical documentation submitted for review, the medical necessity for the MRI of knee has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested platelet rich plasma injection for medical treatment of the enrollees torn labrum. Findings:  Three physician reviewers found that the current medical literature indicates that conservative care should be carried out prior to a surgical intervention. The documentation provided does not indicate that the patient had undergone any physical therapy, medications, or injections to attempt and alleviate his pain and symptoms prior to opting to undergo surgery. There was no indication that the patients condition was severe enough to require immediate surgery without undergoing conservative care. Also, the current medical literature does not support the use of platelet rich plasma injections intra/postoperatively and states that there is little evidence to support their efficacy. Based on the documentation provided, the patients diagnosis, and the current medical literature, the platelet rich plasma injection was not likely to have been more beneficial for the patients medical condition that any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested Pediasure for treatment of the enrollees food aversion.  Findings:  The physician reviewer found that the patient has food aversion related to his underlying autism spectrum disorder, exacerbated by intercurrent illness. In children with autism, food refusal may result in severe nutritional deficiency. Thus, supplementation with enteral formula is medically necessary to prevent essential vitamin and mineral deficiencies. In this case, vanilla Pediasure both satisfied the patients taste and allows for appropriate nutritional supplementation. Based on the medical literature cited above and the documentation submitted for review, the request for Pediasure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee requested orthodontic services for medical treatment of the enrollees overjet and overbite.  Findings:  The physician reviewer found that the records submitted do not document a medical condition or significant impairment caused by the malocclusion. The patient presents with mild to moderate displacement of the teeth, a score of 7 on the HLD index with no documentation of any handicapping situation or health issues caused by the dentition. For the reasons provided, the orthodontic services were not dentally necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an ultrasound for medical evaluation of her medical condition.  Findings:  The physician reviewer found that in this patients case, due to the advantages of mammographic screening versus ultrasound, it would be reasonable to make an attempt at mammography.  At the completion of the mammogram, the interpreting radiologist would be in a position to decide if ultrasound or attempts at additional mammographic images are appropriate.  Mammography offers distinct advantages such as search for architectural distortion or calcifications which may be associated with malignancy.  All told, the requested ultrasound is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested bilateral upper lid blepharoplasty for medical treatment of her bilateral upper dermatochalasis.  Findings:  The physician reviewer found that the patient presents with evidence of droopy eyelids, but without evidence of visual problems such as obstruction on symptomatology or clinical evaluation. The patient does not report visual obstruction. The photograph submitted for review demonstrates a mild condition of dermatochalasis. In addition, the visual field analysis does not show evidence of a clinically significant visual obstruction. Therefore, a functional deficit has not been demonstrated to establish the medical necessity of the requested services. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested bilateral upper lid blepharoplasty 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 Harvoni for 12 weeks for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and the 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. Evidence supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy due to non-liver-related comorbid conditions. This patient already has advanced fibrosis based upon his FibroSURE test, and therefore, it is medically necessary to treat him to eradicate infection and prevent progression of his cirrhosis to a decompensated state, and also prevent complications of cirrhosis. Therefore, based upon this approval supported by large clinical trials, Harvoni is medically necessary for 12 weeks in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Valium for medical treatment of his chronic back pain and spinal stenosis.  Findings:  The physician reviewer found that long-term use of benzodiazepines particularly in patients over the age of 60 increases the risk of dementia, decreased cognitive ability, fall dependence and other potentially harmful effects. Additionally, the patient is already taking Serax, another benzodiazepine which can further potentiate their harmful effects. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Sovaldi 400mg and ribavirin for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated with antiviral therapy regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response and is expected to benefit chronically infected persons.  The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  Therefore, the requested Sovaldi 400mg and ribavirin are likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Cialis 20 mg, 10 pills per month for medical treatment his erectile dysfunction. Findings:  The physician reviewer found that sexual dysfunction is a common side effect of megestrol acetate and treatment for erectile dysfunction is indicated.  However, the requested dosage is not medically necessary and the alternative of Cialis 20 mg #6 per month is appropriate. The requested dosage over the allowed amount is not justified by the medical literature. Therefore, the medical necessity of the requested medication dosage has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested emergency services for medical treatment of his medical condition.   Findings:  The physician reviewer found that an emergency is defined as acute symptoms of such severity that a prudent layperson would believe his health to be at risk without immediate medical attention. Urgently needed services are those necessary to prevent serious deterioration of the health of a patient resulting from unforeseen illness or complication of existing condition for which care cannot be delayed until return to the Health Plans service area. A patient is considered stable when he or she has received such medical treatment of the emergent condition that no material deterioration of the condition is likely to result from or occur during the transfer. When this patient arrived at the hospital he was in critical condition and required ICU admission. His condition stabilized, and he was transferred out of the ICU to a neurologic unit. Subsequently, the patient had stable vital signs and his neurologic condition had improved to the point where he was stable for transfer to an in-Plan facility. Consistent with these findings, a portion of the requested emergency services was required for medical treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested bronchial thermoplasty for medical treatment of his severe persistent asthma.   Findings:  Two physician reviewers found that this patients records do not support an indication for bronchial thermoplasty. He is on an aggressive regimen of bronchodilators, has his allergic and sinus disease, and has no intercurrent smoking history to raise the possibility of chronic obstructive pulmonary disease (COPD). Further, his sinus disease is being treated medically and surgically and he has no evident reflux. The patient has not undergone a trial of Xolair for his elevated IgE, which is more likely to provide this patient with an improved health outcome than the requested bronchial thermoplasty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested spine surgery (CPT codes 22633, lumbar spine fusion combined, CPT 22634, spine fusion extra segment and CPT 22842, insert spine fixation device) with a 3 day hospital stay for medical treatment of his degenerative disc disease and foraminal stenosis.   Findings:  The physician reviewer found that this patient presents with chronic back pain but he has no symptoms or signs of a lumbar radiculopathy with matching motor, sensory, and reflex findings (Tarulli and Raynor). In addition, the patient has persistent hematuria and significant weight loss of unknown etiology, which should be addressed prior to considering major spinal surgery. Further, the patient does not have a lumbar radiculopathy or myelopathy, his imaging is not consistent with his clinical condition, and he does not have spinal stenosis with spondylolisthesis and neurogenic claudication or a progressive neurologic condition. Moreover, he has not had a psychological evaluation nor participated in cognitive rehabilitation sessions. All told, the requested spine surgery (CPT codes 22633, lumbar spine fusion combined, CPT 22634, spine fusion extra segment and CPT 22842, insert spine fixation device) with a 3 day hospital is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested diagnostic imaging, a magnetic resonance imaging (MRI) of the shoulder without dye for medical evaluation of his adhesive capsulitis of the right shoulder.  Findings:  The physician reviewer found that according to imaging guidelines and accepted standards of practice, advanced imaging of the shoulder with MRI is not appropriate for chronic pain in the absence of trauma unless the patient has failed a period of physical therapy and anti-inflammatory medication or unless the patient has signs of instability/labral tear/impingement on physical exam. This patients medical records do not document that an adequate period of conservative treatment has failed. Moreover, there is no documentation of any suspicion of instability, labral tear, or impingement. Thus, the requested diagnostic imaging, MRI of the shoulder without dye, is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Synvisc One injections for medical treatment of her osteoarthritis.  Findings:  The physician reviewer found that there was a lack of imaging studies provided for review to confirm the patient has osteoarthritis in either knee to support the requested Synvisc One injection.  Additionally, the records failed to indicate which of the knee joints is being treated at this time.  Although the patient had undergone a prior series of Synvisc injections to her right knee, the records do not document that she had pathology in the left knee of end stage osteoarthritis to warrant the injection.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Synvisc One injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested residential mental health and substance abuse treatment for medical treatment of his opioid dependence.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  The recent clinical documentation does not demonstrate the need for residential mental health and substance abuse treatment at this time.  Given the paucity of recent clinical records, the medical necessity of the requested services has not been established.  All told, the requested residential mental health and substance abuse treatment is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

female enrollee requested lymphedema drainage therapy with the use of low-level laser instrument LTU 904 for medical treatment of her postmastectomy lymphedema syndrome. Findings:  Two physician reviewers found that treatment of lymphedema typically involves some combination of manual treatment, pressure garments, and elevation. Smoot and colleagues reported that low-level laser therapy is more effective in decreasing swelling but not pain, when compared to treatments that did include low-level laser therapy. Further, this patients treatment has included low-level laser therapy with superior results compared to other available therapies. Thus, low-level laser therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee requested residential treatment for medical treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that the weekly notes prior to discharge and the last master treatment plan indicate that the patient continued to have difficulty engaging in treatment and communicating with his treatment team and family. He was at less than 50% in his achievement of his treatment goals. Given the level of the patients involvement and progress, continuation of residential treatment services was medically necessary to prevent relapse and ensure a smooth transition to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Pristiq ER 100mg for medical treatment of his major depressive disorder.  Findings:  The physician reviewer found that this patient has been diagnosed with major depressive disorder.  According to subjective report and validated rating scales, the patient was in remission and functioning well in all domains on the combination of bupropion and Pristiq.  He had previously tried alternative medications, including a recent trial of Effexor.  However, the other medicines were poorly tolerated.  Considering the patients history and the uniqueness of the disputed medication, additional pharmacologic trials are unnecessary.  The requested medication is well-tolerated and has been efficacious for this patient.  Continued treatment is reasonably expected to maintain the patients remission.  All told, Pristiq ER 100mg is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A female enrollee requested air ambulance services for medical treatment of her brain hemorrhage, left-sided paralysis and severe cognitive defects.  Findings:  The physician reviewer found that the patient sustained a cerebrovascular accident (CVA) and was transported from her current state to a mid-western state for further rehabilitation. Her transport via commercial air or by ground over the distance covered would not have been feasible. However, the patient could have received further care appropriate to her condition much closer to the facility in her current state, where her rehabilitation care was being provided. Transporting the patient to a mid-western state was not medically necessary. Therefore, the ambulance services were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the cooling device (water circulating cold pad with pump) for medical treatment of her status post right foot bunionectomy.  Findings:  Three physician reviewers found that in this clinical scenario the standard of care is the use of elevation and ice packs to the surgical area to achieve reduction in swelling as well as reduction in pain. Pain medication may also be used to alleviate surgical pain. The medical literature does not demonstrate that cryotherapy pumps and pads are more efficacious than the use of elevation and ice pack applications. Furthermore, there are some risks and complications associated with cryotherapy units (Wilke and Weiner). Therefore, based on the peer-reviewed literature and medical evidence submitted the device at issue was not likely to be more beneficial than standard medical therapy.