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

The parent of a 15-year-old male enrollee requested subtalar arthroereisis surgery for medical treatment of the enrollees foot deformity. Findings:  Two physician reviewers found that the current peer-reviewed medical literature does not support the clinical effectiveness and safety of subtalar arthroereisis in this clinical setting. The procedure has limited potential for substantial improvement in pediatric patients with symptomatic flatfoot (Jay and Din). In addition, this patients history and physical findings do not document exhaustion of conservative therapies. All told, the available scientific data does not demonstrate subtalar arthroereisis 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 a two-year-old male enrollee requested speech therapy services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of speech therapy for this patient. The peer-reviewed literature supports speech therapy in this clinical setting. Law and colleagues reported that children with speech delay can be readily and successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. In addition, Goorhuis-Brouwer and Knijff emphasized that normal, as well as cognitively delayed children, are candidates for successful speech therapy. In this case, at 17 months of age this patient had no language, his expressive output was equivalent to the gestures and vocalizations of a 10 month old child. The customary and usual medical intervention for a child with this marked delay in language development would be speech therapy intervention.  The patient should continue to receive one hour of weekly speech therapy as he has made such significant progress with speech therapy at the frequency of one time per week. Therefore, based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested steroid injections (cortisone injections), one injection in each knee on the same day, for treatment of the enrollees bilateral knee degenerative joint disease.  Findings:  The physician reviewer found that documentation fails to demonstrate the medical necessity of the requested services.  Per the medical records, this patient had blood sugar levels in the 400s following bilateral knee cortisone injections.  It is appropriate to perform one steroid local injection at a time with monitoring of blood sugar levels following the injection.  The overall efficacy of intra-articular steroid injections in nonoperative management of osteoarthritis is supported as a standard of care, but the providers recommendation for avoiding bilateral injections with doubling of the steroid load is medically appropriate. There have been reports of hyperglycemic reactions following intra-articular steroid local injection.  All told, the requested steroid injections (cortisone injections), one injection in each knee on the same day are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee requested percutaneous tibial nerve stimulation (PTNS) for medical treatment of the enrollees overactive bladder syndrome.  Findings:  Two physician reviewers found that the available clinical data does not support the utility of PTNS as equivalent or superior to standard first- and second-line therapies. Moreover, there is a paucity of evidence demonstrating improved health outcomes at long-term follow-up. Although this patient has been treated with various modalities, the records do not establish that standard therapies have been exhausted. Given the lack of evidence supporting the safety and efficacy of PTNS in this clinical setting, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested lumbar spinal fusion at L5-S1 for treatment of her low back pain with left lower extremity radiculopathy.  Findings:  The physician reviewer found that the Milliman Care Guidelines (MCG) and National Imaging Associates (NIA) criteria for decompression and fusion require a detailed history, physical, and neurological exam. The guidelines state that an indication for the procedure may include spondylolisthesis, stenosis with neurogenic claudication, instability, scoliosis, recurrent herniated nucleus pulposus (HNP), infection, cauda equine syndrome, new or progressive neurologic deficit, tumor, or hematoma, as well as imaging studies matching the patients clinical condition. This patient has chronic back and left leg pain. She is said to have a radiculopathy, but there is no substantiating history or physical exam with motor, sensory, and reflex findings to support a diagnosis of radiculopathy (Tarulli and Raynor). The operative report noted the nerve roots were decompressed on the date indicated. However, no trauma, accident, or injury occurred subsequent to the decompression on the date indicated to cause stenosis in such a short time period. The patients records only document one injection post-operatively. The records do not demonstrate the presence of recurrent HNP, evidence of recurrent stenosis, instability, or infection. Further, she does not have a progressive neurologic deficit or cauda equine syndrome. Consistent with these findings, the proposed decompression or the proposed decompression and fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee requested long-acting insulin, Lantus (insulin glargine) for medical treatment of his type 2 diabetes.  Findings:  The physician reviewer found that the patient has had hypoglycemia with NPH insulin and did not have this, at least to this degree, with Lantus. The patient also has CAD and has had myocardial infarction. There is particular concern about low blood sugar levels in this population of patients with known CAD. There are concerns that this might induce heart arrhythmias and possibly sudden death. In addition, recent treatment recommendations suggest relaxing the A1C goal in such patients who have had diabetes for many years and take insulin and have a history of CAD in order to avoid low blood sugar levels and hypoglycemic reactions. Thus, it is medically appropriate to avoid NPH insulin in this clinical setting. Furthermore, Lantus has been more effective for this patient in terms of overall control and frequency of hypoglycemia. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested a 12-week course of Sovaldi 400 mg in combination with ribavirin 600 mg for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that at this time there is a lack of clinical documentation that shows the patient has significant liver disease. The clinical documentation provided shows no evidence of an assessment of the degree of liver fibrosis. Moreover, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg in combination with ribavirin 600 mg is not medically necessary. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee requested the prescription medication Pentasa for medical treatment of his Crohns disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Apriso ER has been offered as a first-line therapy , however, in this patients case, Apriso ER is an inappropriate alternative.  Since this patient has ileal disease, he requires a mesalamine product which will deliver 5-aminosalicylic acid (5-ASA) to the entire ileal mucosa.  Per the current medical evidence, this can be achieved by Pentasa due to its unique drug delivery.  In contrast, the formulary alternative will only deliver mesalamine to the colonic mucosa, which will be not be of benefit in this clinical setting.  All told, Pentasa is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the detailed assessment performed at the specified facility was medically necessary given the patients symptoms and behavior. As documented by the treating provider and discharge summary, the patients problems deteriorated markedly over a period of two months prior to admission. He has been abusive to his parents and has made threats to harm his sister. Given the patients age, the severity of these symptoms is considered quite severe. Currently, the patients actions represent a potential for harm to self and others and requires treatment at the recommended PHP level of care. Therefore, the PHP services provided through the specified facility for children age 6-12 years from the time period specified, as well as future services at the facility are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested trametinib (Mekinist) for medical treatment of her acute myeloid leukemia.   Findings:  The physician reviewer found that based on review of the available records, this patient has highly refractory AML that has relapsed on conventional cytotoxic chemotherapy. With genomic profiling, the patients providers have identified a mutation which is present in about 10% of patients with AML (Pylayeva-Gupta, et al). The results from molecular profiling should help guide this patients next treatment regimen. Further, there is medical evidence supporting the safety and efficacy of trametinib in AML patients with NRAS mutations (Lauchle, et al; Lyubynska, et al). Consistent with these findings, the requested trametinib is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee requested comprehensive inpatient neurocognitive rehabilitation for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that acute brain injury rehabilitation programs have been shown to provide benefit to patients with cognitive dysfunction.  In this case, the patient has documented cognitive dysfunction including problems with comprehension, expression, problem solving and memory.  There is data in the medical literature that demonstrates the utility of cognitive rehabilitation programs in this clinical setting.  All told, the requested comprehensive inpatient neurocognitive rehabilitation is likely to be of greater benefit than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested for a 12-week course of Sovaldi 400 mg and Olysio 150 mg for medical treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medications. According to the documentation submitted for review, there is a lack of evidence that shows the patient has significant fibrosis. In addition, the laboratory work-up and imaging suggests the patient has minimal disease. Thus, the benefit of treatment with respect to long-term outcomes in this clinical setting has not been established. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg and Olysio 150 mg is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old female enrollee requested (1) 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy; (2) 3 hours per week of ABA parent training; (3) 6 hours per week of ABA supervision; (4) 2 hours per week of occupational therapy; and (5) 2 hours per week of speech therapy for medical reatment of the enrollees autism spectrum disorder (ASD), developmental delay and developmental speech and language delay.  Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy, 3 hours per week of ABA parent training and 6 hours per week of ABA supervision is medically necessary for treatment of the patients ASD. Applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  Speech therapy at the frequency of 2 hours per week is medically necessary in this clinical setting. This patient presents with ASD and a history of expressive and receptive language delays with socialization and pragmatic deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance on communication development for individuals with autism. Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Volkmar and Wiesner). The request for occupational therapy (OT) at the frequency of 2 hours per week is not clinically indicated. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks or activities of daily living (Baranek). In this case, the patient presents with age-appropriate fine motor skills.   I have determined that a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested Azor 5 mg/40 mg tablet for medical treatment of her essential hypertension. Findings:  The physician reviewer found that based on the records provided, this patient has essential hypertension, intolerance to an ACE-inhibitor and chlorthalidone as well as ineffectiveness with losartan. However, there is no documentation that the patient has experienced an inadequate response or intolerable side effects to two standard angiotensin receptor blockers. In addition, there are other antihypertensive medication classes that have not reportedly been tried as well. Therefore, the specific use of Azor is not medically necessary, since other antihypertensive medications are available and would likely result in similar tolerability and effectiveness of blood pressure control in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee requested a continuous glucose monitoring system (Medtronic Pump E0784, A9277, A9276, and 530G system for medical treatment of the enrollees type I diabetes mellitus. Findings:  Three physician reviewers found that this patient has been unable to optimize his glycemic control despite diligent management of insulin pump therapy. Due to his inability to improve his diabetic control, he has experienced complications from diabetes, such as diabetic retinopathy. By using the recommended CGM system, he should be able to improve his glycemic control and prevent worsening of his diabetic complications. For these reasons, the requested CGM system (Medtronic Pump E0784, A9277, A9276, and 530G system) 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 a 13-year-old male enrollee requested speech therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature supports speech therapy in this clinical setting.  The patient is a 13-year-old autistic male who utilizes DynaVox to communicate. The records show that he continues to learn to use the DynaVox device with reported progress in communication goals. Although, his progress has been noted as slow, he is reported to have demonstrated consistent skills in basic communication, receptive and expressive language and social language. As such, continued speech therapy is medically necessary in this clinical setting for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested alprazolam and/or clonazepam for medical treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current medical evidence does not support alprazolam and/or clonazepam in this clinical setting.  The use of alprazolam and/or clonazepam in such high doses for the treatment of attention deficit/hyperactivity disorder poses a risk to the patients health.  The requested medications are not in accordance with generally accepted professional standards of practice and are not consistent with the standard of care in the medical community for the treatment of this patients condition.  All told, alprazolam and/or clonazepam are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Orthovisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that in this patients case, the submitted documentation does not demonstrate the medical necessity of the requested services.  There is a lack of support for the requested Orthovisc injections in this clinical setting.  Per the current medical evidence, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection there is an increased risk of allergic response.  There is also a risk of iatrogenic infection within the joint.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections.  Well-designed, double-blinded studies have documented limited or no benefit of viscosupplementation for the treatment of this patients condition.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested radiofrequency ablation treatment (L5-S1) for treatment of his low back pain. Findings:  Three physician reviewers found that requested services are not likely to be of greater benefit than other treatment options in this patients case.  Facet joint lumbar spine pain has been treated with a number of methods, including intra-articular injections, medial branch blocks and radiofrequency neurolysis.  This patient has chronic low back pain and is status post multiple surgical interventions.  There is a lack of support for the requested services for the treatment of this patient.  There is no documentation of previous lumbar medial branch blocks or facet injections to confirm location of the patients pain.  Given the absence of documentation of lumbar medial branch blocks, the superior efficacy of the requested radiofrequency ablation treatment (L5-S1) has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested a positron emission tomography (PET) with computed tomography (CT) skull to thigh (CPT code 78815) for medical evaluation of his primary mediastinal germ cell tumor. Findings:  Three physician reviewers found that AFP measurements play a central role in the diagnosis and follow-up of patients with non-seminomatous germ cell tumor. This patients most recent AFP values demonstrate an increase from 3.9 to 9.8. He has undergone multiple courses of chemotherapy, as well as surgical resection and radiation therapy, thus restaging at this time is appropriate. However, CT performed without PET may not be able to distinguish malignant tumor from benign components such as post-radiation fibrosis. PET/CT adds a metabolic component that is not offered by CT alone and is more useful than CT alone in assessing the aggressiveness of the malignancy and identifying active malignancy. For these reasons, the requested PET/CT is likely to be more beneficial than other standard imaging techniques in guiding this patients further care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Isolated fetal pyelectasis is well-established in the medical literature as an ultrasound marker associated with an increased risk of aneuploidy, specific trisomy 21. The American Congress of Obstetricians and Gynecologists (ACOG) list ultrasound markers associated with increased risk for aneuploidy as an accepted indication for offering NIPT, if a patient declines amniocentesis. Also, the fact that a woman is less 35 years of age is irrelevant once an ultrasound marker increasing the risk of aneuploidy is identified. Furthermore, NIPT is an amplified screening test and is appropriately offered to women at increased risk for aneuploidy, particularly trisomy 21, where the sensitivity for NIPT exceeds 99%. The validation of this test for high-risk populations has been established, and ACOG has endorsed its value in these situations for high-risk pregnancies. Given these factors, the services at issue were medically indicated. All told, the medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) has been established in this clinical setting.