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

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C virus genotype 1a.   Findings:  Two physician reviewers found that the selection of a hepatitis C virus antiviral regimen for patients with renal disease depends upon the extent of renal impairment, genotype, extent of underlying liver disease, and history of past antiviral treatment. Levels of sofosbuvir and its metabolite are substantially higher in patients with severe renal impairment or end stage renal disease on dialysis than in patients who have normal renal functions, so the safety of sofosbuvir-containing regimens in such patients has not been established. Viekira Pak is considered a safer alternative for patients with severe renal impairment. For treatment-naive patients, the duration of Viekira Pak and the addition of weight-based ribavirin depend on the infecting subtype and the presence of cirrhosis. Consistent with these findings, the requested Viekira Pak is medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested residential treatment for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the patient was responding to treatment and improving in terms of her eating disorder behaviors, which were decreasing and she was learning to reach out to others for help. Although she continued to report the desire to restrict fluids, this did not require 24-hour monitoring. Further, there was no objective evidence to suggest that a lower level of care would have resulted in exacerbation that would necessitate continued residential treatment, given that the patient was cooperative and improving. Thus, residential treatment was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested urinary tumor marker (FISH Assay) testing for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the peer-reviewed literature does not support the use of UroVysion in this clinical setting. UroVysion is a fluorescence in situ hybridization (FISH) assay that detects bladder cancer in urine specimens. At this time, cystoscopy and cytology, and possible biopsy, is indicated in this clinical setting regardless of the results of FISH testing. In sum, the testing at issue was not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested genetic testing for medical evaluation of her basal cell skin cancer and family history of breast cancer.  Findings:  The physician reviewer found that while the recommendations vary somewhat from group to group, between the American College of Medical Genetics (ACMG) and the American Society of Breast Surgeons (ASBS), patients who are candidates for genetic testing to assess cancer predisposition require a family history of early onset breast cancer, a previously identified BRCA1 or BRCA2 mutation in the family, Ashkenazi Jewish ancestry and breast cancer at any age, and more than three cases of breast, ovarian, pancreatic and/or aggressive prostate cancer in close relatives, including the patient.  All told, the requested genetic testing is not supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested acupuncture for medical treatment of his atypical facial pain. Findings:  The physician reviewer found that the patient has had acupuncture in the past. However, there is no objective evidence submitted that acupuncture has helped with his condition. According to the Centers for Medicare and Medicaid Services (CMS), acupuncture is not supported as medically necessary for treatment of atypical facial pain. The records provided for review do not demonstrate that the requested acupuncture is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee requested Subutex (buprenorphine) for medical treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that the medical records provided for review indicate the patient has a chronic pain condition with associated postural hypotension and a reported history of pain control with oxycodone in the past. The provider reports that the patient was switched to Subutex and reduced overall opioid use while maintaining good pain control and not experiencing any adverse events. As the medical records support the patient has maintained good pain control for chronic pain condition and markedly reduced previous opioid use with Subutex, the requested medication is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested residential substance abuse treatment services for medical treatment of his alcohol and cocaine dependence and major depressive disorder.  Findings:  The physician reviewer found that the records demonstrate that overall, there is a lack of evidence that 24-hour supervised care was required to prevent decompensation. Treatment could have safely been given at a lower level of care along with community support such as a 12-step group with a sponsor. Thus, residential substance abuse treatment services was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested residential treatment for treatment of her schizoaffective disorder and substance abuse.  Findings:  The physician reviewer found that generally accepted standards of care state that residential treatment is reserved for patients with substance use disorders or mental disorders such as schizoaffective disorder that are dangerous to themselves or others due to suicidal or homicidal ideation (Sharfstein). As noted in the review by McCarty and colleagues, intensive outpatient treatment programs are as effective as inpatient treatment for most individuals. Facility records indicate that this patient denied suicidal and homicidal ideation at admission. Moreover, facility records show that the patient denied suicidal and homicidal ideation throughout the residential stay. The providers records do not support an indication for treatment at the residential level of care for this patient. Moreover, the records do not explain why residential level of care continued to be needed for this patient during the stay. Overall, the patient could have been safely and effectively treated in a less restrictive level of care. For these reasons, residential treatment services were not and are not medically necessary for treatment of this patients medical condition.
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:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations, 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. Moreover, per AASLD/IDSA, HIV/HCV-coinfected patients suffer from more liver-related morbidity and mortality, nonhepatic organ dysfunction, and overall mortality than HCV-monoinfected patients. Based on the reasons provided above, Harvoni is medically necessary for the patients 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.  In an article authored by Thomson and colleagues, the authors noted that, bronchial thermoplasty has a role in the management of patients with severe asthma who have uncontrolled symptoms despite current therapies. Future studies need to identify factors that predict a beneficial clinical response. Bel indicated bronchial thermoplasty appeared to have a benefit on the quality of life and severe exacerbations. However, the author cautioned that it was unclear what phenotype of severe asthma would benefit the most, and the durability of any benefit needs to be further established to ensure that the benefits outweigh the risks and burden of the procedure. While this patient does have severe, uncontrolled, persistent asthma, the use of bronchial thermoplasty would not be the most beneficial treatment due to a lack of scientific peer-reviewed literature to support a long-term efficacy and safety of the treatment. Given these findings, the requested bronchial thermoplasty would not be likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested catheter based impedance pH monitoring for medical evaluation of her gastroesophageal reflux disease (GERD) and nausea. Findings:  Three physician reviewers found that The American Society of Gastrointestinal Endoscopy (ASGE) guidelines indicate that pH testing is usually performed for evaluation of reflux symptoms, particularly in patients with incomplete or no response to PPI therapy (Wang, et al). In this patients circumstance, available records document an incomplete response to PPI treatment. Since her endoscopy was inconclusive regarding evidence of GERD associated esophagitis, a peptic versus non-peptic component to her refractory chest symptoms could not be assessed without the pH study. For these reasons, the catheter based impedance pH monitoring was likely to have yielded additional information relevant to this patients diagnosis and treatment, and was likely to have been more beneficial than other available testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his rectal cancer. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends that IMRT only be used in a clinical trial or when there are unique clinical circumstances such as irradiation of recurrent disease after previous radiation (Benson, et al). In this patients case, the records do not support the medical necessity of treatment with IMRT.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested BRCA genetic testing for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested testing is likely to be more effective for this patient than other available treatment options. The National Comprehensive Cancer Network (NCCN) guidelines state that testing criteria includes an Individual from a family with a known deleterious BRCA1/BRCA2 mutation. In this case, there is documentation indicating that the patients mother tested BRCA positive. Thus, in this clinical setting BRCA genetic testing is clinically indicated and 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 female enrollee requested Subsys 200 mcg spray for medical treatment of her failed back surgery syndrome and lumbar radicular pain as well as right brachial plexopathy.  Findings:  The physician reviewer found that the use of Subsys for chronic low back pain is not supported in the medical literature or endorsed by the U.S. Food and Drug Administration (FDA). The use of Subsys has been only studied in oncology pain with severe breakthrough pain (Smith). It is not approved for chronic use in low back pain or for brachial plexopathy. As this patient does not have a diagnosis of cancer, the requested Subsys is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee requested Lyrica for medical treatment of his diabetic neuropathy.  Findings:  The physician reviewer found that while Lyrica (pregabalin) is not considered first-line therapy for diabetic pain, there is adequate literature supporting its safety and efficacy for the treatment of this condition. A placebo-controlled trial of pregabalin by Raskin and colleagues showed that pregabalin was associated with clinically relevant improvement versus placebo in patients with inadequately treated painful diabetic peripheral neuropathy. In this patients case, he failed first-line therapy with Neurontin because of side effects and limited benefit. As such, a trial of Lyrica is medically reasonable and necessary given the patients persistent pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee requested residential treatment center substance abuse services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patients life and social interactions do not focus primarily on substance use. The records do not demonstrate denial, as he was open with his substance issues. Moreover, the patient had a supportive recovery environment, was cooperative in treatment, and gained insight into his need for treatment. Thus, he does not meet criteria for residential treatment center placement and residential treatment services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested an eight-week course of Harvoni 90/400 mg for medical treatment of his hepatitis C virus. Findings:  Two physician reviewers found that the current guidelines emphasize that those patients most likely to benefit from viral eradication should be treated with a direct-acting antiviral (DAA) hepatitis C drugs. Individuals with advanced fibrosis and/or severe disease activity would benefit the most such as those with extrahepatic manifestations such as cryoglobulinemia, which this patient is not known to have. In this clinical setting, the patient should be followed by fibrosis parameters serially and begin therapy if there is evidence of histologic progression. For the reasons provided, the requested medication 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 Harvoni for medical treatment of his hepatitis C genotype 1.  Findings:  Two physician reviewers found that the current guidelines emphasize that those patients most likely to benefit from viral eradication should be treated with direct acting antiviral (DAA) hepatitis C drugs. Most data suggests that patients with advanced fibrosis, severe disease activity, or those with extrahepatic manifestations such as cryoglobulinemia would benefit the most from treatment. For this patient with minimal to no fibrosis, the recommendation would be to follow non-invasive fibrosis parameters serially and consider therapy if there is evidence of histologic progression. Consistent with these findings, the requested Harvoni is not medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested substance abuse residential treatment center (RTC) services  for medical treatment of her substance abuse.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented for detoxification after her provider refused to refill her prescription medication. The amount of medication she was using did not require inpatient detoxification. In addition, her withdrawal symptoms did not result in a COWS score to support a residential level of care. Her psychiatric and medical conditions were managed with medications and did not require 24-hour supervision. She had no prior treatment history and there is no evidence to suggest that treatment at a lower level of care would have resulted in complications or that she was at imminent risk for withdrawals. Based on the medical literature cited above and the documentation submitted for review, the substance abuse residential treatment center services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested an oral appliance for medical treatment of her obstructive sleep apnea (OSA).  Findings:  The physician reviewer found that in the medical literature, Epstein and colleagues concluded that treatment strategies for obstructive sleep apnea may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. The records document that this patient has contraindication to CPAP use due to the perforation of the nasal septum. Given these findings, the requested oral appliance is a reasonable treatment alternative and is therefore supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested rhizotomy for medical treatment of his sacroiliac (SI) joint arthropathy and lumbago.  Findings:  Three physician reviewers found that SI rhizotomy (neurotomy) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The review by Muhlner indicates that there is limited evidence in treating SI joint syndrome with radiofrequency neurotomy. Based on the limited evidence supporting radiofrequency neurotomy in SI joint syndrome, rhizotomy was not 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

A female enrollee requested weekly individual therapy sessions with a therapist for medical treatment of her social anxiety disorder, bipolar disorder type 2, obsessive compulsive disorder, and depression.   Findings:  The physician reviewer found that this patient is complex and symptomatic with depression and anxiety and probably PTSD. It is noted that the facility keeps changing her providers, which has made it very difficult for her to form a therapeutic bond with a therapist. Given these findings, the patients current treatment plan has been ineffective. Therefore, it is reasonable for this patient to begin receiving weekly psychotherapy sessions by a consistent provider. All told, the records support the medical necessity of the requested weekly individual therapy sessions with a therapist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested platelet rich plasma (PRP) injections for medical treatment of his partial tears of his left supraspinatous tendon and infraspinatous tendon. Findings:  Three physician reviewers found that orthopedic literature indicates that PRP injections are being widely investigated. However, there is a paucity of long-term studies indicating specific efficacy of their use in this clinical setting. There is a lack of studies indicating that PRP injections for this diagnosis are any more beneficial than regular conservative care to include a cortisone injection home exercises, physical therapy and anti-inflammatory medication. For these reasons, PRP injections were not 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 male enrollee requested growth hormone (GH) therapy with Genotropin for medical treatment of the enrollees Prader-Willi syndrome.  Findings:  The physician reviewer found that GH therapy for treatment of short stature from Prader-Willi syndrome is approved by the U.S. Food and Drug Administration (Wilson, et al). GH treatment of children with Prader-Willi syndrome has been shown not only to improve linear growth, but also promotes growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors and motor and mental development. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered to be generally safe in this population. All told, the GH therapy with Genotropin is 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 medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, 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. Therefore, regardless of fibrosis, the patient should be approved for treatment of HCV. Thus, Harvoni is medically necessary for 12 weeks for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested hip surgery for medical treatment of the her left hip pain. Findings:  The physician reviewer found that this patients clinical documentation provides evidence of complete obliteration of superior articular cartilage in the hip joint, with subchondral cyst formation and diffuse sclerosis. However, the clinical documentation does not document that the patient has been diagnosed with osteoarthritis of the hip. Further, there is a lack of evidence that the patient has participated in and failed conservative medical therapy including physical therapy. For these reasons, the requested hip surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested GeneSight testing for medical evaluation of her bipolar disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that  the American Psychiatric Association (APA) practice guidelines do not recommend genetic testing for cases involving routine medication management. Regarding this patients scenario, there is a lack of specific information detailing the history of her illness, functional impairment, or contemporaneous psychosocial stressors. Further, there is no documentation of prior treatment interventions tried and failed, including the type, setting and outcome. In the absence of this information, the requested GeneSight testing is not medically necessary for evaluation and treatment of this patients medical condition.