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

A 42-year-old female enrollee requested endovenous laser ablation (endoluminal ablation of varicose veins for medical treatment of the enrollees varicose veins.  Findings:  Two physician reviewers found that endoluminal ablation of varicose veins is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has an anterior accessory saphenous vein that could be contributing to the symptom constellation. However, these are usually treated with phlebectomy rather than endovenous laser ablation. In this clinical setting the standard of care is treatment by either phlebectomy or foam sclerotherapy. As such, the request for endovenous laser ablation has not been established in this clinical setting. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee requested a continuous glucose monitoring system (E0784 insulin pump, A9277 transmitter, A9276 sensors, 530G with enlite) for medical treatment of his diabetes.  Findings:  Two physician reviewers found that this patient has poorly controlled diabetes, with HbA1c of 8.5% complicated by bipolar disorder. It is important that the patient controls his diabetes by bringing his glucose levels to a more acceptable range without increasing his risk of hypoglycemic coma. In this patient, the insulin dose is difficult to increase as needed because of risk of dangerous hypoglycemia. The CGM requested has the added feature of automatically suspending the delivery of insulin when hypoglycemia occurs, therefore limiting the time that the patient is in hypoglycemia. For these reasons, the system prescribed, (E0784 insulin pump, A9277 transmitter, A9276 sensors, 530G with Enlite) is more beneficial for this patient than any other standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested a pain management consultation for treatment of her sciatica.  Findings:  The physician reviewer found that the requested pain management consultation is not medically necessary for evaluation and treatment of this patients medical condition. There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician. Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications. Additionally, the results of the MRI do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.  All told, the requested pain management consultation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested modafinil for medical treatment of her multiple sclerosis (MS) related fatigue.  Findings:  The physician reviewer found that MS related fatigue is not an indication for Provigil. The patient does not have an FDA approved indication for the use of Provigil. The use of Provigil for the treatment of fatigue for patients with MS is not the standard of care and is not medically necessary for this patient. Based on the medical literature cited above and the documentation submitted for review, the request for modafinil is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Nexium 40mg for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as for managing symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action and side effects characterize proton pump inhibitor variations.  No particular proton pump inhibitor has been demonstrated to provide superior results, since as a class proton pump inhibitors are interchangeable.  In this patients case, the medical records do not document that her gastroesophageal reflux disease is advanced or refractory to multiple proton pump inhibitors, and she has not demonstrated intolerance to specific proton pump inhibitors.  All told, the requested Nexium 40mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee  requested a breast magnetic resonance imaging (MRI) with contrast for medical evaluation of her medial right breast asymmetry.   Findings:  Two physician reviewers found that this patient has a persistent abnormality on mammography seen on only one view and the finding has increased in size over the past few exams. There is no correlate on alternate views and ultrasound has been negative. The exclusion of a deep mass within the breast as well as the chest wall remains the primary concern. Due to limitations with mammography and ultrasound, the requested MRI remains the best tool for evaluation. Due to the highly sensitive nature of MRI in the detection of breast masses, the requested exam would be of more benefit to this patient than any other technique.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 21-month-old male enrollee has requested repair of the transverse arch and tricuspid valvuloplasty for treatment of the enrollee's medical condition.   Findings:  The physician reviewer found that  the submitted documentation supports the medical necessity of the requested services in this patients case.  In order to have a successful Fontan operation, the patient must have good right ventricular function, a competent tricuspid valve and unobstructed flow through the lungs.  This patient is not a Fontan candidate at this time due to severe tricuspid regurgitation and what appears to be significant long segment left pulmonary stenosis due to the enlarged transverse aorta.  However, his right ventricular function is good.  In this patients case, the tricuspid valve needs to be repaired in order for him to be a candidate for the next stage repair Fontan.  Based on the medical records and review of the medical literature, the request for surgical repair of the tricuspid valve is medically necessary in order to preserve right ventricular function and make the patient a better candidate for the Fontan procedure.  The left pulmonary artery repair is also medically indicated based upon the clinical documentation.  Early left pulmonary artery repair will promote growth of the artery and left lung and may make him a better Fontan candidate in the future.  All told, repair of the transverse arch and tricuspid valvuloplasty are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested Duragesic (fentanyl) patches for treatment of her low back and hip pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Current standard of care for chronic pain associated with lumbar radiculopathy 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 anti-convulsants and anti-depressants considered adjunctive to this therapy (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Long-term opiates are more likely to cause adverse outcomes and therefore the patients request for Duragesic patch is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. The Duragesic patch as requested by the patient would be contradictory to providing safe and effective healthcare. 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: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested the growth hormone (GH) therapy with Nutropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that although the patients height is two standard deviations below normal for age and gender, his growth factors are normal, there is no documentation of an abnormal growth velocity as measured over a one year period, and there is no known morphologic abnormality of his pituitary gland. Results of laboratory tests demonstrating that all other causes of short stature have been ruled out, including occult systemic disease and celiac sprue, have not been provided. Further, a longitudinal growth chart documenting that the patients rate of weight gain has been adequate to support growth is not included for review. All told, the patient does not meet criteria for classic GH deficiency. Based on the bone age, the patients estimated final adult height is 64-65 inches, using the Bayley-Pinneau method. This height prediction is not short enough to warrant GH therapy based on the U.S. Food and Drug Administration (FDA) criteria for treatment of idiopathic short stature. Therefore, the requested GH therapy with Nutropin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested Enlite 530G insulin pump (E0784), sensors (A9276 x 90), and transmitter (A9277) for medical treatment of her type 1diabetes.  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient has low blood sugar levels in the 50s-60s range. The use of the Enlite system with the threshold suspend feature is likely to be beneficial for this patient and will likely lower the frequency of severe low blood sugars (Bergenstal, et al). Therefore, the requested Enlite 530G insulin pump (E0784), sensors (A9276 x 90), and transmitter (A9277) are likely to be more beneficial than other available therapies for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee requested Androgel for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Wiechno and colleagues assessed the degree of hormonal abnormalities in testicular cancer survivors and the effect of these changes on patients quality of life. The authors concluded that hormonal abnormalities have a negative impact on the quality of life of testicular cancer survivors. In addition, patients treated for testicular cancer have a higher risk of ejaculatory, orgasmic and erectile dysfunctions compared with healthy males (Rosendal, et al). In this case, the patient has a history of testicular cancer with symptoms of decreased libido, weight gain, and decreased energy. The patient has previously been treated with Androgel with relief of symptoms. As such, the patients request for Androgel is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested Afirma gene expression classifier (CPT 84999) for evaluation of her thyroid nodule.  Findings:  Two physician reviewers found that the Afirma gene expression analysis was likely to be more effective for this patient than other available treatment options. The patient had a biopsy with an indeterminate diagnosis. In this case, the genetic testing performed was a useful tool to aid in the distinction of a cytologically indeterminate nodule. Moreover, the medical literature supports the use of Afirma gene expression classifier in this clinical setting. As such, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested genetic testing DYT-1 (CPT code 81400), DYT-11 (CPT 81405), GTP (CPT 81406) and cyclohydrolase (CPT 81479) for evaluation of her suspected spasmodic dysphonia.  Findings:  Two physician reviewers found that the patients history and physical examination document a diagnosis of spasmodic dysphonia that has been successfully treated with Botox. The scientific data demonstrates the superior effectiveness of Botox injections into the laryngeal muscles for spasmodic dysphonia. However, the use of genetic testing to show if the patient is a candidate for deep brain stimulation is not supported. All told, the requested genetic testing consisting of DYT-1 (CPT code 81400), DYT-11 (CPT 81405), GTP (CPT 81406) and cyclohydrolase (CPT 81479), is not likely to result in an improved health outcome in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested the MiniMed 530G Enlite (E0784 external ambulatory infusion pump, insulin), A4230 (infusion set non-needle cannula type), A4232 (syringe with needle sterile, 3 cc), A9276 (sensor; invasive), and A9277 (transmitter; external) for medical treatment of her diabetes mellitus. Findings:  Two physician reviewers found that this patient has poorly controlled diabetes complicated by pulmonary hypertension, on Coumadin.  It is important that the patient controls her diabetes by bringing her glucose levels to a more acceptable range without increasing her risk of hypoglycemic coma. The records suggest the patients insulin dose is difficult to increase as needed because of unpredictable hypoglycemic events. The CGM requested has the added feature of automatically suspending the delivery of insulin when hypoglycemia occurs, therefore limiting the time that the patient is in hypoglycemia, and hopefully prior to loss of consciousness. This patient will benefit from the MiniMed 530G Enlite (E0784 external ambulatory infusion pump, insulin), A4230 (infusion set non-needle cannula type), A4232 (syringe with needle sterile, 3 cc), A9276 (sensor; invasive), and A9277 (transmitter; external) more than any other standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested the growth hormone (GH) therapy with Genotropin for treatment of the enrollees small for gestational age (SGA).  Findings:  The physician reviewer found that the patient has a history of SGA and has extreme short stature with failure to catch up in growth by two to three years of age after resolution of critical illness. She has reportedly gained appropriate weight with total parenteral nutrition, yet has a persistently poor growth velocity. Thus, she meets the U.S. Food and Drug Administration (FDA) criteria for a trial of GH therapy. According to the American Association of Clinical Endocrinologists and the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children who have been SGA is considered an indication for GH treatment in children. Treatment with GH in children with SGA usually stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. GH treatment regimens prescribed for children with SGA have a reassuring safety profile (Ranke and Lindberg). All told, the requested GH therapy with Genotropin has been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested the LINX Reflux Management System procedure and esophagogastroduodenoscopy (EGD) for medical treatment of her gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Moreover, Nissen fundoplication has been found superior with symptomatic improvement occurring in 85 to 90 percent of patients. Finally, the request for a repeat EGD is not clinically indicated as the patient has already had three EGD exams and a repeat EGD is not likely to be more beneficial for treatment of the patients medical condition than other modalities. For the reasons provided, the requested services are not likely to be 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 56-year-old female enrollee requested inpatient hospitalization for medical treatment of the enrollees hypercalcemia, hyperkalemia, and falls.  Findings:  The physician reviewer found that based on the available medical records, inpatient hospitalization services were not medically necessary. The records indicate the patient had stable vital signs and her electrolyte disturbances had resolved. There were no complaints related to unresolved symptoms and the patient was able to walk. Endurance training does not require a continued hospital stay. Moreover, she did not need continued daily physician visits or consultations and had no daily nursing needs. All told, her care needs could have been provided at an outpatient level. Therefore, inpatient hospitalization services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested  gene testing for prostate cancer for medical evaluation of his medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. The use of genetic screening to detect the presence of prostate cancer is not the standard of care in clinical practice. Digital rectal exam along with periodic determination of PSA levels and velocity as well as repeat biopsies are the commonly employed modalities to determine clinical status. As such, the testing at issue was not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested AlloMap testing for medical evaluation of her status, post orthotopic heart transplantation.  Findings:  Two physician reviewers found that for low risk patients more than six months status post orthotopic cardiac transplantation, there is support for AlloMap testing in lieu of endomyocardial biopsy to monitor for acute rejection.  This is an appropriate test to obviate the need for repeated invasive evaluation post transplantation.  There is sufficient support for the use of AlloMap testing between six months and five years post transplantation.  All told, AlloMap testing was likely to have been more efficacious than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested air and ground ambulance transport services for medical treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Intracranial hemorrhage can result in various sequelae, including severe functional and cognitive impairments and recovery can take months or longer (Naidech). There is a lack of support in the medical literature that establishes that functional or health outcomes following severe hemorrhagic strokes are significantly improved with family/caregiver proximity or involvement during inpatient rehabilitative care. In this case, the patients transfer to a skilled nursing facility in Ohio versus a similar type facility in California was not medically necessary for treatment of the patients health condition. Therefore, the transfer of the patient from California to Ohio by air and ground ambulance transport services was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested digital breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that this patient has dense breasts and a family history of breast cancer.  Per the current medical evidence, she is an optimal candidate for breast tomosynthesis.  Therefore, digital breast tomosynthesis was likely to have been more effective than other alternatives for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee requested measurement of serum concentration of infliximab (IFX) and antibodies to infliximab (ATI) performed for medical treatment of the enrollees inflammatory bowel disease.  Findings:  Two physician reviewers found that in this case, the patient has inflammatory bowel disease, specifically Crohns disease. Due to the multitude of management options, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. Measurement of serum concentration of IFX and ATI provides this roadmap and is the standard of care in treating Crohns disease. Based on its utility in managing the patients Crohns disease, the services at issue was likely to be 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 53-year-old female enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the peer-reviewed literature demonstrates positivism for TMS, as researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama, et al). In addition, TMS is approved by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient has major depressive disorder and she is symptomatic from her affective illness. Her response to traditionally accepted therapeutic interventions has been suboptimal. The patient is self-advocating for TMS therapy and a consultation with a TMS provider to evaluate the appropriateness of the treatment modality is clinically indicated prior to starting treatment. If, an evaluation results in a recommendation for TMS therapy, then a course of TMS would be considered medically necessary. However, in the absence of a recommendation by a TMS provider, the requested services are not medically indicated at this time.