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

A female enrollee requested endoluminal ablation of the perforator vein (CPT 36475 for medical treatment of her chronic venous insufficiency.  Findings:  Two physician reviewers found that endovascular treatment using either sclerotherapy or thermal ablation are presently recommended. According to the Society for Vascular Surgery and the American Venous Forum practice guidelines, We recommend treatment by percutaneous techniques that include ultrasound guided sclerotherapy or endovenous ablation [radiofrequency or laser] over open venous perforator surgery.  For these reasons, the request for endoluminal ablation of the perforator vein is likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested 27 hours of applied behavioral analysis (ABA) therapy per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  In this case, it is medically necessary for this patient to receive ABA therapy as recommended at the frequency of 27 hours per week given the maladaptive behaviors of aggression, tantrums, elopement and self-injurious behaviors as well as overall assistance with self-help, safety, adaptive, communication and socialization skills. All told, the requested 27 hours per week of ABA therapy is medically necessary for treatment of the patients autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested weekly occupational therapy for medical treatment of the enrollees oral motor skills delay.  Findings:  The physician reviewer found this patient cannot swallow solids which will significantly impair his nutrition and his inability to be fed outside of the home, such as at school. Schwarz and colleagues reports that successful treatment of a feeding disorder results in improved energy consumption, nutritional status, and reduced hospitalizations. The occupational therapists notes document modest improvement, but not successful nutrition. In sum, it is medically necessary that this patient continue with weekly occupational therapy. Therefore, the requested weekly occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus genotype 1a.   Findings:  Two physician reviewers found that the records provided for review document that this patient has minimal to no liver fibrosis. She is not immunosuppressed and demonstrates no extrahepatic manifestations of hepatitis C. The patient does not have concomitant liver diseases such as non-alcoholic fatty liver disease. Overall, her prognosis is excellent and there is a lack of clinical findings to support treatment with Harvoni. It is recommended to follow patients serially for evidence of progression using non-invasive markers of fibrosis such as Fibrospect II. All told, the requested Harvoni is not supported as medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested single photon emission computed tomography (SPECT) scans for medical evaluation of his attention deficit/hyperactivity disorder.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The patient had already been diagnosed with attention deficit/hyperactivity disorder, hypothyroidism and depression.  The treatment recommendations in the record include having the patient refrain from smoking marijuana and excess alcohol, and to engage in a healthy diet and exercise plan as well as psychotherapy utilizing cognitive behavioral therapy.  These general recommendations for treatment are fairly standard and do not require a SPECT scan for support.  There is no evidence that this patient meets these criteria.  In sum, SPECT scans were not likely to have been superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90mg-400mg (12 weeks) for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that per American Association of the Study of Liver Diseases and the Infectious Diseases Society of America, immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority.  This patient meets classification as high priority for medically necessary treatment.  Therefore, Harvoni 90mg-400mg (12 weeks) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested Onfi (clobazam) for medical treatment of the enrollees epilepsy.  Findings:  The physician reviewer found that the patient has a diagnosis of medically refractory epilepsy, characterized by head drops.  Empirical evidence has demonstrated a clear indication for clobazam as an efficacious antiepileptic drug (AED). Montenegro and colleagues retrospectively reviewed the use of clobazam (CLB), in terms of efficacy, retention, and tolerability in patients with epilepsy over a five-year period. The authors concluded In this population of patients with highly refractory epilepsy at a US center, 11% of patients became seizure-free for at least 6 months after addition of CLB, and the 1-year retention rate was 61%. As such, the use of clobazam demonstrates best clinical practice for this patient, and the available literature supports this decision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Sovaldi 400 mg and Olysio 150 mg for 12 weeks for medical treatment of his chronic hepatitis C genotype 1b. Findings:  Two physician reviewers found that the patient has essentially no fibrosis by non-invasive testing. At this point, this patient has little to gain in treatment of his hepatitis C. His renal failure does not appear to be an extrahepatic manifestation of hepatitis C such as mixed essential cryoglobulinemia. Moreover, there is a lack of information that Olysio and Sovaldi are safe in the setting of this degree of renal insufficiency. For these reasons, the requested Sovaldi 400 mg and Olysio 150 mg for 12 weeks are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the AlloMax surgical graft used during a breast reconstruction procedure for medical treatment of her bilateral Grade IV capsular contracture. Findings:  Two physician reviewers found that Busse and colleagues stated that some of the key benefits of AlloMax as compared to AlloDerm are the shorter preparation time, terminal sterility, and the fact that no orientation is necessary for implantation. Additionally, an article by Carruthers and colleagues stated that AlloMax incorporated more readily with surrounding host tissue as measured by earlier and greater cell infiltration, fewer foreign body giant cells, and faster remodeling of acellular dermal matrices. The authors concluded that these findings correlated with the in vitro composition and cytocompatibility analysis, which showed AlloMax to more readily support in vitro cell growth. For these reasons, the AlloMax surgical graft was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested hormone pellet implants for treatment of her artificial menopause status post total abdominal hysterectomy. Findings:  Three physician reviewers found that bioidentical hormone therapy is considered controversial and is not supported by the American Association of Clinical Endocrinologists (AACE) or Endocrine Society. Moreover, preparations vary widely including the type of hormonal preparation and the dosages used. There is controversy as to what hormone assay should be used to measure levels and the proper treatment range. All told, there is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of the requested hormone pellet implants as likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested juvenile cartilage transplant into the talar dome for medical treatment of her osteochondral lesion. Findings:  Three physician reviewers found that there is a lack of quality studies supporting the use of juvenile cartilage transplant into the ankle. Overall, the use of juvenile cartilage transplant into the talar dome was not likely to be more beneficial than conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs), adaptive shoes, activity modification, appropriate low-impact exercise, or autologous chondrocyte transfer or osteochondral allograft transportation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus. Findings:  Two 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. AASLD/IDSA further state, 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, by the achievement of virologic cure as evidenced by an SVR. Therefore, the patient should be approved for treatment of HCV. Thus, Harvoni is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested the Optune system (formerly known as NovoTTF-100A) for medical treatment of his glioblastoma multiforme. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) approved the NovoTTF-100A System (now Optune) for the treatment of adults with glioblastoma multiforme that recurs or progresses after receiving chemotherapy and radiation therapy. Based on the available data, Optune is medically necessary for this patient presenting with recurrent glioblastoma multiforme, after surgical resection, concurrent chemoradiation and adjuvant chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested quarterly magnetic resonance imaging (MRI) for medical evaluation of his medical condition.  Findings:  The physician reviewer found that this patient was found to have an arachnoid cyst, which may have been present preoperatively, and which has been stable on postoperative imaging for greater than one year.  This patients cyst is not likely to be causing his ongoing pain syndrome, and has been stable. Serial imaging on a quarterly or other set interval basis is not medically needed. Should there be significant clinical change, such as new focal posterior fossa neurologic findings, repeat imaging may be needed at that time.  All told, the requested quarterly MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested expansion sphincter pharyngoplasty, uvulopalatopharyngoplasty and tissue rearrangement (Health Plan has listed as 42145 repair of palate, pharynx/uvula and 14040 skin tissue rearrangement, 14040-50  tissue transfer) for medical treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that this patient has been diagnosed with severe obstructive sleep apnea and has failed use of CPAP.  Therefore, surgical intervention is medically indicated.  In this patients case, 42145 is medically necessary and 14040 and 14040-50 are not medically necessary.  The use of CPT 14040 is not applicable as it applies to adjacent tissue transfer or rearrangement during surgery on the integumentary system.  All told, a portion of the requested services is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that the U.S. Food and Drug Administration (FDA) has approved Harvoni for patients with early stage disease. Moreover, according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, 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. In this case, the patient has chronic HCV and AASLD/IDSA guidelines support treating this patients HCV with Harvoni. Therefore, Harvoni is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Viekira Pak for medical treatment of his chronic hepatitis C virus genotype 1b. Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy due to nonliver-related comorbid conditions. In treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Viekira Pak is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus. Findings:  Two physician reviewers found that current treatment guidelines by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) emphasize that those patients most likely to benefit from viral eradication should be treated with a direct-acting antiviral (DAA) hepatitis C drug. 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, following this patient by yearly assessments for fibrosis using non-invasive testing is appropriate. Therefore, 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 a six to eight week pain management program to increase functionality for chronic pain through medication adjustments and therapy for medical treatment of her chronic pain. The therapeutic environment of a functional restoration program is appropriate to address pain management strategies, and increase physical activity and independence without reliance on medications. Based on the documentation submitted for review, a six-week functional restoration program with concomitant outpatient detoxification from opioids as part of the program is medically necessary. Based on the documentation submitted for review and the peer-reviewed literature cited above, 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 male enrollee requested prostate magnetic resonance imaging (MRI), three Tesla high resolution for medical treatment of his prostate cancer.  Findings:  The physician reviewer found that this patients most recent PSA was normal at 1.8.  If the patient has a rising PSA, the medical literature shows a distinct advantage of MRI of the prostate using a 3 Tesla system over the conventional 1.5 Tesla units.  However, a recent PSA was not provided in this patients case.  All told, the requested prostate MRI, three Tesla high resolution is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Celebrex 200 mg for medical treatment of his back pain status post lumbar discectomy.   Findings:  The physician reviewer found that  Celebrex is a cox-2 inhibitor (coxib) nonsteroidal anti-inflammatory drug (NSAID). The medical literature states that NSAIDs are recommended for osteoarthritis at the lowest dose for the shortest period in patients with moderate to severe pain to reduce the risk of complications associated with cardiovascular disease and gastrointestinal distress.  In this patients case, there is lack of documentation of gastrointestinal risk requiring a cox-2 inhibitor NSAID. Thus, the requested Celebrex 200 mg is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request for residential treatment services is not medically necessary for treatment of the patients medical condition. In reviewing the records of this case, partial hospitalization services provided previously were safe, appropriate and adequately addressing the patients needs. Thus, there is no evidence that the patient has failed a less restrictive treatment setting. Further, since there were no clinical assessments provided, making the patients current status unknown, it is not possible to assert that a higher level of care is indicated.  Therefore, residential treatment center services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested 24 weeks of Harvoni and ribavirin for treatment of his hepatitis C.  Findings:  Three physician reviewers found that this patients clinical record, laboratory results, and imaging confirm cirrhosis.  Per the medical records, he is beginning to show evidence of decompensation from his liver disease including encephalopathy and volume overload.  The current medical evidence supports treatment of patients with cirrhosis with Harvoni with or without ribavirin for 24 weeks if they failed sofosbuvir with simeprevir.  All told, 24 weeks of Harvoni and ribavirin is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested genetic testing for medical evaluation of the enrollees family history of Down syndrome and trisomy. Findings:  Two physician reviewers found thatcell free DNA testing does not replace the precision obtained with diagnostic tests, such as chorionic villus sampling or amniocentesis, and currently does not offer other genetic information. Other limitations of cell free fetal DNA includes the lack of outcome data for low-risk populations. Accordingly, cell free fetal DNA testing is not currently recommended for low-risk women. Based on the clinical information provided, this patient is considered a low risk patient. Therefore, genetic testing is not likely to have been 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 female enrollee requested platelet plasma injections provided during corrective spine surgery for medical treatment of her disc herniation and foraminal stenosis.  Findings: Three physician reviewers found that the peer-reviewed medical literature fails to evidence that the platelet plasma injections were likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. In this case, the patient received platelet rich and platelet poor plasma at end of her ACDF. The platelet plasma injections provided were not likely to have promoted improved healing or improved neurologic function of this patient. In addition, medical studies on the use of platelet plasma in spine surgery have not shown improvement of the rate of healing (Carreon, et al; Feiz-Erfan, et al). All told, there is insufficient outcomes data from high quality, well-designed studies to support the use of platelet plasma in this clinical setting. As such, the services at issue 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

A male enrollee requested Harvoni for medical treatment of hischronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines state that successful hepatitis C treatment results in sustained virologic response, 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. In addition, the guidelines state that treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. This patient has a Metavir of F2-F4, which is consistent with an F3 and short of having cirrhosis. Thus, the requested Harvoni is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested canagliflozin for medical treatment of his type 2 diabetes.  Findings:  The physician reviewer found that Canagliflozin is the first approved agent in a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein inhibitors. Many providers and medical organizations currently recommend subtype 2 sodium-glucose transport protein inhibitors as part of a recommended regimen for treatment of diabetes. All told, the requested canagliflozin is medically necessary for this patient.