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

A 43-year-old male enrollee requested an insulin pump (E0784), continuous glucose monitor transmitter (A9277) and continuous glucose monitor sensors (A9276) for medical treatment of his type 1 diabetes.  Findings:  Three physician reviewers found that the requested equipment is likely to be of greater benefit than other available options.  This patient has type 1 diabetes and has been using an insulin pump.  He has been compliant with therapy, but continues to have low blood glucose levels and wide variations in his blood glucose levels.  There is sufficient medical evidence supporting the requested equipment in this clinical setting, as it will allow the patient to experience less glycemic excursions, with overall improved glycemic control.  Thus, the requested insulin pump (E0784), continuous glucose monitor transmitter (A9277) and continuous glucose monitor sensors (A9276) are likely to be superior over other alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee requested adalimumab (Humira) injections for medical treatment of the enrollees inflammatory spondyloarthritis and plantar fasciitis. Findings:  The physician reviewer found that the medical records document that the patient has failed multiple medications for the treatment of her inflammatory spondyloarthritis. Review of the medical literature shows that tumor necrosis factor (TNF) alpha inhibitors improve functional capacity and disease activity in both ankylosing spondylitis and non-radiographic axial spondyloarthritis (Callhoff, et al). Although many patients with spondyloarthritis respond well to non-steroidal anti-inflammatory drugs (NSAIDs), a small number of patients have resistant symptoms and are candidates for treatment with TNF inhibitors. The rapid clinical response to Humira in this patient shows the efficacy of TNF inhibition in the treatment of her disease. All told, Humira is medically necessary for treatment of this patients inflammatory spondyloarthritis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee requested Concerta (methylphenidate 18mg extended release for medical treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold standard pharmacologic intervention for attention deficit/hyperactivity disorder.  According to guidance from the American Academy of Child and Adolescent Psychiatry, long-acting formulations, such as Concerta, are first-line initial treatments.  They are efficacious and optimize adherence as they are single daily dosing medications.  In this case, the patient was previously treated with Concerta.  The submitted documentation noted that this medication was well-tolerated and effective for the treatment of this patient.  The medical evidence supports the requested medication in this clinical setting, given this patients prior response.  All told, Concerta (methylphenidate 18mg extended release) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee requested Anser IFX testing for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the superior effectiveness of the services at issue has not been established.  Based on the medical records submitted for review, it is not clear if the Remicade dosage has been increased.  Additionally, details regarding response to treatment were not provided.  This test is not the standard of care, and there is a lack of clinical guidelines supporting Anser IFX testing in this clinical setting.  Therefore, Anser IFX testing was not likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee requested individual speech therapy at the frequency of one hour per week for medical treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. Based upon the documentation provided, the patient has a serious speech problem. His speech is intelligible 70% of the time to people who know him and per the Goldman-Fristoe Test of articulation he scored in the lowest percentile for age. The patients speech impairment is likely impacting his learning as he cannot be readily understood by his teachers or his peers. Moreover, a home program as recommended by the Health Plan is not appropriate in this case, given his degree of speech impairment. Therefore, based on the medical literature cited above and documentation submitted for review the medical necessity of the requested individual speech therapy at the frequency of one hour per week has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested right shoulder surgery (acromioplasty with rotator cuff repair) for medical  treatment of her shoulder pain.   Findings:  The physician reviewer found while a shoulder arthroscopy will not address the patients cervical issues, there is good documentation of post-fracture osteoarthritic changes at the acromion and AC joint to support a diagnosis of chronic shoulder pain with impingement syndrome. An arthroscopic intervention is therefore indicated to provide partial, but significant, benefit in management of her condition of chronic pain. The importance of the AC joint and the shape and type of downward sloping acromion or post-fracture changes within the acromion is a widely accepted finding important in shoulder pain, and in this case is a justification for shoulder arthroscopic surgery with subacromial decompression despite the lack of evidence of a rotator cuff tear on MRI. All told, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested LINX Reflux Management System procedure for medical treatment of her gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the request for LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the study by Salminen and colleagues, Nissen fundoplication as the procedure of choice in surgical management of gastroesophageal reflux disease. In addition, there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Although early studies in regards to LINX are encouraging, the studies to date are primarily less than five years. Because of the lack of controlled data and long-term studies, 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: Upheld Decision of Health Plan

A 52-year-old female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis. Findings:  Two physician reviewers found that there is a lack of evidence that this patient has frontal sinus disease, as the frontal sinuses are noted to be hypoplastic on CT imaging. Further, there is no mention in the chart notes that the patient has frontal sinus pressure and no mucosal abnormality is seen on intra-nasal exam. For these reasons, the frontal balloon sinus ostial dilation was not likely to be more beneficial for treatment of this patients sinus problems than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested the MiniMed 530G with Enlite (E0784, A9277, and A9276) for medical treatment of her type 1 diabetes.   Findings:  The physician reviewer found that this patient has longstanding type 1 diabetes mellitus with poor glycemic control, unstable blood glucose levels with large glycemic fluctuations, and wide fluctuations in preprandial blood sugars as well as hypoglycemia. Her provider has recommended she switch from conventional insulin injections to an insulin pump. Based on the available medical records, the requested equipment including the MiniMed 530G with Enlite (E0784, A9277, and A9276) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee requested abdominoplasty for medical treatment of her medical condition status post laparoscopic gastric band placement.  Findings:  The physician reviewer found that Coriddi and colleagues evaluated functional status following abdominoplasty and noted that, rectus plication did not significantly improve functional outcomes. Thus, the medical literature does not adequately establish that there is direct functional benefit from muscle plication. Overall, this patients documented diastasis is mild as demonstrated on CT scan and the scientific evidence does not provide sufficient justification for abdominal muscle plication in this clinical setting. Therefore, the requested abdominoplasty is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation of her medical condition.   Findings:  Three physician reviewers found that this patient has a 7.7% lifetime risk of breast cancer, which is well below the threshold for significant increased risk and qualification for screening MRI.  The mammogram report did not indicate that the benign nodule required additional imaging such as ultrasound.  If there is concern regarding the nodule, MRI is not indicated for further investigation and biopsy would be the only additional test to provide a diagnosis.  The use of MRI of the breasts in this clinical setting falls outside of the usual and customary guidelines as recognized by the American Cancer Society and the American College of Radiology.  All told, the requested MRI of the breasts is not likely to be of greater benefit than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested intra-fraction localization and tracking of target or PT motion during delivery of radiation therapy (CPT code 0197T) and unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999) for treatment of her cancer in the left breast.   Findings:  Two physician reviewers found that use of intra-fraction localization and tracking of target or PT motion during delivery of radiation therapy (CPT code 0197T) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. However, the records do not include a request by the radiation oncologist for the requested unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999). Further, the providers notes did not recommend this diagnostic procedure. Moreover there is a lack of a clinical indication for the requested unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999). Therefore, the requested diagnostic procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  A portion of the requested services 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

A 34-year-old female enrollee requested a water circulating cold pad with pump (E0218), pad for water circulating heat unit (E0249), and the Smart-Sling (L3670) for medical treatment of her left shoulder bursitis, impingement, and acromioclavicular (AC) joint arthritis. Findings:  The physician reviewer found that based on the current medical literature, it was not medically necessary for this patent to receive passive water circulating cold pad with pump, water circulating heat unit as opposed to simpler applications of cold for post-operative shoulder care. Use of the Smart-Sling was likely to be beneficial given its design to assure some passive abduction, as well as versatility in allowing for beginning of range of motion in internal, external rotation at the discretion and supervision of the orthopedic surgeon. The abduction pillow is likely to help in decreasing tension at the surgical repair site, which is important during the healing phases post-surgically and will improve the likelihood of healing. All told, the use of the water circulating cold pad with pump (E0218) and pad for water circulating heat unit (E0249) were not medically necessary, but the Smart-Sling (L3670) was medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee requested the LINX procedure (placement of esophageal sphincter augmentation device for medical treatment of her gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that this patients failure to respond to PPI therapy is a strong predictor that she will not experience a significant benefit from the requested anti-reflux surgery. For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested robotic laparoscopy for medical treatment of her endometriosis.   Findings:  The physician reviewer found that when analyzed prospectively on a cohort basis, robotics has not been demonstrated to provide improved benefits in terms of post-operative pain, length of stay, and complications (Wright, et al). In addition, Liu and colleagues concluded that, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. For providers who are not adept at standard laparoscopy, robotic surgery may help provide minimally invasive surgery to their patients (Kho). All told, the use of robotic assistance for this patients hysteroscopy is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested a subcutaneous implantable defibrillator (S-ICD) for medical treatment of the enrollees long QT syndrome (LQTS).  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. Patients with LQTS are considered high-risk when associated with a family history of sudden death. In this case, the patient presents with LQTS type 5 and a strong family history of sudden cardiac death in three generations. Subcutaneous defibrillators have been shown to be effective in terminating induced and spontaneous ventricular arrhythmia and are U.S. Food and Drug Administration (FDA) approved. Therefore, the requested S-ICD is likely to be more beneficial for her medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee requested Copaxone 40mg, three times per week for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage in this clinical setting.  This patient has been diagnosed with relapsing-remitting multiple sclerosis.  She has been treated with daily Copaxone injections since.  The patient has noted pain at injection sites, with associated lipoatrophy.  There is sufficient support for Copaxone 40mg, three times per week, in this clinical setting.  Patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, injections at a frequency of three times per week instead of daily are likely to be less irritating and foster adherence.  All told, the requested Copaxone 40mg, three times per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested blepharoplasty (CPT code 15823) and repair of blepharoptosis (CPT code 67904) for treatment of his medical condition.  Findings:  The physician reviewer found that the documentation submitted for review indicated the patient had bilateral dermatochalasis.  It was recommended that the patient see an ophthalmologist to evaluate for visual field loss.  The documentation submitted for review did indicate the patient presented to an ophthalmologist , however, the documentation does not indicate or address the patients visual field.  As such, the degree of visual field loss cannot be established.  Given the lack of visual field testing and clear documentation of the peripheral vision being affected, the medical necessity for the proposed procedure is not established.  All told, the requested blepharoplasty (CPT code 15823) and repair of blepharoptosis (CPT code 67904) are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee requested positron emission tomography (PET) with computed tomography (CT), skull base to thigh (CPT code 78815) for evaluation of the enrollees Burkitts lymphoma.  Findings:  Two physician reviewers found that the diagnostic procedure at issue was likely to have been superior over other modalities.  PET/CT scans are an effective method of evaluating patients with lymphoma.  Per the current medical evidence, a minimum of three years surveillance with PET/CT is recommended in this clinical setting.  There is sufficient support for the diagnostic procedure.  Therefore, PET/CT, skull base to thigh (CPT code 78815 was likely to have been more efficacious than other available methods for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested lab testing for medical evaluation of her Crohns disease.  Findings:  Two physician reviewers found that in this patients specific case, her clinical presentation prior to undergoing Anser IFX testing suggested therapeutic infliximab response had already been achieved. Therefore, the Anser IFX testing was not performed for a specific indication. Also, available records do not support that the Anser IFX had any immediate impact on her health outcome. For these reasons, lab testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee requested applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (pervasive developmental disorder). Findings:  Two physician reviewers found that, based on the available medical literature, the requested ABA therapy is supported as medically necessary for treatment of this patients autism spectrum disorder. ABA therapy is well-established as a standard modality for individuals with autism spectrum disorder. Specific treatment, including ABA therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that cause developmental delays and social disconnection associated with autism spectrum disorder. Consistent with these findings, the requested ABA therapy is medically necessary for treatment of this patients autism spectrum disorder.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee requested percutaneous patent foramen ovale closure for treatment of her patent foramen ovale.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other available treatment options.  The current medical evidence supports the requested percutaneous patent foramen ovale closure in this clinical setting.  This patient had a stroke in the postpartum period, and the record documents plans for future pregnancies.  At 32 years of age, she is likely to need anticoagulants for several decades.  Given this patients clinical history, the requested percutaneous patent foramen ovale closure is likely to be superior over other available therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee requested eating disorder residential treatment center services for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the medical records document multiple psychiatric conditions.  She remained symptomatic throughout her course of treatment.  The following day, the patient was anxious, with tremor.  The provider noted poor eye contact and loose associations.  The treatment was reasonably expected to improve her condition, prevent a more serious episode of illness and facilitate a successful transition to a less restrictive setting.  All told, eating disorder residential treatment center services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee  requested breast implant removal (CPT code 19371, periprosthetic capsulectomy, breast; CPT code 19328 removal of intact mammary implant) for treatment of her capsular contracture.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. Capsular contracture is a well-recognized complication following augmentation mammaplasty and can cause pain. The treating surgeon notes that she has been having no significant discomfort, but is complaining of the hardness of the implants. This does not support that there is a significant functional deficit. Overall, based on the medical documentation provided for review, there is a lack of support that a significant functional deficit exists and that the patient has failed non-operative medical management. Thus, the medical necessity for implant removal with capsulectomy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee requested continuous glucose monitoring (CGM) system (including insulin pump (E0784); disposable sensor CGM system (A9276); external transmitter, CGM system (A9277); and external receiver, CGM system (A9278)) for medical treatment of his type 1 diabetes.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. The patient has long-standing type 1 diabetes with a less than optimal HbA1c level of 9.7 and unstable blood glucose levels with large glycemic fluctuations and wide fluctuations in preprandial blood sugars. As this system is likely to benefit the patients health, the requested services are likely to be more beneficial than other available therapies for this particular patient.