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

The parent of a 10-year-old male enrollee requested magnetic resonance spectroscopy (MRS) (CPT 76390) for medical evaluation of the enrollees optic glioma of the brain.  Findings:  The physician reviewer found that the requested magnetic resonance spectroscopy is not medically necessary for evaluation of this patients optic glioma of the brain. Magnetic resonance spectroscopy can be useful to determine whether a mass is a brain tumor or to distinguish viable tumor from radiation necrosis. However, this patient has not been treated with radiation. Further, there is a lack of evidence that magnetic resonance spectroscopy has a role in assessing a patients response to therapy (Chronaiou, et al; Rossi, et al). Moreover, there is no indication that a magnetic resonance spectroscopy would have any impact on this patients treatment. All told, the requested magnetic resonance spectroscopy is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested psychiatric inpatient hospitalization for medical treatment of her bipolar disorder, depressed type.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The documentation included a letter from the patients psychiatrist, an admitting note and a history and physical, in addition to notes from the emergency department.  However, records detailing the inpatient stay were lacking.  The documentation did not contain information such as a treatment plan, an interpretative summary, daily progress notes with mental status examination, serial suicide risk assessments or evidence of discharge planning efforts.  As such, there was no sequential description of the illness burden and its subsequent impairment, status update of the home environment, or review of past treatments tried and failed that would have justified treatment at the inpatient level of care.  Without said information, and considering the relevant peer-reviewed literature and current practice standards, the records do not demonstrate that the service improved the patients condition, prevented a more serious health condition or reduced morbidity.  All told, psychiatric inpatient was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee requested laboratory services received during the course of his emergency treatment for medical evaluation of the his episode of diaphoresis and dizziness.   Findings:  The physician reviewer found that based on the available medical records, the comprehensive metabolic panel, CPK, CPK-MB, BNP, troponin, hemogram and platelet count, and prothrombin time were medically necessary.  The above mentioned tests are standard for evaluation of potential causes of pre-syncope. The troponin and CPK and CPK-MB determine whether the patient has suffered an acute myocardial infarction. The BNP assesses congestive heart failure. The CBC checks for anemia, which this patient, being on an anticoagulant would be at risk for, or infection. The chemistry panel assesses hydration status and electrolyte balance. The PT measure the patients warfarin levels. The only test that appears was not medically necessary was the PTT, which is used in patients who are currently taking heparin, or in whom heparin therapy is anticipated. Thus, a portion of the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee  requested a crown for medical treatment of her cracked tooth.  Findings:  The physician reviewer found that while preparing a crown with placement of a provisional crown did alleviate symptoms, there is no evidence provided that a traditional restoration would not have accomplished the same clinical result. Given that there is no documentation of caries or cuspal fracture and no evidence suggesting diagnosis or treatment for cracked tooth the services have not been established as dentally necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee requested continued pediatric psychotherapy from a specialist experienced in severe early childhood trauma utilizing eye movement desensitization and reprocessing (EMDR) treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a diagnosis of post-traumatic stress disorder (PTSD) and behavioral issues due to trauma. According to the American Academy of Child and Adolescent Psychiatry, Among the trauma-focused psychotherapies, [trauma focused-cognitive behavioral therapy] TF-CBT has received the most empirical support for the treatment of childhood PTSD.  A review of the therapy progress notes submitted for review does not demonstrate that the patients therapist is performing TF-CBT. The progress notes demonstrate active listening and validation as the therapeutic techniques being used in the patients sessions. Moreover, the requested therapy of eye movement desensitization and reprocessing (EMDR) is not mentioned in the therapy notes as a therapy technique that is being used in the patients therapy sessions. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested  L4-5 disc replacement arthroplasty for treatment of his severe back pain.  Findings:  Three physician reviewers found that the medical records indicate that this patient has multiple levels of lumbar disc degeneration on MRI scans. Artificial lumbar disc replacement is only U.S. Food and Drug Administration (FDA) approved for single-level disc degeneration. Multiple levels are a contraindication at this time. More outcomes data is needed to support the safety and efficacy of this procedure when there are multiple levels of lumbar degeneration. Given the lack of peer-reviewed medical literature demonstrating the clinical efficacy of the requested L4-5 disc replacement arthroplasty, the requested services are 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 60-year-old female enrollee has requested intensive inpatient neurocognitive rehabilitation program (acute rehabilitation) for treatment of her non-ruptured cerebral aneurysm status post craniotomy/surgical clipping with altered mental status.  Findings:  The physician reviewer found that overall, the medical literature does not support acute rehabilitation services for treatment of this patients cognitive deficits. There is a lack of well-designed studies demonstrating the benefit of acute inpatient neurocognitive rehabilitation over outpatient services in patients six months following a brain aneurysm repair. The records indicate that this patient is currently receiving extensive outpatient services in multiple areas. In addition, despite a thorough evaluation, an intensive inpatient neurocognitive rehabilitation program has not been recommended by any of her treating specialists. All told, the requested intensive inpatient neurocognitive rehabilitation program (acute rehabilitation) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested  radiofrequency neurolysis for treatment of her back pain. Findings:  Three physician reviewers found that lumbar medial branch radiofrequency neurolysis is a well-documented procedure which may help with chronic low back pain due to lumbar facet pain.  However, there is a lack of support for the requested services in this clinical setting.  This patient has chronic low back pain and is status post spinal fusion from L3 to L5.  The medical records document lumbar medial branch blocks at L2, L3, L4 and L5 on two separate dates.  However, the records do not document at least 50% reduction of pain following the intervention.  The current medical evidence does not support the requested services in this patients case.  Thus, the requested radiofrequency neurolysis is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Pyridium (phenazopyridine) 200 mg. for treatment of her chronic interstitial cystitis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. A review of current literature and treatment guidelines fails to show Pyridium (phenazopyridine) at any dose is effective of the amelioration of interstitial cystitis symptoms and it is not commonly considered in treatment algorithms. Based on the patients history, Pyridium (phenazopyridine) appears symptomatically valuable for this particular patient. However, there is a lack of medical literature to support any substantive difference between two over-the-counter Pyridium (phenazopyridine) 97.5 mg tablets, as recommended by the Health Plan and one prescription Pyridium (phenazopyridine) 200 mg tablet with regard to equivalence in bioavailability or likely treatment effect. All told, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support Norco in this clinical setting.  Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Chronic opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested rhizotomy (radiofrequency neurolysis) of the sacroiliac joint for medical reatment of her back pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has had positive results with facet joint injections. In addition, the medical literature supports the requested services in this clinical setting. Therefore, the requested services are 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 63-year-old male enrollee requested acupuncture for treatment of his tinnitus.   Findings:  The physician reviewer found that currently, there are no known effective medications to treat tinnitus (Baguley, et al). A thorough search of recent peer-reviewed medical literature reveals that acupuncture can improve tinnitus in some well-selected patients (Rogha, et al). Consequently, an acupuncture trial for this patients diagnosis of tinnitus is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for a 12-week course of Sovaldi and Olysio. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1A. Findings:  Three physician reviewers found that given that this patient is co-infected with HIV and has previously failed an interferon based regimen, the request for a 12-week course of Sovaldi and Olysio is medically necessary for treatment of his hepatitis C infection.  The U.S. Food and Drug Administration (FDA) approved combination treatment consisting of Olysio with Sovaldi in this clinical setting. For these reasons, the requested 12-week course of Sovaldi and Olysio is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee requested licensed vocational nurse services for 14 hours per day during the week and 8 hours per day on the weekends for medical treatment of the enrollees ataxia, moderate intellectual disability and seizure disorder.  Findings:  The physician reviewer found that in order to provide a safe and secure environment, including medication administration, recognition of distress, and prevention of complications, the requested services are medically necessary.  Although her mother is a trained caregiver, the patient is now the size of an adult and requires two adults to move her, bathe her, and transport her.  This patient requires monitoring of seizure activity, medication administration, and gastrostomy tube feedings.  The services of a licensed vocational nurse are needed to identify subtle seizure activity or signs of aspiration.  All told, licensed vocational nurse services for 14 hours per day during the week and 8 hours per day on the weekends are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested r the OVA 1 test for medical evaluation of her bilateral complex ovarian cysts, right greater than left.  Findings:  Two physician reviewers found that the use of the OVA 1 test in this clinical situation meets the U.S. Food and Drug Administration (FDA) guidelines which state that this test is indicated in women over the age of 18, with an ovarian/adnexal mass and not yet referred to a gynecologic oncologist. Although the OVA 1 test is not designed as a screening test, its greatest utility is in determining whether a gynecologic oncologist should be involved in their surgical care. The medical literature suggests that patients with ovarian cancer whose initial surgery is performed by a gynecologic oncologist have an improved outcome. Thus, the use of the OVA 1 test was likely to have been more beneficial for evaluation and treatment of this patients medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested bariatric surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the National Institute of Health (NIH) consensus guidelines recommended that bariatric surgery should be considered for patients who have a BMI greater than 40, or a BMI greater than 35 in association with major comorbidities such as severe sleep apnea, Pickwickian syndrome, and obesity related comorbidities. According to the documentation submitted for review, the patient presents with clinically severe obesity with a BMI of 41 and comorbid conditions that include hypertension and back pain. Based on the documentation submitted for review, the patient meets the accepted criteria for bariatric surgery. As such, the requested procedure is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested the zoster vaccine for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested zoster vaccine in this clinical setting.  The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention has recommended the zoster vaccine only for patient 60 years of age and older.  In this patients case, the rationale for the vaccine is not clear.  She does not appear to have had a history of zoster, and the relationship between development of leg pain and a chest rash is not obvious.  There is a lack of evidence suggesting that neuropathic pain would be reduced by vaccination.  All told, the requested zoster vaccine is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested carisoprodol 350mg, 180 tablets per 30 days for medical treatment of her back pain.  Findings:  The physician reviewer found that the current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Carisoprodol is a centrally-acting muscle relaxant associated with a high-risk of dependence and tolerance.  Therefore, long-term administration of this medication is not recommended.  In the study by Gatch and colleagues, the authors noted that carisoprodol treatment resulted in tolerance and antagonist-precipitated withdrawal.  Centrally-acting and addictive muscle relaxants are more likely to cause adverse outcomes.  All told, the requested carisoprodol 350mg, 180 tablets per 30 days is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested electric powered for medical treatment of her skin cancer.  Findings:  Three physician reviewers found that electric powered brachytherapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has basal cell carcinoma of skin which can be treated with conventional external beam radiation therapy. Electronic brachytherapy is a novel technique which has been used to treat several malignancies including skin cancers. However, there are few published studies supporting safety and efficacy of electronic brachytherapy for skin cancer. In addition, there is a lack of randomized or large cohort trials supporting long term outcome of this treatment compared to conventional well established treatments. Thus in absence of supporting long term outcome data, 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: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee requested residential treatment center for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, a large portion of the patients issues appear to be due to behavioral problems and oppositional actions.  The patient was not having active suicidal ideation or behaviors or thoughts. The patient attended to his activities of daily living in an age appropriate manner. The patient had no reported co-morbidities. The patients family was supportive as they were actively involved in his care and attended family therapy sessions on a regular basis. The patient actively participated in therapy, although with poor insight and obstructive at times. All told, the patient was sufficiently stabilized and could have transferred to a less restrictive setting to obtain continued care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested 120 tablets of buprenorphine-naloxone 8 mg, four times per day (120 tablets for 30 days) for medical treatment of her complex chronic pain syndrome.  Findings:  The physician reviewer found that the request for 120 tablets of buprenorphine-naloxone 8 mg, four times per day (120 tablets for 30 days) was not and is not medically necessary. Suboxone is U.S. Food and Drug Administration (FDA) approved for opioid dependence at a recommended maximum dose of 24 mg per day. In this case, the patient has chronic pain and Suboxone is not FDA-approved for chronic pain. Furthermore, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. Based on the documentation submitted for review and the peer-reviewed literature cited above, the medication quantity at issue was not and 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 13-year-old male enrollee requested somatropin (recombinant human growth hormone) for medical treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has mild constitutional delay and his IGF-I measurement is within normal range. Growth hormone supplementation is not indicated for constitutional delay. In addition, the patient has a normal height percentile for his adult height potential.  Based on the medical literature and the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee requested a functional electrical stimulation (FES) cycle ergometer for medical treatment of the enrollee, who has a spinal cord injury.  Findings:  Three physician reviewers found that the requested device is not likely to be of greater benefit than other treatment options.  This patient is now status post traumatic spinal cord injury.  There is a lack of support for the requested device.  The use of the requested device might carry some increased risk of skin breakdown over insensate areas.  At this level of injury, the patient is expected to be independent at a wheelchair level.  He should be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning.  All told, the requested FES cycle ergometer is not likely to be superior over other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested surgical implantation of naltrexone for medical treatment of her alcohol dependence.  Findings:  Three physician reviewers found that although naltrexone was appropriate and reasonably expected to improve the patients condition and foster longer-term recovery, the particular delivery method was not likely to be more beneficial than any available standard therapy, namely oral or intramuscular preparations of naltrexone.  The medical documentation did not suggest that adherence to oral medication was problematic in this case. All told, the superior efficacy of surgical implantation of the medication naltrexone has not been established.