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

A 57-year-old male enrollee has requested Zohydro extended release (ER) 50mg, #60 for treatment of his arachnoiditis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  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.  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.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose 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, the requested Zohydro extended release (ER) 50mg, #60 is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee  requested the combination medications ribavirin, Sovaldi, and Pegasys for medical treatment of his hepatitis C genotype 4.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines allow for a delay in treatment for some patients with documented early fibrosis stage, because waiting for future highly effective, pan-genotypic, DAA combinations in interferon-free regimens may be prudent. However, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy to prevent further progression of disease. Per AASLD/IDSA guidelines, few data are available to help guide decision making in patients infected with HCV genotype 4. The guidelines indicate that treatment naive patients with HCV genotype 4 who are eligible to receive interferon should include daily sofosbuvir and weight-based ribavirin plus weekly Pegasys for 12 weeks. Given these findings, the requested medication combination therapy including ribavirin, Sovaldi, and Pegasys is medically necessary for treatment of this patients chronic hepatitis C.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested oxymorphone HCL 10mg tablets #90 for medical treatment of the enrollees back pain.  Findings:  The physician reviewer found that oxymorphone HCL is not medically necessary for treatment of the patients medical condition. Review of the documentation provided demonstrates the patient has a chronic pain condition secondary to lumbar degenerative disc disease. Additionally, the patient has a history of liver disease due to hepatitis C virus. As a result, the patient needs to avoid products containing acetaminophen, non-steroidals and most medications metabolized by the liver. The submitted records indicate that the patient cannot tolerate Butrans or Norco; however, there was no documentation of failure to other medications including oxycodone, morphine or methadone - all of which have a high safety profile in patients with liver failure and are FDA-approved in low doses for moderate to severe chronic pain, particularly due to spinal and joint pain. Given the availability of medically appropriate alternatives, oxymorphone HCL 10mg tablets #90 is not medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested the compounded prescription drug tobramycin sulfate for the treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the current medical evidence does not support the medication in this clinical setting.  Per the peer-reviewed medical literature, the use of topical intranasal antibiotics is no more effective than topical nasal saline in this patients case.  The current medical literature suggests that the addition of topical intranasal antibiotics is no more beneficial than intranasal saline alone in the management of symptoms of purulent nasal discharge following sinus surgery.  Additionally, there is a lack of evidence that the patient had clinically positive bacterial growth requiring either oral or other topical antibiotic usage.  The provider stated that previous nasal cultures had shown bacterial growth, but there is no documentation of the results of those cultures.  All told, the compounded prescription drug tobramycin sulfate was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested tramadol ER 100 mg for medical treatment of the enrollees chronic pain status post bilateral hemi surgery and right hallux implant surgery.  Findings:  The physician reviewer found that tramadol ER 100 mg is not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has non-malignant chronic postsurgical pain. 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.  Ballantyne and Mao reported that prolonged use of high dose 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. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address chronic pain. Consistent with these findings, the requested tramadol ER 100 mg is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested hyperthermic administration of intraperitoneal chemotherapy (HIPEC) for medical treatment of the enrollees ovarian cancer.  Findings:  Two physician reviewers found that the superior efficacy of the requested services has not been established.  The National Comprehensive Cancer Network guidelines do not include the use of HIPEC in their recommendations for post-surgical management of resected ovarian cancer.  Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option, specifically in cases where surgical debulking was suboptimal.  There is a lack of high-quality prospective trials showing benefit of HIPEC over standard treatment options.  All told, the requested HIPEC is not likely to be more efficacious than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested oral chemotherapy with Afinitor for medical treatment of the enrollees recurrent highly anaplastic pinealoblastoma.  Findings:  Two physician reviewers found that there is a paucity of clinical evidence supporting the use of Afinitor in the treatment of pinealoblastoma. The National Comprehensive Cancer Network (NCCN) treatment guidelines have not included Afinitor in its recommendations for patients with pinealoblastoma. All told, the peer-reviewed medical literature has not demonstrated that treatment with Afinitor is 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 60-year-old female enrollee requested repeat epidural injection, herniated discs (L2-3) and discs bulge (L3-4) for medical treatment of the enrollees lumbar radiculopathy.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The clinical documentation submitted for review indicates that the patient received a transforaminal epidural steroid injection at the L2-3 and L3-4 that initially provided complete pain relief. Subsequently, the patient was examined with increasing pain complaints.  It was noted that a different approach would be taken in an attempt to provide pain relief to the patient; a recommendation was made for lumbar interlaminar epidural steroid injection. However, according to the American Academy of Pain Medicine there is not a significant difference between a transforaminal and interlaminar approach. Therefore, a different result would not be expected from an injection with a different approach. As the patient did not have a significant response to the initial injection, it is unclear how an additional injection would assist in avoiding surgical intervention. Furthermore, the patients most recent clinical evaluation did not provide any physical findings of radiculopathy correlating with the nerve pathology identified on the MRI. There is no documentation of motor strength weakness, sensation deficits, or decreased reflexes. Therefore, an additional epidural steroid injection would not be supported by the peer-reviewed literature. As such, the request for repeat epidural injection, herniated discs (L2-3) and discs bulge (L3-4) is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee requested buprenorphine/naloxone (Suboxone) film or tablets for medical treatment of the enrollees opioid dependency. Findings:  The physician reviewer found that the limited records available for review on this patients substance abuse history do not support the medical necessity of the requested buprenorphine/naloxone (Suboxone) film or tablets. There is a lack of documentation on the patients pattern of abuse including the quantity and length of time, withdrawal symptoms, the presence of medical or psychiatric comorbid conditions, titration of Suboxone to the current dose, and the patients response to treatment. Moreover, it is unknown whether the patient has participated in prior treatments or detoxifications. Based on records provided for review, the medical necessity has not been established for the requested buprenorphine/naloxone (Suboxone) film or tablets for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee requested Nutropin AQ NuSpin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patients fall-off in growth velocity occurred at a time of concomitant weight loss and complaints of abdominal pain and diarrhea.  The patients pre-treatment growth factors were normal, he had no known morphological abnormality of the pituitary gland on MRI and he did not fail two standard provocative growth hormone tests.  Thus, he did not meet standard criteria for growth hormone deficiency prior to initiation of growth hormone therapy.  Other causes of the patients transient growth fall-off were not definitely ruled out prior to initiation of growth hormone therapy.  The fact that the patients growth velocity picked up after initiation of growth hormone therapy does not prove that he was growth hormone deficient, as growth hormone was administered after the patient had already started puberty, as evidenced by pubertal levels of gonadotropins prior to treatment.  Thus, concomitant secretion of endogenous sex steroids likely augmented the effect of growth hormone on statural growth.  The patient did not allow for genitourinary examination, and so it cannot be stated with certainty that the patient did not progress in puberty between the pre-treatment evaluation and post-treatment assessment.  All told, the requested Nutropin AQ NuSpin treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 42-year-old female enrollee has requested Irlen spectral filters (glasses) for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The medical literature does not support the requested services in this clinical setting. There is a lack of adequate evidence in the peer-reviewed literature that demonstrates Irlen lenses are a useful intervention in treating the patients condition. Given the lack of support in the medical literature and the documentation submitted for review, the medical necessity for Irlen spectral filters has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested blepharoplasty and ptosis repair for medical treatment of the enrollees bilateral eyelid dermatochalasis and ptosis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Visual field obstruction in the absence of eyelid ptosis signifies a problem in the eyeball itself. Visual field obstruction can also be due to some combination of lid position and excess upper eyelid skin hanging over the eyelid margin. In this case, the patients upper eyelid skin is not excessive enough to cause mechanical ptosis as it does not cover the skin below the palpebral crease. Therefore, upper eyelid blepharoplasty is not medically necessary for either upper eyelid.Although the exam documents MRD of 2 mm on the left and 3 mm on the right, the close-up photos show MRDs of about 2 mm bilaterally. The normal MRD is 4 to 5 mm. Therefore some ptosis is present. The surgical options for treating ptosis without excessive skin include frontalis sling or brow suspension, Fasanella-Servat mullerectomy, and levator surgery (resect or repair). The sling suspension is only indicated when the lid is more than 3 mm below in its normal position and the levator function is less than 4 mm. Given that the levator function is not noted it is not possible to know whether levator surgery or sling suspension would be effective. Therefore the documentation submitted for review does not support the medical necessity of a frontalis to upper eyelid fascial sling. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested blepharoplasty and ptosis repair are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested intensive outpatient program (IOP) services for medical treatment of the enrollees polysubstance dependence, anxiety, depression, and post-traumatic stress disorder (PTSD).  Findings:  The physician reviewer found that episodic placement in more restrictive settings is often clinically appropriate for patients with serious mental and addictive illness. Applying the American Psychiatric Association (APA) guidelines, the records support the medical necessity of IOP services while the patient was actively involved in her treatment; while the providers were mobilizing the patient towards community programming to facilitate a smooth transition to a less restrictive setting; when she met with a psychiatrist resulting in a dose increase of her antidepressant and the addition of an anxiolytic medicine,  and while she was focusing on longstanding issues with her mother which was relevant to the transition plan as the patient resided at home.  Overall, the records indicate that a portion of the substance abuse treatment services provided at the IOP level of care were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee requested substance abuse intensive outpatient program level of care for treatment of the enrollees alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  Although the patient has a significant alcohol use disorder, the documentation provided does not support the medical necessity of the intervention.  A comprehensive treatment plan and thorough intake note were included in the medical records, but daily progress notes and serial assessments were not provided.  Thus, there was no means to assess the patients clinical progress or the appropriateness of the service.  Considering the documentation, and the fact that the patient started an anti-craving medication, had a supportive family, and was described self-motivated for treatment and recovery, the substance abuse treatment services provided at the intensive outpatient level of care are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested immune cell function assay (CPT code 86352) for treatment of his status post open heart surgery. Findings:  Two physician reviewers found that the immune cell function assay testing performed was not likely to be more effective for this patient than other available options. Although the International Society of Heart and Lung Transplantation give a Class IIa recommendation for acute cellular rejection screening using gene expression profiling (AlloMap testing), there is a lack of consensus at this time on the use or value of immune cell function assay testing using a functional T cell assay. In order to assess the value of functional T cell assays in heart transplantation, future prospective studies are needed. Therefore, the services at issue were not likely to be more beneficial than any standard treatments for this patient medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested dermatological medical treatment for a dark spot on his right arm.  Findings:  The physician reviewer found that the patient presented to a dermatologist with reported dark nevi on his arm and trunk. The medical record notes that the dark nevi had been present for approximately 6 to 7 months. During this period, several lesions were biopsied which revealed some dysplasia with no significant melanocytic atypia. The documentation submitted for review does not describe any symptoms of pain, bleeding or rapid changes in the nevi. Additionally, the pathology failed to reveal a malignancy, such as melanoma or severe dysplasia.   In sum, based on the patient's clinical presentation, his symptoms would not cause a reasonable and prudent layperson to believe he or she required immediate medical attention. Thus, the patient's symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested treatment of an injury to his left hand and wrist. Findings: The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis.  This patient presented with a moderate amount of pain to his left hand and wrist. He denied any numbness or other neurologic deficit. He had not sustained any laceration. He denied any systemic symptoms such as trouble breathing, nausea, or fever. No deformity was noted. The patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. There is no evidence the patient was in severe pain or was experiencing any symptoms that needed to be addressed on an immediate basis. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee  requested spinal fusion (20930  allograft, morselized, or placement of osteopromotive material, for spine surgery only; 22552  arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace; 22845  anterior instrumentation; 2 or 3 vertebral segments; 22851  application of intervertebral biomechanical device)  for medical treatment of the enrollees spine.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting.  According to Bambakidis and colleagues, strict prospective studies are needed to determine when a fusion of the degenerative cervical and lumbar spine is indicated.  Patients with severe radicular pain may be considered for surgery after a comprehensive trial of conservative management.  The authors noted that surgery should only be considered after conservative measures have been exhausted and a radiographic abnormality is present at the symptomatic level.  As per the documentation submitted, the most recent physician progress notes were provided, however, the patients physical examination at that time was not provided for this review.  Therefore, there was no objective evidence of a significant musculoskeletal or neurological deficit.  There was no documentation of instability upon flexion and extension view radiographs or electrodiagnostic evidence of cervical radiculopathy.  Without objective evidence of an abnormality and imaging evidence of instability and neurocompression, the medical necessity of the requested services cannot be established.  Therefore, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested Acthar gel injections for medical treatment of the enrollees health condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patients disease, variously described in the medical records as lupus, undifferentiated connective tissue disease, and mixed connective tissue disease, is characterized by pleural effusion, pericardial effusion, ascites, renal disease of unknown classification and stage, and pulmonary hypertension.  The medical records do not support the requested medication in this clinical setting.  In the progress notes, she is described as being in no distress with stable vital signs.  She is on a low dose of prednisone and is on Plaquenil.  The clinical notes do not document auscultation of the heart or lungs or describe a recent chest x-ray, so the degree of pleural or pericardial effusion present cannot be assessed from the medical records. There is no documentation of recent radiographic studies that would help to determine the amount of serositis in this patient.  The patients polyserositis might be treated with higher-dose oral corticosteroids, parenteral corticosteroids, or immunosuppressants such as azathioprine or mycophenolate.  There is no evidence of nephrotic syndrome which may be treated with Acthar gel.  All told, the requested Acthar gel injections are not medically indicated for the treatment of this patient.