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

A 57-year-old female enrollee has requested a scooter (power operated vehicle) and ramp for medical treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, there are no indications that the patients mobility was assessed in detail by her physicians or by a physical or occupational therapist.  There are no objective indications that the patient is unable to manage her basic household mobility by ambulating, using a walker.  There is a lack of documentation of musculoskeletal or cardiovascular impairments that would preclude the use of an optimally fitted manual wheelchair allowing for bimanual propulsion (or bimanual and bipedal propulsion), for accomplishing her mobility related activities of daily living if the walker is insufficient for her mobility needs.  Overall, the records do not establish that the patient would be bed or chair confined without a power mobility device.  Additionally, physical activity is generally appropriate for general musculoskeletal health and for chronic pain syndromes.  All told, the requested scooter (power operated vehicle) and ramp are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, this patient fits in to the unique patient populations who develop recurrent HCV infection post-liver transplantation. In addition, given his status as a post-liver transplant patient, the patient qualifies for AASLD/IDSA's Highest Priority for immediate treatment of his HCV. Therefore, the requested medication is medically necessary for this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee requested services on an emergent or urgent basis for medical treatment of her metastatic neuroendocrine tumor with carcinoid syndrome. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patients decision to seek care in Switzerland was consistent with the actions of a prudent layperson in this setting. Although the patient's medical condition may not have been emergent, her symptoms meet the urgently needed criteria given that the services at issue were necessary to prevent serious deterioration as no available treatment options existed for her in the United States. The record demonstrates that a CT scan revealed moderate disease progression. Given the nature of the disease, limited options for the patient in the United States, and a viable option that existed for her in Switzerland, the services at issue were urgently need to prevent serious deterioration. In sum, a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Therefore, the services at issue meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee requested post-acute neuro/brain rehabilitation for medical treatment of his traumatic brain injury (TBI).   Findings:  The physician reviewer found that the patient has had substantial neurocognitive residuals from TBI, with impaired concentration and cognitive fatigue. He has completed acute rehab, skilled nursing facility rehabilitation, and home therapies. He has potential for further gains as noted by neuropsychological assessment. The medical literature notes long timelines for recovery after TBI, with potential for better recovery with structured rehabilitation programs. Based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested compound high blood pressure medication for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation submitted for review fails to demonstrate the patient has a medication allergy, known side effect or other common adverse drug reactions. It is possible that she may have an intolerance as noted by her allergy referral, however the symptoms seem to wax and wane and have preceded the medications. After a thorough review of the literature, there is only one case of a true drug allergy to magnesium stearate reported in a patient who presented with symptoms of hives (Tammaro, et al). However, there are no other types of reactions documented to this compound. The patient does have a history of intolerances to many other medications. An option may be to try another class of blood pressure medications. As such, the request for compounded amlodipine and atenolol without magnesium stearate for a presumed sensitivity is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a portable oxygen device (E1390) for treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that the requested device is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has mild obstructive sleep apnea (OSA) and a listed diagnosis of congestive heart failure (CHF). The standard of care for the treatment of OSA is continuous positive airway pressure (CPAP). The criterion for the treatment of OSA with CPAP is an AHI of 15 or greater. In this case, the patients estimated AHI during the home sleep study was 9.  However, for patients with hypertension, cerebral vascular accident (CVA) or heart disease, the criteria for treatment with CPAP is changed to an AHI of 5 or greater. Therefore, the patient meets criteria for treatment with CPAP because of the listed diagnosis of CHF. Thus, the standard of care treatment for this patients nocturnal, mild hypoxia is CPAP, not oxygen. Thus, oxygen during sleep is not clinically indicated. Although, it would be substantiated if despite treatment with the optimal setting of CPAP the patient continued to have significant hypoxia. However, there is no documentation to substantiate this. Furthermore, a portable oxygen device is indicated by objective documentation that during ambulation the patient has an oxygen saturation of 89% or lower. There is no documentation of hypoxia on ambulation. Therefore, she does not meet criteria for a portable oxygen device. Based on the medical literature and documentation submitted for review, requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested platelet-rich plasma injection treatment for treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  There is a paucity of medical evidence to support the safety and efficacy of platelet-rich plasma injections into the lumbar spine or facet joints.  Additionally, the patient has multiple pathological findings on the MRI contributing to her chronic pain condition, making the injection of platelet-rich plasma less likely to beneficial.  In sum, there is a lack of support for the requested services in this clinical setting.  All told, the requested platelet-rich plasma treatment is not likely to be superior over other available alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A female enrollee requested vaginal birth for medical treatment of her breech presentation.  Findings:  The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) committee opinion in regards to the mode of term singleton breech delivery issues the following recommendations: Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented.  Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient's informed consent should be documented. In this case, the patient has been counseled regarding the risks of vaginal breech birth and the risks of cesarean section. The patient has indicated that a non-Plan provider and facility has experience with vaginal breech deliveries and is willing to offer this option to her.  Based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested  a discography (procedure codes 72295 and 62290) to prepare for a platelet-rich plasma treatment for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that the patient reported lumbar spine pain.  She described it as constant, severe, and caused her to have trouble walking, eating and sleeping.  The current medical evidence does not support the requested discography in this clinical setting.  Carragee and colleagues reported that In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (non-injected) discs.  There is a lack of a recent clinical notes submitted for review.  In this patients case, the records do not provide an adequate description of the intended level(s) for the proposed discogram.  In addition, given the annular tear at L4-5, the discogram would be non-diagnostic at that level.  All told, the medical necessity of the requested discography has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings:  Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America 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. In addition, the guidelines further indicate that Harvoni is recommended for treatment- naive patients with HCV genotype 1a infection. In this case, the patient has a HCV genotype 1a with a Metavir score of F2-F4 and is treatment naive. Therefore, treatment with Harvoni is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested the brand name medication Diovan 160mg for medical treatment of his hypertension.  Findings:  The physician reviewer found thatthe documentation provided in the medical records does not support that there has been intolerance to or inefficacy of the specific formulary medications referenced by the Health Plan.  Generally, generic alternatives to the brand name medication Diovan have been demonstrated to be of equal effectiveness in treatment of hypertension.  Generic alternatives contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name medication with respect to pharmacokinetic and pharmacodynamic properties.  Moreover, side effect profiles of the formulary medications would not typically include symptoms of chest discomfort or dyspnea that the patient has reported.  Therefore, the requested brand name medication Diovan 160mg 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 Harvoni 90mg-400mg for medical treatment of her hepatitis C. Findings:  Two physician reviewers found that in this patients case, the requested medication is not medically necessary.  The medical records do not include the results of a recent liver biopsy or non-invasive testing to determine the severity of her fibrosis.  She has no mentioned systemic manifestations of hepatitis C, such as cryoglobulinemia or leukocytoclastic vasculitis.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Harvoni 90mg-400mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested Jardiance and Bydureon for medical treatment of the enrollee, who has diabetes.  Findings:  The physician reviewer found that there is sufficient support for Jardiance and Bydureon in this clinical setting.  The medical records document a history of bariatric surgery and poorly controlled diabetes.  This combination of medications has helped the patient to lose weight and achieve improved diabetes control.  The current medical evidence supports the requested medications for the treatment of this patient.  All told, Jardiance and Bydureon are medically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Harvoni for treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose of Harvoni 90/400 mg is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested posterior tibial nerve stimulation (PTNS) for treatment of her overactive bladder.  Findings:  Two physician reviewers found that this patient has previously undergone surgery for incontinence without substantial improvement. Subsequently, her symptoms persisted after removal of the transvaginal tape. Given that this patient has failed surgery and medical therapy, additional data on her medical condition is needed via complex cystometrics, cystoscopy and video urodynamics to support an indication for the requested PTNS. Accordingly, the requested PTNS is 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 68-year-old female enrollee requested thoracic anterior discectomy with decompression, including osteophytectomy (63077, 22610, 22802, 32100, 63046 and 63048) for medical treatment of her medical condition.  Findings:  The physician reviewer found that the medical records indicate that the patient has experienced pedicle fractures and vertebral body fracture above the levels of prior fusion.  Additionally, she has had multiple surgical procedures and has developed instability following the most recent surgical procedure.  A kyphotic deformity has developed, which is described as increasing in severity.  There is sufficient support for the requested services in this clinical setting.  The failure of posterior elements necessitates a combined posterior and anterior approach.  The current medical evidence supports the planned anterior and posterior exposures and extension of the prior fusion constructs to introduce stability to the patients spine.  All told, the requested thoracic anterior discectomy with decompression, including osteophytectomy (63077, 22610, 22802, 32100, 63046 and 63048) is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested  emergency services for treatment of her rash.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. In this case, the patient presented ambulatory with a pruritic rash for several days. The patient reported to the triage nurse that her eyes were swollen. However, the photos provided for review show what appears to be mild lid edema. In addition, the patient was not in distress. Multiple entries in the record note that she was not having any difficulty breathing or swallowing. The patients symptoms were not acute in onset. She had experienced similar symptoms in the past. A prudent layperson would not have sought medical attention on the date of service in question because the absence of immediate medical attention could not reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested single photon emission computed tomography (SPECT) scan for evaluation of his penile melanoma.  Findings:  Three physician reviewers found that it is generally accepted that sentinel lymph node excision is the most important diagnostic procedure for patients with melanoma.  This can be accomplished by injecting isotope in the periphery of the melanoma and then by obtaining either simple planar images, or by obtaining SPECT images.  Per the current medical evidence, SPECT imaging assists in determining the exact location and visualization of sentinel lymph nodes.  The purpose of the scan is to direct the provider to sample the appropriate node.  In sum, SPECT offers advantages over planar nuclear medicine imaging in identifying sentinel nodes and directing surgical excision.  Therefore, SPECT scan was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee requested one hour of speech therapy at the frequency of 1-2 times per week for medical treatment of the enrollees severe receptive and expressive language delays.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Myers, et al). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Goldstein). Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested emergency services for treatment of her pain.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with left buttock and left leg pain that had been ongoing for three months. Although the patient rated the pain as an 8/10, there was no acute exacerbation of pain or any new neurologic deficits. Moreover, a physical examination did not reveal any acute neurologic deficits or indication for emergent imaging. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested a powered mobility scooter for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed by a physical therapist and it was noted that he could ambulate household distances within the home without an assistive device and could also use a walker with seat as needed.  The current medical evidence does not support the requested equipment in this clinical setting.  The records do not establish that the patient would be bed or chair confined without a power mobility device.  The documentation indicates that the patients in-home mobility needs would be met with a walker with a seat.  Moreover, physical activity is generally appropriate for general musculoskeletal health and for chronic pain syndromes.  All told, the requested powered mobility scooter is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested Harvoni 90mg/400mg for 12 weeks for treatment of his hepatitis C. Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  Per the current medical evidence, successful hepatitis C treatment results in sustained virologic response.  Based upon this patients Metavir score, treatment is indicated.  There is support for Harvoni for patients with hepatitis C, genotype 1 infection who do not have cirrhosis and who have failed prior interferon and ribavirin treatment.  Thus, the requested Harvoni 90mg/400mg for 12 weeks is medically indicated in this patients case.