Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A male enrollee requested ambulance transport services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought ambulance transport.  In this case, the patient called 911 due to abdominal pain associated with nausea and persistent vomiting. In this clinical setting, the patient should not have driven to the emergency department due to his pain, nausea, vomiting, and feeling like he may pass out. Thus, his symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did meet prudent layperson criteria for ambulance transport.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the Zoll Life Vest (automatic external defibrillator vest) for medical treatment of her new onset heart failure.  Findings:  Two physician reviewers found that the patient does not meet the standard American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) criteria for an ICD, as she has a new diagnosis of non-ischemic cardiomyopathy. It is recommended to wait for a period of at least three months to optimize medical therapy before ICD placement. As the patient does not meet criteria for an ICD, she does not meet the criteria for the Life Vest device.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested embolization of hepatic artery and surgical removal of cancerous pancreatic tumor (possible Whipple procedure for medical treatment of his pancreatic cancer.  Findings:  The physician reviewer found that surgical resection of all local/regional disease with negative margins is the only potential treatment to offer a modest chance at long-term survival.   Surgical resection and reconstruction of the common hepatic artery is an option for those rare patients with localized pancreatic cancer of the head/neck of the pancreas to provide a modest chance at long-term survival that would otherwise not be achieved with chemotherapy alone In sum, the request for embolization of hepatic artery and surgical removal of cancerous pancreatic tumor (possible Whipple procedure) is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Treximet 85 mg/500 mg for medical treatment of her chronic migraine. Findings:  The physician reviewer found Treximet is a proprietary combination of 85 mg of sumatriptan and 500 mg of naproxen that is U.S. Food and Drug Administration (FDA) approved for treatment of migraine. In this case, there is a lack of documentation demonstrating the objective degree of success of Treximet or the degree of failure of generic sumatriptan/naproxen combination in terms of degree of relief, need for rescue, and need to re-dose.  In this patients case, a trial of generic sumatriptan and naproxen, or rizatriptan, zolmatriptan, or naratriptan with or without a nonsteroidal anti-inflammatory is reasonable and appropriate. All told, the request for Treximet 85 mg/500 mg is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a skin surface biopsy Cyanoacrylate Adhesion and the following procedures by microscopy: skin scraping, adhesive bands, expressed follicular contents, comedone extraction, hair epilation, punch biopsy, and skin impression for medical treatment of her dermatitis.  Findings:  The physician reviewer found that the requested services, some of which have no relation to skin disease diagnosis or treatment are not clinically indicated. In addition, hair epilation and comedone extraction are considered dermatologic cosmetic treatments.  The patient has a number of complaints and concerns regarding infestation of the skin. It is reasonable that she see a dermatologist to rule out organic skin disease, or an infectious disease specialist to rule out systemic infection. In this case, the requested services are not medically necessary and the Health Plans recommendation to follow-up with her dermatologist is reasonable and appropriate. All told, based on the medical records submitted for review and the peer-reviewed literature, 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 male enrollee requested percutaneous kyphoplasty for medical treatment of his bilateral lower back pain.  Findings:  Three physician reviewers found that The current peer-reviewed medical literature does not support the long-term safety and effectiveness of percutaneous kyphoplasty in this clinical setting. The literature is ambiguous in the support of kyphoplasty except in indications of hemangiomas with collapse, metastatic carcinomas to bone or primary malignancies of bone, none of which have been documented in this patients case. Thus, percutaneous kyphoplasty 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 female enrollee requested the cool/ice unit intermittent limb compression device for medical treatment of her status post ankle fusion surgery.  Findings:  The physician reviewer found that the cool/ice compression unit was utilized after ankle surgery. The device is indicated to reduce swelling and pain. Block reports that cryotherapy and static compression is commonly used for acute injuries as this intervention is thought to be most effective if applied almost immediately after injury or at the conclusion of an operative procedure. There is also benefit noted in the post-operative period. In sum, despite the limited clinical records submitted, the device at issue was medically necessary for treatment this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested acupuncture for medical treatment of her upper back and shoulder pain.  Findings:  The physician reviewer found that neither the number of prior acupuncture sessions nor the benefits obtained with such care were documented.  The request for additional acupuncture did not include current examination findings, orthopedic tests performed, or functional-motor-sensory deficits to be addressed by the acupuncture requested.  Although there is peer-reviewed literature that supports acupuncture as appropriate for the shoulder, there is a lack of documentation of examination findings, significant orthopedic tests results and functional deficits in order to demonstrate the necessity of the requested services.  All told, the requested acupuncture is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested 15 hours per week of applied behavior analysis (ABA) therapy, occupational therapy (twice per week) and speech therapy (twice per week) for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that based on the documentation submitted for review, a diagnosis of autism has not been established. The patient has had several evaluations with most reporting a diagnosis of ADHD. The speech therapy report, occupational therapy report and both neurology reports note the patients problems with focus and moving around the room. The patient was reported to have good social reciprocity and good eye contact. The description of this patient is not consistent with a patient with autism. Moreover, the evaluation performed  most recently, diagnosing the patient with autism does not comment on his significant problems with inattention. This evaluation also did not utilize the Diagnostic and Statistical Manual of Mental Disorders (DSM)-V. In sum, this patient presents with findings consistent with ADHD with oppositional and disruptive behaviors; therefore, the requested services are not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested Afirma FNA Thyroid Analysis testing for medical evaluation of her thyroid nodule.  Findings:  Two physician reviewers found that in this case, the patient was facing total thyroidectomy if malignancy was present and only a subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted to Veracyte for gene expression analysis. The gene expression test done by Veracyte has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). The overall conclusions of the last two cited studies are that unnecessary thyroid surgeries may actually be prevented by implementation of the gene expression test. The studies are well conducted and their utility demonstrated in the medical literature. In this case, the Afirma test performed was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested occupational therapy (twice per week), speech therapy (twice per week) and 15 hours per week of applied behavior analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this patients case.    In sum, the requested occupational therapy (twice per week), speech therapy (twice per week) and 15 hours per week of applied behavior analysis (ABA) therapy are medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A male enrollee requested urgent care services on an emergent basis. Findings:  The physician reviewer found that this patient presented to the urgent care in no acute stress, with symptoms of watery stool present for five days and with no vomiting. In this clinical setting he could have made an appointment with his primary care physician for evaluation. The patient did not have fever, vomiting, weight loss, and his vital signs were normal. Moreover, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, the services did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested wireless capsule endoscopy of the gastrointestinal tract for medical evaluation of her abnormal weight loss with lower abdominal pain and history of celiac disease.   Findings:  Two physician reviewers found that in this patients case, the indication for wireless capsule endoscopy is not her abdominal pain, but to reassess her celiac disease that has proven symptomatically refractory to gluten restriction. Accordingly, the requested wireless capsule endoscopy is likely to be more beneficial for evaluation of the patients medical condition than any standard approach.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that based on the information provided, which includes two non-invasive assessments of liver fibrosis, the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.  He is unlikely to gain meaningful benefit from eradication of hepatitis C, and his prognosis is excellent.  This patient should have significant fibrosis in order to warrant treatment with Harvoni.  In this clinical setting, longitudinal assessments via noninvasive measures of fibrosis are medically appropriate.  All told, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found thatTMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder and has been approved by the U.S. Food and Drug Administration (FDA).   Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice. Further, since the patient has responded well to the therapy in the past, it is reasonably expected that the intervention will improve her condition and prevent a more serious episode of illness. In sum, the request for TMS is medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested mental health residential treatment for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patient had attempted treatment in the outpatient setting.  However, his alcohol and cocaine use dominated his daily routine, negatively impact his relationships and caused significant impairment across multiple domains of functionality.  His social and living environments were unable to support sober living.  Further, his drinking jeopardized his health and possibly the safety of others.  Finally, the patient had multiple co-occurring psychiatric conditions which compromised his prognosis.  He was described as minimizing his situation and lacking coping skills.  He continued to struggle with poor frustration tolerance and feelings of inadequacy.  Based upon the medical records, in the absence of residential programming, the patient was likely to have promptly relapsed.  All told, mental health residential treatment was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested epidural steroid injections for medical treatment of her degenerative joint disease. Findings:  The physician reviewer found that the records document that this patient has attempted physical therapy in the past with documented aqua therapy. MRI demonstrated degenerative disc disease, with vacuum disc, foraminal narrowing and arthropathy with spondylisthesis. However, the provider noted that the patients pain is mainly into the low back and buttock, and it does not appear that this patient has pain from radiculopathy. Without documented radiculopathy or radiculitis, the use of epidural steroids in this case is not indicated. All told, the requested ESI are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested therapy, once per week (code 90834) for medical treatment of his social anxiety disorder.  Findings:  The physician reviewer found that the patient has requested weekly psychotherapy.  The requested service is recommended by the peer-reviewed literature.  The requested service is safe, appropriate and consistent with good medical practice.  The frequency of the service is within typical practice standards.  It is reasonably expected that this patient may benefit from the intervention.  All told, the requested therapy, once per week (code 90834) is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested genetic testing for medical evaluation of his rectal cancer. Findings:  Two physician reviewers found that in patients diagnosed with colon cancer at a young age the odds of carrying a HNPCC mutation are increased, and as such, the revised Bethesda criteria recommend screening for HNPCC, with IHC and/or MSI, in any individual diagnosed with colon cancer younger than age 50. In this regard, the patient is eligible for screening with MSI and/or IHC. In cases where tumor tissue is not available for screening with MSI or IHC, it would be reasonable to proceed directly to genetic screening of the HNPCC-related genes. Screening for other non-HNPCC related genes included in the ColoNext panel has no proven clinical role, and are not clinically indicated. Testing for epithelial cell adhesion molecule (EPCAM) gene mutations, which are implicated in HNPCC, are not relevant in this case given that the IHC screen was intact. In sum, testing for HNPCC-related deleterious gene mutations of MLH1, PMS2, MSH2, and MSH6 were clinically indicated and likely to be more beneficial than other modalities. However, the other non-HNPCC related genes in the panel do not demonstrate a clinically proven role and were not likely to be more beneficial for evaluation of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested a computed tomography (CT) scan for medical evaluation of his prostate cancer.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of CT of the abdomen and pelvis in this clinical scenario where there is low risk for lymph node involvement.  The requested CT of the abdomen and pelvis is not medically necessary as the yield of imaging in the setting of little clinical risk of metastatic lymph node spread is very low.
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 according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Harvoni has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. In this case, the patient presents with chronic HCV genotype 1b and is treatment-naive with non-invasive testing demonstrating advanced fibrosis. Therefore, Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested 12 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested services. Significant attempts have been made to increase his social skills, both in and out of school. Out of school he is involved in a martial arts program, dance classes, and church activities. In school he has joined a film club. In this clinical setting, the emphasis should be to increase the patients social integration. Therefore, the Health Plans authorization of 8 hours per week of ABA therapy is medically reasonable and appropriate; the medical necessity of the requested 12 hours per week of ABA therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested inpatient psychiatric hospitalization services for medical treatment of his major depressive disorder status post pedestrian versus motor vehicle accident.  Findings:  The physician reviewer found that the documentation provided did not substantiate the medical necessity of acute level of care services. The documentation included a medication list and a history and physical, but did not include important elements such as a psychiatric assessment, treatment plan, physician impression and daily progress notes. Overall, there was no report of suicidal ideation, homicidality, psychosis, delusions, paranoia, rumination, anxiety, insomnia or disordered thinking. Further, the extent and outcome of evidence-based therapies and community interventions in less restrictive settings during the episode of illness was not detailed. Thus, there is a lack of evidence to suggest that the absence of acute hospitalization would have resulted in significant morbidity and likelihood for re-admission. Since modern psychiatric practice favors community-based treatment as outcome measures and therapeutic gains are optimized in this environment, inpatient psychiatric hospitalization services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested (temsirolimus) Torisel for medical treatment of her recurrent clear cell ovarian cancer. Findings:  The physician reviewer found that recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that regimen selected by molecular profiling offered a 27% survival advantage. Based on this information, this patient was prescribed Torisel in combination with Alimta. Both of these agents have activity against ovarian cancer and clinical trials have demonstrated their safety as well (Takano, et al). All told, Torisel is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 24-week course of Sovaldi 400 mg and ribavirin 600 mg for medical 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 (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated - except those with life expectancy less than 12 months due to nonliver-related comorbid conditions (Class I, Level A recommendation). For the reasons provided, the request for the proposed medication combination is medically necessary for treatment of the patients HCV.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested unicompartmental/total knee replacement of the left knee for medical treatment of her knee pain.  Findings:  The physician reviewer found thatthis patient has failed conservative measures, including nonsteroidal anti-inflammatory medications and steroid injections.  Prior interventions have not significantly influenced the patients bilateral knee pain.  The current medical evidence supports either unicompartmental arthroplasty or total knee arthroplasty in this clinical setting.  All told, the requested services are medically indicated for the treatment of this patient.