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

A 53-year-old female enrollee has requested Baraclude (entecavir) 0.5 mg tablet for treatment of her hepatitis B virus.  Findings:  The physician reviewer found that Tenney and colleagues reported results for over five years of therapy showed that in nucleoside-naive patients, the cumulative probability of genotypic entecavir resistance (ETVr) and genotypic ETVr associated with virologic breakthrough was 1.2% and 0.8%, respectively. The authors concluded that Long-term monitoring showed low rates of resistance in nucleoside-naive patients during 5 years of [entecavir] ETV therapy, corresponding with potent viral suppression and a high genetic barrier to resistance. These findings support [entecavir] ETV as a primary therapy that enables prolonged treatment with potent viral suppression and minimal resistance. Although the goal of treatment end-point of therapy for patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B includes HBeAg seroconversion, the HBeAg seroconversion rate seen in clinical settings for oral nucleosides appears much lower than  the 15% to 22% after one year of oral nucleosides reported in pivotal trials (Lin, et al). Lin and colleagues study concluded that, HBeAg-positive patients should be counseled about the high possibility of the long treatment duration required to achieve recommended treatment end-points. Accordingly, Bang and Kim note The correct choice of a first-line treatment of high potency and with a high genetic barrier to achieve sustained long-term suppression of viral replication provides the best chance of preventing treatment failure and the emergence of drug resistance. This is the providers intention with the recommendation for continuing Baraclude for this patient. Therefore, the medical necessity of the requested medication has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested Celebrex 200 mg twice per day for treatment of her spinal cord injury (SCI) at C3-4.  Findings:  The physician reviewer found that Celebrex 200 mg twice per day is not medically necessary for treatment of this patients SCI. The medical literature states that non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for osteoarthritis at the lowest dose for the shortest period in patients with moderate to severe pain to prevent or lower the risk of complications associated with cardiovascular disease and gastrointestinal (GI) distress. Celebrex is a cox-2 inhibitor NSAID. The scientific data supports use of cox-2 inhibitor NSAIDs for patients with a history of gastroesophageal reflux disease (GERD), or those at increased risk for GI ulcers or bleeding. Laine evaluated the role of cox-2 inhibitors and reported that these agents reduce the rate of endoscopic ulcers as compared to traditional NSAIDs. Brown and colleagues performed a retrospective study to assess the relative effectiveness for prevention of NSAID-induced GI toxicity. The authors found that cox-2 specific inhibitor NSAIDs are better at preventing GI complications than non-selective NSAIDs. However, the medical records provided for review do not document the length of time this patient has been on Celebrex. Additionally, there is no documentation of an increased GI risk requiring a cox-2 inhibitor in lieu of a standard NSAID. All told, the medical records do not support the medical necessity of the requested Celebrex 200 mg twice per day.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee requested 15 hours per week of direct applied behavioral analysis (ABA) and 4 hours per month of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  While this patient has made significant gains in behavior with ABA services, he continues to present with specific maladaptive traits that need to be addressed.  Moreover, the services provided in the school through the patients IEP are unrelated to the services needed per his behavioral health treatment plan.  All told, the requested 15 hours per week of direct ABA and 4 hours per month of supervision are medically necessary for treatment of the patients autism spectrum disorder.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee requested the Medtronic Pump, E0784, A9277, and A9276 x 90 for medical treatment of his diabetes.  Findings:  Two physician reviewers found that the main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia.  It can be used to prevent potentially dangerous consequences of uncontrolled diabetes.  Continuous glucose monitoring systems have been shown to improve hemoglobin A1C levels of diabetic patients.  The requested device is likely to benefit the patients health and prevent complications from diabetes, including reduction of the frequency of hypoglycemic events.  All told, the requested Medtronic Pump, E0784, A9277, and A9276 x 90 is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee requested genioplasty (CPT code 21123) for treatment of the enrollees bilateral temporomandibular joint (TMJ), adolescent internal condylar resorption (AICR), mandibular hypoplasia, and maxillary hypoplasia.  Findings:  The physician reviewer found that the patient has been diagnosed with bilateral condylar resorption, which is a maxillofacial skeletal deformity. Per the notes provided, the patient also has documented OSA. The surgery including the genioplasty was appropriate for the patients condition. The procedure was likely to result in improved musculoskeletal and dento-osseous relationships. Moreover, the procedure should provide an improved airway, including improvement of signs and symptoms of sleep disordered breathing. For these reasons, the genioplasty was medically necessary for treatment of this patients medical conditions. Moreover, performance of the genioplasty will help correct the patients developmental abnormality and create a more normal appearance. Consistent with these findings, the genioplasty performed was reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested eating disorder partial hospitalization program (PHP) services for treatment of her post-traumatic stress disorder (PTSD), bulimia, and depression.  Findings:  The physician reviewer found that the records indicate this patient has complex psychopathology and a tendency to deteriorate rapidly and severely when the level of care is reduced too quickly. Aside from her needs for psychotherapy, structure, and monitoring of her mood and suicide risk, she has been monitored using the Clinical Institute Withdrawal Assessment (CIWA) scale, a process that tends to require inpatient admission. Further, this patients potential for delirium tremens supports treatment at the PHP level of care. For these reasons, the PHP services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested an insulin pen for treatment of her diabetes. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested insulin pen in this clinical setting.  There is evidence in the literature indicating that insulin pens are superior to use of insulin vials and syringes.  Insulin pens improve patient compliance and diabetes management.  Based upon the medical records, the insulin pen is medically appropriate to deliver meal insulin for this patient.  Her diabetes is suboptimally controlled, given her medical problems and poor insulin regimen.  This patient is active and self-adjusts her insulin dosage.  There is sufficient support for the use of an insulin pen in this clinical setting.  All told, the requested insulin pen is medically indicated for the management of this patients diabetes.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee requested combination therapy consisting of Sovaldi 400 mg tablets, Ribapak (ribavirin) 200 mg tablets, and Pegasys 180 mcg/0.5 ml injection for medical treatment of her hepatitis C genotype 1a.   Findings:  Three physician reviewers found that the prescribed treatment regimen with Sovaldi, Ribapak, and Pegasys is consistent with the most recent and most standardized treatment guidelines for chronic hepatitis virus. Moreover, this regimen is endorsed by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The treatment is greater than 90% effective and consistent with the standard of care. For these reasons, the requested medications are medically necessary for treatment of this patients chronic hepatitis C genotype 1a.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested total hip replacement with use of the anterior approach for treatment of her osteoarthritis of the bilateral hips.  Findings:  The physician reviewer found that it is medically necessary for this patient to undergo total hip arthroplasty with an anterior approach as recommended by the independent provider. Even though she may require revision, there is no other approach that will provide pain relief for her documented severe degenerative osteoarthritis of the left hip. The history of total hip arthroplasty provides an understanding of the likely benefits of an anterior approach. There is adequate data demonstrating improvement in instrumentation and greater precision in positioning of components through use of the anterior approach. Although not all patients are candidates for an anterior approach, in this specific patient, there is a case to be made for a more predictable outcome through an anterior approach given the providers findings. In summary, it is medically necessary for this patient to have total hip arthroplasty with use of the anterior approach as recommended by the provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee requested mental health residential treatment center (RTC) for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, at the time of admission the patient was completely non-functional.  She had regressed to such a point that she did require 24-hour medical and nursing care. She had already received two years of outpatient psychiatric treatment and several weeks of inpatient treatment. The notes from the end of the disputed time period indicate that progress had been made in ADLs, but much remained to be done. For the reasons provided, the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee requested surgery to replace the right breast implant for medical treatment of her likely implant rupture.  Findings:  The physician reviewer found that although this patients original surgery appears to have been for cosmetic reasons, she is well-documented to have sustained trauma to the implant from a mammogram, as the implant was noted to be intact on the radiographic assessment and ruptured on later examination shortly thereafter. Thus, trauma is the cause of the patients documented breast asymmetry. Correcting this rupture as a direct result of trauma from a mammogram is expected to reestablish normal breast symmetry and likely to provide more than a minimal improvement in the appearance of this patient. Accordingly, the requested right breast implant replacement procedure meets criteria for reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested substance abuse rehabilitation residential treatment services for treatment of his substance abuse treatment.  Findings:  The physician reviewer found that the substance abuse rehabilitation residential treatment services were not medically necessary for treatment of the patients medical condition. On admission to residential treatment the patient was not in withdrawals nor was he at risk for the development of withdrawals. His psychiatric comorbidity was not of a severity that required 24-hour supervision in a restricted setting. Medically he was stable. There was no homicidal ideation, plan, or intent, and he did not represent a danger to others. Although his psychosocial assessment indicated suicidal ideation without plan or intent, ongoing passive suicidal ideation is a hallmark feature of many psychiatric illnesses. In and of itself it does not constitute a rationale to admit a patient to a residential setting without the presence of concomitant aggressive behavior, intent, planning, substance abuse and withdrawal. In regards to the incident where the patient drank rubbing alcohol and blacked out, the patient specifically indicated that this was for purposes of becoming intoxicated and was not suicidal in nature. His cognitive and thought processes were intact and there was no risk of impairment in the patients self-care capabilities. He required structure to work on issues such as coping mechanisms, relapse triggers, and accepting consequences for his actions, however this could have been accomplished at a lower level of care. His family was supportive of his treatment and recovery and he had been seeing a psychotherapist weekly since 2012. In sum, the patient did not meet American Society of Addiction Medicine criteria for residential level of care. He did not require 24-hour monitoring and he could have received treatment at a lower level of care with augmentation by supportive and structured community based resources such as Alcoholics Anonymous. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested rhizotomy for treatment of his back pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. According to Chan and Peng, failed back surgery syndrome is a challenging clinical entity with significant impact on the individual and to better prevent and manage this condition, knowledge of the factors contributing to its development is necessary. In regards to postsurgical spine syndrome, Ordia and Vaisman indicates that the degenerated disc collapses causing misalignment of the facet joint which could result in facet pain. The authors note that diagnostic facet medial branch injections may help to determine who may benefit from radiofrequency rhizotomy. However, according to Huang and colleagues, Lumbar facet joint injection has a characteristic appearance and can be distinguished from epidural injection. However, since this event can simulate the appearance of a successful [epidural injection injection] ESI, it may be unrecognized during the procedure. This suggests that epidural blocks should not be performed on the same day of treatment as facet blocks as this may lead to improper diagnosis or unnecessary treatment.  In this case, the patient underwent concomitant L4-5 lumbar epidural steroid injection in addition to L4-S1 medial branch blocks in a singular session. While the notes indicate the patient had relief from the injections for a period of one to two days, there is no clear indication that the patient had benefit strictly from the medial branch blocks to support the recommendation for rhizotomy. Given the above, the rhizotomy was not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 53-year-old female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the use of balloon ostial dilation in this clinical setting. There is a lack of evidence in the medical literature that demonstrates balloon sinus ostial dilation is more efficacious than standard FESS when utilized in a patient with chronic sinus disease who has already undergone multiple sinus procedures. In such a setting the ostia may or may not already be patent and, if not, the restenosis of ostia is complicated by the presence of cicatrix and/or polypoid tissue regrowth. As such,  balloon sinus ostial is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested functional endoscopic sinus surgery (FESS) for medical treatment of her chronic sinusitis.  Findings:  The physician reviewer found that patients with symptoms of recurrent, refractory and chronic rhinosinusitis should have documentation of medical therapy for at least four weeks including antibiotics. Medical therapies including intranasal topical steroids, oral steroids, antibiotics, and other medications should be documented including the results of those medical treatments. Although the patients surgeon reported that the patient received a course of levofloxacin, the patients response to that therapy was not provided for review. In addition, there is no documentation showing the patient received antibiotics or results of the treatment. In the absence of documentation of prior medical therapies and response to those therapies, the medical necessity of the services at issue has not been established in this clinical setting.  Therefore, the services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested an abdominoplasty and a panniculectomy for medical treatment of her abdominal pannus. Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.  The requested panniculectomy is medically necessary for treatment of the patients medical condition. The history of pannus skin infection and the photographic evidence of a chronic skin condition related to a large hanging pannus support the medical necessity of a panniculectomy in this patient.  Therefore, a portion of the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old transgender female enrollee requested facial feminization surgery for treatment of the enrollees gender identity disorder.  Findings:  The physician reviewer found that the World Professional Association for Transgender Health (WPATH) Standards of Care indicate that some procedures that may be considered cosmetic under some circumstances are medically necessary under other circumstances.  A specialty therapists evaluation is an essential component of that determination. In order to establish the medical necessity and/or the reconstructive nature of the requested services, there must be documentation of the following:  One or more consults or letters of support from licensed individuals with experience in transgender therapy and issues (such as a licensed Psychiatrist, Psychologist or Licensed Family Therapist) which includes: Summary of the patients mental health assessment and mental health history; Discussion of the patients gender history, gender procedure history and response to prior procedures with regard to alleviation of gender dysphoria symptoms; and assessment of current symptoms of gender dysphoria specific to the facial areas considered to be masculine and in request of therapy (i.e., To what degree does the patient experience gender dysphoria relative to her forehead/brow shape, jawline and chin, prominent tracheal cartilage, nose, and/or other specific aspects of her facial appearance?).  In the absence of documentation from a specialty clinician establishing a connection between the patients gender dysphoria and the specific areas of treatment, the medical necessity and/or reconstructive nature of the requested services cannot be established at this time. Once the above information is obtained, the patient's request for facial feminization surgery should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee requested the medication combination Sovaldi 400mg and Olysio 150mg for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication combination.  Based upon examination, laboratory testing, radiology evaluations, and endoscopy, the patient has cirrhosis.  He is not eligible for interferon-based regimens due to depression and severe thrombocytopenia.  This patient would benefit from eradication of hepatitis C, as his risk for further decompensation and hepatocellular carcinoma will be attenuated.  All told, the requested medication combination Sovaldi 400mg and Olysio 150mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a portable air concentrator (backpack) for treatment of his chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested equipment. This patient requires continuous oxygen therapy. His room air oxygen saturation is less than 88% and he currently uses three liters per minute of oxygen via nasal cannula. The patient is also physically unable to push a portable tank without severe pain. The patient has documented physical limitations to pushing or pulling an oxygen tank with wheels, while he uses a cane. The requested backpack air concentrator will likely improve his mobility and decreases his pain associated with ambulation.  The patient indicates that he usually goes out in the early morning or early evening, so the backpack unit is being requested for more than physician visits. In addition, the home health companys request to surrender his home oxygen unit with humidifier that he uses around the house in order to obtain the backpack unit is not medically reasonable or appropriate in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested portable air concentrator (backpack) is medically necessary for treatment of the patients medical condition.