Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee requested the Lariat procedure for medical treatment of her atrial fibrillation.  Findings:  Two physician reviewers found that the requested procedure is not likely to be more effective for this patient than other available options. The requested procedure is not supported by the medical literature given the lack of long-term studies demonstrating its safety and efficacy. In addition, it is not clear, based on the existing data, whether the Lariat device lowers stroke risk (January, et al). In this case, there is also the possibility that the patient may be able to tolerate less intensive anti-coagulation with anti-platelet therapy. Based on the medical literature cited above and the documentation submitted for review, the requested Lariat procedure is not likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee requested mental health residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the medical records indicate that the patient was cooperative with her treatment and processed information well.  She was not noted to be suicidal or homicidal.  She had two episodes of cutting during the month of treatment.  In each case, she was able to process the information in group and individual therapy and understand the stressors that led her to her decision to cut.  She did not exhibit any behavior problems other than these two incidents that would have required 24-hour medical or nursing care, and on these two occasions, the staff did not directly witness the event or intervene.  All told, mental health residential treatment center services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee requested platelet-rich plasma injections for medical treatment of his right medial epicondylitis.  Findings:  Three physician reviewers found that the requested services are not likely to be superior over other treatment modalities.  Randomized controlled trials have not found superiority of platelet-rich plasma injections over standard available treatments such as steroid injections.  In addition, the few randomized controlled trials supporting platelet-rich plasma injections have relatively short-term follow-up.  All told, the requested platelet-rich plasma injections are not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested the Butrans Patch 5 mcg/hr, one patch per week for medical treatment of her osteoarthritis and fibromyalgia.   Findings:  The physician reviewer found the current standard of care for chronic pain associated with osteoarthritis and fibromyalgia is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain (Fishman). 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.  All told, the requested Butrans Patch 5 mcg/hr, one patch per week is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee requested vancomycin HCL (Vancocin) 250 mg for medical treatment of the enrollees primary sclerosing cholangitis. Findings:  Three physician reviewers found that this patient has had demonstrated improvement in his liver histology and hepatic function tests after receiving therapy with vancomycin.  There is sufficient anecdotal evidence to support the use of Vancocin 250 mg in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his large cell lymphoma. Findings:  Two physician reviewers found that Terasawa and Nagai found that interim PET should at present not be regarded as an established procedure and it still remains as an unproven test for routine clinical practice. In the absence of a clinical indication for the requested diagnostic procedure, the requested PET scan is not likely to be more beneficial for evaluation of the patients diffuse large cell lymphoma than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested gene expression profiling or evaluation of her colon cancer.  Findings:  Two physician reviewers found that Oncotype Dx was developed and validated as a gene expression assay that predicts with some accuracy the risk of recurrence in stage II colon cancers. As such, it is frequently used in contexts where decisions regarding use of chemotherapy are challenging. In this case, the patient was pregnant and prognostic information about the expected course of her colon cancer was invaluable, and influenced management decisions. Although Oncotype Dx predicts risk of recurrence, it has not been shown to be predictive of the benefit of adjuvant chemotherapy, and as such adds little to decision making in this regard. However, in this case, where decisions were required to be made not only about chemotherapy, but also about ongoing management of a high-risk pregnancy, the prognostic information provided by the assay was of value. Therefore, in this clinical setting the testing at issue was 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

A 55-year-old female enrollee has requested consultation with a pain management specialist for treatment of her chronic lower back pain, degenerative disc disease, and rheumatoid arthritis.  Findings:  The physician reviewer found that the clinical documentation submitted for review indicates the patient was diagnosed with arthritis at the age of 12. In addition, the providers notes indicate the patient has pain of a 9/10 in the low back. There was documentation of a failure of conservative care including medications, injections and the use of a cane. Given these findings, the requested referral for a consultation with a pain management specialist is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested mental health inpatient services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the mental health inpatient services provided were medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, the patient has endured multiple traumas, which take time and patience to address and treat, while at the same time she requires close monitoring to ensure safety.  Previously, she had been discharged to lower levels of care, only to relapse and require readmission. Managing her medications was also noted to be difficult, as she had side effects of treatment with Thorazine, even though it provided the best control for her. On Latuda, an antipsychotic, she required admission to the PICU secondary to side effects. This patient is an adolescent in crisis who required the highest level of treatment. Moreover, a return to partial hospital programming would likely have resulted in re-admission given that she had already failed treatment at this level. The inpatient records provided for review demonstrate that from both the behavioral and medication standpoint, she required close monitoring that could only be provided in a 24-hour setting. Her treatment plan appears to have been revised at intervals as she received changes. As such, the mental health inpatient services provided from the dates indicated were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The documentation submitted for review did not contain a clear rationale as to the need for a cryotherapy unit versus standard cold packs or pain relieving ointments.  There is a lack of evidence that the proposed treatment would be more beneficial for the patients noted condition than available standard therapy.  All told, the superior efficacy of the requested water circulating cold pad with pump has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee requested post-exposure prophylaxis (PEP) on an emergent basis for medical treatment of his possible HIV exposure.  Findings:  The physician reviewer found that it is recommended that patients with a known exposure to HIV receive PEP as soon as possible, up to 72 hours post exposure. PEP is a time-sensitive treatment and should be administered as soon as is possible. It requires baseline laboratory testing and rapid HIV testing prior to administration. Therefore, a prudent layperson would have sought medical attention because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested a 12-week course of Sovaldi 400 mg per day and ribavirin 600 mg for medical treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that review of the submitted documentation fails to establish the medical necessity of the requested medications. According to the documentation submitted for review, the patient has minimal to no fibrosis despite years of infection with hepatitis C and chronic alcohol use. He has no systemic manifestations of hepatitis C such as cryoglobulinemia or leukocytoclastic vasculitis. Based on the clinical records submitted for review, national guidelines recommend monitoring his fibrosis levels non-invasively, 1-2 times annually and commence therapy if there is evidence of increasing fibrosis. Therefore, at this time the requested medication combination is not medically necessary for treatment of the patients HCV.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested Botox for medical treatment of her medical condition.  Findings:  Three physician reviewers found that while there is evidence that Botox can be used for patients with refractory migraine headaches, it should not be used as a first-line therapy for this condition.  In this patients case, there is a lack of support for the services at issue.  The timing, frequency, history and associated findings of this patients ocular events have not been adequately described.  In addition, there is no documentation that the patient has tried, failed or has a contraindication to other standard headache medications.  Thus, the superior effectiveness of Botox injections has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee requested joint manipulation under anesthesia (right forearm, wrist and fingers) for medical treatment of hers joint manipulation disorder. Findings:  Three physician reviewers found that the current peer-reviewed medical literature includes retrospective chart reviews, small sample sizes, and single case series. However, there are no controlled studies or any studies reporting long-term beneficial results. Given the lack of scientific data demonstrating that joint manipulation under anesthesia is likely to provide improved health benefits over treatment with standard available therapies, the services were not likely to have been more beneficial for treatment of the patients medical condition than any available standard modality.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.  Findings:  Two physician reviewers found that according to the NCCN guidelines, the Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. In this case, it was under these circumstances that the Foundation One assay was ordered, and as such, its use was consistent with current standards of care and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of his medical condition status post left femur status post intramedullary nailing removal.  Findings:  The physician reviewer found that the records indicate that he is able to walk 250 feet and is able to move from bed to chair and stand from chair with hands on assistance. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, in the absence of daily skilled therapy needs, SNF services are not considered medically necessary. A patient who does not require hands on support for walking or transfers is able to do daily exercise without support from a therapist. There is no expectation that this patients course of rehabilitation will change as his surgical procedure was uncomplicated as was his rehabilitation thus far (Ward, et al). The patient had reached a level of function that did not require daily skilled therapy to restore or maintain function. Continued progress can be achieved with continued exercise without daily supervision from a skilled therapist. Further, there were no daily skilled nursing needs. Daily skilled services are not necessary to restore or maintain function. The patient did not require SNF services to establish a safe and effective maintenance program. For these reasons, the SNF services provided from the dates indicated were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested a water circulating cold pack with pump for medical treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the use of water circulating pump was not likely to have been more beneficial than simpler applications.  While the use of cryotherapy may have been beneficial, simpler applications of cold have been demonstrated to be equally efficacious.  Thus, the use of a water circulating cold pack with pump was not likely to be more effective than other options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a power wheelchair for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that based on the clinical information provided for review, the patients functional status does not meet the evidence based guidelines for use of a power wheelchair. The lower limb motor strength in physical examination on the date indicated was not consistent with the patients functional status determined during a physical therapy evaluation on the date indicated, or with physical examination findings by her pain management physician on the dates indicated. Motor strength of the lower limbs was graded 1/5 on the date indicated, but was 4+/5 during the physical therapy evaluation. Given these findings, an updated physical therapy mobility evaluation is required before it can be determined if the patients functional status meets the criteria for a power wheelchair versus a manual wheelchair. Therefore, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested radiofrequency ablation for medical treatment of her symptomatic varicose veins. Findings:  Three physician reviewers found that the current guidelines from the Society for Vascular Surgery and the American Venous Forum recommend against selective treatment of incompetent perforating veins in patients with simple varicose veins. This patients provider has planned the use of RFA ablation for the perforator vein. However, there is no history of a venous ulcer, either healed, or currently present. Therefore, the patient cannot be graded as either C5 or C6. All told, the information as presented does not support the treatment beyond conservative measures for this patients perforator vein. Thus, the requested RFA is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 22-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the patient is at the 7th percentile which is approximately 1.5 standard deviations below the mean. In general, there is insufficient evidence or established criteria which would classify this level of disability as a disorder for which speech therapy is medically necessary. In sum, there is insufficient evidence in the accepted guidelines to establish that speech therapy services are the standard of care in this clinical setting. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested home health services for treatment of the enrollees dysphagia.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient is stable on his current regimen of G-tube feedings and is doing well. His parent is able to administer the patients G-tube feedings without issues. Managing caloric intake or any formula changes could be performed on an outpatient basis. The clinical documentation submitted for review does not support the need for home health services to help with feedings. Parab and colleagues evaluated specialist home-based nursing services for children with acute and chronic illnesses. The authors concluded, Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a lymphedema pump for treatment of her lymphedema.  Findings:  The physician reviewer found that the nature of this patients limb swelling condition is unclear. The records primarily indicate that the patient is obese and has had chronic lower leg swelling, but there are no documented characteristic skin changes or other signs of lymphedema. She has not had any documented lymphatic system pathology. It is not evident that the patients condition is not due to venous insufficiency and dependent edema. There is an extensive differential diagnosis for chronic leg edema of unclear etiology besides primary lymphedema (Ely, et al). The patient, moreover, has not been documented to have compliantly undergone an appropriate trial of conservative management that includes adequate manual decompression, compression garment wear, and use of compression wraps, elevation, exercise, and weight loss. There is no documentation of a trial of compression pump therapy in the therapy setting demonstrating effective volume reduction. All told, the requested lymphedema pump is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested dental anesthesia for treatment of the enrollees dental surgery. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Based upon the documentation provided, the patient has not been able to cooperate with routine dental care. He has severe dental caries requiring fillings and root canals, and experiences daily pain as a result. Further, he is at risk for infection due to untreated severe dental and gingival disease. Although he does not have a diagnosis of psychiatric illness, autism, or global developmental delay, he has been described as mentally challenged, uncooperative and anxious in the documentation submitted. Regardless of underlying diagnosis and age, the patient is unable to comply with standard and routine dental care and restoration. In patients with severe cognitive delay, autism, psychiatric conditions, or behavioral problems, it is medically necessary and appropriate to provide dental evaluation and treatment under general anesthesia. To do otherwise will delay treatment and place the patient at risk of morbidity from his dental disease. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested a nuclear cardiology scan for medical evaluation of his chest pain and shortness of breath.  Findings:  The physician reviewer found that based on the records provided, this patient has known coronary disease but no ischemia on stress echocardiography performed on the date indicated and no symptoms or objective findings concerning for ischemia on follow-up clinic visits. In this circumstance of a clinically stable patient with favorable stress testing results less than two years ago, repeat stress testing is not indicated and not considered standard of care in the medical community. The current guidelines that are endorsed by several national organizations also do not recommend repeat stress testing in this clinical setting (Hendel, et al). Generally, routine screening stress testing has not been shown to improve cardiac outcome, even in patients with high coronary risk (Young, et al). All told, the requested nuclear cardiology scan is not medically necessary for evaluation of his medical condition.