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

A female enrollee requested a power wheelchair for medical treatment of her right knee osteoarthritis and shoulder pain. Findings:  The physician reviewer found that in the current case, physical therapy noted good strength and functional range of motion in the left-sided limbs. There are no musculoskeletal or cardiovascular impairments that would preclude the use of an optimally fitted manual wheelchair in an appropriate environment. Moreover, physical activity is appropriate for general health and especially for musculoskeletal conditions such as osteoarthrosis (Hagen, et al). All told, the requested power mobility device is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A female enrollee requested ambulance transportation required on an emergent or urgently needed basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient called 911 as she was concerned for her health with progressive symptoms. Further, it has been established that criteria for urgently needed services were met on the date in dispute. In sum, based on the patients clinical presentation she did meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested a positron emission tomography (PET) scan for medical evaluation of her melanoma.  Findings:  Two physician reviewers found that current medical evidence supports up to three PET scans for all solid tumors. The Centers of Medicare and Medicaid Services decision memo recognized melanoma as a valid indication in cases where there is suspicion of recurrence to regional lymph nodes such as this case. The ability of PET scans to analyze the physiologic properties of masses or nodes provides more information than standard imaging techniques. All told, a PET scan was likely to have been of greater benefit than other available modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the neck and spine without dye for medical evaluation of her cervicalgia.  Findings:  The physician reviewer found that there are no red flags to establish medical necessity for an MRI of the cervical spine prior to a conservative trial of therapy including physical therapy. In particular, there is no documentation of trauma, plain film findings requiring imaging clarification, tumor, infection or neurological deficit. These red flags provide indications for MRI without prior conservative treatment but no such documentation has been submitted in this case. In the absence of such evidence, the requested MRI is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Namenda XR (memantine HCl Cap. SR 24HR) 28 mg for medical treatment of her Alzheimers disease.  Findings:  The physician reviewer found that this patients records suggest the patient is having significant recent memory issues, and now requires help from the family to take her medications, cook, and take care of her more complex, but not basic needs. According to the Alzheimers Association, this patients symptoms support a diagnosis of moderate Alzheimers, which supports the use of Namenda.  All told, the requested Namenda XR (memantine HCl Cap. SR 24HR) 28 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A female enrollee requested a computed tomography (CT) scan of the thoracic spine and a CT scan of the lumbar spine without contrast for medical evaluation of her back pain.  Findings:  The physician reviewer found that in this patients case, the standard of care is plain film x-rays, particularly in the absence of trauma and neurological deficits. The medical records do not indicate any trauma or neurological deficits. Furthermore, the patient did not have a six-week trial of conservative management prior to the CT scans of the spine, which is discordant with the imaging guidelines and accepted standards of care in medical practice. Therefore, the medical necessity of the services at issue has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested single photon emission computed tomography (SPECT) scans and selective internal radiation therapy (SIRT) and vascular embolization/occlusion (CPT 37243) for medical evaluation and treatment of his metastatic colorectal cancer.  Findings:  Two physician reviewers found that there is evidence that the use of Yitrium-90 may improve median survival in patients who have failed multiple regimens of chemotherapy.  However, there is a lack of prospective, randomized controlled trials supporting radioembolization for colorectal liver metastases. All told, the superior efficacy of SPECT and SIRT and vascular embolization/occlusion (CPT 37243) has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested anterior cervical disc fusion (cervical spine fusion C6-7) for medical treatment of her neck pain and previous anterior cervical discectomy with fusion (ACDF) at C5-6.   Findings:  The physician reviewer found that the C6-7 segment shows no evidence of pathology. There is no disc herniation, no canal or foramen stenosis, no tumor, infection, fracture, or evidence of adjacent segment disease. Further, the patient does not meet criteria for a cervical fusion (Nikolaidis, et al). She lacks cervical radiculopathy/myelopathy, spinal cord or nerve root compression, infection, fracture, tumor, pseudarthrosis, or adjacent segment degeneration. There is no evidence of a cervical anomaly of a cervical bone. There is no correlation of her imaging studies with her clinical condition. There is no evidence she has failed conservative treatment. The requested anterior cervical disc fusion (cervical spine fusion C6-7) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested continuation of treatment with Harvoni for medical treatment of his hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that the patient is currently being treated with Harvoni 400 mg daily. The patient has responded well to therapy and the virus was undetectable at week eight. Based on the current 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. herefore, based upon this approval supported by large clinical trials, Harvoni for an additional four weeks is not supported as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a group 2 power wheelchair for medical treatment of his Charcot Marie Tooth disease. Findings:  The physician reviewer found this patient has a congenital peripheral neuropathy which has progressed over the past year to cause significant weakness and loss of sensation in the feet and right wrist. The providers agree that he cannot safely walk with assistive devices or control a manual wheelchair in a residential or community setting. All told, the patient meets the Centers for Medicare and Medicaid Services (CMS) criteria for use of a powered mobility device. Thus, the requested group 2 power wheelchair is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Xiaflex for medical treatment of his Peyronies disease. Findings:  The physician reviewer found that Xiaflex is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. Moreover, Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy and is an appropriate candidate for Xiaflex given the presence of penile plaque, 50 degree penile curvature, and pain with erections. All told, the medical records support the requested Xiaflex injections as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for 24 weeks for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that this patient has cirrhosis proven on CT scan, ultrasound and FibroSURE. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, extended therapy is recommended for patients with cirrhosis who have relapsed after therapy (as is the case with this patient). These guideline recommendations are based on randomized clinical trials, such as the ION-2 trial, which proved the importance of extended therapy in cirrhotic patients with prior treatment failure. Harvoni is FDA-approved for patients with chronic hepatitis C genotype 1. Based on published evidence of safety and efficacy and current clinical guidelines, the requested treatment with Harvoni for 24 weeks is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an electric mobility device for medical treatment of her medical condition. Findings:  The physician reviewer found that in this patients case, an assessment revealed that the patient had no significant gait impairments while walking more than 250 feet at a time, including outdoors.  There are no documented musculoskeletal or cardiovascular impairments that would preclude the use of a gait implement such as a walker for accomplishing her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate for general musculoskeletal health and for chronic pain syndromes such as fibromyalgia.  All told, the requested electric mobility device 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 group dialectical behavior therapy (DBT) services for medical treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that Rathus and Miller noted that DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics. By contrast, Martin and Volkmar reported that mentalized based treatment (MBT) showed significant benefits, in randomized controlled trials, in anxiety, depression, and in social and interpersonal functioning, areas in which DBT has not been shown to be effective. DBT was apparently recommended to treat the patients interpersonal relationships issues, for which adolescent DBT is not indicated. For these reasons, DBT services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee requested inpatient psychiatric services for medical treatment of his major depressive disorder and posttraumatic stress disorder.  Findings:  The physician reviewer found that although inpatient psychiatric care was initially indicated for this patient with psychiatric comorbidity and multiple dynamic risk factors for suicide and domestic violence, the records do not support the medical necessity of subsequent inpatient psychiatric services.  Nursing documented that the patient was eating 100% of his meals.  He was independently attending to his activities of daily living.  The patients mood had improved.  He denied suicidal ideation and feelings of hopelessness.  He was not psychotic. All told, inpatient psychiatric services initially provided were medically indicated for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of subsequent inpatient psychiatric services in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested buprenorphine HCL for medical treatment of her Crohns disease.  Findings:  The physician reviewer found that buprenorphine will likely exacerbate the patients constipation and worsen the patients condition. Baron and McDonald reported that chronic opiates have side effects that do not dissipate with time including constipation, respiratory depression, and may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. It would therefore be in the best interest of the patient to wean down or off all opiates as this could reduce her incidence of opioid-induced hyperalgesia and other adverse effects, including constipation. For these reasons, the requested buprenorphine HCL is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested urgent care services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question.  The patients condition could have potentially led to serious dysfunction of his ankle and long-term disability. Further, it has been established that criteria for urgently needed services were met.  In this case, the patients presentation was significant for acute right ankle sprain. Based on the documentation submitted for review, a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested continued skilled nursing facility services for medical treatment of his medical condition.  Findings:  The physician reviewer found that the records in this patients case indicate that he has experienced favorable results following lumbar decompressive surgery.  Initially, he was allowed to leave the facility for up to four hours at a time and later the patient had recovered sufficient function to care for himself and ambulate within the facility at the independent to supervision level.  He was subsequently noted to have been ambulating from the facility to his home and back.  The records do not establish that there are medical reasons for continued skilled nursing facility services.  There are no documented skilled nursing, medical or therapy needs that could not be met on an outpatient or community-based basis.  All told, continued skilled nursing facility services were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Humira for medical treatment of his plaque psoriasis.  Findings:  The physician reviewer found that Humira is a fully human tumor necrosis factor (TNF)-alpha monoclonal antibody approved for the treatment of rheumatoid arthritis which is also used in treating other conditions, including psoriasis and psoriatic arthritis (Scheinfeld). Humira has been shown to treat moderate to severe chronic plaque psoriasis and psoriatic arthritis (Croom and McCormack). Moreover, this patients provider noted that the patient is unable to visit his provider three times per week for UV light therapy treatments. Thus, treatment of this patient with Humira is supported as medically necessary as recommended by the patients provider.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested vasectomy reversal surgery for medical treatment  of his condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records noted orchialgia and physical examination revealed diffuse scrotal tenderness.  Post vasectomy orchialgia is a possible complication following bilateral vasectomy.  However, it is rare for this pain to be bilateral and is usually secondary to a sperm granuloma at the excision site.  Per the current medical evidence, vasectomy reversal does not consistently resolve the pain.  All told, the requested vasectomy reversal surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Fiorinal (butalbital-aspirin-caffeine for medical treatment of her migraine. Findings:  The physician reviewer found that the use of Fiorinal in migraine has gradually diminished over the past two decades due to the high frequency of medication overuse headache. Recent recommendations from the American Headache Society, Canadian Headache Society, and a meta-analysis of acute therapy all indicate that the risks with Fiorinal far outweigh benefits for patients with headache. Fiorinal has been shown to cause physical and psychological dependence due to its sedative properties. Continued use of Fiorinal would be the counterproductive in the long-term as headaches typically become more frequent and patients require increasing doses. All told, the requested Fiorinal (butalbital-aspirin-caffeine) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A male enrollee requested Sovaldi for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that the recommended treatment regimen of Sovaldi with ribavirin has been demonstrated to be effective for patients with hepatitis C, genotype 2.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  Early treatment may allow patients to avoid complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, the requested Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested surgical attachment of tendon (bicep tendon, left arm for medical treatment of his ruptured distal biceps tendon left arm. Findings:  The physician reviewer found that this patient has had sufficient time for fibrotic change in the tissues surrounding the distal rupture, which would make repair difficult and there have been adaptive changes in the longhead of the biceps with shortening of the muscle belly. Further, the proximal portion of the ruptured tendon is not likely to be successfully brought to a secure attachment to the proximal radius. Thus, the requested surgical attachment of tendon (bicep tendon, left arm) is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a 12-week course of Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found the current national guidelines that set the standard of care in managing and treating patients with hepatitis C support Harvoni in this patients case. Per the national guidelines, this patient should be treated urgently with Harvoni for 12 weeks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a diagnostic cast model and oral surgical splint and temporomandibular joint manipulation with arthrocentesis for medical treatment of her temporomandibular joint arthralgia and dysfunction.  Findings:  The physician reviewer found that  given her symptoms and history, treatment with arthrocentesis and oral appliance was medically appropriate and consistent with accepted standards of care.  Arthrocentesis has been shown to be a very effective, minimally invasive technique for treatment of temporomandibular joint pain and acute closed lock conditions.  Fabrication of a splint for this patients condition was also medically indicated.  All told, the diagnostic cast model and oral surgical splint service and temporomandibular joint manipulation with arthrocentesis are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested for the pulse stimulation (P-Stim) treatment device for medical treatment of her post-operative back pain. Findings:  The physician reviewer found that there is a lack of medical literature to support its use in failed back surgery syndrome, post laminectomy syndrome or lumbar neuroma pain. This patients records do not document that she has undergone regular auricular acupuncture to determine effectiveness. Also, there is no documentation that she has received any psychological treatment for her condition, which has been shown to be beneficial (Hussain and Erdek). Therefore, the use of P-Stim is not medically necessary for the treatment of this patients failed back surgery syndrome, post laminectomy syndrome or lumbar neuroma pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for 24 weeks for medical treatment of her hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines offer recommendations unique to patients with hepatitis C virus with decompensated cirrhosis and bone marrow suppression. The guidelines state that for patients with decompensated cirrhosis and anemia or ribavirin intolerance, daily fixed-dose combination ledipasvir (90 mg)/sofosbuvir (400 mg) for 24 weeks is recommended. All told, the requested treatment with Harvoni for 24 weeks is supported as medically necessary for treatment of this patients chronic hepatitis C virus.