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

The parent of a male enrollee requested endoscopic resection of the pineal lesion via a supracerebellar approach for medical treatment of the enrollees pineal lesion.  Findings:  The physician reviewer found that the current medical literature does not support an advantage of endoscopic removal of the pineal lesion as compared to the standard approach of suboccipital craniotomy with a supracerebellar approach.  The medical evidence does not support a demonstrable benefit of one procedure as opposed to another.  Thus, endoscopic resection of the pineal gland is not medically necessary over the standard approach of a suboccipital supracerebellar craniotomy.  All told, the requested endoscopic resection of the pineal lesion via a supracerebellar approach is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested disc replacement and hybrid spinal repair (artificial disc replacement and spinal fusion) for medical treatment of his back pain.  Findings:  The physician reviewer found that there is no documentation of a recent physical examination of the lumbar spine. There was no documentation of a significant functional deficit. In addition, there is no evidence of spinal instability to support the necessity for spinal fusion. Based on the clinical documentation submitted for review, a disc replacement and hybrid spinal repair (artificial disc replacement and spinal fusion) is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Vikiera Pak for 12 weeks for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found thatper the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Therefore, Viekira Pak for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that  according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment recommendations, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment naive patients with HCV genotype 1. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks (Kowdley, et al). Therefore, Harvoni for 8 weeks is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a hysterectomy for medical treatment of her abdominal pain, cramping, and bleeding.   Findings:  The physician reviewer found that, other than the bleeding that was likely related to a steroid injection, there is a lack of evidence of any uterine pathology that would warrant hysterectomy. The patients uterus is small, with normal findings on ultrasound and a normal appearance at laparoscopy. All told, the documentation does not support the medical necessity of the requested hysterectomy for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested a panel of genetic hereditary cancer tests for medical evaluation of his medical condition.  Findings:  Two physician reviewers found thatLynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, is a common dominant genetic syndrome characterized by early age at onset neoplastic lesions with particular molecular signatures.  Lynch syndrome testing is indicated for patients with two or more first-degree or second-degree relatives with HNPCC-related tumors, regardless of the age of those with cancer.  In this patients case, he has two first-degree relatives with colorectal cancer, one first-degree relative with ovarian cancer, and his aunt had brain cancer.  All told, the panel of genetic hereditary cancer tests was likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested residential behavioral health treatment center services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that considering the patients severe mental illness and treatment history, a brief course of care at the residential setting would have been inadequate. After initial programming, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting and discharge would have likely resulted in undue morbidity, relapse and prompt readmission to the acute level of care. Additionally, the services provided were for active treatment, and reasonably expected to improve his condition and prevent a more serious episode of illness. Further, the duration of services was consistent with community practice standards. Considering the clinical presentation and peer-reviewed literature, the residential behavioral health treatment center services were medically necessary for treatment of the patient behavioral health conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested the surgical procedure, cervical C4 and C5 fusion for medical treatment of her flare up of cervical pain with left sided radiculopathy status post motor vehicle accident.   Findings:  The physician reviewer found that the patients records do not document an indication for the requested surgery such as unstable vertebral fracture, spinal dislocation, segmental instability, tumor or infection.  Moreover, there are no findings consistent with cervical radiculopathy with matching dermatomal and myotomal symptoms and findings, evidence of a myelopathy, pseudarthrosis, or evidence of failure of conservative therapy (Polston). All told, the requested surgical procedure, cervical C4 and C5 fusion is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested partial hospitalization program (PHP) services for medical treatment of her substance abuse and depression. Findings:  The physician reviewer found thatThe American Psychiatric Association (APA) treatment guidelines recommend that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Thus, continued admission to PHP is appropriate to treat her condition, consistent with standards of good medical practice in the United States, could not be managed effectively at a lower level of care and is thus medically necessary.
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 there was no indication that this patient lacked improvement or could not safely return home to be evaluated for home physical therapy if necessary.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested magnetic resonance imaging (MRI) for medical evaluation of his shoulder pain.  Findings:  The physician reviewer found that per the clinical notes, physical examination does not detail laxity, weakness or other red flags to mandate immediate imaging.  The requirement of a trial of conservative management, including physical therapy, is a well-recognized precursor to advanced imaging, which is not documented in this case.  All told, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a 12 week course of Sovaldi for medical treatment of her chronic hepatitis C genotype 2b. Findings:  Three physician reviewers found that  according to the most recent 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 limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested 12 week course of Sovaldi should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Norco for medical treatment of her pelvic bone replacement.  Findings:  The physician reviewer found that in this case, there is a lack of evidence of objective functional improvement following the initial use of Norco. It is noted that the patient reported a significant improvement in symptoms. There is no documentation of an attempt at psychological modalities or non-opioid analgesic medication prior to the initiation of Norco. Only after all other treatment modalities have been exhausted should opioid therapy be considered. Based on the clinical documentation provided and the peer-reviewed literature, the request for coverage of Norco is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the peripheral bone density test (CPT 77081) for medical evaluation of her postmenopausal osteoporosis. Findings:  Two physician reviewers found thatthere is no indication that the spine and hip were not readable on the axial DEXA scan, which fails to produce a clinical indication for the forearm DEXA scan. Accordingly, the peripheral bone density test (CPT 77081) was not likely to have been 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 female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that Per American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, treatment-naive patients with HCV genotype 1a are recommended for treatment with a daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. However, the effectiveness of Harvoni in patients who are treatment naive and non-cirrhotic is the same with 8 weeks and 12 weeks of Harvoni in patients who have a baseline HCV RNA levels below 6 million IU/mL. Therefore, Harvoni is medically necessary for 8 weeks in this treatment-naive patient with HCV and a viral load of less than 6 million.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested speech therapy, one hour per week, for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that speech therapy is effective for expressive and receptive language delays. In this case, the patient does not have expressive or receptive language delays. A recent speech evaluation revealed a total language score of 104. As such, the patient does not meet clinical indications for individual speech therapy. For the reasons stated, speech therapy, one hour per week is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Viekira Pak and ribavirin for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response and is expected to benefit nearly all chronically infected persons.  All told, the requested Viekira Pak and ribavirin are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Xyrem for medical treatment of his narcolepsy with cataplexy.  Findings:  The physician reviewer found that Xyrem is not indicated for patients who are taking sedative agents. The patient is on moderate doses of chronic oxycodone which is consistently taken as the patient is refilling on a regular basis. She is also on clonazepam 1.0 mg per day. These medications can be the primary cause of excessive daytime somnolence, and can alter the results of the sleep study. Based on the clinical documentation submitted for review, Xyrem is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested weekly individual therapy for medical treatment of her post-traumatic stress disorder (PTSD), depression, and anxiety.  Findings:  The physician reviewer found that the patients continuing behavior may represent an untreated underlying affective disorder with gross irritability. According to the medical literature, the value of psychotherapy in this setting is to get her to understand that her struggles are with her illnesses. Thus, weekly individual therapy should provide this patient with much needed support and is likely to facilitate continued progress. For these reasons, the requested weekly individual therapy 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 a colonoscopy screening for medical evaluation of his risk for colon cancer given his family history of colon cancer. Findings:  The physician reviewer found that this patients personal risk for Lynch syndrome diminishes with every serial negative colonoscopy exam. However, two negative colonoscopies do not inoculate him against colon cancer and a five-year repeat colonoscopy is clinically appropriate given the patients potential risk. Thus, the available records support the medical necessity of the requested colonoscopy procedure for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested corneal collagen cross linking for medical treatment of her keratoconus.  Findings:  Two physician reviewers found that the patients corrected visual acuity is fairly good in both eyes. Thus, before recommending cross linking therapy, contact lens fitting should be attempted. There are also corneal surgical procedures such as INTACS or penetrating keratoplasty that may improve this patients health condition. Accordingly, the requested corneal collagen cross linking 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 a 12 week course of Harvoni for medical treatment of her hepatitis C virus genotype 1.   Findings:  Two physician reviewers found that according to the most recent 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 limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested treatment with Harvoni should be approved 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 8 weeks for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Those with substantial fibrosis (defined as Metavir F2 or higher) should be given priority for therapy in an effort to decrease the risk of clinical consequences such as cirrhosis, liver failure, and hepatocellular cancer. Given that the patient has a Metavir score of F2 with genotype 1 infection, Harvoni for 8 weeks is medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A female enrollee requested ambulance services on an emergent or urgent basis.  The physician reviewer found that the patients bleeding and cramping was not acute or sudden in onset. She had been evaluated for her symptoms six days before and was non-compliant with the prescribed medication. No interventions were required during transport. In addition, the patient refused a pelvic exam after she arrived in the emergency department. Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place her health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Thus, the patients symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Rituxan for medical treatment of her multiple sclerosis. Findings:  Three physician reviewers found that this patient has a history consistent with aggressive multiple sclerosis, and she has tried and failed Avonex, Rebif, and Tysabri.  The current medical evidence has not established the superior efficacy of the requested medication in this clinical setting.  She has not been treated with Aubagio or Gilenya, two oral agents which are established disease modifying medications for multiple sclerosis, with known safety and efficacy.  Based upon the clinical documentation, Rituxan is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an inpatient sleep study (CPT codes 95810 and 95811) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There has been insufficient time to evaluate if the recommended sleep hygiene efforts were beneficial.  All told, the requested inpatient sleep study is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested or one 60-minute session of occupational therapy per week; one 60-minute session of speech therapy per week; and one 60-minute session of physical therapy per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that in this case, the continuation of PT, OT and ST are medically necessary for treatment of the patients autism. However, there is a lack of medical literature supporting the benefit of a single 60-minute session of OT, PT, and ST compared to two 30-minute sessions. A developmentally impaired autistic three-year-old likely has a short attention span, so two 30-minute sessions would be advantageous in this clinical setting. As such, it is not medically necessary for this patient to receive one 60-minute therapy sessions of PT, OT and ST rather than two 30-minute therapy sessions. Therefore, based on the medical literature cited above and the documentation submitted for review, two thirty-minute sessions per week of occupational therapy, speech therapy and physical therapy are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested valacyclovir for medical treatment of her medical condition.  Findings:  The physician reviewer found that this patient has documented recurrent herpes zoster.  Based on the description of her provider, she had recurrent rash as well as pain.  The current medical evidence supports the requested medication in this clinical setting.  Valacyclovir has been approved by the U.S. Food and Drug Administration for the treatment of this patients condition.  Because valacyclovir may be dosed less frequently, it is easier to use than acyclovir.  In this patients case, the requested medication is consistent with the usual standard of care.  All told, valacyclovir is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not yet extend to bipolar disorder.  Moreover, it does not appear that the patient has failed other treatments commonly relied upon to treat bipolar disorder.  It is unclear if the patient has completed an evidence-based therapeutic intervention for bipolar illness such as cognitive behavioral therapy, family therapy or interpersonal/social rhythm therapy. In conclusion, based on the documentation provided within context of current practice guidelines and relevant peer-reviewed literature from the scientific community, the requested TMS therapy is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested Oncotype DX gene expression testing for medical evaluation of his prostate cancer.  Findings:  Two physician reviewers found that molecular profiling as obtained with Oncotype DX carries the promise of further, more accurate, risk profiling, and is useful in determining which patients would benefit from active management, and which could be safely observed. 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: Upheld Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the left knee for medical evaluation of her left knee pain.  Findings:  The physician reviewer found that in this case, due to persistent left knee pain, a left knee MRI has been requested. However, the medical records submitted for review do not demonstrate physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been tried and failed. Further, the medical records also do not indicate a trial of anti-inflammatory medication or acetaminophen for three or more weeks, which is standard of care treatment prior to MRI study. Based on the clinical documentation submitted for review, the medical necessity for the MRI of the left knee has not been established.