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

The parent of a male enrollee requested an additional 36 sessions of speech therapy for medical treatment of the enrollees autism and delayed receptive language.  Findings:  The physician reviewer found that in this case, it is medically necessary that this patient receive an additional 36 sessions of speech therapy, as he has severe delay in his receptive and expressive communicative skills. Testing of receptive, expressive, and articulation skills noted an overall profound speech delay. The available speech therapy assessments document these delays and also proposed a specific set of five goals including articulation skills and the ability to sit still. However, in a period of 6 months he achieved only one of these five goals; therefore, continued speech therapy is clinically indicated. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested point-stimulation (P-Stim) therapy for medical treatment of her fibromyalgia.  Findings:  Two physician reviewers found that the patient is being treated for chronic pain with a diagnosis of fibromyalgia which is a disorder which typically has significant psychological components, particularly depression and other affective problems.  This type of electrostimulation is being evaluated for a variety of conditions, including pain, depression, and anxiety.  It is not a recommended treatment as the evidence is insufficient to evaluate the effect of auricular electroacupuncture on acute and chronic pain.  All told, the requested P-Stim therapy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested readmission and treatment including physical and occupational therapy for treatment of his difficulty walking, unspecified essential hypertension, and cellulitis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient did not sustain any lower body injuries.  He underwent inpatient rehabilitation for a rotator cuff repair that was complicated by a contralateral upper limb deep vein thrombosis and pulmonary embolus.  Further care could have been provided in the community setting with caregiver assistance and home health services.  His warfarin anticoagulation could have been followed as an outpatient, as planned by the treating providers.  Given that further care could be provided at a less intensive setting, readmission and treatment including physical and occupational therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, patients with prior liver transplant are highest priority for treatment of hepatitis C.  For patients with hepatitis C, genotype 4 and prior transplant, the guidelines recommend Harvoni with ribavirin for 12 weeks.  In sum, the requested medication Harvoni is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested services on an emergent or urgently needed basis.  Findings:  The physician reviewer found that as a rule of thumb, a blood clot creates significant concern among laypeople. Although based upon the records provided the providers concern for DVT does not appear to be supported by the clinical findings, the average layperson cannot be expected to disregard the recommendation of his provider to seek immediate evaluation and/or treatment. A prudent layperson with an average knowledge of medicine who has been told by his health care provider that he requires a stat ultrasound to rule out a blood clot would reasonably expect the absence of immediate care to seriously jeopardize his health. All told, based upon the documentation provided for review, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested Singulair (montelukast) for treatment of her allergic rhinitis. Findings:  The physician reviewer found that the patient has a history of allergic rhinitis, hypothyroidism and hives and has failed oral antihistamines. Given that this patient also has a history of hives and hypothyroidism, it is medically reasonable and appropriate to use the montelukast to treat both disorders. There is documentation that the patient tolerates the medication with no side effects. It was noted that there is no documented history of hydroxyzine, a sedating class 1 antihistamine. This patient cannot tolerate the sedation caused by Benadryl and given that hydroxyzine is even more sedating, she will likely not tolerate it as well. As such, the request for Singulair (montelukast) is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested Botox injections for medical treatment of her chronic migraines. Findings:  Two physician reviewers found that Botox injections are likely to be more effective for this patient than other available options. This patient has a 10-year history of migraines with significant worsening in the last two years. She has been treated with Botox injections, which has provided a substantial reduction in migraine and headache frequency. The patient reports a marked reduction in severity and reduction in disability. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A male enrollee requested clinical chemistry testing (Prometheus Anser IFX) for medical evaluation of his Crohns disease.  Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available treatment options. Therapeutic drug monitoring is the clinical practice of measuring drug concentrations or metabolites to attain a targeted concentration in a patient's bloodstream, thereby optimizing individual dosage regimens. In this patients case, Prometheus Anser IFX testing was useful and 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 cataract surgery for medical treatment of her medical condition.  Findings:  The physician reviewer found that the medical literature and national guidelines recommend that vision in patients who are diagnosed with cataracts should be 20/50 or worse best corrected for cataract surgery to be performed. In addition, glare testing worse than 20/50 is also acceptable for surgery. In this case, the provider has not documented glare testing results nor has he documented the density of the cataract. Based on the clinical documentation provided for review and peer-reviewed literature, cataract surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested the continuous passive motion (CPM) machine for medical treatment of his status post right total knee arthroplasty.  Findings:  The physician reviewer found that there is evidence in the medical literature that CPM may not significantly influence range of motion gain. Herbold and colleagues compared CPM use with non-CPM use and determined that the application of CPM may not significantly influence ROM gain. In addition, Mau-Moeller and colleagues indicated sling therapy has a clinically relevant beneficial short-term effect compared to CPM. Based on the clinical documentation submitted for review and the peer reviewed literature, the CPM machine is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested intravenous infusions of Rocephin (ceftriaxone); and home health visits ancillary to the intravenous infusions for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. Despite treatment with ceftriaxone daily for three months there was no appreciable improvement after treatment which provides doubt to the diagnosis of neuroborreliosis. Further, there is a lack of evidence in the peer reviewed medical literature that prolonged or repeat courses of antibiotic are efficacious. In sum, the ceftriaxone was not medically necessary. Further the home health services associated with the administration and care of the patient for visits ancillary to the intravenous infusions were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested Hyalgan/Supartz injection for treatment of the temporomandibular joint (TMJ) disorder.  Findings:  Two physician reviewers found that there is a lack of controlled studies supporting the efficacy and safety of the use of hyaluronic acid injection for the treatment of TMJ. Furthermore, the patient received injections without any objective documentation of efficacy, pain reduction or functional improvement. Therefore, the request for an additional injection is not clinically indicated. Based on the medical literature cited above, the request for Hyalgan/Supartz injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested the positron emission tomography (PET) with computed tomography (CT) for attenuation (CPT 78815, A9552) for medical evaluation of her hip pain. Findings:  The physician reviewer found that the performance of PET/CT for further analysis of an enlarged lymph node seen on routine imaging modality such as ultrasound is not supported in the medical literature. Since the lymph node could be seen on ultrasound, a sonographic guided biopsy would have been appropriate if the enlarged lymph node persisted over a couple weeks. However, PET/CT was not indicated without a tissue diagnosis indicating malignancy. Thus, the PET with CT for attenuation (CPT 78815, A9552) was not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the LINX Anti-Reflux procedure for medical treatment of her gastroesophageal reflux disease.  Findings:  Two physician reviewers found that The LINX Anti-Reflux procedure has been approved for lower esophageal sphincter augmentation.  Eligible candidates for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Anti-reflux surgery is designed to provide benefit for many years, and this has not been demonstrated.  Moreover, there is a lack of controlled data comparing this technology to continued proton pump inhibitor therapy or fundoplication.  All told, the requested services are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the left breast for medical evaluation of her left nipple discharge.  Findings:  Two physician reviewers found that the requested MRI of the left breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Nipple discharge is the third most common breast complaint after breast pain and breast mass (Hussain, et al). Lubina and colleagues prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound using breast MRI. The authors concluded that MRI of the breast is an accurate imaging test and can replace galactography in the work-up of nipple discharge in patients with inconspicuous mammography and ultrasound. Thus, the medical literature supports MRI of the breast for patients with nipple discharge despite inconspicuous mammography and ultrasound.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee requested mental health services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient did not have a psychiatric emergency medical condition that required the services at issue on an emergent basis.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee requested medical services on an emergent or urgently needed basis. Findings: The physician reviewer found that the patient presented with complaints of severe abdominal pain. Based on the documentation submitted for review, a prudent layperson would have sought medical care due to the severe abdominal pain such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. In sum, based on the patients clinical presentation she did meet prudent layperson criteria for urgently needed services. However, subsequent clinical documentation demonstrates that a prudent layperson would not have sought subsequent immediate medical attention. Follow-up images such as magnetic resonance imaging (MRI) were not performed for diagnosis. Typical management includes hydration, pain management, and antibiotics, which was not performed. The patient was treated with surgery for a non-acute presentation. Pathology after surgery was not consistent with acute/chronic degenerative changes. Moreover, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for subsequent emergency care. In sum, based on the patients subsequent clinical presentation, she did not meet prudent layperson criteria for urgently needed services. I have determined that a portion of the services requested met prudent layperson criteria for emergency care or urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested the ColonSentry laboratory test for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the ColonSentry test is a blood-based panel made up of biomarkers that have been determined to be predictive of a patient having colon cancer. In clinical practice in the United States, it is used rarely compared to other non-invasive tests such as stool fecal occult blood test, fecal immunochemical testing, and stool DNA testing.  All told, the ColonSentry laboratory test was not likely to be of greater benefit than other available modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested positron emission tomography/computed tomography (PET/CT) fusion for medical evaluation of her nodular sclerosing Hodgkin disease.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other methods of evaluation.  The Centers for Medicare and Medicaid Services decision memo recognizes the utility of PET/CT in the diagnosis, staging and surveillance of therapy for all solid tumors, including lymphoma.  The memo approves up to three scans for all solid tumors.  PET/CT has the unique ability to offer physiologic analysis of tumors.  This feature is not available with other conventional imaging techniques.  All told, the superior efficacy of PET/CT has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested Botox injections for medical treatment of her gastroparesis.  Findings:  The physician reviewer found that there is a lack of support for Botox injections in this clinical setting.  Bai and colleagues performed a systematic literature review evaluating the efficacy of Botox injection for patients with gastroparesis.  The authors concluded that there is no evidence to recommend this treatment for gastroparesis.  Camilleri and colleagues noted that intrapyloric Botox injection was not effective in randomized controlled trials.  In this patients case, there are multiple possible contributors to her gastrointestinal complaints.  The submitted records do not include contemporary documentation of gastroparesis or improvement of gastroparesis with Botox.  All told, Botox injections 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  Harvoni 90-400 mg for medical treatment of his chronic hepatitis C virus genotype 1b. 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. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al).  Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni 90-400 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested substance abuse residential treatment center level of care for medical treatment of his substance abuse.  Findings:  The physician reviewer found that the records indicate that this patient was not in withdrawals, and was not at risk for imminent withdrawals on admission or during the treatment period under review. There was no suicidal, homicidal, or psychotic ideation and no self-harm behavior. In addition, the patient was medically and psychiatrically stable such that medication changes could have been achieved at a lower level of care. He was cooperative and participated in his treatment plan. There was no evidence that 24-hour supervised care was required to prevent decompensation. Treatment could have been safely and adequately provided at a lower level of care along with community support such as a 12-step group with a sponsor. Consistent with these findings, substance abuse residential treatment center level of care was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested Fentanyl 75 mcg every 72 hours, and Soma 350 mg twice per day for medical treatment of his chronic low back pain with exacerbation secondary to lumbar facet arthropathy and lumbar degenerative disc disease.  Findings:  The physician reviewer found that the current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Chronic opioids and Soma are associated with a high risk of dependence and tolerance and therefore long-term administration is not recommended (Fishman.)   Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. All told, the requested Fentanyl 75 mcg every 72 hours, and Soma 350 mg twice per day are 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 real-time heart monitor study for medical evaluation of her atrial fibrillation. Findings:  Three physician reviewers found that for patients with atrial fibrillation, a standard patient activated or auto-activated monitor is considered the standard of care. Immediate data transmission with the real-time heart monitor is not needed for evaluation of this patients non-life threatening arrhythmia. Thus, the real-time heart monitoring was not 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 male enrollee requested the prescription drug Prolia 60 mg for treatment of his osteoporosis with compression fracture at T8 with back pain.  Findings:  The physician reviewer found that Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. Although the patient may benefit from Prolia treatment, he does not meet the criteria for this medication at the present time, as he has not failed bisphosphonate treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Lyrica 75 mg three times per day for treatment of his neuropathic pain as a result of cervical arthritis and impingement.  Findings:  The physician reviewer found the medical records provided for review document that this patient has physical exam findings and imaging studies consistent with radiculopathy and neuropathic pain. Additionally, there is further documentation that the patient failed other anticonvulsant medications in the same class. Given that this patient does seem to be exhibiting neuropathic or radicular pain and has failed trials of similar medications, Lyrica is medically necessary at the requested dosage of 75 mg three times per day.