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

A 62-year-old female has requested radiofrequency neurolysis for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient has chronic low back pain, diagnosed as sacroiliitis. She is status post an L5-S1 discectomy fourteen years ago, an artificial disc replacement nine years ago L5-S1 and a spinal fusion procedure five years ago. She has undergone treatment with medications, physical therapy and sacroiliac (SI) joint injections. The SI joint injections were noted to provide 80% relief of the patients pain, with the pain relief lasting for only one day. The requested SI joint radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients sacroiliitis than any other available standard therapies. The literature suggests that benefit from this procedure may be limited and there is a paucity of evidence demonstrating the safety and efficacy of the requested procedure. The study by Hanson and colleagues concluded that evidence is limited regarding the following: the accuracy of provocative maneuvers in the diagnosis of SI joint pain, the therapeutic value of intra-articular SI injections, and for the use of radiofrequency neurotomy in managing chronic SI joint pain. All told, the requested radiofrequency neurolysis remains investigational.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female has requested arthroscopic total rotator cuff reconstruction with human allograft (GraftJacket) for treatment of her chronic right shoulder pain.  Findings:  Two physician reviewers found that the patient has persistent right shoulder pain. The patient has been treated with two to three cortisone injections per year. Magnetic resonance imaging (MRI) revealed a massive rotator cuff tear. The provider states that despite the cause, the patient has no remaining tendon that can be stitched together or to the bone to affect a cure for the chronic pain and weakness. The provider indicates that in the absence of arthritis in the shoulder, a joint replacement is not recommended, and a graft is appropriate treatment. The provider has recommended use of the GraftJacket skin allograft taken from a human donor. Review of the literature shows that the requested GraftJacket is likely to be more efficacious than conservative care for management of this patients medical condition. Bond and colleagues reported that GraftJacket allograft is a viable solution for surgical salvage in select cases of massive, irreparable rotator cuff pathology. The literature supports the use of GraftJacket during this patients reconstructive surgery and is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested reimbursement for Suboxone for a four-month period for treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that in this case, the patient was being treated with Suboxone sublingual film for treatment of her opioid dependence and chronic severe abdominal pain.  She was being appropriately treated as she failed to respond to high dose narcotics, which have effects to spasm the sphincter of Oddi, which is part of her pain generator. The patient had developed significant dependence on her medications and obtained no pain relief with pure Mu agonists.  In addition she had failed treatment with Methadone, as she experienced significant adverse -effects.  The American Society of Interventional Pain Physicians (ASIPP) opioid guidelines recommend the use of buprenorphine with or without naloxone for chronic pain as a good step therapy medication with good results.  There is little sphincter of Oddi tone change and multiple opioid receptor agonism and partial antagonism for the pain control and for abuse diversion.  Additionally, there is no contraindication to concomitant use of the Butrans patch, which was promptly discontinued, and the sparing use of short term medications such as hydromorphone for breakthrough pain. The use of such agents along with Suboxone is acceptable in very judicious and short term situations.  Overall, the medication at issue was medically necessary for treatment of the patients opioid dependence and chronic pain for the time period in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-old female enrollee has requested authorization and coverage for a colonoscopy for evaluation of the enrollees colon polyps and family history of colon cancer.  Findings:  The physician reviewer found that based on review of the available records, this patient had already developed adenomas at a young age. Therefore, a shorter interval may be appropriate for follow-up colonoscopy. The most rigorous guidelines for colonoscopy surveillance intervals are published in average risk populations. This patients case is unique given her familial and personal history of colon polyps, as well as her family history of colon cancer. The request for a follow-up colonoscopy at this time is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested reimbursement and continued authorization and coverage for residential treatment facility level of care services provided from a spefici date to the present and ongoing for treatment of the enrollees bulimia nervosa, major depressive disorder and anxiety disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. It is impossible for even the most comprehensive of standard placement algorithms to account for the myriad of variables unique to complex cases.  Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria in consideration of clinical presentation and treatment needs.  This current concept of care is accurately captured in the American Psychiatry Association (APA) Clinical Practice Guideline: In determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge; patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decrease their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight.This patient, with a long mental health history including suicide attempts, has neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in the outpatient setting.  She requires the structure and 24 hour supervision afforded by residential placement to cement the therapeutic skills necessary for success.  Further, her persistent symptomatologies, negative schemas, self-defeating behaviors, unrefined copings strategies including suicidal ideation as a punishment for her failure to progress, and pathological distortionism would more than likely undermine efforts at a lower level of care at this time, thus creating a risk for acute psychiatric admission.  Accordingly, the eating disorder residential treatment center services provided from the date in question and forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 67-year-old male has requested minimally invasive lumbar decompression for treatment of his chronic low back pain.  Findings:  Two physician reviewers found that his medical records note tingling and numbness in the right leg.  The patient has been diagnosed with central stenosis at L4-5 and bilateral neural foraminal stenosis.  The clinical notes indicate that the patient has degenerative disc disease which has worsened over time.  His prior treatment has included facet joint nerve blocks, epidural steroid injections, medications, and radiofrequency ablation.  Per the submitted documentation, prior treatment has not resulted in long-term relief.  In this patients case, the requested minimally invasive lumbar decompression is likely to be superior over other treatment options.  Currently, this is an emerging procedure.  Although there have not been randomized double-blind trials in large populations, many studies have shown significant improvement with positive results.  In this patients case, there are limited treatment options.  The requested minimally invasive lumbar decompression is associated with minimal complications.  Thus, the requested services are likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for surgery to resolve bruising, lumping and skin discoloration at the sclerotherapy injection site.  Findings:  The physician reviewer found that the records indicate that this patient developed known complications of spider vein sclerotherapy. The sclerotherapy procedure is designed to create inflammation within the spider vein in order for it to shrivel and collapse. However, the bodys response to the inflammatory process is unpredictable. Further, the complication described in this case causes no dysfunction and is not considered an abnormal condition. All told, the requested procedure is not expected to significantly improve the patients function or appearance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male has requested monthly intramuscular injections of Invega Sustenna 156mg, two weeks following a loading dose of Invega Sustenna 234mg for treatment of his schizoaffective disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The effectiveness of a particular antipsychotic varies according to clinical circumstances.  Treatment with antipsychotic medication is indicated, as schizoaffective disorder is a chronic illness with far-reaching functional deterioration.  Often, multiple medication trials are common in this patient population.  In this clinical setting, effective treatment has to be individualized.  The treating team has recommended intramuscular injections of Invega Sustenna after multiple antipsychotic and mood stabilizing medication trials.  In this case, the requested medication is medically appropriate and consistent with good medical practice.  All told, monthly intramuscular injections of Invega Sustenna 156mg, two weeks following a loading dose of Invega Sustenna 234mg are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male has requested coverage for a past sodium fluoride (NaF-18) positron emission tomography scan performed for evaluation of his prostate cancer.  Findings:  Three physician reviewers found that the patient has prostate cancer (stage T3B, N1, M0).  On the date at issue, a nuclear medicine bone scan showed no evidence of bone metastases.  Per the submitted documentation, PET/CT scan performed subsequently confirmed nodal involvement.  The patients case was presented to a Tumor Board, and a sodium fluoride (NaF-18) positron emission tomography scan was recommended.  This diagnostic procedure was performed.  In this clinical setting, the sodium fluoride (NaF-18) positron emission tomography scan performed was likely to have been of greater benefit than other tools for evaluating this patient.  The diagnostic procedure at issue is more sensitive than conventional bone scans.  The results of the sodium fluoride (NaF-18) positron emission tomography were needed for treatment planning in this patients case.  The current medical evidence supports the superior efficacy of the diagnostic procedure at issue in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) for treatment of the enrollees possible pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS).  Findings:  Two physician reviewers found that the patient was a normally functioning patient until about the age of 9. At this age, the patient began to develop severe behavioral changes consisting of severe anxiety, phobias and tics. Subsequently, he developed symptoms of severe abdominal discomfort, frequent vomiting, weight loss, and persistent psychiatric dysfunction requiring hospitalization. Laboratory studies recorded severe eosinophilia, intestinal parasites, but lacked a specific diagnosis. He was evaluated by multiple pediatric subspecialists including pediatric neurologists, psychiatrists, psychologist, and gastroenterologists again without any specific diagnosis, but a strong suggestion of Tourettes syndrome with tics and progressive obsessive-compulsive behavior. A pediatric rheumatologist noted that there was a possibility of a diagnosis of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS). The patient had an elevated CD3 serum level which did suggest an immunological autoimmune abnormality. The provider recommended a trial of intravenous immunoglobulin (IVIG) for treatment of this possible disorder. The Health Plan denied the request for IVIG as its utilization in PANDAS is considered investigational. This patients diagnoses as supported in the chart include Tourettes syndrome with tics and obsessive-compulsive behavior. The provider considered the possibility of PANDAS based on the patients history and minimal laboratory confirmation of this diagnosis. PANDAS is essentially a clinical diagnosis with this patient demonstrating some of its characteristics, while he simultaneously evolved severe personality and behavioral changes. Initial reports of treatment of PANDAS, by either IVIG or plasmapheresis, noted patient improvement. Perlmutter and colleagues conducted a controlled study in which nine children who received IVIG with improvement at one-month and one-year follow-up when compared with controls. However, 10 years later Martino and colleagues commented that there was a lack of conclusive evidence that either antibiotics or immune modulation with IVIG were useful in the treatment of PANDAS. Currently, there is inadequate evidence or clinical support for the existence of PANDAS as a clinical entity. As such, IVIG in this patient is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested coverage for past hospitalization services provided at Contra Costa Regional Medical Center.  The Health Plan has denied this request indicating that the services at issue were out-of-plan post-stabilization care.  Findings:  The physician reviewer found that the presentation of acute leukemia includes symptoms of relatively short duration, including fever, fatigue, and bleeding.  In this patients case, she was appropriately treated in the emergency department.  However, based upon the submitted medical records, the patients emergency medical condition stabilized on the date at issue.  Additionally, the medical records do not demonstrate any periods of destabilization from the date at issue through the remainder of the patient's stay.  This patient was hemodynamically stable and appropriate for transport to an in-plan facility for inpatient level of care services following the emergency department evaluation.  She had no evidence of purpura or petechiae.  Her absolute neutrophil count was 300, but there was no overt source of infection.  This patient had no evidence of gum hypertrophy or bone and joint pain, and there was no evidence of active bleeding.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested sacroiliac (SI) joint fusion using the iFuse implant for treatment of her sacroiliitis and lumbago.  Findings:  Three physician reviewers found that the patient has been diagnosed with sacroiliitis, not elsewhere classified, lumbago, and autoimmune disorder. A neurosurgery consultation note documents persistent left sacroiliac (SI) pain. A computed tomography (CT) of the lumbar spine  demonstrated Baastrups disease at L4-5, a 1 mm diffuse disc bulge at L4-5, mild to moderate degenerative facet hypertrophy bilaterally at L5-S1 with mild right neural foraminal narrowing, and right adnexal cyst versus free fluid in the cul-de-sac.The patients pain is noted to originate in the lower back. The patient has had multiple falls. The patient has been treated with acupuncture, chiropractic therapy, physical therapy (PT), and yoga. The patient was treated with radiofrequency thermal coagulation (RFTC) of the right lowest lumbar facet joint medial branch nerves with injection under fluoroscopic guidance. The providers notes describe complaints of lumbar radicular pain worse on the left at L5-S1 from neural foraminal stenosis (NFS) and stenosis as well as degenerative disc disease. The patients neurological examination on that date revealed diminished sensory to light touch bilaterally at L5, positive lumbar facet loading, and otherwise normal exam with 5 of 5 strength in the upper and lower extremities. The providers assessment was SI joint dysfunction that partially responded to therapeutic RFTC injection. The provider has recommended treatment consisting of a left SI fuse procedure. There may well be an element of pain originating from the SI joint but some of the pain may well also originate from the lumbar spine. The patients area of pain, symptoms, exam findings and imaging suggest that there may well be a component of symptoms originating from the lumbar spine. Moreover, there is not yet sufficient evidence to support that the requested SI fusion is likely to produce a better outcome than available standard therapies for SI joint pain/dysfunction.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested artificial disc insertion at C6-C7 for treatment of her neck pain.  Findings:  Three physician reviewers found that the patient is status post cervical fusion.  Six months ago she reported electric shock-like sensations going down from the neck and up the extremities, and this is increased by extension.  The medical records noted no clumsiness, no myelopathy, and no weakness.  She denied incontinence.  The provider noted that a prior MRI scan showed disc fragments at C6-7 and a collapsed disc at C7-T1.  In this case, the requested procedure is not likely to be more efficacious than other treatment options.  She reports electric shock-like sensations that are increased with certain neck movements.  The patient has disc protrusions below her fusion, although she has no radicular or myelopathic symptoms.  The long-term efficacy and safety of the requested procedure has not been established in this clinical setting.  Although there are some promising reports of short-term safety and efficacy, there is a lack of long-term data supporting the requested artificial disc insertion in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for cryosurgical ablation for treatment of the enrollees solid mass within the right kidney. Findings:  Two physician reviewers found that the patient has a history of dermatomyositis, lupus, deep vein thrombosis and bilateral total knee replacements. He was found to have a right renal mass and he underwent a CT guided biopsy of the mass. The biopsy revealed the mass to be consistent with oncocytoma, however, renal cell cancer was not able to be excluded as a diagnosis. The patients provider recommended cryoablation surgery to remove the renal mass, given the patients medical history and current medication regimen. The Health Plan denied the requested procedure, indicating that the procedure is not likely to be more beneficial for treatment of the patients medical condition than other available standard therapies. In cases such as this patients, open or laparoscopic surgical resection is the first line treatment typically utilized. This patient does not have a solitary kidney or known renal insufficiency that support the use of an alternative to standard surgical treatment, such as cryosurgical ablation. Additionally, the available peer-reviewed medical literature has not established the long-term efficacy of cryosurgical ablation in the treatment of renal masses. All told, the patient has no contraindications to standard surgical treatment for his renal mass. Therefore, the requested cryosurgical ablation 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 20-old female has requested allergy shots for treatment of her allergies.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with moderate to severe allergic symptoms. Diagnostic testing including skin tests have been positive. As is the case for patients who are college students, injections must be given at a providers office at some distance from the students home during the school year. This patients records demonstrate the medical necessity for allergy injections. For these reasons, the patients request for allergy shots provided from the dates at issue and forward are medically necessary for management of her medical condition.