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

A 25-year-old male enrollee has requested 30 days of inpatient residential treatment for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) placement criteria, the patient is an appropriate candidate for treatment in a less restrictive setting than residential treatment level of care. Per the ASAM guidelines, this patient has not shown any acute withdrawal symptoms and is not at significant risk for severe withdrawal. The records indicate that he has been able to limit his use to the weekends only. The patient has no documented medical conditions or complications that would require continuous 24-hour monitoring and care. Further, the patient has been motivated to change. While the patients recovery environment is not supportive, he could be safely treated in a sober environment, such as a half-way house. As the patient continues to require close monitoring and support several times a week, services can be provided at the intensive outpatient program (IOP) or partial hospitalization program (PHP) level. Consistent with these findings, the requested residential level of care is not supported as medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested OxyContin 40mg every six hours, and oxycodone (IR 30mg twice per day, as needed  not KV Tech brand) for treatment of her neck pain.  Findings :  The physician reviewer found that Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing painful condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is the patients best interest to wean down or off opiates, and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address her chronic pain. High dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Any opioids as requested by the patient for her chronic pain would be contradictory to providing safe and effective healthcare. The requested medications are therefore not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested computed tomography (CT) of the abdomen and pelvis and sacroiliac joint injections for treatment of his lumbago and epigastric pain.  Findings:  The physician reviewer found that the requested CT of the abdomen and pelvis and sacroiliac joint injections are not medically necessary for evaluation and treatment of this patients medical condition. The patient had a normal blood test and urine test. Therefore, there is no indication for a CT scan of the abdomen and pelvis. Additionally, the patient describes low back pain characteristic of lumbar radiculitis from a nerve root irritation. The physical examination and patient subjective symptoms do not indicate sacroiliac joint dysfunction. A sacroiliac joint injection is also not medically necessary.Dreyfuss and colleagues suggested that diagnosing sacroiliac joint mediated pain is difficult because the presenting complaints were similar to other causes of back pain. The authors noted that radiographic and laboratory tests primarily help exclude other sources of low back pain while MRI, CT, and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain. The authors concluded that, controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis. Zelle and colleagues assessed the clinical presentation, diagnostic testing and treatment options for sacroiliac joint dysfunction via a systematic literature review. They found that a reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be relief of pain following a radiological guided injection of local anesthetic into the sacroiliac joint. However, the current literature does not include generally accepted guidelines for the diagnosis and treatment of sacroiliac instability. All told, the requested CT of the abdomen and pelvis, and sacroiliac joint injections, are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female enrollee has requested an MRI brain stem with and without contrast and an MRI of the orbit/face/neck with and without contrast to be performed at UCLA Medical Center for evaluation of her left temporal bone squamous cell carcinoma.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services in this patients case.  Based upon the clinical notes, it is medically necessary that the requested services be performed at UCLA Medical Center.  While the requested scans may be performed at an in-network facility, there is no guarantee the necessary sequences and other scanning parameters used at UCLA Medical Center in the past will be utilized by the in-network facility.  In addition, the in-network interpreting radiologist will not have the host of prior studies done at UCLA Medical Center in order to conduct a detailed comparison over time, which is crucial to detect subtle changes in a complicated tumor treated previously with surgery, chemotherapy, and radiation.  All told, it is medically necessary that the requested MRI brain stem with and without contrast and the MRI of the orbit/face/neck with and without contrast be performed at UCLA Medical Center.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee has requested an endoscopic Maze procedure for treatment of his atrial fibrillation.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature and clinical practice, the endoscopic Maze, mini-Maze, or robotic Maze, are all recognized treatment options for patients with AF following failure of medical therapy and cardioversion procedures. The Maze procedure is less invasive than the Cox-Maze approach, and there are reliable data demonstrating positive outcomes with the Maze technique. As this patients provider has recommended the Maze instead of the Cox-Maze procedure, the requested services are likely to provide this patient with greater benefit than any standard alternative and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a bariatric consultation for bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Current guidelines do not support the requested services in this clinical setting.  The submitted medical records do not document prior failed weight loss efforts.  A behavioral clearance was obtained.  However, a thorough multidisciplinary evaluation also includes a dietary evaluation, and there was no record of a dietary evaluation.  All told, the requested bariatric consultation for bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested Ozurdex intraocular implant for treatment of his chronic macular edema.  Findings:  Three physician reviewers found that per the submitted documentation, this patient has refractory macular edema, and the only treatment shown to be efficacious is treatment with high-dose steroids via Ozurdex intraocular implant.  When the dose wears off, the macular edema recurs.  The provider has recommended Retisert intraocular implant, and this provides the same treatment over a longer duration.  In this patients case, there are limited available treatment options.  Steroids are the treatment of choice for macular edema, and this patients condition has been shown to be refractory to all treatments other than high-dose intravitreal steroids.  All told, Ozurdex intraocular implant provided on the said date and future treatment with Retisert intraocular implant were and are likely to be more beneficial than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested breast reconstruction with submuscular implants for treatment of her hypomastia. Findings:  The physician reviewer found that tuberous breast syndrome is characterized by a constricting ring at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast parenchyma toward the nipple areolar complex and areola enlargement. This patient has enlarged areola and vertical deficiency below the nipple level. Tuberous breast syndrome is classified into four types. These types range from Type I, which involves hypoplasia of the lower medial quadrant, to Type IV, which is characterized by severe breast constriction, minimal breast base, and herniation of breast tissue into the nipple areolar complex. In this patients case, she has Type I tuberous breasts as the side view photograph demonstrates adequate lower outer quadrant tissue, especially on the left side. Type I tuberous breasts is considered a normal variant of breast appearance and within the range of accepted variations. Therefore, the patients condition does not constitute an abnormal structure of the body and does not meet criteria for reconstructive surgery. Further, breast reconstruction with submuscular implants is not medically necessary for the patients medical condition. The requested surgery is not being performed to improve function, as there is no functional deficit.  All told, the requested breast reconstruction with submuscular implants is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested radiofrequency bipolar ablation  right, sacral S1, S2, S3, and L5 for treatment of his back pain.  Findings:  Two physician reviewers found that in a study authored by Cohen and colleagues evaluating lateral branch radiofrequency denervation for SI joint pain, the authors indicate that, larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder. Further, Rupert and colleagues concluded that, the evidence for radiofrequency neurotomy is also limited (level II-III). All told, this request is not supported by long-term studies documented in the peer-reviewed medical literature and is not likely to provide this patient with a superior outcome when compared to standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Although this patient has a body mass index of 53.72, there is no documentation of any failed dietary efforts.  There is a lack of documentation regarding supervised or non-supervised weight loss.  In addition, the submitted records do not include a multidisciplinary evaluation.  This would include a dietary evaluation and a behavioral evaluation.  All told, the requested bariatric surgery is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of  her breast cancer.  Findings:  Three physician reviewers found that aggressive screening for recurrence after successful treatment of early breast cancer, in general, has not been shown to have any effect on survival. The National Comprehensive Cancer Network (NCCN) recommends only four to six months of clinical examinations for the first five years after completion of treatment. Subsequently, the NCCN recommends only annual visits. In terms of imaging, only mammography is recommended. Thus, the requested PET/CT scan for evaluation of this patient who is almost 10 years of recurrence free survival is not likely to be more beneficial for evaluation of her medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested the Halo procedure (radiofrequency ablation) for treatment of her Barretts Esophagus.  Findings:  Two physician reviewers found that the records indicate this patient has no dysplasia and the size of the Barretts is small. Currently, there are no generally accepted guidelines supporting the use of Halo procedure for non-dysplastic Barretts esophagus. As it is not within the standard of care to proceed with ablation in a simple case of Barretts esophagus, in this patient who is not at high risk for developing dysplasia or malignancy, the requested services are not likely to be more beneficial than any available standard therapy for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested ongoing home speech therapy (2 times per week, 1 hour sessions) for treatment of her expressive aphasia.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. This patient is improving clinically with home speech therapy. The patient requires continued speech therapy to treat her documented expressive aphasia. The submitted documentation demonstrates that she is restricted to the home environment by a medical diagnosis of anxiety. The patient is medicated for her anxiety but cannot leave the home environment without significant difficulty. Since the patients anxiety renders her homebound, she was and is an appropriate candidate for home speech therapy services. All told, the medical necessity of at home speech therapy at a frequency of two 1-hour sessions per week has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Synvisc One (hyaluronic acid) injection for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested Synvisc One injection (viscosupplementation). The patient has both an MRI and arthroscopically documented degenerative osteoarthritis of the knee joint with the MRI showing marrow edema in the femoral condyle. There have been carefully conducted double-blinded studies which do not document that viscosupplementation has any meaningful benefit in this clinical setting. In addition, there is a recognized incidence of aseptic inflammatory reaction due to allergic response. There is also a risk of iatrogenic infection. A recent metaanalysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials, (involving 12,667 adults) that patients with knee osteoarthritis viscosupplementation are associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse events (Rutjes, et al.). In conclusion, the medical necessity of the requested therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested DeNovo NT Natural Tissue Graft for treatment of the enrollees osteochondral defect in the medial facet of the patella.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other available treatment alternatives.  This patient had a large osteochondral defect involving the entire medial facet.  There was also deep involvement of the subchondral bone, which the provider addressed through bone graft.  There is a lack of options for the treatment of the combination of full thickness cartilage loss and lack of supporting bone.  There is adequate support in the current medical literature for the services at issue in this clinical setting.  All told, DeNovo NT Natural Tissue Graft was likely to have been more efficacious than other modalities for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested services on an emergent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date of service at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. 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 principal determinate of the need to seek evaluation in an emergency department was the degree of pain that the patient was in. The fact that she had a pain level of 8 out of 10, constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. The patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested outpatient therapy sessions at a frequency of once per week for treatment of her depression and anxiety. Findings:  The physician reviewer found that the therapeutic resolution of an adjustment disorder involves patient identification and understanding of the stressor.  The literature supports an array of interventions including cognitive therapy, family therapy, patient-centered therapy, supportive therapy, psychodynamic therapy, and time-limited, targeted psychotropic medication management.  Considering this patients emotional fragility and poor sense of self, and reluctantly estranged relationship with her son, weekly therapy was indicated through the date indicated.  During the session on the date specified, the patient was stable.  She was committed to treatment and self-improvement.  The therapist made a point to commend her on the progress she had made.  There was no evidence of specific functional impairment, grave disability, or imminent threat.  The medical records do not include longitudinal documentation including treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination, or supportive community interventions.  In this patients case, scaling back frequency of sessions to every two weeks as of the date specified to bolster autonomy and resiliency while mobilizing the patient towards remission within her community would have been medically appropriate.  Thus, weekly outpatient therapy sessions were medically necessary from the time frame specified.  However, the medical necessity of weekly outpatient therapy sessions from the date indicated forward has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested emergency services for treatment of the enrollee's fever.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patients symptoms met prudent layperson criteria for emergency care. The patient presented with acute symptoms of pain, lethargy and fever which were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in jeopardy due to the risk of serious and life threatening infection such as meningitis. Given the lack of adequate response to treatments administered at home, it was reasonable for the patients parents to seek immediate medical attention on the date of service in question.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested emergency services for treatment of his abnormal behavior.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention for the patient. The patient was experiencing acute paranoia and was actively hallucinating.  His medical condition was of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy and potential harm to others. The visit to the emergency department on the date indicated was appropriate; the patient was experiencing active psychotic symptoms on that day and it appears his family was unable to secure immediate care through the patients primary care physicians office. As such, the patients symptoms on the date indicated met prudent layperson criteria for emergency care.