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

A 60-year-old female has requested coverage for past as well as future skilled nursing facility services for treatment of her medical condition status post fistula repair.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue in this patients case.  As of a date at issue, the patient was stable on her medical therapy, was tolerating an oral diet, and had no complex wound care issues.  Per the therapy notes, she required minimal assistance with her activities of daily living.  She was receiving no intravenous medications, and she did not require further diagnostic studies or therapeutic interventions.  The submitted documentation does not demonstrate that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled level of care services.  She did not require daily skilled therapy services to prevent deterioration with mobility or activities of daily living.  All told, skilled nursing facility services through the dates at issue, and continued skilled nursing facility services were not and are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested authorization and coverage for Requip XL 12mg for treatment of the enrollees Parkinsons disease.  Findings:  The physician reviewer found that based on review of the available records, this patient has a diagnosis of Parkinsons with described symptoms consistent with that diagnosis. He has been treated with a dopamine agonist, Requip, with reported benefit. Requip has a short half life of five to six hours, and thus immediate release preparations need be taken three to four times per day. The Requip XL preparation and immediate release preparation are not the equivalent. A medical literature review reveals that treatment adherence, and thus treatment results, are enhanced by less frequent dosing, and are worsened with more frequent dosing across a variety of chronic conditions. This patients statement that it is more difficult to adhere to a less frequent dosing schedule is clinically reasonable and supported by the literature. Therefore, use of Requip XL, which requires less frequent dosing, is supported as medically necessary in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 8-year-old female enrollee has requested 12 additional speech therapy sessions for treatment of the enrollees autism. Findings:  The physician reviewer found that  speech therapy is a standard treatment modality for children who are diagnosed with an autism spectrum disorder and who have documented expressive and receptive language delays and socialization and pragmatic deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance with communication development for individuals with autism (Volmar and Wiesner).  Furthermore, language skills make a significant difference in the ability of children to control their environment, especially those with social skills deficits. The paper by Goldstein reviewed communication interventions for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions exist to teach communication skills to children with autism. While speech therapy is a well accepted treatment modality for children with autism who have documented expressive and receptive language delays and socialization and pragmatic deficits, in this patients case it does not appear that she has undergone a recent speech and language evaluation. As such, a current speech and language re-evaluation should be obtained. If the results of the re-evaluation indicate that the patient continues to demonstrate delays in language and social pragmatics, the requested speech therapy would be considered medically necessary and should be authorized.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 36-year-old female has requested coverage for past emergency services provided. Findings:  The physician reviewer found that the patient presented to the emergency department with a sore throat. The patient also felt as though her throat was swollen. She reported excessive sweating and difficulty breathing when she awoke in the middle of the night and therefore decided to go to the emergency room. In the emergency department, her vital signs were normal. The severity of the patients pain was documented as moderate. The patient was not short of breath while in the emergency department. Throat examination was significant for uvular swelling and swelling of both tonsillar pillars. A lateral neck x-ray was performed to assess the degree of soft tissue swelling and to rule out epiglottitis. The patient was diagnosed with acute pharyngitis and administered prednisone (most likely to reduce throat swelling) and amoxicillin in the emergency department. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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.Upon review of the submitted documentation, a prudent layperson would have sought immediate medical attention due to the severity of pain as well as the symptoms of throat swelling and difficulty breathing when she awoke in the middle of the night. These symptoms may be presenting symptoms of potentially life threatening disorders including epiglottitis, tonsillar abscess and other causes of throat swelling which may compromise the airway. Thus, the absence of immediate medical attention could reasonably be expected to place the patients health in serious jeopardy. Accordingly, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female has requested coverage for residential treatment program services for approximately four weeks for treatment of her anorexia nervosa, purge type, and major depressive disorder, recurrent, moderate.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The aim of modern psychiatry is to provide effective interventions in the least restrictive setting, as treatment in the community is consistent with better outcomes.  In this patients case, the records demonstrate acute-on-chronic eating disorder with co-occurring mood and anxiety symptomatologies.  However, there is no evidence that this motivated patient required the structure and supervision of a 24-hour setting, and there is no documentation indicating that she had recently failed less restrictive settings, such as partial hospitalization or intensive outpatient programming.  The current medical evidence does not support the services at issue in this case.  All told, residential treatment program services were not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested coverage for partial hospitalization services for 18 days for treatment of the enrollees polysubstance dependence.  Findings:  The physician reviewer found that based on review of the available records, the PHP services provided to this patient on the dates in question are not supported as medically necessary. Applying the treatment guidelines from the American Psychiatric Association (APA), the patients records do not document any risk factors that would require PHP level of care. The patient was cooperative and lived in a supportive family. The provider did not document the presence of any medical or psychiatric co-morbidities, or of any suicidal or homicidal ideation, psychosis, or run away behavior, that would preclude treatment at a lower level of care. Therefore, the services at issue were not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.   Findings:  The physician reviewer found that based on review of the available records, the patient has sustained a severe brain injury. His hospitalization with severe pneumonia in underscores the severity of his illness. The medical literature, including Eskildsen and colleagues review, discuss the indications for long-term acute care. Specifically, the authors noted that a patient needs to have an unstable condition with a need for multiple specialists providing frequent care. This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction. In addition, he continues to have severe brain injury and ventilator dependence more than three months post-stroke. He is unable to make gains consistent with intense rehabilitation. He will need a protracted course with rehabilitation with small gains expected over a long period of time. The anticipated benefit from acute rehabilitation follows from progressive recovery from brain injury. The degree of this patients brain injury prohibits him from progressing with intensive therapy at this time. All told, the requested services are not supported as medically necessary in treating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement for percutaneous hemilaminectomy for treatment of the enrollees degenerative disc disease.  Findings:  Three physician reviewers found that the patient has an approximately seven-year history of low back pain, bilateral leg pain, numbness and tingling. On neurological testing, he has some hypesthesia in the right S1 distribution, with 5/5 strength throughout in both lower extremities and normal symmetric reflexes. His lumbar magnetic resonance imaging (MRI) revealed advanced degenerative disc disease at L1-2 and L2-3, small posterior annular fissure at L3-4, mild spinal canal stenosis at L2-3 through L4-5, possible nerve root impingement on the left side on the exiting left L3 and L4 nerve roots, and possible right-sided nerve root impingement on the exiting right L5 nerve root. A lateral spine x-ray shows no instability. The records indicate the patient underwent a percutaneous hemilaminectomy. The patients request for reimbursement for the procedure has been denied by the Health Plan as investigational. In one of the most comprehensive reviews to date, Boswell and colleagues sought to develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. With regard to percutaneous discectomies, the authors reported that there was limited and contradictory evidence that automated percutaneous discectomy gives poorer clinical results than alternative surgical techniques with which it has been compared. The authors concluded that the evidence is moderate for short-term and limited for long-term relief. In another review, Freeman and Mehdian reviewed the current evidence for intradiscal electrothermal therapy (IDET), percutaneous discectomy, and nucleoplasty. The authors concluded that trials of automated percutaneous discectomy suggest that clinical outcomes after treatment are at best fair and often worse when compared with microdiscectomy. Based on these two comprehensive reviews, the safety and efficacy of percutaneous discectomy have not been demonstrated. Therefore, the procedure was not likely to have been more beneficial than any available standard therapy in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male has requested acute inpatient detoxification followed by transitional residential recovery services for treatment of his opioid dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current guidelines do not support the services at issue in this clinical setting.  Regarding the patients request for acute inpatient detoxification, the medical records do not support these services.  This patient was motivated for treatment, and he had not pursued any treatment prior to presentation.  He had an unremarkable physical examination.  Opioid detoxification can be appropriately addressed in the outpatient setting with medications such as metoclopramide, hydroxyzine, and clonidine, which were all prescribed.  In terms of substance abuse treatment, this patient had not failed any less restrictive interventions during the course of illness, such as intensive outpatient, partial hospitalization, or supportive sober living in the community.  Considering this patients clinical presentation and current practice guidelines, acute inpatient detoxification followed by transitional residential recovery services are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested authorization and coverage for oxycodone for treatment of the enrollees pain management.  Findings:  The physician reviewer found that based on review of the available records, the patient does have chronic pain in the low back and more acute pain in the cervical spine and the upper extremities. He has been on methadone, which is a very potent narcotic analgesic that stimulates multiple narcotic receptors along with the NMDA antagonism that has been implicated in the control of central pain syndromes and neuropathic pain. The patient in this case is a chronic pain patient who should be on a long acting medication with a breakthrough short acting medication that is available one to two times per day. The individual narcotic needs to be approved based on tolerance, receptor activity and side effects as well as addiction potential. There is data to suggest that the rotation of opioids is reasonable. However, methadone is a difficult medication to convert from as it has such a long half life and agonizes and antagonizes multiple receptors, so it is a difficult and delicate conversion. There is no reason the patient needs to be placed on oxycodone if the provider determines this is not the ideal choice for his medication. There are several new long acting and short acting medications that may be of benefit, including Butrans, Exalgo, Opana, and long acting oxycodone. All told, the records do not establish that the specifically requested narcotic compound is superior in this clinical setting. The patient should have a full pain evaluation with an opioid risk assessment to best determine the best medication option. Therefore, the requested medication has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested surgery consisting of lumbar spinal fusion, anterior approach, exploratory retroperitoneal, insertion vertebral device anterior 2-3 segments, application of spine prosthetic device, and extensive fluoroscope exam for treatment of her back and leg pain.   Findings:  The physician reviewer found that in the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick, et al. examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.  Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain.The American Pain Society (APS) has also developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain (Chou, et al). A multidisciplinary panel developed a total of eight recommendations on treatment. The recommendation applicable to this patient states that, In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, it is recommended that clinicians discuss risks and benefits of surgery as an option (strong recommendation, high-quality evidence). It is recommended that shared decision-making regarding surgery include a specific discussion about moderate average benefits, which appear to decrease over time in patients who undergo surgery. Surgery, in this context, specifically refers to discectomy, not fusion. Based on these two comprehensive literature reviews, the requested surgical fusion at the L4-5 level is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female has requested coverage for partial hospitalization level of care for the treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  In this clinical setting, treatment at the partial hospitalization level of care is medically indicated.  As noted by the American Psychiatric Association, the determination regarding appropriate level of care is based upon overall physical condition, psychology, behaviors, and social circumstances.  In this patients case, she had not consolidated the treatment gains necessary in the intensive outpatient setting.  Per the clinical documentation, her condition was likely to worsen without appropriate treatment.  The current medical evidence and clinical guidelines support partial hospitalization level of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male has requested past and future coverage for continuation of skilled nursing facility services for treatment of his metastatic melanoma to the brain and lungs.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  As of the date at issue, he required maximum assistance with all transfers.  Despite skilled level of care physical therapy services, he could only ambulate 50 feet with a front-wheeled walker, and he required two people for assistance.  Per the submitted medical records, the patient was receiving no skilled level of care nursing or therapy services.  He was tolerating his medical regimen, and he had no complex wound care issues.  The patient did not require further diagnostic studies or therapeutic interventions.  There was no documentation indicating that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled nursing facility level of care.  Thirteen days after the date at issue, he did not require daily skilled level of care services to prevent deterioration with mobility or activities of daily living.  From this date forward, the patients needs were custodial in nature.  All told, skilled nursing facility services from this date forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested LINX surgery for treatment of her gastroesophageal reflux disease.  Findings:  Three physician reviewers found that per the medical records, the patient has experienced gastroesophageal reflux disease symptoms for approximately 20 years.  She has been tried on a number of acid reducing therapies, including proton pump inhibitors.  The patients main symptoms include nocturnal coughing, voice hoarseness, an acid sensation in the chest, and early morning dysphagia.  An upper endoscopy with biopsy and placement of a Bravo pH monitoring device confirmed acid reflux primarily in the upright position.  The current medical evidence does not support the requested procedure in this case.  There is a lack of long-term data supporting the LINX procedure in this clinical setting.  Acid reflux is a chronic condition.  The durability of the LINX procedure has not been established.  In this clinical setting, the requested procedure is not likely to be of greater benefit than traditional fundoplication or maximization of medical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested reimbursement for MammaPrint gene testing for evaluation of the enrollees breast cancer. Findings:  Two physician reviewers found that the patient presented with an abnormal mammogram.  A biopsy was performed.  The tumor was an infiltrating ductal carcinoma, grade 2, hormone receptor positive, and HER-2 positive. The following month she underwent a right segmental resection and sentinel lymph node biopsy.  One of the nodes showed a 0.01 mm focus of metastatic disease.  MammaPrint gene testing has been validated in clinical trials.  Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in post-menopausal women.  In this case, there is a 15% chance of recurrence.  It is this 15% that needs adjuvant chemotherapy.  This patient has been diagnosed with early breast cancer.  In this clinical setting, there is sufficient rationale and medical evidence supporting MammaPrint gene testing to decide upon adjuvant treatment.  The use of the MammaPrint is also listed in the Physician Data Query of the National Cancer Institute.  The current medical evidence supports the testing at issue in this patients case.  Thus, MammaPrint gene testing was likely to have been more effective than other options for evaluating this patient.