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

A 34-year-old female enrollee has requested for partial hospital mental health therapy for treatment of her anorexia nervosa. Findings:  The physician reviewer found that the patient continued to have anxiety and some depression and there was some ambivalence regarding taking prescribed medications. However, these concerns could have been appropriately addressed at a less intensive level of care. Based upon the American Psychiatric Association guidelines, the patient was a candidate for a range of outpatient services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a functional electrical stimulator (prosthetic WalkAide System) for treatment of his foot drop. Findings:  Two physician reviewers found that this patient has a documented benefit from the use of a WalkAide for his right lower extremity. There is documented improvement in his gait and stabilization of his palpable sclerosis. He has bilateral foot drop. There are several studies that have documented the benefit of a functional electrical stimulation for patients with foot drop. Given the functional benefit that he has seen from the device on his right leg, as well as the evidence in the literature to support its use, a prosthetic WalkAide System is likely to be superior to any standard device/modality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for magnetic resonance imaging of the left foot and leg for evaluation of her left foot pain.  Findings:  The physician reviewer found that this patient has been evaluated with an MRI without evidence of pathology. The records are absent documentation of any trauma or signs of infection. In addition, the patients pain is lateral in distribution, but the posterior tibialis tendon is a more medial structure. The provider has not reported any point tenderness over the patients proximal posterior tibialis tendon to warrant further investigation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a one-year-old male enrollee has requested a bone-anchored hearing aid for treatment of the enrollees moderate to severe mixed hearing loss. Findings:  Three physician reviewers found that there are a limited number of scientific studies regarding bone-anchored hearing aid implantation in children younger than five years of age. Most studies regarding the use of this device in children involved an older age group. Although the outcomes were generally positive and not with greater than expected complication rates for the procedure, there have been limited studies involving children less than five years of age. More outcome data is needed to determine if implantation at such a young age is safe.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that this patient had a recent history of being treated for a urinary tract infection (UTI) with complaints of rapid onset bladder spasm and gross hematuria prior to admission to the emergency department. The patient reported her pain level at 9 on a scale of 1 to 10 at triage. The emergency physician did a urinalysis which showed evidence of pyuria and hematuria. She was discharged with a diagnosis of cystitis (UTI) and provided a prescription for Macrobid and pain medicine. This case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. The patient rated her pain as 9 of 10 on initial presentation in association with gross hematuria. The patients pain level or the blood in urine alone would have been a sufficient basis for a layperson to consider this patients condition to be an emergency. She had a history of urinary tract infections including pyelonephritis and had been told in the past by a medical professional to seek immediate medical attention for similar symptoms to prevent progression to pyelonephritis. Thus, a prudent layperson would have been appropriately concerned for her imminent health under these circumstances.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested Oncotype DX genotype testing for an evaluation of her breast cancer. Findings:  Two physician reviewers found that Oncotype DX testing is a 21-gene signature performed on breast cancer specimens. This assay is a validated tool in determining the recurrence risk in patients with ER+, node negative breast cancer. This patient meets the clinical criteria upon which this test is based. The use of this assay in this clinical situation is well supported by the peer-reviewed scientific literature. Furthermore, the National Comprehensive Cancer Network (NCCN) endorses the use of this assay in this patients particular clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested termination of pregnancy for treatment of her medical condition. Findings:  The physician reviewer found that the patient had two maternal fetal medicine consultations suggestive of the diagnosis of craniosynostosis. The differential diagnosis was discussed, and prenatal molecular testing was offered for further diagnostic evaluation. The syndromes associated with craniosynostosis and FGFR mutations include Apert syndrome, Crouzon, Pfeiffer, Jackson-Weiss and Adelaide type.  As noted by Renier and colleagues, although these syndromes can be associated with possible mental retardation and possible developmental delay and can require several significant surgical procedures, the long-term prognosis can be very good and is associated with long-term survival. Given the specific nature of the sonographic findings and consistency between the two maternal fetal centers, it is unlikely that the differential diagnosis would have also included other syndromes that are associated with a fetus that would be more likely nonviable. In this patients case, her life was not in jeopardy based upon the sonogram findings. Additionally, had the fetus been carried to full-term and delivered, her life would not have been in any greater jeopardy than the normal risks associated with full-term pregnancy. Furthermore, termination of pregnancy was not medically necessary due to fetal nonviability.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested lumbar spinal fusion (L5-S1) for treatment of her back pain. Findings:  The physician reviewer found that the submitted clinical evidence does not reveal signs or symptoms of radiculopathy in this patient (Tarulli and Raynor). Based on the submitted documentation, she has no spondylolysis or spondylolisthesis. Postoperative scar tissue is an expected finding in this patients case. It will be found in up to 25% of patients after fusion. It is an x-ray finding rather than a clinical disease. Postoperative scar tissue is not an indication for surgery unless radiculopathy, angulation, kyphosis or sagittal or coronal imbalance occurs, as noted by Cheh, et al. None of these conditions are present in this case. As such, the patient does not meet clinical indications for a lumbar spinal fusion.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested left total ankle replacement for treatment of his progressive osteoarthritis of the left ankle. Findings:  Two physician reviewers found that total ankle replacement (arthroplasty) is an appropriate surgical treatment in patients with severe inflammatory arthritis of the ankle joint. This is especially true when there is significant involvement of the subtalar joints, as is the case with this patient. Recent studies demonstrate positive intermediate-term results in this subset of patients when treated with total ankle arthroplasty. As reported by Haddad and colleagues, The five-year implant survival rate was 78%...and the ten-year survival rate was 77%. Regarding this particular patient, magnetic resonance imaging (MRI) revealed significant subtalar and midtarsal changes. In addition, the provider noted decreased range of motion, and increased pain and tenderness in the subtalar joints on physical examination. These clinical findings support diagnoses of inflammatory arthritis and arthritis in adjacent joints. Even separately, each of these diagnoses is sufficient to support the likelihood that the requested surgery is 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 58-year-old male enrollee has requested repeat right knee viscosupplementation with Orthovisc for treatment of his degenerative joint disease of the right knee. Findings:  Two physician reviewers found that this patient had an excellent response in the past to the series of Orthovisc injections.  He has an accelerated degenerative osteoarthritis.  Per the medical literature, hyaluronic acid injections are indicated for moderate to severe osteoarthritis and are indicated for treatment about once a year to help delay surgery or to supplement for surgery in patients who are not surgical candidates.  In this case, the submitted documentation does not note any contraindication for repeat viscosupplementation therapy with Orthovisc, and the results he has had thus far have been excellent. A literature review shows the benefit of repeat right knee viscosupplementation in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 72-year-old male enrollee has requested Bystolic 10mg for treatment of his hypertension. Findings:  The physician reviewer found that this patient is being treated with Bystolic, a non-formulary drug, for the management of hypertension. The only other beta blocker trial documented was atenolol, and this was not tolerated due to cold hands and toes with Raynauds syndrome. The medical records do not document treatment failure or intolerable side effects to other formulary beta blockers. Bystolic is a beta-1 selective beta blocker at the dose prescribed. There are alternative formulary beta-1 selective beta blockers available, including metoprolol, bisoprolol and acebutolol. These should not result in the beta-2 side effects that this patient experienced with atenolol. In this patients case, the alternatives offered by the Health Plan are medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested Genotropin for treatment of her medical condition. Findings:  Three physician reviewers found that the medical records submitted do no support the diagnosis of GH deficiency in this patient, and there is no evidence submitted to support other pituitary hormone deficiencies. The patients low thyroid stimulating hormone (TSH) level is likely due to the thyroid hormone she is taking. Furthermore, based on the submitted records, this patients prior hysterectomy (surgical menopause) cannot be ruled out as the cause for her low luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels. This is evidence against the suggestion of pituitary dysfunction. This patients endocrinologist feels that an MRI is contraindicated for this patient because she has a prolactinoma. However, according to the submitted records, the only finding suggestive of a pituitary problem is an elevated prolactin level (171-215). Because this patient is on medications for her eating disorder, it is not possible to rule these medications out as the cause of her elevated prolactin levels (Molitch). Lastly, this patient has normal growth hormone levels and although she had low-to-normal IGF-1 levels, patients with an eating disorder commonly exhibit such low levels.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a standing magnetic resonance imaging (MRI) scan of the spine for an evaluation of his medical condition. Findings:  Two physician reviewers found that the submitted clinical evidence demonstrates that there is not an established and predictable benefit for a standing MRI in this setting. The relevant literature documents that the spine is a dynamic functional structure and that the relationship between the spinal canal and nerve roots does change with weight-bearing and changes of position. A supine MRI is a standard assessment method. Because the anatomical findings in an upright or positional MRI with weight-bearing are so variable, it is unlikely that the findings can be systematically applied in a clinical setting. Standardizations of technique are important so that clinical criteria can also be standardized. Review of the literature does not demonstrate that this level of standardization has yet been achieved in positional or upright MRIs. Until there is careful standardizations of the technique of obtaining the anatomical study and the diagnostic criteria to be applied in analyzing the images obtained, upright and weight-bearing MRIs have the potential of leading to incorrect clinical diagnoses and unsuccessful interventions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested residential psychiatric treatment for the treatment of her major depressive disorder. Findings:  The physician reviewer found that the medical records indicate that the patient completed family week and was stable on current medication. Two days later, the nursing notes indicated that the patient reported slight depression. However, the nursing notes also indicated no suicidal or homicidal ideation. There was some anxiety, which was responsive to medication.  The medical records demonstrate that the patient was compliant with treatment, was sleeping well and was attending all groups and sharing with peers during the dates of service at issue. Overall, the documentation does not support the medical necessity for continued residential treatment during the time period at issue. Per the American Psychiatric Association guidelines and Level of Care Utilization System (LOCUS) criteria, this patient was appropriate for a less restrictive level of care during the time period at issue. The patient did not meet clinical indications for residential psychiatric treatment during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for laparoscopic myomectomy combined with hysteroscopic myomectomy for treatment of her uterine fibroids. Findings:  The physician reviewer found that the studies by Walid and Heaton and Sinha, et al. support the use of minimally invasive techniques in the management of fibroids, including fibroids of a substantially greater size than is involved here. In addition, hysteroscopic resection of fibroids is an accepted practice for the treatment of intra-cavitary fibroids.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Lyrica for treatment of her pain. Findings:  The physician reviewer found that there is a lack of clinical trial evidence supporting the use of antiepileptic medications such as Lyrica for chronic low back pain (Chang, et al.). Per Eisenberg, et al., there is a need for large-scale randomized controlled trials on the efficacy of antiepileptic drugs in neuropathic pain. The authors note that trials with long-term follow-up are required to establish the sustained efficacy of antiepileptic drugs for this indication. Recent systematic reviews recommend a treatment algorithm for any neuropathic pain syndrome, regardless of etiology, with the drugs of first choice being tricyclic antidepressants, gabapentin or pregabalin (Lyrica), and opioids (Dworkin, et al. and Finnerup, et al.). However, these papers acknowledge the limitation that most of their conclusions are drawn from randomized trials in patients with diabetic neuropathy and postherpetic neuralgia. Extrapolation to neuropathic pain of other etiologies is unproven. As such, further studies are warranted to establish the medical necessity of Lyrica in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested adult psychiatric acute inpatient treatment for treatment of his severe depression. Findings:  The physician reviewer found that at the time of admission, the patient was on multiple medications. During his hospital stay, there was a need to taper and discontinue several medications. These adjustments required close monitoring due to his marked sensitivity to medication changes and risk for further mood instability and decompensation. In summary, an analysis supports a finding of medical necessity for the inpatient services provided during the time period in question for management of his condition. This conclusion is consistent with standards of practice, the American Psychiatric Association (APA) practice guidelines and the level of care utilization system for psychiatric and addiction services (LOCUS).
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested first trimester pregnancy testing for treatment of her medical condition. Findings:  The physician reviewer found that this patient was evaluated in an office visit by an obstetrician. She presented reporting a positive home pregnancy test. She denied weight loss, headache, chest pain, difficulty breathing or urinary frequency. The patient did not report any vaginal bleeding or discharge. Her vital signs revealed a blood pressure of 100/60 and her physical exam was otherwise normal. A pap smear was taken and sent for analysis. An ultrasound was obtained showing a 6-week, 3-day intrauterine gestation. Blood tests were ordered for a urinalysis, obstetrical panel, HIV test, parvovirus, and varicella assay. No medical intervention or medications were administered. At issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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. This patient sought medical attention on an outpatient basis for evaluation of her pregnancy. She was not experiencing any acute symptoms at the time of her initial visit. The patient did not report vaginal bleeding, discharge, or pelvic pain. Her physical exam was normal. There was no medical indication for an emergent ultrasound on an asymptomatic patient in this case. Additionally, while the screening exams ordered may be indicated for routine obstetrical care, the tests ordered in this patients case were not required on an emergency basis. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergent care to jeopardize her health or the health of her fetus in this situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Aciphex for treatment of her chronic gastritis. Findings:  The physician reviewer found that Nexium is the S-isomer of omeprazole. Based on the records provided, the patient developed an allergic reaction to Nexium. Not only is omeprazole not indicated for this patient, she should avoid any related compounds. Omeprazole is a related compound to Nexium, and is in fact very similar. Therefore, it is contraindicated to give omeprazole to this patient since a rechallenge may cause a very severe reaction with potentially life-threatening consequences. The patient has been taking Aciphex with benefit and without untoward side effects. It is medically appropriate for the patient to remain on Aciphex and avoid taking omeprezole, Nexium and Prevacid.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested chlordiazepoxide (Librium) 10 mg, three times per day for treatment of his anxiety and alcohol recovery. Findings:  The physician reviewer found that paroxetine (Paxil) is an efficacious and well-tolerated treatment for generalized anxiety disorder (Rickels and colleagues). Overall, the medical literature suggests that although Benzodiazepines, of which Librium is one, may offer short-term benefit in lessening anxiety symptoms but they are not considered appropriate for long-term treatment. In fact, some studies suggest that Librium is no more beneficial than placebo over the long-term. At this time, selective serotonin reuptake inhibitors (SSRIs), including Paxil, are recognized as the pharmacologic treatment of choice for generalized anxiety disorder (GAD). It should be noted that this patient has not completed a reasonable trial of Paxil, Buspar, or Effexor, as more than one week is generally required in order for a patient to glean benefits. All told, there is inadequate medical justification for continued use of Librium to treat this patients GAD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested authorization and coverage for a duodenal switch procedure for treatment her morbid obesity. Findings:  The physician reviewer found that the patients BMI of 48 and co-morbidities he meets medical necessity criteria for weight loss surgery. The safety and efficacy of the duodenal switch is well established based on the available medical evidence including long-term follow-up of over 10 years. While the duodenal switch procedure is indicated for this patient, the submitted information lacks documentation that the patient has stopped smoking. Smoking is a contraindication to any weight loss surgery and documentation of smoking cessation should be obtained prior to authorization of the requested procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for pelvic floor rehabilitation through biofeedback for treatment of her urinary tract symptoms. Findings:  Three physician reviewers found that although the literature is encouraging as to the efficacy of biofeedback in the treatment of lower urinary tract symptoms, there is a lack of adequate support in the medical literature for this treatment modality at this time. The superior efficacy of biofeedback has not been established in this clinical situation. There has been long-standing debate regarding biofeedback for treating pelvic floor symptoms. However, there is no high quality data showing the role or place for this therapy and how it is to be used effectively.