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

The parent of a 2-year, 8-month-old female enrollee has requested speech therapy for treatment of the enrollees expressive speech delay.  Findings:  The physician reviewer found that this young patient is cognitively normal and actually advanced in all her tested parameters except for the production of speech. When tested at 2-years, 6-months of age, she had a 15 word vocabulary and no phrases with skills at approximately a 1-year level. For this reason, she is likely to significantly benefit from speech therapy as supported by ample medical literature. Law and colleagues concluded in their meta-analysis of numerous medical studies that children with speech delay can be readily treated. In addition, Goorhuis-Brouwer and Kniff found that cognitively normal and delayed children with delayed speech are candidates for improvement with speech therapy. Further, Buschmann and colleagues addressed the accuracy of speech testing in a 2-year-old population and found that these patients are likely to benefit from speech therapy. All told, speech therapy is medically necessary to address this patients expressive language delay. The medical community standard for a two-year-old patient functioning at the level of a one-year-old peer includes speech therapy. This patient should receive two hours per week of speech therapy for six months followed by re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued for an additional six months.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested emergency room services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would believe he or she was experiencing an emergency medical condition on the date of service at issue requiring emergency medical services. Under Health and Safety Code 1317.1, 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: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that the patient was experiencing an emergency medical condition upon presentation to the Emergency Department. The physician gave the patient prescriptions for multiple potent medications to treat her illness, an indication of the seriousness of her clinical situation. Acute wheezing, particularly in a non-asthmatic individual, with or without perceived shortness of breath, chest pain or fever, is considered a medical emergency by emergency physicians and likewise should be perceived as a medical emergency by a reasonable and prudent layperson.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female has requested speech therapy for treatment of her autism.  Findings:  The physician reviewer found that there is ample peer reviewed medical literature demonstrating that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain still exists, and speech therapy can be utilized to improve overall neurologic health, even in patients with underlying neurologic disease. Thus, speech therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills. The evidence is clear that language skills and to a lesser degree, non-verbal skills, improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for the oxygen concentrator and/or oxygen for treatment of her Osler-Weber-Rendu syndrome. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the equipment at issue.  Per the submitted medical records, the patient has a history of known pulmonary arteriovenous malformations.  She is status post embolization. Per the documentation provided, there is no evidence of significant hypoxemia.  Additionally, there is no evidence of arterial oxygen desaturations which would require long-term oxygen therapy. Based upon the blood gases provided, long-term oxygen therapy is not medically indicated. The current medical evidence does not support the use of the equipment at issue in this clinical scenario.  All told, the oxygen concentrator and/or oxygen received from the date in question onward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested one-on-one speech therapy and occupational therapy for treatment of his pervasive developmental disorder not otherwise specified (PDD NOS).  Findings:  The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. As studies have shown, plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy and occupational therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood. Review of the available peer reviewed medical literature indicates that speech therapy and occupational therapy are medically necessary interventions for the treatment of patients diagnosed with autism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested a subcutaneous mastectomy for treatment of his gynecomastia. Findings:  The physician reviewer found that lipomas are localized over growths of fat into a separate mass or benign tumor from surrounding soft tissue. They are benign but can cause problems if they grow to a sufficient size to compress adjacent structures such as nerves or arteries. The vast majority of lipomas are so close to the skin surface that they will never cause a problem other than a cosmetic problem and therefore their removal is not medically necessary. The only other exception to their removal being cosmetic is if the physician suspected a malignant process and was removing the mass for biopsy. That is unlikely when the lipoma has been present for many years and is not accompanied by lymphadenopathy or skin changes, as is the case with this patient. Thus, the submitted documentation does not support the medical necessity of subcutaneous mastectomy.  With regard to whether the requested procedure is reconstructive in nature, the proposed surgery will not improve function and is not required to create a normal appearance from an abnormal appearance. Based on the documentation provided, the degree of breast enlargement is not severe and is reportedly visible only in certain positions. As such, the proposed surgery will not offer more than a minimal improvement in the appearance of the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a referral to a bariatric surgeon for treatment of her obesity. Findings:  The physician reviewer found that applying the National Institutes of Health (NIH) consensus guidelines, this patient meets the standard definition for clinically severe obesity. The NIH criteria require a BMI of 40 or a BMI greater than 35 with a serious weight related co-morbid condition. This patient has a BMI greater than 35 with a serious weight related co-morbid condition. In addition, she has failed dietary efforts in the past and completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers including medical, endocrine, behavioral or dietary, to surgery. For these reasons, the patient meets all generally accepted criteria for bariatric surgery and therefore the requested referral has been established as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease. Findings:  The physician reviewer found that the literature evidences that the etiology of Peyronies Disease is not clearly understood, however the effect of the disease is a plaque that affects the elasticity of the corporal body. This results in non-uniform distension of the corporeal bodies which leads to a curvature of the erection. The surgical treatment of the plaque is still considered to be the standard method of treatment when a patients disease is determined to be stable and mature (Gordon). As with other methods of treatment for Peyronies Disease, Interferon therapy requires further investigation to define its efficacy, proper dosing regimens and side-effect profiles (Larsen & Levine). In sum, the requested medication is not considered medically necessary in this setting, as this treatment modality is still being evaluated and is not considered to be an accepted option for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for pelvic floor stimulation for treatment of her urinary frequency, urgency and urinary incontinence. Findings:  Two physician reviewers found that as noted by Dumoulin and colleagues, the optimal pelvic floor muscle training regimen for achieving continence remains unknown.  The authors noted that many questions regarding pelvic floor muscle training remain, including the frequency of pelvic floor muscle training and the number of contractions that should be performed for maximal effect. The authors noted that the actual regimen of pelvic floor muscle training used varied widely in randomized controlled trials.  In this patients case, the superior efficacy of the services at issue has not been established.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for services she received in the Philippines indicating that her condition was  emergent or urgent in nature. Findings:  The physician reviewer found that the patient had low back pain and right groin pain radiating down her right leg. At that time, she was assessed with lumbar radiculopathy. The submitted records shows there is inadequate documentation of what the patient was told about her condition by the spine surgeon or the emergency department personnel in the Philippines to conclude that she reasonably believed she was experiencing an emergent or urgent medical condition. The clinical records available demonstrate that neither the MRI performed in the United States nor the MRI performed in the Philippines supports a diagnosis of cauda equina syndrome. Cauda equina syndrome is characterized by severe compression of nerve roots in the lumbosacral spine by a large disc herniation. The clinical findings include saddle anesthesia, urinary retention, overflow incontinence, impotence, bilateral leg pain and lower extremity weakness. There is substantial agreement that surgery should take place on an emergent basis for a diagnosis of cauda equina syndrome. There is insufficient documentation in the medical records from the Philippines that such a diagnosis was present. There is no documentation of the emergency room history or physical findings.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this 17-year-old male was admitted to residential treatment facility because of aggression and threatening behavior at home. On the mental status examination by the treating psychiatrist he was not found to have any active suicidal or homicidal ideation, mood disorder or psychosis which was requiring 24-hour supervision and monitoring care. This patient did have a substance abuse issue however, the records do not document that he exhibited symptoms of withdrawal or imminent withdrawal which required the residential level of care. Further, the patient was not described as showing any significant psychiatric symptoms or withdrawal risks which required this level of care. Thus, applying the treatment guidelines from the American Society of Addiction Medicine (ASAM) and the American Psychiatric Association (APA), this patient could have been treated in a lower level of care such as a partial hospitalization program or intensive than outpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested continued physical therapy and rehabilitation in the skilled nursing facility for treatment of her status post hemorrhagic cerebrovascular accident.  Findings:  The physician reviewer found that this patient has a high baseline level of function, including living independently in the community, ambulating without an assistive device, driving and working.  She had profound acute changes to her functional status due to a hemorrhagic stroke.  She has been making slow, but fairly steady, progress while at the skilled nursing facility.  The distances she is ambulating and the level of assistance needed for ambulation have been improving steadily.  Her ability to transfer and perform self-care has been improving. This patient would have been expected to make further functional progress from the said date forward based on her progress up to that date and her high baseline functional status.  Stroke is a condition that is amenable to natural recovery and therapy interventions.  These expected functional gains would be clinically meaningful.  While these gains would not likely eliminate the need for care, they would be expected to significantly improve the patients independence. All told, continued physical therapy and rehabilitation in the skilled nursing facility during this timeframe was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested skilled nursing facility (SNF) services (including occupational therapy and physical therapy)  for treatment of her medical condition status post ischemic stroke.  Findings:  The physician reviewer found that in the present case, the patient sustained an acute brain stem stroke and has become severely debilitated in comparison to her baseline status of living alone independently in the community, driving and working. She has made significant progress since her initial stroke, but these improvements have largely been limited to the domains of speech and swallowing. Despite ongoing inpatient therapy care, her self-care and mobility have remained at close to total assistance. As of the said date, she was still requiring multiple person assistance for getting to a stand position, had poor standing balance, and was dependent for transfers. She was non-ambulatory and not making any documented progress with wheelchair mobility. She had already been upgraded to a regular diet and thin liquids, which she was tolerating without signs of aspiration and was no longer in need of inpatient level speech therapy services. There were no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding or ostomy care, or medical needs requiring ongoing inpatient care. As such, the SNF level of care has not been established as medically necessary in this patients care from the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability for certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies. These conditions are typically best treated with proton therapy due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.Whether proton therapy for prostate cancer affords any advantage over IMRT remains the subject of debate. Most reports, including a systemic review conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation, such as IMRT. Vargas, et al. demonstrated that proton therapy yields improved normal tissue sparing as compared to IMRT. However, other accepted technologies such as image guided radiation therapy (IGRT) with daily CT imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing; these technologies were not investigated in the study by Vargas. There is also the possibility that proton therapy is disadvantageous.  The depth of proton delivery is more susceptible to changes in tissue density, such as changes of air in the rectum. While some assert that proton therapy could lower the risk of secondary radiation-associated malignancies, there is no published clinical data that support this contention. Though proton therapy reduces the low dose deposition, proton therapy results in a greater dose rate and appreciably more neutron exposure, when compared to essentially none with IMRT using 6 MV photons. All told, proton beam therapy for prostate cancer is one of several available treatment approaches that are highly effective and well tolerated. There are no compelling data to suggest that proton therapy is superior to IMRT in this setting. Therefore, since the Health Plan is offering IMRT as a treatment option, proton beam therapy is not medically necessary for treatment of this patients prostate cancer.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested Erbitux, carboplatin and 5-FU, used in combination, or as single agents for treatment of his squamous cell carcinoma with metastatic disease to the liver.  Findings:  Three physician reviewers found that this patient has metastatic cancer to his liver of unknown primary.  In view of the squamous cell histology, it was felt to be most likely of lung or head and neck primary.  National Comprehensive Cancer Network guidelines for the treatment of squamous cell carcinoma of unknown primary include two regimens, cisplatin/paclitaxel/5-FU or cisplatin/Taxotere/5-FU.  Thus, it is reasonable to conclude that the use of a platinum analogue, with 5-FU, and a taxane, would be acceptable treatments, with some track record of efficacy. He previously responded to carboplatin.  Thus, this medication, in combination with 5-FU, is a reasonable alternative. However, there is a lack of data demonstrating that adding Erbitux would add to this regimens effectiveness. Vermorken and colleagues reported on a randomized study comparing treatment of patients with recurrent head and neck cancer with carboplatin and 5-FU with or without Erbitux. The patients who received the Erbitux did experience an overall median survival gain of about two to three months.  However, it should be noted that this was first-line chemotherapy.  Accordingly, this study cannot be applied to this patient.  All told, carboplatin and 5-FU are likely to be superior to other available treatment alternatives in this patients case.  However, the superior efficacy of Erbitux in this clinical situation has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested continued residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that based on review of the available records, in addition to the patients diagnosis of eating disorder, she has a mental health disorder which includes impulsive, self-destructive behaviors as well as drug use. The records demonstrate the patients weight is still lower than 75% of her IBW. As such, she is at risk for fluid and electrolyte disturbances which may result in destabilization. In addition, the patient has had cardiac symptoms. Further, the records indicate that the patient has been unable to stabilize in a lower level of care. Based on these factors, the patient meets criteria for continued residential treatment services, as described in the American Psychiatric Association Practice Guidelines. Thus, residential treatment level of care was and is medically necessary for this patient beyond the date in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested intensive outpatient program services and continued intensive outpatient program at a frequency of four times per week for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the data reviewed indicate that the patient shows good motivation and has no history of suicidal behavior despite the presence of some passive suicidal ideation. Her weight has increased, and there is no indication of laboratory abnormalities, deranged vital signs or other evidence of physiological compromise. There is no risk to others, and no indication that she presents a potential risk to be placed in a higher level of care if she is not in this program. The information submitted for review in sum fails to establish the medical necessity for this level of care. It is not evident that she has benefitted substantially, and there is no indication of medical compromise. Per the submitted documentation, the medical necessity of intensive outpatient program treatment provided from the said date onward has not been established.  Additionally, continued outpatient treatment of any frequency is not medically indicated in this patients case.