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

A 58-year-old female enrollee has requested home nurse aide services for treatment of her bilateral wrist fractures status post open reduction with internal fixation.  Findings:  The physician reviewer found that services are considered medically necessary when they are used to treat or prevent an illness or injury, are generally accepted as standard of care, and are not considered investigational. In general, medically necessary rehabilitation services require that the provider be a skilled licensed nurse or therapist. In the case under review, the patient required the assistance of a certified home health aide to perform her ADLs, but did not require the services of a skilled therapist or nurse. The services were intended to provide assistance with self-care tasks rather than manage impairment. Therefore, the home nurse aide services were not medically necessary during the said timeframe for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar disorder, type II.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more efficacious than other available treatment options.  TMS therapy has been approved for the treatment of major depressive disorder which is resistant to other treatments.  However, this patients diagnosis is bipolar disorder, type II.  This patient has not exhausted standard therapies for her condition, including electroconvulsive therapy.  The current medical evidence does not indicate that TMS therapy is likely to be of greater benefit than other options in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested inpatient psychiatric hospitalization services for treatment of her major depressive disorder and bulimia nervosa.  Findings:  The physician reviewer found that clinical guidelines and patient placement criteria have been developed to assist with complicated determinations as with this patient, and it is the task of the providers working directly with the patient to interpret and apply these tools. In this patients case, discharge on the said date would have been premature and inconsistent with good medical practice as the patient was endorsing physical symptoms and suicidal ideation with plan. On the said date, in context of continued suicidality, the patients antipsychotic medication was changed. Shortly thereafter, the patients chronic suicidality, enduring negative schemas, and somatic preoccupation were demanding of treatment but no longer acute in nature. She was better able to contain her emotions while eating up to 80% of meals and tolerating her psychotropic medications in the absence of any reported symptoms of alcohol withdrawal. In conclusion, the acute inpatient psychiatric services were medically necessary during the said time frame for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested hospitalization services for treatment of cervical decompression. Findings:  The physician reviewer found that the documentation submitted for review indicates that the patient contacted her surgeon on the specified date and was told to fly to Germany as soon as possible for surgical intervention. Although the patient was told to seek treatment, she did not arrive in Germany and receive care until the subsequent date. The patient did not seek immediate medical treatment on the day the symptoms presented. A three-day delay in seeking treatment is not consistent with the definition of an emergency medical condition. A prudent layperson who believed she was experiencing an emergency medical condition would have sought immediate medical attention at the time the symptoms presented. Additionally, while the patient states that her acute pareses in the right C7 myotome warranted emergency surgery, the extent of the pareses is not quantified or documented in the medical records. Furthermore, there is no documentation of acute myopathic findings on physical examination. Based upon the documentation provided, the hospital stay from the time frame specified did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested Xolair injections for treatment of the enrollees asthma.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested medication. Xolair has been approved by the U.S. Food and Drug Administration (FDA) for use in patients who are 12 years of age or older and who have IgE levels less than 700. In the case of this patient, he is age 10 and has an IgE level in excess of 700. However, the use of Xolair is not contraindicated in a child with an IgE level greater than 700. In this case, the patient remains unstable despite an aggressive treatment regimen. While the patients pulmonary function tests have been reasonably normal the submitted clinical information documents that he has a history of frequent exacerbations requiring the use of rescue medications. All told, Xolair injections are medically necessary for the treatment of the patients medical condition. Therefore, the requested medication should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male enrollee has requested speech therapy for treatment of the enrollees language delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are optimal.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  The current medical evidence supports the requested therapy in this clinical setting.  Broomfield and Dodd noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  In this patients case, he demonstrates expressive language delays that are negatively impacting his ability to communicate and interact successfully with his environment. The literature supports the use of speech and language therapy to address expressive deficits and facilitate development of age-appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested continued transcranial magnetic stimulation (TMS) therapy  for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, he did not achieve remission despite a course of TMS therapy.  Per the submitted records, the patient required acute hospitalization during his treatment course.  Thus, the requested services are not likely to be an efficacious modality in this setting.  The utility of TMS therapy in long-term or maintenance treatment for major depressive disorder has not been established at this time.  Based upon the clinical records, he responded to unilateral electroconvulsive therapy.  All told, continued TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a two-level decompression, stabilization, and fusion with connection to inferior instrumentation for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services for the treatment of this patient.  The current medical evidence does not support the requested services in this clinical setting.  Resnick and colleagues noted that lumbar spinal fusion was recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability.  Based upon the radiologists report, there is no evidence of spinal instability at L1-2 and L2-3.  The American Pain Society has developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary intervention for low back pain of any duration, with or without back pain.  The authors noted that intensive interdisciplinary intervention with a cognitive/behavioral emphasis should be considered for patients with non-radicular low back pain who do not respond to non-interdisciplinary interventions.  Based upon the medical records provided, this patient has not received this therapy.  All told, the requested two-level decompression, stabilization, and fusion with connection to inferior instrumentation is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested NovoTTF treatment for treatment of her meningioma. Findings:  Two physician reviewers found that meningiomas are brain tumors arising from the dura mater of the brain. They are typically slow growing and amenable to resection if pathologically classified as Grade I. However, Grade II and Grade III meningiomas have higher proliferative rates and are usually only partially resected. In 2011, the U.S. Food and Drug Administration approved the NovoTTF-100A device to deliver alternating electrical fields to treat recurrent glioblastoma multiforme (GBM). The approval was based on a randomized clinical study where 237 patients were treated with either NovoTTF versus best standard of care chemotherapy (including bevacizumab) (Stupp et al). There is also a case report of a long term survivor with recurrent GBM treated with NovoTTF (Villano et al). While there is limited data regarding the use of NovoTTF in the treatment of meningiomas, the device has FDA approval and based upon studies of its use in patients with GBM, it is appropriate for use in this patient who has exhausted standard treatment options. There is sufficient medical evidence to demonstrate the safety of this device and the off-label use for this patient. All told, there is adequate evidence demonstrating that the requested equipment is likely to be more beneficial for this patient than any available standard treatment modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested robotic laparoscopic partial nephrectomy for treatment of his right renal mass.  Findings:  Three physician reviewers found that the current published peer-reviewed studies have not demonstrated that robotic partial nephrectomy is superior to laparoscopic partial nephrectomy. Comparison of conversion to open rates, ischemia time, recovery of renal function, and operative time have not shown any benefit of robotic partial nephrectomy over laparoscopic partial nephrectomy. Given the lack of clinical data showing superior outcomes with robotic partial nephrectomy over conventional laparoscopic partial nephrectomy, the requested services are not likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested an MRI for evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested diagnostic procedure in this clinical setting.  This patient has a history of knee pain with activity.  Plain films have been negative.  His pain has persisted despite treatment with non-steroidal anti-inflammatory drugs.  Per the medical records, the possibility of internal derangement has been noted due to continued pain.  The current medical evidence supports the requested MRI in this patients case.  All told, the requested MRI is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested a circumcision for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there has been significant debate about the necessity of neonatal circumcision.  Most recently, the American Academy of Pediatrics published a policy statement which noted that the health benefits of newborn male circumcision outweigh the risks.  Per the current medical evidence, these benefits include prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections.  There is sufficient medical evidence supporting the requested services in this setting.  All told, the requested circumcision is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential treatment for the enrollees generalized anxiety disorder, bipolar disorder, and substance abuse.  Findings:  The physician reviewer found that the medical necessity of residential treatment care provided at the facility from the time frame specified is not supported in the records provided for review. The patient has not had prior outpatient treatment, and does not present any barriers to treatment at that level of care. In addition, there is no documentation of any risk factors such as being a threat to self or others. He was cooperative with treatment and there is no indication in the record that he would not have been able to cooperate and benefit from treatment at a less intensive level. Therefore, the residential treatment care provided at said facility from the time frame specified was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested 30 hours a week of direct applied behavioral analysis (ABA) treatment (CPT Code H2019), 12 hours a month of supervision (CPT Code H0032) and 8 hours a week of parent consultation (CPT Code H2012) for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 15-year-old patient has been receiving ABA therapy for at least seven years. At this point in the patients treatment regimen, the frequency of services offered by the Health Plan is medically reasonable and appropriate. The relevant scientific evidence and clinical documentation does not support the medical necessity of the requested frequency of ABA services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, the clinical notes do not document the diagnosis of benign prostatic hypertrophy (BPH). The medical records noted that there were no lower urinary tract symptoms (LUTS), which is a symptom of BPH. Moreover, BPH has not been fully evaluated or addressed as there is no documentation of a digital rectal exam, which should be done to diagnose BPH. Although the patient indicates that he has BPH, the urologists diagnosis did not indicate BPH, and the current medical evidence does not support daily use of Cialis 5mgin this setting. All told, daily use of Cialis 5mg is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old male 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 in question. 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 the patient had tonsillitis. He had been experiencing symptoms for two days. Although febrile, the patient was not in any distress. He described his symptoms as moderate. He was not experiencing any difficulty breathing or swallowing. The patients symptoms were not acute in onset and lacked the intensity that would cause a prudent layperson to believe his health was in jeopardy without immediate medical attention. As such, a prudent layperson would not have sought immediate medical attention on the date of service in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested proton beam therapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that whether proton therapy affords any benefit over conventional radiation therapy remains unsettled. Many radiation oncologists indicate that proton therapy has a role in the treatment of some cancer patients. Proton therapy is an accepted, safe and effective treatment modality for prostate cancer (Zietman, et al). However, most reports, including a systemic review conclude that patients treated with proton therapy fare comparably to patients treated with intensity modulated radiation therapy (IMRT) (Vargas, et al). The depth of proton delivery is more susceptible to changes in tissue density (such as changes of air in the rectum). Generally proton beam arrangements are designed so as to not enter through the rectum. Given these issues, there is also the possibility that proton therapy is disadvantageous. The most recent National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state that, proton beams can be used as an alternative radiation source but proton therapy is not recommended for routine use at this time, since clinical trials have not yet yielded data that demonstrates superiority to, or equivalence of, proton bean and conventional external beam for treatment of prostate cancer. All told, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. Therefore, the requested proton beam therapy is not supported as medically necessary for treatment of this patients prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested L5-S1 anterior lumbar interbody fusion (single level) for treatment of her back pain.  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 medical evidence does not support the requested services in this clinical setting.  There is no evidence of spinal instability at L5-S1.  The American Pain Society has 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 and colleagues noted that in this setting, patients should be considered for intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis.  For individuals with persistent back pain despite non-interdisciplinary therapies, the authors recommended counseling these patients regarding interdisciplinary rehabilitation.  Per the submitted documentation, this patient has not had such therapy.  All told, the requested L5-S1 anterior lumbar interbody fusion (single level) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 16-year-old patient has been receiving ABA therapy for at least 7 years. While intensive ABA services are not likely to result in further significant improvement, continuation of ABA therapy at a reduced frequency is medically necessary to maintain the patients current level of function. As such, continued ABA therapy at a frequency of 5 hours per week of direct ABA therapy, 1 hour per week of supervision and 1 hour per month of parent consultation is medically necessary to maintain the patients present level of function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Promethazine with Codeine cough syrup for treatment of his chronic asthma and chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that ongoing use of Promethazine with Codeine cough syrup for cough suppression is not justified in the medical literature. Specifically, there are no evidence based guidelines that support the chronic use of Promethazine with Codeine cough syrup for cough in patients with COPD for more than episodic therapy longer than three months (Irwin, et al; Bolser). Therefore, the requested Promethazine with Codeine cough syrup is not medically necessary for treatment of this patients medical condition.