Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female has requested laser hair removal for treatment of her pseudofolliculitis and hidradenitis suppurativa.   Findings:  Two physician reviewers found that this patient has insulin dependent diabetes mellitus and has had a diagnosis of hidradenitis supportiva and pseudofolliculitis for four years. The records indicate the patient has been treated with incision and drainage on multiple occasions and oral antibiotics. The abscesses cause her sugars to elevate. She reportedly experienced a serum sickness like reaction to one of the antibiotics. Her provider has recommended treatment with laser hair removal to give her some relief of this chronic disease.  Hidradenitis supportiva is a chronic debilitating disease without any known long-term effective cure. Treatment modalities are largely anecdotal and not based on double blind placebo controlled studies. The provider must consider multiple factors in formulating a treatment approach for his patient based on severity of disease and individual comorbidities. Use of oral antibiotics in combination, rather than in series, can be effective. Hormonal therapy, systemic retinoids, and intralesional corticosteroids are also treatment options. More recently, tumor necrosis factor (TNF) alpha blocking drugs have shown promise in the medical treatment of this disease. Surgical excision has been proven to be effective, but can be associated with scarring. Many types of laser have been described in the treatment of hidradenitis. Publications on hair removal lasers, specifically the long pulsed Nd:YAG laser treatment, do cite some short-term improvement in disease. However, this improvement has not been compared directly to oral antibiotic therapy, which remains the standard of care. Although hair removal may give this patient some relief, it is not likely to be superior to standard available treatments. According to a recent review from Jemec, there is a paucity of data from controlled trials on which to base a treatment plan. Further, the author noted that a direct comparison of surgical techniques is necessary to support an improvement in patient health outcomes. As such, the requested laser hair removal is not likely to provide this patient with equivalent, or superior results, when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male has requested acute rehabilitation care for treatment of his medical condition status post intracranial hemorrhage with right sided hemiparesis.  Findings:  The physician reviewer found that it is generally agreed that a patient meets guidelines for acute inpatient rehabilitation when the following conditions are met: 1) Requires close physician supervision in order to care for multiple complex medical conditions; 2) requires the coordinated care of skilled therapists from multiple disciplines; 3) has the ability to participate in an intensive rehabilitation program and progress toward defined goals at a predictable and reasonable rate; 4) requires inpatient care and 24-hour rehabilitation nursing care; 5) could not achieve similar functional recovery in a less intensive setting. In the case under review, the patient sustained a severe brain injury secondary to ICH. He demonstrated the ability to participate and achieve functional gains in an intensive rehabilitation setting. He also appeared to benefit significantly from close physician monitoring for the early detection and management of medical complications. While in the skilled facility setting, the patient developed multiple medical complications requiring repeated hospitalizations. Recovery from ICH can be slow and significant recovery has been observed up to six months to one year following presentation. The patient therefore meets the generally accepted guidelines for acute inpatient rehabilitation and continues to have the potential to achieve further functional recovery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male has requested a Livingskin custom made silicone prosthesis for his medical condition status post left arm amputation.  Findings:  The physician reviewer found that upper extremity prostheses need to be tailored to the specific needs of the individual to achieve successful use of the device (Kejlaa). Some individuals benefit from an active prosthesis but others prefer a passive design. According to Ritchie and colleagues, both function and cosmesis are important factors that impact on use of the device (Ritchie, et al.). This patient has used a Livingskin prosthesis for several years and relies on this passive prosthesis as his primary prosthesis for functional tasks. The submitted documentation demonstrates the Livingskin prosthesis helps the patient maintain a high functional level. At the time a new Livingskin prosthesis was recommended, the patients existing Livingskin prosthesis was five years old and in disrepair. Therefore, a replacement Livingskin custom prosthesis was medically appropriate and necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested breast implant removal for treatment of neck and shoulder pain.  Findings:  The physician reviewer found that based on review of the available records, the patient had undergone previous breast augmentation. She complains of chronic neck and back pain, which is well documented. These are functional complaints. She is undergoing multiple medical therapies including narcotics, non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. She also has upper extremity parasthesias that could be related to her breast size. Her source for pain is most likely multifactorial. She has a history of traumatic injury, which is part of the etiology. However, her large implants have contributed to the worsening of her symptoms. Her examination and documented standard breast dimensions, nipple to inframammary distances, and notch to nipple distances are consistent with macromastia causing functional impairment. The patient has functional complaints related to her breast size and dimensions. This appears to be severe and significantly affecting her daily activities. She has attempted to treat her condition with medical therapy and physical therapy. This has not been successful. Work-up of her pain complaints has also been performed. Breast implant removal would therefore not be considered cosmetic treatment in this patient. The records document that she has a severe functional problem due to augmented breasts and would likely benefit from removal. With respect to capsulectomy, the patient has not been adequately documented to have capsular contracture and this should not be considered a separate procedure that is medically indicated. The source of the functional problem is weight and volume of the breasts but this is not a capsule related issue. In summary, breast implant removal is medically necessary, but capsulectomy is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male has requested bronchial thermoplasty for treatment of severe persistent asthma.  Findings:  Three physician reviewers found that the patient is a former smoker, with a history of poorly controlled, severe, persistent asthma, fibromyalgia, hypercholesterolemia, depression, gastroesophageal reflux disease, sinus disease, and atopy. Bronchial thermoplasty, the third of a planned three treatments, has been requested by the patient and the patients provider to treat the patients asthma. The patient has undergone the thermoplasty procedure on two previous occasions. A third planned treatment is requested for the upper lobes. The patient is currently receiving inhaled bronchodilators, inhaled corticosteroids, as well as inhaled and oral corticosteroids for severe persistent asthma. The patient continues with symptoms of shortness of breath, chest tightness, and exertional dyspnea despite these therapies. The patient has had significant radiation and chemical exposures that were work related. Pulmonary function tests done were normal, including forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity for carbon monoxide (DLCO). A cardiopulmonary exercise test was also normal. A computed tomography (CT) scan of the chest was normal. An allergy evaluation  was negative except for Bermuda grass. After the patients hospitalization a year ago, the patient was on oral prednisone with tapers. The most recent office note, written four months ago, indicates the patient is on an alternating dose of 20 and 10 mg per day. He continues to have significant symptoms with exacerbations despite the bronchial thermoplasty interventions (Pavord, et al). Bronchial thermoplasty is a non-drug procedure that was approved by the FDA for treatment of severe and persistent asthma in 2010. The procedure delivers thermal energy to the airways to reduce airway constriction in asthma patients. It is performed as part of a bronchoscopy. It has been shown to improve air flow and reduce exacerbations, emergency room visits, hospitalizations, and lost days at work in patients with moderate and severe, persistent asthma. These benefits can persist up to two years after the initial procedure. Consistent with these findings, the requested procedure is likely to provide this patient with greater benefits than standard interventions for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested a stress test (stress echocardiogram) for evaluation of her intermittent chest pressure.  Findings:  The physician reviewer found that based on the records provided the patient presents with no cardiac risk, very atypical (likely non-anginal) chest discomfort, a normal cardiovascular physical exam and a normal electrocardiogram. In this clinical circumstance, the pretest likelihood of significant obstructive coronary disease is low, such that additional cardiac evaluation with stress testing is not supported as medically necessary. If stress testing were thought to be indicated, then routine exercise electrocardiography should be sufficient given the patients low pretest risk, normal baseline electrocardiogram, and ability to ambulate on a treadmill. Current guidelines endorsed by several national organizations also do not consider exercise stress echocardiography appropriate in this setting (Douglas, et al). Adding imaging to conventional exercise electrocardiography in low risk patients with low risk Duke treadmill scores has not been show to be of incremental benefit (Poornima, et al).
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested approval for past treatment of varicose veins provided on three dates at issue on an emergent basis.   Findings:  The physician reviewer found that this patient had a long-standing history of venous insufficiency, although she had not followed through on definitive treatment. She reports that she was traveling throughout Europe and South America during the dates at issue and felt that her legs acutely worsened. She became concerned and sought treatment. Her physician in Ecuador recommended and performed bilateral greater and lessor saphenous vein ablations as well as phlebectomies. The patient states that she is now cured and she is seeking approval for these procedures on the basis that she required immediate medical attention. Her particular concern was the risk of deep vein thrombosis (DVT) with travel.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the dates at issue.  California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.A prudent layperson would reasonably seek immediate medical attention if concerned about the possibility of DVT as the cause of worsening symptoms. However, once a DVT was ruled out by an ultrasound, a prudent layperson would not believe that multiple bilateral lower extremity procedures were required on an immediate basis to treat her long-standing chronic venous insufficiency. It would have been reasonable for the patient to use compression and even maybe lovenox for her long flight, but as far as the need for immediate surgical intervention before undertaking long air travel, there is no imminent need for treatment. In fact, evidenced-based recommendations in this setting are as follows: Individual risk factors for air travel-related VTE include age over 40 years, gender (female), women who use oral contraceptives, varicose veins in lower limbs, obesity and genetic thrombophilia. Prevention measures include environmental protection such as keeping the pressure inside the airplane cabinet in hypobaric condition, avoiding dehydration and prolonged sitting. For individuals at increased risk, venous blood stasis can be reduced by wearing elastic stockings and prophylactic use of low-molecular-weight heparin. Further, the fact that the services were rendered over the course of several weeks does not support the contention that the patient reasonably believed the services were required on an immediate basis. Therefore, although the ultrasound of the lower extremities met prudent layperson criteria for emergency care, the rest of the services the patient received on the dates at issue did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male has requested approval for a distraction arthroplasty for treatment of his left ankle pain.   Findings:  The physician reviewer found that interest in surgical procedures for ankle arthritis not responding to conservative measures has led to consideration of distraction arthroplasty, and early reports have been encouraging, although the need for additional laboratory and clinical reports has been noted (Tellisi, et al; Morse, et al). Some reports have also considered the possibility of allowing motion as opposed to fixed distraction (Saltzman, et al). Further study is required to evaluate the true value of distraction ankle arthroplasty, since there is currently inadequate evidence based literature supporting its utility (Smith, et al).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female has requested a replacement ultra lightweight wheelchair for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that rheumatoid arthritis is associated with significant declines in functional mobility. The documentation under review indicates that the patient requires a wheelchair to safely perform her MRADLs and that her home will accommodate a wheelchair. The records also indicate that she has significant upper extremity contractures. Given the patients current medical condition, the requested ultra lightweight manual wheelchair is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female has requested a foot brace insert consisting of removable, molded to patient model, longitudinal/metatarsal support (CPT code L3020) for treatment of her congenital pes planus.  Findings:  The physician reviewer found that it is not medically necessary for this patient to have custom orthotics prescribed as first-line treatment. It is a time of rapid growth of the patient. It is reasonable that she receive a trial of non-custom fabricated orthotics or a carefully selected recreational sneaker with longitudinal arch support and metatarsal pad. The patient should also have a careful evaluation to rule out a non-flexible flatfoot. There should be documentation of whether the patient has heel cord tightness. Once the primary orthopedic conditions are ruled out, then a simple soft orthotic is indicated. However, the requested custom molded orthotic is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested acupuncture for treatment of her migraine headaches and sinus pain.  Findings:  The physician reviewer found that the requested acupuncture treatments for the patients chronic migraine and sinus headaches are not medically necessary. There is a paucity of medical literature to support long-term treatment of chronic migraine and sinus pain with acupuncture. Additionally, several treatments for chronic migraines and sinus pain have been demonstrated in clinical trials to be superior over acupuncture. Nicholson and colleagues evaluated a variety of non-pharmacologic treatments for headache. The authors reported that behavioral treatments including relaxation, biofeedback, and cognitive behavioral therapy provide the best evidence for successful headache management. The authors stated that these modalities are considered first-line preventive options. In addition, Linde and colleagues performed a randomized control trial to investigate the effectiveness of acupuncture compared to sham acupuncture and with no acupuncture in patients with migraine. The authors measured differences in headache days of moderate to severe intensity over weeks after randomization. The authors concluded that acupuncture was no more effective than sham acupuncture in reducing migraine headaches, although both interventions were more effective than no treatment at all. Rossberg and colleagues performed a three-armed single blind randomized controlled study to compare traditional Chinese acupuncture, minimal acupuncture at non-acupoints, and conventional treatments for sinusitis. The authors concluded that sinus soft tissue swelling was reduced in the conventional treatment group. There was only a non-significant difference in symptom score change between conventional medication and traditional Chinese acupuncture.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested approval  for past computer aided detection (CAD) with magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that the patient was diagnosed with a low grade breast cancer seven months ago. She had had a history of fibrocystic changes, but a mammogram demonstrated abnormal appearing calcifications and she ultimately underwent a stereotactic biopsy. Following the initial biopsy, she underwent a breast magnetic resonance imaging (MRI). The purpose of this MRI was to evaluate the extent of disease and to exclude additional lesions.  One of the recognized indications for a diagnostic MRI of the breasts is to evaluate the extent of disease and to determine whether there might be additional lesions that may eliminate the possibility for breast conserving surgery. One critical issue with breast MRI is the lack of specificity. MRI studies of the breast are highly sensitive, but are not at all specific. It is for this reason that MRI interpreters generally utilize CAD, in an effort to distinguish malignant changes. This is in contrast to the use of CAD in routine mammography where the goal is to increase sensitivity. With routine mammography, one generally only is concerned with two or three images of each breast. But with breast MRI, the provider generally has to evaluate hundreds of images, and CAD has become an integral tool in the general practice of radiology. However, there are conflicting results in the peer-reviewed medical literature. Arazi-Kleinman and colleagues state that, breast MRI CAD system used could not improve the radiologists accuracy for distinguishing all malignant from benign lesions, due to the poor sensitivity for DCIS detection. This patient had a lobular carcinoma in situ. Meeuwis and colleagues noted that, CAD-based analysis improved the specificity compared with manual analysis of enhancement. Automated analysis at 50% and 100% thresholds showed a high sensitivity and specificity for readers with varying levels of experience.In this patient with known malignancy, there was a need to exclude more widespread involvement and prepare for surgical planning. As such, CAD was reasonably expected to provide an added value to this patients evaluation and treatment and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested approval for weekly occupational therapy sessions for treatment of his attention deficit hyperactivity disorder.   Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Few well designed studies examine the effectiveness of frequently used pediatric occupational therapy in well-defined, homogenous populations on outcomes that target participation in everyday life. A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has significant delays in fine motor and adaptive skills. Appropriate occupational therapy is medically necessary to help promote his adaptive skill development and independence (Wolraich and Bennett). All told, occupational therapy is medically necessary for treatment of this patients medical condition.