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

A 60-year-old female enrollee has requested endovenous chemical ablation (ultrasound-guided vein injection) of the left leg for the treatment of her varicose veins. Findings:  The physician reviewer found that this patient has poor valvular function which constitutes an abnormal structure of the body. This venous insufficiency is caused by a disease process. The requested services will be performed to assist the patient with normal activities of living, thus improving function. Furthermore, although the services are intended to improve function, more than minimal improvement in appearance will result as a byproduct of the treatment. Therefore, the proposed services should be considered reconstructive surgery as defined by California law. Moreover, the proposed services are medically necessary to treat the patients functional problems. The patient does not have typical venous insufficiency associated with an incompetent saphenous system. Rather, there is some reflux at the level of the knee feeding directly into a very large, refluxing branch. There is also a degree of lesser saphenous reflux. This anatomical situation does not lend itself to traditional treatment plans. The patient has completed conservative management. Thus, endovenous chemical ablation (ultrasound-guided vein injection) of the left leg is medically necessary for treatment of the large, palpable branches.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Botox injections for the treatment of her lumbosacral and gluteal pain. Findings:  Two physician reviewers found that this patient has low back and gluteal pain, with diagnoses of sacroiliitis, piriformis syndrome, trochanteric bursitis, degenerative disc disease and chronic pain. She has been maintained on a variety of pain medications as well as a wide variety of pain interventional treatments. The medical records indicate that prior Botox injections gave minimal pain relief. A later note indicates that only Botox injections had resulted in significant benefit. The patients pain has been refractory to physical therapy, transcutaneous electrical nerve stimulation (TENS) and ultrasound. Botox injections are not a generally accepted medical intervention for the treatment of tightened muscle pain syndromes such as piriformis syndrome. While studies of the treatment of piriformis syndrome with Botox have shown potential for benefit, there is no class I data available to confirm efficacy. No significant trials have been performed demonstrating that Botox is clinically advantageous in the treatment of piriformis syndrome. Thus, there is insufficient peer-reviewed literature to support the efficacy of Botox injections for the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a bilateral mastopexy for the treatment of her intertrigo. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The documentation does not support the existence of an abnormal structure of the body caused by congenital defect, infection, trauma, tumor or disease. While the patient does have sagging breast tissue, the excess tissue is not so great that it constitutes an abnormal structure of the body. Thus, the requested procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, there is no documentation in the submitted records of office visits for intertrigo or monitoring of progress of any treatment of such. Although Diprolene is listed as one of the patients medications, there is no statement concerning what this medication was prescribed for or what the patients response was to the medication. Nor is there photographic documentation of irritation of the inframammary fold skin. All told, the submitted evidence does not demonstrate the medical necessity of the proposed bilateral mastopexy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested acute inpatient psychiatric hospital treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the medical records indicate the patient was admitted on a 72-hour hold on an involuntary basis via ambulance following self-inflicted cuts to her face and chest and verbalized suicidal ideation. This patients history is positive for suicidal gestures in the past with cutting. She was also noted to have severe family stressors. The provider noted impaired judgment on admission with a global assessment of functioning (GAF) of 20. The provider noted depressed mood and guarded behavior in the progress notes, and ordered checks on the patient every 15 minutes. The treating psychiatrists notes indicate the patient was unable to come up with any strategies besides cutting, she continued to display depressed mood, and had flat affect. The patient was able to identify one coping skill and it was determined she could return home. She was discharged the next day. Acute inpatient psychiatric hospitalization from was medically necessary and supported by the submitted medical documentation. The patient was a danger to herself, she engaged in high risk self-harm behavior, there were severe family stressors, and there was a history of previous self-harm behavior. She required containment and treatment in an acute 24-hour setting. This conclusion is consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines and CALOCUS placement criteria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a PET scan for evaluation of her gallbladder cancer. Findings:  The physician reviewer found that a PET scan is the only test that will allow for both the anatomical analysis of the tumor remaining and the metabolic nature of the tumor remaining.  In addition, these tumors may occasionally metastasize to unusual places, and a PET scan will allow for such detection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested artificial disc replacement (cervical disc arthroplasty) for the treatment of his cervical stenosis. Findings:  Three physician reviewers found that there has been a continuing interest in the cervical disc arthroplasty to avoid the possible problems following the present standard, cervical fusion, but questions remain. There is a tendency toward loss of mobility in the operated segments with time, and longer follow-up is recommended to assess functionality over time. Some early studies have shown improvements after arthroplasty, but long-term follow-up is necessary.  The effectiveness of the implants remains uncertain, and there is still a need for prospective, randomized, clinical trials with adequate follow-up to establish the advantages of cervical spine disc replacement over fusion. Overall, artificial disc replacement is not likely to be more efficacious than alternate treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old enrollee has requested amphetamine salt combination (generic Adderall XR) for the treatment of her Attention-Deficit-Hyperactivity-Disorder (ADHD).The submitted clinical information, although limited, is sufficient to establish the medical necessity for this patient to be maintained on amphetamine salt combination (generic Adderall XR). The patients physician states that shorter-acting stimulants have not proven satisfactory, and that generic Adderall XR has been successful in treating the patients ADHD. Additionally, the patient states that the long-acting Adderall XR has been successful in controlling symptoms of ADHD for 12 hours, which allows the patient to get through the school-day, and that other medications have caused significant side effects. The paper by Huskam and colleagues is on point in this case. This paper reported that in cases in which patient or physician preference has no weight in the selection of the stimulant medication, there is a significant (17%) probability that the patient will not take any medication. The paper by Faraohe and Anishe discussed adult ADHD. It reported, in 2008, that only two medications have been approved by the Food and Drug Administration: extended release mixed amphetamine salt combination (i.e., generic Adderall XR) and lisdexamfetamine dimesylate, although other medications may be considered for treatment. Spencer and colleagues stated that Adderall is effective and well-tolerated in adults with ADHD. The paper by Kolar and Keller reports that if side-effects [occur] switching to another stimulant is warrantedan important advantage [of Adderall XR] is its extended duration of action. As the cited literature demonstrates, there is significant evidence to support the patients and physicians claims that generic Adderall XR is the drug of choice for this individual. The literature strongly supports that this patient be maintained on generic Adderall XR.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested a WalkAide neuromuscular electrical stimulator for the treatment of her cerebral aneurysm and lower extremity hemiplegia. Findings:  Three physician reviewers found that this patient has a brain injury secondary to hemorrhage with foot drop. She has tried the WalkAide NMES with improvement in her gait. This device is gaining widespread utilization and has been demonstrated to improve gait speed. Positive effects have been seen in appropriately selected patients. While an ankle foot orthosis (AFO) is often adequate for some patients, this patient is young and normalization of gait will prevent further issues in the future. There are several small studies that demonstrate a positive effect on gait. Although further study of the WalkAide device is needed, there is adequate evidence at this time to conclude that the device is likely to be of greater benefit for this patient than standard therapy. The recent studies support the beneficial effects this device has on gait and balance in similar patients.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested intensive in home and/or community-based behavior support for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the requested services are likely to be more efficacious for this patient than any available standard therapy. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Although most studies of applied behavioral analysis involve young children, there is evidence that the postnatal brain continues to develop particularly with respect to myelination of the prefrontal cortex throughout adolescence and well into the third decade. Thus, specific treatment, including applied behavioral analysis that encompasses cognitive therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry that has not been compromised by the underlying pathogenetic process. This approach, which does embrace the activities of daily living, will deliver therapeutic benefit to the portion of the patients central nervous system that retains plasticity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested chemical dependency residential treatment services for the treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that this patient presented with a significant chemical dependency problem which required treatment. Upon admission, the patient was using intravenous OxyContin and heroin, which are very dangerous substances. Of further concern in this case was the patients relationship with a family member who fostered the patients drug use, and thus, the home environment was not supportive. Furthermore, the evidence demonstrates the patient was benefitting from the services he received at the chemical dependency facility. He was motivated for treatment and beginning to experience improvement in mood. The patients provider indicates the patient was at high risk for relapse without the structure, support and education offered by a higher level of care.  All told, the services the patient received (which were residential treatment services rather than partial hospitalization services) were medically necessary for treatment of his condition. Given that the services provided were part of an integrated 30-day treatment program, the entire length of stay was medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested Provigil for the treatment of her insomnia and borderline narcolepsy. Findings:  The physician reviewer found that this patient has excessive sleepiness which poses a threat to her and others when she is driving. She gets sufficient amounts of sleep during bouts of excessive sleepiness (she reports that she used to sleep up to 90% of the time) and currently the lack of sleep does not appear to be the cause of her daytime sleepiness. She appears to have a sleep disorder, the exact nature of which is not clear. Provigil has been used as an adjunct in chronic debilitating conditions associated with excessive sleepiness including depression, cancer, multiple sclerosis and auto-immune disorders. In this case, the extent of the patients sleepiness is such that treatment is medically necessary due to the potential for injury. Based on the available scientific evidence, Provigil is likely to be effective for treatment of this patients daytime sleepiness. As such, this patient should be treated with Provigil as it is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested OB nuchal translucency ultrasound, blood test and consultation for an evaluation of her pregnancy. Findings:  Three physician reviewers found that nuchal translucency testing is becoming the standard of care and has been recommended by the American College of Obstetrics and Gynecologists (ACOG) as a screening test for all pregnant women. According to the ACOG, the goal is to offer screening tests with high detection rates and low false positive rates that also provide patients with diagnostic testing options if the screening test indicates that the patient is at an increased risk for having a child with Down syndrome.  Thus, the use of nuchal translucency testing in this case was consistent with generally accepted standards of practice and was likely to be more beneficial than the alternative of not performing the screening.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested the Flexitouch System for the treatment of her postmastectomy lymphedema. Findings:  The physician reviewer found that although this patient meets criteria for a pneumatic compression device, there have been no randomized or controlled studies that demonstrate superior efficacy of the Flexitouch System as compared to standard pneumatic compression devices. Although the patient indicates she requires the Flexitouch System to treat her truncal edema, the Lympha Press System offered by the Health Plan can also be used to treat the trunk. There is no evidence that the requested device offers significant clinical benefit over the device offered by the Health Plan or that the device offered by the Health Plan will not meet the patients needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested bi-annual follow-up visits with the out-of-network neurosurgeon who performed her emergency brain surgery for the treatment of her brain tumor. Findings:  The physician reviewer found that it is necessary to perform follow-up evaluations after resection of any tumor to make sure there is no recurrence and to detect any new lesions. As such, an MRI every three months is appropriate in this setting. Physician follow-up can be performed by the patients primary care doctor, or oncologist, either of whom can order an MRI. There is no indication that the patient requires re-operation as the last MRI showed no definitive recurrence. If there is a recurrence or new lesion, the patient can then be referred to an in-network neurosurgeon to discuss treatment options. Her ongoing care with respect to her systemic chemotherapy and surveillance can be performed by her medical oncologist. The submitted clinical information does not demonstrate that appropriate evaluation and treatment is not available from in-network physicians.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested for selective internal radiation therapy (SIRT) using yttrium-90 microspheres for treatment of his small bowel neuroendocrine tumor with metastases to the liver.  Findings:  Three physician reviewers found that the study by Kennedy and colleagues demonstrated that 86% of the entire group of patients demonstrated control of liver disease with SIRT therapy with Y-90 microspheres and 67% of the patients had no grade III or IV toxicities. The study by King and colleagues showed radiologic response in 50% of patients. The study by Rhee and colleagues concluded that over 90% of the patients had partial response or stable disease. This study showed that SIRT of metastatic neuroendocrine tumor is a viable therapy with acceptable toxicity. The study by Lim and colleagues indicated that overall treatment compared to toxicity was acceptable. In sum, the studies suggest that SIRT is a useful option for treatment of patients with multiple liver metastases from neuroendocrine tumor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested a referral to an out-of-network provider for repair of the sternum for the treatment of his acquired pectus deformity. Findings:  The physician reviewer found that the patients condition does constitute an abnormality of a bodily structure due to a malignant process (i.e., multiple myeloma) with subsequent bony destruction and likely fracture. It appears the primary goal of the requested surgery appears to be to create a normal appearance to the extent possible. However, due to the possibility of persistent myeloma as well as cortical weakness of the sternum, the proposed procedure is unlikely to achieve this goal if performed currently. Although there may be a time in the future with further treatment of the myeloma and therapy to restore bone loss in which the likelihood of success is greater, the proposed surgery is not likely to result in more than a minimal improvement in appearance at this time. Therefore, the requested sternum repair is not considered reconstructive surgery as defined by California law. Furthermore, the submitted clinical evidence does not demonstrate that the requested procedure is indicated based on general concepts of medical necessity. Current indications for sternum repair would include improving functional limitations, ensuring stability of the bone and maintaining acceptable cosmesis. Based on the clinical evidence provided, it is not clear that the patient suffers pulmonary dysfunction due to the deformity. Nor are there any clinical signs of instability documented in the submitted records. Moreover, it is not clear that the patients symptom of pain will be improved by the proposed repair. As such, medical necessity criteria for surgical repair of the patients sternum have not been met.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has a vertical sleeve gastrectomy (gastric sleeve laparoscopic surgery) for the treatment of her morbid obesity. Findings:  The physician reviewer found that there has been much enthusiasm in the literature for vertical sleeve gastrectomy (VSG) due to early reports of good results. However, as a stand alone procedure there are no credible long-term studies that prove the weight loss will continue. Early studies reveal some patients may stop losing or even regain weight. Since the VSG operative technique has not been standardized, an article by Roa and colleagues states that there is no consensus regarding what gastric volume should be created. Many of the studies use different bougie sizes for the sleeve and different antral resection lines. Nearly all of the studies in the relevant medical literature including those referenced above indicate that long-term results are still necessary to confirm the value of VSG as a stand alone procedure. The surgical alternatives proposed by the Health Plan are medically appropriate and viable options and have greater support in the clinical literature than VSG.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested a bone scan, spiral CT and/or biopsy for an evaluation of his jaw infection. Findings:  The physician reviewer found that the patient has been seen by multiple providers during which appropriate history, physical examination, radiographic, and laboratory evaluations were obtained. The patient has been evaluated by an oral and maxillofacial surgeon who documented an exam without any significant findings or concerns. The surgeon also reviewed the mandible CT scan and found this to be within normal limits. The evidence provided does not raise suspicions for any pathology not detected during the patients previous examinations. Thus, there are no clinical indications for additional radiographic examination or diagnostic procedures in this case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for emergency ambulance services. Findings:  The physician reviewer found that her illness level of severity was described as mild. No medications were administered. In the Emergency Department, the patient was found to have normal blood tests. She was given intravenous fluids and an antiemetic and discharged. The purpose of ambulance services are not to provide transportation, but rather to provide a safe method of transporting patients who require stabilization or treatment en route to the Emergency Department. This patient did not require any medical intervention during her transport. She did not require services that only a fully equipped ambulance can provide. This patient could have been safely transported by means other than ambulance. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.