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

A 57-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that proton radiation is indicated over standard radiation techniques in patients with chordomas and chondrosarcomas of the base of skull and spine. However, proton radiation does not have significant proven advantages over modern conformal techniques such as image-guided intensity modulated radiation therapy (IMRT) in the treatment of prostate cancer. While anecdotal data suggests increased fatigue with IMRT, it also reveals more patients experience late rectal bleeding with proton therapy. Zietman and colleagues concluded that IMRT has superior bladder dose distributions when compared to proton radiation. Moreover, there is a paucity of evidence supporting protons over conventional therapy in terms of potency preservation. While there may be some benefit in less integral dose to the pelvis with proton beam therapy, this alone does not indicate that proton beam therapy is standard treatment for prostate cancer. In addition, this patients records do not specify that the protons will be significantly dose escalated beyond that of IMRT.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested residential treatment facility services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that the submitted clinical records demonstrates that this patient had failed prior treatment at inpatient and residential treatment levels of care. She left treatment in the past against medical advice and also insisted that her psychiatric medications be discontinued despite her psychiatrist recommending against this. Her insight and judgment were very poor when she entered treatment. The treatment center and her family both indicate that her insight and judgment are vastly improved after her stay at the residential treatment center. Her functioning has dramatically improved as a result of the services at issue. This patient was admitted to an inpatient level of care numerous times in the past secondary to medical complications of her anorexia nervosa. The medical literature on the necessity for inpatient weight restoration is contradictory, as is the literature on appropriate level of care for those who are diagnosed with anorexia nervosa. While much of the literature is variable, the records provided demonstrate that this patient did benefit from her stay at the residential treatment center and had failed several other treatments in the past.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The conservator of a 19-year-old female enrollee has requested for eating disorder residential treatment level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the literature on the necessity for inpatient weight restoration is contradictory, as is the literature on the appropriate level of care for individuals with AN. According to Bulik and colleagues, `No studies address the optimal conditions under which a patient should be discharged from inpatient treatment and stepped down to less structured environments. This underscores the point that the patients symptoms must be managed appropriately prior to being stepped down to a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for continued residential treatment for treatment of the enrollees polysubstance dependence, major depressive disorder and generalized anxiety disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System guidelines, the  findings demonstrate that the patient did not require 24-hour psychiatric monitoring and was appropriate for step-down to partial hospitalization program (PHP) services. The intensive milieu of services offered by a PHP would be appropriate to allow the patient to return to the community environment with support and continuity of care. This is also consistent with the American Academy of Child and Adolescent Psychiatry guidelines. As such, I have determined that continued residential treatment and Adolescent Change was no longer medically necessary
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for Zofran 8mg for treatment of her hyperemesis gravidarum. Findings:  The physician reviewer found that hyperemesis gravidarum often involves more severe symptoms, including weight loss, dehydration, vitamin deficiencies and nutritional deficiencies. Vomiting may result in electrolyte and acid-base disturbances and starvation ketosis. This progresses to hyperemesis gravidarum when there is dehydration, weight loss and ketonuria. Ptyalism is a frequent accompaniment, due to an inability to swallow saliva. Biochemical changes often include elevated liver transaminases, elevated free T4 and depressed thyroid stimulating hormones. Hyperthyroxinaemia associated with hyperemesis gravidarum coincides with the rise and fall of serum human chorionic gonadotropin, which has thyroid stimulating activity. Treatment of hyperemesis corrects the abnormal biochemistry.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for acupuncture for treatment of her migraine, back pain and neck pain. Findings:  The physician reviewer found that records do not indicate headache etiology or a detailed history and diagnostic workup. No imaging was provided for the etiology of the neck pain. There is no correlation between causality of the head and neck pain to discern which course of treatment is likely to be most efficacious. Short courses of acupuncture have been shown to be beneficial in the management of intermediate and chronic pain syndromes for acute or breakthrough symptom management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested for a magnetic resonance angiography of the brain for evaluation of his refractory headaches. Findings:  The physician reviewer found that the published evidence-based guidelines support the use of brain imaging for some patients with headache, to address possible structural sources of secondary headache. These guidelines indicate that neuro-imaging should be considered in patients with non-acute headache and an unexplained abnormal finding on the neurological examination. The guidelines further indicate that neuro-imaging is not usually warranted for patients with migraine and normal neurological examination. Additionally, in the case of patients with atypical headache features or patients who do not fulfill the strict definition of migraine (or have some additional risk factor), a lower threshold for neuro-imaging may be applied. Imaging is also felt to be medically necessary in patients with a recent change in headache pattern, or who have other significant risk factors, such as systemic malignancy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for inpatient treatment for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that suicidal ideation is a qualifying condition that necessitates further inpatient stay. After her suicidal and aggressive ideation resolved, she appeared to do well in the hospital without any complications.the patient was stabilized and there was no continued acute need for the restrictiveness of the acute hospital setting.  The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible. This is best accomplished in a community setting. The patient could have been safely and effectively treated in a less restrictive setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for total disc arthroplasty for treatment of her cervical degenerative disc disease.   Findings:  Three physician reviewers found that artificial disc replacement is based on the concept that by preserving motion, the progression of adjacent-segment degeneration will be lessened (see Baaj and colleagues). However, the effectiveness of these implants is still uncertain, and may be related to the progression of the natural history of arthritic disc (Denaro and colleagues). Early results of the procedure have been encouraging, but the importance of long-term studies to demonstrate maintenance of these results has been stressed (Murrey and colleagues), and was included in the original approval of the ProDisc-C. In addition, heterotopic ossification has been seen in many patients (Mehren and colleagues), and the clinical significance of this may be variable and requires study (Suchomel and colleagues). Further, artificial disc replacement surgery adjacent to levels that have prior fusion potentially leads to a greater risk of failure because of the increased biomechanical forces. Continued studies are needed to clarify this (Phillips and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an MRI of the breast for evaluation of her inverted breast nipple. Findings:  Two physician reviewers found that the patient did not meet appropriateness criteria for a breast MRI.  This patient does not have known BRCA1 or BRCA2 mutation. She has no known first-degree relatives with these mutations. She does not have a history of receiving radiation therapy to the chest between 10 and 30 years of age. Moreover, the patient has no personal history of breast cancer. All told, the use of breast MRI in this clinical situation is not supported by the literature and was not likely to yield clinically significant information that was unavailable through conventional testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for high definition 3.0 Tesla magnetic resonance imaging (MRI) scans of the brain and skull/orbits for evaluation of her medical condition. Findings:  The physician reviewer found that while a 3.0 Tesla magnet scan would likely provide excellent images, it is also expected that excellent images can be achieved with a 1.5 Tesla magnet. 1.5 Tesla magnets are the general standard of care for excellent images throughout the United States.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for chemoembolization of the hepatic artery with Carmustine and Sutent oral chemotherapy for treatment of her choroidal melanoma with liver and lung metastases.  Findings:  The physician reviewer found that a study by Bedikian and colleagues dating back to 1995 studied 201 patients who were treated with chemoembolization with cisplatin-based regimens and realized a 36% response rate. In addition, this conclusion is consistent with the findings by Leyvraz and colleagues who reported on 12 patients out of 30 who experienced a positive response. More recently, a study by Sharma and colleagues noted that survival was improved in patients treated with chemoembolization. Thus, chemoembolization has become an accepted treatment for ocular melanoma metastatic to the liver and is therefore clinically appropriate therapy for this patient. With regard to the request for Sutent as systemic chemotherapy, there is a lack of clinically significant data demonstrating that this agent is useful in the treatment of metastatic ocular melanoma. Sutent is currently being studied as part of an early phase clinical trial. At this time, the potential benefit of Sutent in this particular setting remains speculative. In the absence of evidence demonstrating that Sutent is likely to result in a positive response in this situation, the medical necessity of this agent is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for a Lap-band procedure for treatment of her obesity. Findings:  The physician reviewer found that patients with a BMI between 35 and 40 must have significant co-morbidities in order to be considered appropriate candidates for weight loss surgery. This patient has a BMI of 37. Serious weight related co-morbid conditions such as hypertension or diabetes are not documented. Sleep apnea is listed by the patient as one of her conditions, but is not mentioned in the medical evaluation or surgical evaluation. Furthermore, there is no evidence of a sleep study documenting obstructive sleep apnea. In the absence of evidence of significant weigh-related co-morbidities, this patient does not meet medical necessity criteria for weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for L3-4 discectomy and fusion surgery for treatment of her lower back and leg pain. Findings:  The physician reviewer found that there is no MRI evidence documenting recurrent herniation. Furthermore, the interval since the patients last surgery has been relatively brief and further conservative management is an appropriate treatment course at this point in time. However, at this time the medical necessity of L3-4 spinal level discectomy and fusion has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested coverage for two hours per week of speech therapy and two hours per week of occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that with regard to the requested speech therapy, while the patient is profoundly delayed in speech, his speech therapist did report some gains (though minimal) after one year of therapy.  Myers and Johnson state, Most children with ASDs can develop useful speech  traditional, low-intensity pull-out service delivery models are ineffective  speech-language pathologists are likely most effective when they work  to promote functional communication throughout the day. Turner, et al. reported on the success of an integrated speech and behavioral program in a controlled study, with the speech therapy group having far better communication skills at the age of 9 than the non-intervention group (e.g., school program, limited services, etc.). Goldstein discussed the various speech treatment modalities and their application to autistic children. Based on the medical literature discussed above, as well as the fact that this patient showed some response to prior therapy, there is adequate evidence to support the medical necessity of speech therapy in this setting. The patient should receive individual speech therapy for one hour two times per week. Concerning the requested occupational therapy, the paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population. Schaaf, et al. noted success with sensory integration occupational therapy in an autistic patient population. While this patient is severely delayed, there is evidence that he has the capacity to benefit from rehabilitative therapies (given his documented response to speech therapy). As such, the patient is an appropriate candidate for occupational therapy, which is part of the standard treatment protocol for patients with autism. The patient should receive occupational therapy for one hour two times per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for mental health inpatient adolescent treatmentfor treatment of the enrollees autism and mood disorder.  Findings:  The physician reviewer found that this patient presented with major co-morbid disorders, i.e., autism spectrum disorder and mood disorder including a positive family history of bipolar disorder.  Severe functional impairment was evident.The level of care provided was consistent with Child and Adolescent Level of Care Utilization System criteria and American Academy of Child and Adolescent Psychiatry practice parameters.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested  for speech therapy and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in reviewing the speech therapy report provided by the non-plan speech therapist, the program goals are functional in nature and are not solely within the purview of educational therapies. I therefore find them medical in nature. The in-plan speech and language evaluation included no standardized testing and limited the evaluation only to physical function of speech without taking into account the pragmatic nature of speech. There need not be impairment in physical function in order for speech and language therapy to be considered medically necessary. California Assembly Bill (AB) 88 lists autism spectrum disorder as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. Furthermore, the above-cited literature demonstrates that speech and language therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function. Accordingly, I find the requested speech and language therapy twice per week is medically necessary.Regarding occupational therapy, the in-plan evaluation included no standardized testing. The only comment regarding activities of daily living was observation of the patients ability to put on/take off her coat and shoes. The therapist noted that these required setup. The non-plan occupational therapist utilized standardized testing including the Hawaii Early Learning Profile and the Sensory Profile. These tests revealed significant deficits in praxis and sensory processing associated with the patients autism. This therapist proposed goals that are functional in nature including traversing steps and throwing a ball. Occupational therapy is a well accepted modality for patients with autism. There is evidence supporting the use of occupational therapy to improve deficits of neurologic processing and sensory information. Based on this patients documented deficits, she is an appropriate candidate for occupational therapy. As such, 10 hours per month of occupational therapy is medically necessary for the patient.For the reasons set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested coverage for speech and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that regarding the requested speech therapy services, the submitted evidence demonstrates that the patient has delayed speech functioning which was at the 3rd percentile for her age. Myers and Johnson state, Most children with ASDs can develop useful speech  traditional, low-intensity pull-out service delivery models are ineffective  speech-language pathologists are likely most effective when they work  to promote functional communication throughout the day. Turner, et al. reported on the success of an integrated speech and behavioral program in a controlled study, with the speech therapy group having far better communication skills at the age of 9 than the non-intervention group (e.g., school program, limited services, etc.). Goldstein discussed the various speech treatment modalities and their application to autistic children. Based on the results of evaluation by the in-plan Autism Spectrum Disorder Clinic, the patients speech functioning is significantly delayed. As such, individual speech therapy at a frequency of one hour per week is both medically indicated and appropriate for this patient with autism spectrum disorder.  In reference to the requested occupational therapy, the paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population. Schaaf, et al. noted success with sensory integration occupational therapy in an autistic patient population. In the case of this patient, evaluation by the in-plan occupational therapist found the patients functioning within normal limits is inconsistent with the findings of the in-plan Autism Spectrum Disorder Clinic (fine motor skills at the 1st percentile) which occurred just days earlier. It is also inconsistent with the non-plan occupational therapy evaluation performed five months earlier which similarly showed significant deficits. All told, the evidence demonstrates occupational therapy is a medically necessary modality for this patient. The patient should receive occupational therapy at the requested frequency of one hour per week.  Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Avastin injections for treatment of his diabetic retinopathy. Findings:  The physician reviewer found that vascular endothelial growth factor (VEGF), if present in the retina, produces angiogenesis and increased vascular permeability. This can have very serious effects on visual function. The level of VEGF is increased in the retina in patients with proliferative diabetic retinopathy. Anti-VEGF drugs negate this effect to a very significant degree. There are numerous articles documenting the successful treatment of proliferative retinopathy with intraocular Avastin. Avastin injections can be an appropriate and efficacious treatment in patients who present with resistant retinal neo-vascularization, despite repeated laser therapy, in that the cascade of severe ischemia, poor circulation and massive neo-vascularization can be averted. Arevalo and colleagues found that Avastin resulted in marked regression of retinal neo-vascularization in proliferative retinopathy. Mason and colleagues also found that Avastin was an excellent treatment when given before panretinal laser therapy. Spaide and Fisher felt that Avastin injections in patients with proliferative retinopathy and vitreous hemorrhaging resulted in regression of the neo-vascularization, and a clearing of the vitreous hemorrhage. This patient was essentially blind in the OD, with severe proliferative retinopathy in the OS and with vitreous hemorrhaging. The patient had panretinal laser therapy previously, but still had neo-vascularization in the OS. The prior Avastin injections resulted in improvement of his vision, and the clearing of the vitreous hemorrhage. Avastin therapy has become the standard of care in the treatment of neo-vascularization associated with proliferative diabetic retinopathy. This is particularly true when other forms of therapy have failed as is the case with this patient.