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

A 41-year-old male enrollee has requested temporomandibular joint (TMJ) dysfunction treatment (CPT code 99354, prolonged physician services) for treatment of his TMJ dysfunction. Findings:  The physician reviewer found that the evaluation of patients with orofacial pain is generally more involved than a routine dental patient. The exam consists of a detailed history and a thorough physical exam of the head and neck. In this patients case, an extended new patient exam was coded for and appropriate for the work-up of the patient. However, given this, it is unclear for what additional purpose a prolonged physician service was also coded for in that there was no documentation submitted to support this additional billed code.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested temporomandibular joint (TMJ) dysfunction treatment (CPT code 99354, prolonged physician services) for treatment of his TMJ dysfunction. Findings:  The physician reviewer found that the evaluation of patients with orofacial pain is generally more involved than a routine dental patient. The exam consists of a detailed history and a thorough physical exam of the head and neck. In this patients case, an extended new patient exam was coded for and appropriate for the work-up of the patient. However, given this, it is unclear for what additional purpose a prolonged physician service was also coded for in that there was no documentation submitted to support this additional billed code.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for low back fusion surgery for treatment of herlow back pain. Findings:  The physician reviewer found that the patients MRI scan findings have not demonstrated any focal changes which may reasonably be addressed with surgical intervention. In addition, the efficacy of decompression surgery has been reviewed and the study authored by Osterman and colleagues showed that there were no clinically significant differences between patients who underwent decompression surgery versus those treated with conservative management over a two-year follow-up. The study authored by Puel and colleagues did demonstrate a short-term benefit for patients leg pain. However, the patient population in these studies does not appear to match the clinical presentation of  this patient, in that the anatomical studies do not reveal localized focal disc herniation, but rather mild neural foraminal narrowing. The large disc fragment described anterior to the vertebra at L5-S1 level is not likely relevant to the patients lower extremity pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested for acute inpatient level of care for treatment of her behavioral health issues.  Findings:  The physician reviewer found that while the efficacy of acute inpatient treatment for treatment of eating disorders is well established, the evidence regarding the appropriateness of residential level of care for treatment of such patients is less convincing. An article by Frisch, et al. noted that future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders. In the case of this patient, she engaged in many negative behaviors including substance abuse and a lack of overall cooperation during her RTC stay. Moreover, this patient has no previous intensive outpatient program (IOP) or partial day hospital (PDH) treatment history. It is documented on numerous occasions that she needed structure in order to function adequately, however, there are no documented failures at lower levels of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested for residential treatment level of care services for treatment of her eating disorder. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines state that patients who are discharged to partial hospitalization programs before they are clinically ready have a high rate of early relapse. Additionally, such patients experience greater struggles with recovery and slower rates of progress. The APA guidelines indicate that residential treatment is appropriate for patients who struggle with intrusive repetitive thoughts 4-6 hours per day, for patients who are cooperative but who need supervision with meals, and for patients who can ask for and utilize support. This patient meets these criteria. Furthermore, an article by Swinburn suggests that social isolation, dysfunctional family interactions, and insufficient response to outpatient treatment are also indications for 24-hour level of care. Overall, the medical literature indicates that residential level of care is appropriate for patients with limited support systems.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested for continued follow-up by an endocrinologist for treatment of his diabetes. Findings:  The physician reviewer found that this patient has had persistent uncontrolled hyperglycemia as well as frequent episodes of hypoglycemia as noted in his glucose sensor reports. Continued follow-up with an endocrinologist is medically necessary to help manage his disease and prevent both short-term complications of hypoglycemia, as well as long-term complications of hyperglycemia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for AxiaLIF (lumbar interbody fusion) for treatment of her low back pain. Findings:  Three physician reviewers found that there is a lack of randomized, controlled, therapeutic studies available to demonstrate safety and efficacy. In addition, there are case specific considerations which likely limit any potential benefit. These case specific considerations include poor definition of pain generators in this patients experience of chronic lumbosacral pain. A more accurate definition of the source of the patients non-radiating or minimally radiating lumbosacral pain is needed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for a dermatology consultation for treatment of her skin tags.  Findings:  The physician reviewer found that treatment of benign skin lesions is considered medically necessary when lesions display symptoms such as significant change in size, uncertain diagnosis, obstruction of an orifice, or the potential of malignant transformation. As noted by Pariser, Virtually all human beings have a number of benign cutaneous neoplasms, and the primary care provider is expected to make clinical judgments, without recourse to consultation or histopathologic examination. This patients lesions of interest do not fulfill these criteria, as provider did not document the patients skin tags to be symptomatic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  for acute inpatient level of care for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the enrollee reported low self-esteem, decreased concentration, low motivation, fatigue, sleep disturbances, anhedonia, feelings of worthlessness and hopelessness, social isolation, passive suicidal ideation and lack of interest in activities. The enrollee also indicated that she only thinks and dreams about food and feels preoccupied with food and severe calorie restriction. The provider notes the enrollee was diagnosed with anorexia nervosa, restricting type and major depressive disorder, recurrent, moderate, malnutrition, low blood pressure, lack of menses and dizziness. On admission, the enrollees global assessment of functioning (GAF) was 35, with 61 the highest within the past year. The enrollee was treated at the acute level of care then was transferred to residential level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for Synvisc injections in the right knee for treatment of his osteoarthritis. Findings:  The physician reviewer found that viscosupplementation as a treatment for osteoarthritis has been found to be effective in the knee joint, as noted by Bellamy and colleagues. A course of several injections is needed, and aside from the reduction in symptoms, there may be some beneficial effect on the cartilage, as noted by Altman. The medical evidence indicates that this treatment is most suitable for patients with mild to moderate osteoarthritis and is less efficacious when employed in patients with radiologically severe arthritis, as noted by Gossec and Dougados.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested for Botox injections for treatment of her stated diagnosis of migraine headaches secondary to chronic cervicofacial spasm.   Findings:  Three physician reviewers found that absent information regarding the patients symptoms including headache frequency at baseline and post-Botox therapy, as well as the specifics regarding her prior attempts with preventive therapies, it is not possible to conclude that Botox therapy is likely to be more beneficial or effective to treat this patients migraine headaches than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Synvisc injections for treatment of his arthritis of the knees.  Findings:  The physician reviewer found that Dagenais and colleagues concluded that known side effects have been mild and limited, resolving shortly after treatment. The literature recommends the procedure for patients with mild to moderate involvement (Gossec and Dougados), and found to be less efficacious in patients with radiologically severe osteoarthritis (Kolarz, et al.). While Waddell and colleagues convey an increased incidence of adverse events with repeated injections, in a separate study the authors concluded that some patients who have had a previous successful course of therapy may obtain additional benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for an increase in Astelin dosage (two sprays in each nostril three times per day, which is more than one inhaler per 25 days) for treatment of her shortness of breath, upper respiratory infection and chronic sinusitis. Findings:  The physician reviewer found that this request exceeds the Food and Drug Administration approved dosage of Astelin. The use of Astelin at the requested dosage has not been studied and therefore its safety and efficacy are unknown. The requested dose would lead to an increase of the local antihistamine which could then be absorbed to increase the system level of antihistamine. This could potentially result in decreased urine flow in some patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested coverage for speech therapy three times per week and occupational therapy utilizing sensory integration therapy for two hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that while some of the speech and language skills serve the dual purpose of enabling the patient to communicate in both educational and non-educational settings, this does not alter the need for communication skills to function within the community. 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. The above-cited literature demonstrates that speech therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function.Occupational therapy is a well accepted modality for patients with autism. There is evidence supporting the use of occupational therapy including sensory integration techniques to improve deficits of neurologic and sensory processing. Sensory integration therapy is likely to be an integral tool in helping this patient achieve functional goals.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient is a very young patient with severe behavioral health issues. Based on the evidence provided, she was out of control emotionally, which could signal a mood disorder. In addition, she has an eating disorder and also has significant family conflict. Because of this patients extreme behavioral health issues, she required treatment in a 24-hour setting during the period at issue. She could not have been safely treated in a less intensive environment. Her methods for acting-out were potentially very harmful, if not fatal. In light of the severity of the patients symptoms, residential treatment level of care was medically necessary during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for a neurology consultation for treatment of her dizziness.  Findings:  The physician reviewer found that per Milliman Care Guidelines, indications for a referral to a neurologist include unremitting vertigo and disabling vertigo and nystagmus, cerebellar symptoms such as marked ataxia and incoordination, focal neurologic symptoms and persistent vertigo or dizziness.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for Botox injections for treatment of his pain.  Findings:  Two physician reviewers found that there is documented failure of more traditional conservative care and failure of traditional trigger point injection. Botox use is supported in the literature for the treatment of spastic pain due to piriformis syndrome. This is used as a standard of care treatment in refractory cases.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of his growth hormone deficiency. Findings:  The physician reviewer found that the patient demonstrates classic growth hormone deficiency, as manifested by short stature, low IGF-1 level, poor response to two provocative growth hormone tests, low bone density, delayed bone age and small pituitary on MRI. Growth hormone therapy is warranted until fusion of the growth plates, at which point the patient should be retested to assess whether he meets criteria for adult growth hormone deficiency. Retesting is not indicated at this point in time when the patient still has open epiphyses.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Amrix 15mg for treatment of her headaches, neck pain and muscle spasms. Findings:  The physician reviewer found that this patients more severe headaches with nausea and vomiting most likely represent migraine. Triptans are within the standard of care in this setting if not medically contraindicated. Migraine preventive medications such as a tricyclic antidepressant are also well-accepted in this setting. The patient found Amrix to be helpful and cyclobenzaprine 10mg was too sedating. However, there is no indication that cyclobenzaprine 5mg has been tried. A lower dose of cyclobenzaprine may reduce drowsiness. Amrix has not been shown to be more effective than generic cyclobenzaprine.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for Nuvigil for treatment of her fibromyalgia and depression. Findings:  Three physician reviewers found that There is significant evidence supporting the use of Provigil in this patients case.  In light of the molecular similarity of Nuvigil and Provigil, it is reasonable to assume that the Provigil data can be extrapolated to the use of Nuvigil. Additionally, the patient has shown significant benefit from the use of Nuvigil.  There is also some data to suggest that Nuvigil may have benefit over Provigil. As noted by Darwish and colleagues, at steady state, armodafinil produces consistently higher plasma drug concentrations late in the day than modafinil when compared on a milligram-to-milligram basis. Thus, Nuvigil is likely to be the most efficacious treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested for one hour of physical therapy per week and one hour of occupational therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that physical therapy evaluations demonstrate that the patient has significant functional deficits that require physical therapy at this time. The records indicate the patient has mild to moderate delays in stationary development, but he also has achieved major milestones at age-appropriate levels. For these reasons, there is inadequate justification for the medical necessity of physical therapy. the goals outlined by the non-plan occupational therapist include imitating a vertical line, horizontal line, and circle after two demonstrations; stringing three small beads consecutively; removing the lid from a bottle and placing small objects into a bottle using superior pinch grasp; imitating three block bridge using cubes; and snipping with scissors. These goals are not related to functional deficits such as dressing skills, hygiene, feeding skills or other activities of daily living.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his depression. Findings:  Two physician reviewers found that the NeuroStar TMS system has obtained Food and Drug Administration (FDA) approval for the treatment of patients with major depressive disorder who have failed to achieve satisfactory improvement from antidepressant medication. The efficacy and benefit of TMS for major depression was also advocated during several presentations at the American Psychiatric Association (APA) Annual Meeting in May 2010. Janicak and colleagues note that TMS has demonstrated efficacy in the treatment of major depressive disorder. Demitrack and Thase indicate that TMS is clearly safer and better tolerated than many other pharmacotherapeutic options or ECT. In addition, Avery and colleagues controlled study suggests that TMS can produce statistically and clinically significant antidepressant effects in patients with medication resistant major depression, while Schutter and colleagues concluded that TMS represents an alternative for patients who do not tolerate the side effects of medications. Given this patients clinical history, TMS was likely to be more beneficial than any other available  standard treatment and should not be considered investigational in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested Botox therapy, for treatment of her migraine headache.   Findings:  Two physician reviewers found that the American Academy of Neurology guidelines state, Based on published Class I and Class II studies, botulinum neurotoxin injections are probably ineffective in the treatment of episodic migraine. The guidelines conclude, Botulinum neurotoxin injections should not be considered in patients with episodic migraine and chronic tension-type headaches. (Naumann, et al.) Furthermore, David Simpson, MD, chair of the Therapeutics and Technology Subcommittee of the American Academy of Neurology writes in the January 2010 edition of Neurology Today, While abstracts described in recent headache meetings suggest botulinum toxin may be effective in the treatment of migraine headache, there are not yet adequate safety and efficacy data fully presented in the peer-reviewed literature. Finally, a 2009 meta-analysis of eight randomized, double-blind, placebo-controlled trials of botulinum toxin A (Botox) for the treatment of episodic migraine concluded, Botulinum toxin A for the prophylactic treatment of episodic migraine headaches was not significantly different from placebo, both from a clinical and statistical perspective.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this patient presented to the emergency department with complaints of left ear pain and hearing loss that persisted for 2-3 days. On evaluation, the patients vital signs were normal, she was not having a nosebleed when seen, and the physical examination revealed cerumen impaction as the cause of the pain and hearing loss. The cerumen was removed and the patient was discharged with a diagnosis of cerumen disimpaction. This case involves the issue of whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient had symptoms that were persistent for more than two days and were not associated with severe pain or fever. Further, her nose was not bleeding at the time she sought emergency care. Since the patients vital signs were normal and her pain reportedly was not severe, a prudent layperson in these circumstances would not reasonably believe that the absence of immediate medical attention would cause serious impairment to her health or bodily function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for Lyrica for treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the patient has painful neuropathy due to immunosuppressant medications. The mechanism of the neuropathy is different than in diabetic or post-herpetic neuropathies, but the mechanism of pain transmission and the symptoms are the same.  Therefore, the management of these neuropathies is similar, and agents such as membrane stabilizers and antiepileptic medications are useful and efficacious for the management of the over activity associated with the affected nerves.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has requested continued care from a pediatric ophthalmologist for treatment of the enrollees strabismus. Findings:  The physician reviewer found that the patient is stable and doing very well. In fact, she is being followed at recommended intervals of six months to one year, which indicates that her condition is very stable. All board certified ophthalmologists are trained in the treatment of accommodative esotropia and amblyopia. Thus, a general ophthalmologist can follow a patient with strabismus and amblyopia, particularly when the patient is stable as is the case with this patient. A general ophthalmologist has the knowledge and expertise to be able to refer the patient to a pediatric ophthalmologist if the patients condition was to show significant changes or any worsening. The treatment of strabismus and amblyopia is within the scope of practice of a general ophthalmologist.