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

A 62-year-old male enrollee has requested authorization and coverage for bilateral radiofrequency treatment for treatment of the enrollees sesamoidal issues and a plantar ligament tear of the metatarsophalangeal joint complex. Findings:  Three physician reviewers found that the patient has pain at the left second metatarsophalangeal joint. The patient has documented sesamoiditis at the left first metatarsophalangeal joint. An MRI revealed no changes in the left second metatarsophalangeal joint. The patients provider indicated a possible tear of the left second metatarsophalangeal joint, however, this is not evident from the documentation that was provided. The patients provider has recommended bilateral radiofrequency treatment. The Health Plan has denied this request as investigational. There is a paucity of literature examining the safety and efficacy of the proposed radiofrequency treatment. Although this patient has failed conservative treatment for his foot pain, the requested procedure has not been proven to be more beneficial for treatment of this patients medical condition than other available standard treatments. Thus, the requested procedure remains investigational in regards to the foot. In sum, the Health Plans denial was appropriate and should be upheld.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the patient has a past history of prostatic hypertrophy who presented to the emergency department (ED) complaining of constipation, abdominal pain, nausea, nocturnal chills, subjective fever, and malaise for three weeks.  His vital signs and physical examination were unremarkable. An abdominal x-ray revealed marked bowel dilation. A computed tomography (CT) of the abdomen and lab work was normal. He was diagnosed with constipation and fever and was discharged home.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.A prudent layperson would reasonably be expected to seek immediate medical attention due to symptoms of fever, chills, nausea, and abdominal pain which are persistent and not relieved after taking over the counter medications at home. Such presenting signs and symptoms may be suggestive of acute intestinal obstruction, appendicitis, colon cancer, abdominal aortic aneurysm and other conditions which could place the patients health in serious jeopardy. As such, these symptoms were indicative of a possible emergency medical condition and immediate medical evaluation was appropriate and indicated.  Therefore, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested reimbursement and continued authorization and coverage for transcranial magnetic stimulation (TMS) therapy provided from a specific date and ongoing. Findings:  Three physician reviewers found that the patient was diagnosed with major depressive disorder, recurrent, severe. She presents with depressed mood, anhedonia, tearfulness, guilt, difficulty with focus, problematic sleep, lack of motivation, fatigue and, suicidal ideation. She has impaired functioning socially and occupationally. Of note is that this patient has had two suicide attempts. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Zoloft, Prozac, Lexapro, Remeron and Lamictal, which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches and partial hospitalization have also yielded inadequate therapeutic effect. The patient has requested reimbursement and prospective authorization for transcranial magnetic stimulation (TMS) therapy provided from a specific date and ongoing. The Health Plan has denied this request, as investigational.  According to the records provided for review, this patients depression was treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS. A recent report from the New England Comparative Effectiveness Public Advisory Council (CEPAC) indicated that TMS therapy is as good, or better, than usual care and that equivalent or superior outcomes for TMS were found when compared to electroconvulsive therapy. Additionally, Connolly and colleagues reported that TMS was found to be safe and effective in both the acute and maintenance treatment of patients with treatment resistant depression. Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorders. Consistent with this support, the TMS therapy provided from the date in question and forward was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female has requested growth hormone therapy (Saizen) for treatment of her precocious puberty.  Findings:  The physician reviewer found that this patient has normal stature and an expected blunting of her growth spurt while on gonadotropin-releasing hormone agonist therapy.  While on gonadotropin-releasing hormone agonist therapy, the patients skeletal maturation has been arrested and has not outpaced her linear growth.  Thus, her adult height prediction has improved from 62.7 inches prior to Lupron treatment to 64 inches while receiving Lupron.  Her height prediction falls within the normal range for an adult female.  The addition of growth hormone to gonadotropin-releasing hormone agonist therapy cannot be routinely recommended for augmentation of height in a patient being treated for central precocious puberty, particularly in a patient who has a normal adult predicted height while on Lupron treatment.  There is a lack of large-scale randomized, controlled trials evaluating the addition of growth hormone therapy to gonadotropin-releasing hormone agonist therapy for central precocious puberty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees small intestinal bowel overgrowth. Findings:  The physician reviewer found that there has been some recent literature linking SIBO to irritable bowel syndrome as well as dyspeptic symptoms. The most cited papers were published using Xifaxan as the active treatment arm compared to placebo. The medication is known to have a low systemic absorption and favorable side effect profile. However, it is clear that other antibiotic drugs will also successfully treat SIBO. The patient is allergic to sulfa and therefore Bactrim is not a treatment option. However, the use of metronidazole along with ciprofloxacin or a tetracycline would likely be as effective as the requested Xifaxan, and is covered by the Health Plans formulary. For these reasons, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested a semi-electric hospital bed with a mattress and rails due to her history of prior falls.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medically necessity of the requested equipment in this patients case.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation, such as due to respiratory or cardiac impairments.  Additionally, semi-electric or fully electric hospital beds may be indicated if the patient has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if a person is unable to perform sufficient pressure relief independently.  The records forwarded for review do not establish that the patient has impairments which require a semi-electric hospital bed.  The patient reportedly has fallen out of bed on many occasions, but the impairments that are responsible for this are not clearly documented.  All told, the requested semi-electric hospital bed with a mattress and rails is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male has requested bilateral total knee arthroplasty for treatment of his knee pain.  Findings:  The physician reviewer found that the relationship of obesity to outcomes following total knee arthroplasty has been the subject of controversy.  Some studies have reported that any degree of obesity has a negative effect on outcomes.  Other studies have indicated that moderate obesity does not affect outcomes, and that with increased mobility, subsequent weight loss may be enhanced.  Researchers have compared outcomes in obese and normal patients, and there are studies which have found no significant difference in survival or perioperative complications.  Since surgery in the obese carries some risk of additional complications, weight loss prior to surgery may be advisable.  However, since substantial improvement and high patient satisfaction rates have been reported, total knee replacement is an appropriate treatment option in this clinical setting.  In this patients case, the presence of significant joint damage has been documented.  Additionally, he has not benefited from conservative management.  Despite the presence of obesity, the requested procedure is likely to offer significant benefits to this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested access to continuous monitoring and treatment in a pain management department for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that the patient has a history of bipolar disorder, severe chronic back pain, kyphosis and rod placement in her spine. The patient has also been diagnosed with opioid dependence with several reported hospital admissions for overdose. The patient was recommended for a drug rehabilitation program. The patient has been participating in the drug rehabilitation program for several months and has requested pain management treatment, as she has indicated that non-opiate medications have not been effective in treating her condition. Pain management includes multidisciplinary care including psychological assessment and treatment as well as adjuvant medications, non-pharmacologic measures and any interventional procedures that may be applicable to the condition. A patient with chronic non-malignant pain in the setting of an opioid abuse history is appropriate for treatment in the pain management department, with the limitation that the patient is only a candidate for non-opioid treatment. The typical treatment protocol for a patient, such as this, is monthly pain management care with reassessment at twelve months. Thus, a portion of the requested services are medically necessary in this patients case. Therefore, pain management services are medically appropriate at a frequency of one visit per month. However, treatment with opioid medications is not appropriate for the treatment of this patients medical condition, given her history of opiate dependence.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested authorization and coverage for Betaseron for treatment of the enrollees multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  This patient has been started on disease modifying therapy with Betaseron (interferon-beta-1b).  Patti and colleagues conducted a six-year head-to-head study and concluded that both interferon-beta-1a and interferon-beta-1b are effective in slowing disability progression.  Pan and colleagues conducted an analysis of long-term results with Betaseron and reported that treatment with Betaseron during the earlier disease phase of patients with multiple sclerosis significantly increased quality-adjusted life-years.  This patient has been diagnosed with multiple sclerosis, and Betaseron has been shown to reduce long-term disability.  The current medical evidence supports the requested medication in this clinical setting.  All told, Betaseron is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested sacroiliac joint steroid injections for treatment of her lumbar facet arthropathy, sacroiliac joint arthropathy, and myofascial pain syndrome.  Findings:  The physician reviewer found that the use of SI joint injections is very common in patients with low back pain due to SI joint or posterior capsular dysfunction, which account for about 20 to 25% of low back pain. The patient in this case has multiple findings on examination. The records indicate the patient has failed conservative therapy with medication, exercise therapy, and has had the pain for longer than three months. In this case, the role of a single appropriately performed bilateral diagnostic SI joint injection would be reasonable. Per the American Society of Interventional Pain Physicians (ASIPP) guidelines, a successful injection that provides relief would support possible therapeutic phase injections to be determined based on the degree and duration of relief. At this time, the patient should undergo one bilateral SI injection to help with the diagnostic work-up.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female has requested BRCA1 and BRCA2 genetic testing.  Findings:  Three physician reviewers found that the patient does not have a history of breast cancer.  She has a paternal aunt with breast and ovarian cancer.  A cousin (daughter of the affected aunt) tested positive for BRCA mutation and is status post bilateral mastectomy and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patients sister had breast cancer at the age of 50 and is status post bilateral mastectomy.  The patient has had suspicious mammograms, and a recent biopsy showed focal atypia.  BRCA testing is important in clinical oncology because bilateral mastectomy would reduce a carriers chance of developing breast cancer.  Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer.  At the present time, genetic testing is not applied universally, but rather is recommended for patients with family histories that are suggestive of inherited predispositions.  In this patients case, she has one second-degree relative with breast cancer and ovarian cancer.  Additionally, she has a first-degree relative with breast cancer.  There is sufficient evidence to test this patient for BRCA1 and BRCA2 mutations.  All told, the requested BRCA1 and BRCA2 genetic testing is likely to be more effective than other tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old male has requested tongue base suspension for treatment of his severe obstructive sleep apnea.  Findings:  Three physician reviewers found that the patient has severe sleep apnea, which is well documented on his polysomnogram. He is not significantly overweight and does not tolerate treatment with continuous positive airway pressure (CPAP). Endoscopic examination suggests a multi-level obstruction for which uvulopalatopharyngoplasty (UPPP) and tongue suspension has been recommended by the patients provider. The records demonstrate that the severity of the patients sleep apnea warrants aggressive management. Given that the patient is not tolerating CPAP, a benchmark management, and he is not significantly overweight, other measures are indeed indicated. Among the patients alternative treatment options is tracheostomy, which is a more invasive intervention than the proposed treatment. Consistent with these findings, the requested procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested total disc replacement surgery using ProDisc-C for treatment of her neck pain and upper extremity pain.  Findings:  Three physician reviewers found that the patient reports neck pain which radiates down the left upper extremity to the wrist.  She reports numbness in all fingers of her left hand and difficulty with daily activities secondary to pain.  The patient has tried medications, physical therapy, and a TENS unit, which did not result in significant pain relief.  An MRI of the cervical spine showed mild C5-6 spondylosis and a moderately sized left disc extrusion resulting in moderate stenosis of the left lateral recess and left neural foramen.  The current medical literature has not demonstrated the superior efficacy of the requested procedure in this patients case.  Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric and colleagues (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or anterior cervical discectomy and fusion.  Per these studies, both the arthroplasty and anterior cervical discectomy and fusion groups showed clinical improvement.  The arthroplasty group experienced preservation of range of motion at the surgical level.  However, these studies were graded Class II because it was not evident how randomization occurred and whether the assessments were done by blinded observers.  More recently published reports of randomized trials with longer term follow-up suggest that artificial disc replacement may be beneficial, but the percentages of patients receiving four-year (55% of patients) and five-year (50% of patients) follow-up are exceedingly low.  Thus, the requested total disc replacement is not likely to be of greater benefit than other treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-old female enrollee has requested authorization and coverage for laparoscopic sleeve gastrectomy with cholecystectomy for treatment of the enrollees abdominal pain, cholelithiasis, and obesity.  Findings:  The physician reviewer found that although this patient is morbidly obese with a BMI greater than 40, the medical necessity of the requested laparoscopic sleeve gastrectomy with cholecystectomy has not been established at this time. The National Institutes of Health (NIH) consensus guidelines do not recommend bariatric surgery without documentation of prior failed weight loss efforts and compliance with nutritional regimens. In addition, a cholecystectomy would be considered medically necessary for symptomatic cholelithiasis, but this is not documented in the records. The patient should first be treated with dietary control. If the patient were to fail conservative treatment or develop acute cholecystitis, then surgical intervention could be considered. All told, the requested bariatric surgery has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested Applied Behavioral Analysis (ABA) therapy at a frequency of 12 hours per week and ABA supervision at a frequency of 4 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Additionally, the peer-reviewed medical literature has demonstrated that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disabilities (Grey and Hastings). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, aggression, and preoccupations and ritualistic behaviors, such is the case with this patient; and to improve his overall adaptive, socialization and communication skills. Therefore, the requested 12 hours of one to one ABA therapy per week and 4 hours per month of ABA supervision are medically necessary for treatment of the patients autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for left total hip replacement surgery.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  Total hip arthroplasty has been generally accepted as an efficacious procedure for advance osteoarthritis of the hip, with a low risk of failure and durable fixation in patients with advanced disease, or patients who have had a failure of conservative management.  The most common indication for the procedure is the presence of pain, classically located in the groin, and reliably relieved by the procedure.  In this patients case, the diagnosis of advanced degenerative disease was confirmed by x-ray.  Additionally, the medical records document significant pain.  The current medical evidence supports the requested procedure in this clinical setting.  All told, the requested left hip replacement is medically indicated for the treatment of this patient.