Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 19-year-old female has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient, a then 18-year-old female, presented to the Emergency Department (ED) complaining of three days of fever with chills, sore throat, and generalized body aches. She did not have a fever in the ED but did have a rapid pulse at 105 and complained of 8/10 throat pain. The patient was seen by a physician who visualized red tonsils coated with exudate. He diagnosed the patient with exudative tonsillitis and treated her in the ED with Motrin, Decadron, and Bicillin. She was discharged from the ED in an improved condition with a prescription for Motrin.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation demonstrates that this patient had a significant bacterial infection of her throat, with the potential for airway compromise. This condition required intervention with an antibiotic. In addition, her pain was severe, documented in the ED as 8 on a scale of 1 to 10. As noted above, severe pain is an appropriate indication for seeking treatment on an emergent basis. All told, a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention on the date of service in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female has requested anterior surgical approach for hip replacement surgery for treatment of her osteoarthritis of the right hip.  Findings:  The physician reviewer found that Hallert and colleagues evaluated 200 cases of unilateral hip replacement in a prospective study. The authors concluded that the technique was more demanding than other lateral approaches due to limited surgical exposure. Patients with morbid obesity, muscular patients, or patients with short femoral neck or acetabular protrusion are more difficult to manage with an anterior approach. Muller and colleagues noted that minimally invasive total hip arthroplasty has been successfully introduced in the past decade. A direct lateral approach continues to be used commonly because of the advantages in visualization. The authors indicated that in the direct lateral approach fatty atrophy of the anterior third of the gluteus medius muscle may occur with reduced function, gait disorders, and pain. The authors concluded that no influence of the surgical approach could be observed in the gait patterns of their patients. The issue of the safest and best surgical approach for total hip arthroplasty has been an ongoing issue since the beginning of total joint replacement. There are basically four surgical approaches that over the years have been used for total hip replacement. The first would be the anterior Smith-Peterson approach using the interval between the tensor fascia lata and the sartorius muscle. The second is an anterolateral or Watson-Jones approach using the interval between the tensor fascia lata and the gluteus medius. The third is a lateral approach, which is discussed in one of the articles reviewed above where the gluteus minimus is detached and the gluteus medius is split. The posterior approach or Kocher-Langenbeck approach where the external rotators are taken down and the posterior capsule either excised or widely opened. These approaches have been part of the orthopedic methodology for many years being developed even before total joint arthroplasty. Although each of the approaches may be reasonable, the use of a specific approach depends upon the individual patient. In this specific case, there are no contraindications to an anterior approach. The fact that the anterior approach is facilitated by a customized operating room table or special retractors should not rule out the application of this technique when chosen by the operating surgeon.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested  partial hospitalization program (PHP) services for treatment of the enrollees eating disorder and depression.  Findings:  The physician reviewer found that according to the psychiatric notes, the patient was not medically stable on the said dates, as she had documented evidence of orthostatic hypotension. Additionally, she had subjective complaints of dizziness and dehydration. Her treatment plan was changed to increase her fluids and monitor her for this condition. However, a week later she was no longer experiencing subjective complaints of dizziness and there was no notation in the records indicating that her vital signs still demonstrated hypotension. Therefore, the patient was medically stable at that point in time, and could safely be discharged to a lower level of care. According, continued PHP level of care was medically necessary during the said timeframe; PHP level of care was not medically necessary going forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested the brand name prescription Anafranil for treatment of obsessive compulsive disorder.  Findings:  The physician reviewer found that Anafranil is a brand name medication that falls within the tricyclic antidepressant class.  Due to its particularly potent serotonergic properties, this medication remains one of the well-trusted interventions in the treatment of obsessive compulsive disorder.  The generic equivalent to this brand name medication is clomipramine.  It is relevant to consider that nearly 80% of medications dispensed in the United States are generic preparations.  This common practice is supported by United States Food and Drug Administration bioequivalence testing that ensures that the generic product performs the same as its respective brand name product.  In some cases, a particular preparation, either brand name or a specific generic, may be necessary due to tolerability and efficacy reasons.  However, the submitted documentation fails to demonstrate the medical necessity of the requested brand name medication in this patients case.  Although the patient reported poor tolerability, there is no evidence in the medical records that she has had a change in clinical status due to the generic equivalent.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Lap-Band surgery (adjustable gastric banding system) for treatment of her body mass index of 34.29.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  This patient has a reported body mass index of 34.29.  There are no documented chart notes describing prior weight loss efforts.  The medical records do not document the recent completion of a multidisciplinary evaluation with dietary evaluation.  Additionally, there is no documentation of a body mass index of 35 or greater meeting the definition of clinically severe or morbid obesity at this time.  The current medical evidence does not support the requested procedure in this clinical setting.  All told, the requested Lap-Band surgery (adjustable gastric banding system) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female has requested Nexium 40mg for treatment of her esophageal reflux.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The current medical literature supports Nexium (esomeprazole) in this clinical setting.  Hoogendoorn and colleagues conducted a study to determine treatment satisfaction in patients with gastroesophageal reflux disease when switched to esomeprazole.  Per the authors, following switching to esomeprazole, 88.0% of patients were satisfied with the therapy.  The authors noted that esomeprazole was well-tolerated.  They concluded that switching to esomeprazole therapy has positive impacts on treatment satisfaction and symptom control.  In this patients case, she has been on Nexium 40mg for over five years, and this medication has been efficacious.  Alternative therapy tried has been less effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male has requested additional fat grafting and procedures which involve liposuction and mastectomy for gynecomastia, suction assisted lipectomy, revision of reconstructed breast, and tissue grafts, other, e.g., paratenon, fat, dermis for treatment of his gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  As evidenced by the submitted photograph, the patients condition does not constitute an abnormal structure of the body.  Based upon the photograph, the concavity and fold are not of a severity which constitutes an abnormal condition.  Additionally, there is no documented functional deficit.  Thus, the surgery is not being performed to improve function.  All told, additional fat grafting and procedures which involve liposuction , mastectomy for gynecomastia, suction assisted lipectomy, revision of reconstructed breast, and tissue grafts, other, e.g., paratenon, fat, dermis are not reconstructive in nature and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a second bilateral breast reduction revision for treatment of her status post revision of breast reduction with chest wall contouring.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records document obesity, and this is associated with higher complication rates.  In this clinical setting, the optimal approach is weight loss prior to breast surgery.  In this patients case, the current complaints are not related to macromastia.  There are no documented functional complaints.  Given the patients prior medical and surgical history, the submitted photographs demonstrate the expected results in this setting.  Thus, this patients condition does not constitute an abnormal structure of the body.  All told, a second bilateral breast reduction revision is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male has requested coverage for a past CT angiogram of the heart for evaluation of his medical condition after being diagnosed with ascending aortic aneurysm and bicuspid aortic valve.  Findings:  Two physician reviewers found that the patient presents with a history of bicuspid aortic valve, ascending aortic aneurysm, hypertension, gastroesophageal reflux disease, and migraine.  On a date at issue, a CT of the chest reportedly showed a 5 cm ascending aortic aneurysm.  The following month, an echocardiogram reportedly showed left ventricular hypertrophy with normal ejection fraction, a bicuspid aortic valve with mild regurgitation, and an ascending aortic aneurysm.  The patient then had a CT angiogram of the heart one month after the echocardiogram.  In this clinical setting, the services at issue were not likely to be of greater benefit than other modalities for evaluating this patient.  If an assessment of coronary anatomy were thought to be indicated, conventional coronary angiography would have been the preferred method of evaluation.   Conventional coronary angiography provides the ability to intervene with coronary revascularization during the same procedure, if clinically indicated.  Current guidelines that are endorsed by several national organizations do not support the services at issue in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of patients with depression.  In this patients case, the records document an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies used to combat depression.  Per the current peer-reviewed medical literature, TMS therapy is medically indicated to treat this patients depressive symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male has requested speech therapy, three times per week, for 60 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for the treatment of this patient.  The medical records document a history of expressive and receptive language delays with phonological deficits.  Language deficits are one of the core aspects of autism, and speech therapy provides assistance with communication development for individuals with autism.  The development of language skills is necessary in this clinical setting.  This patient will benefit from speech therapy as part of a dedicated intervention program.  The current medical evidence supports speech therapy as an effective intervention in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male has requested residential drug treatment program services for treatment of his polysubstance abuse and depression.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested services at this time.  Aggressive patient-centered care involving robust social support is indicated to achieve the desired end state of sustained sobriety and affective harmony.   Per the American Psychiatric Association, residential treatment is indicated for patients whose lives and social interactions have come to focus predominantly on substance use and who lack substance-free social supports and sufficient social and vocational skills to maintain abstinence in an outpatient setting.  However, according to the American Society of Addiction Medicine, a thorough and current assessment culminates with the determination of the proper placement setting.  In this patients case, an updated, multidimensional comprehensive assessment is required in order to establish the medical necessity of the requested services.  All told, the requested residential drug treatment program services are not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female has requested a specialized bed for her daughter who has been diagnosed with autism and microcephaly.  Findings:  The physician reviewer found that the current medical evidence supports the requested equipment in this clinical setting.  This patient has a complex history with severe sleep disorder, global developmental delay, and autism.  There are significant concerns from multiple medical professionals for self-injury, elopement and safety related to the sleep disorder.  The patients current bed does not provide a safe setting and does not minimize elopement and self-injury. Myers and colleagues noted that sleep problems are common in children with autism spectrum disorder and may have significant effects on daytime function and quality of life.  Poor sleep habits in children with developmental disability have been related to self-injury and aggression.  The goals in this setting include providing a safe environment, and minimizing entrapment, self-injury and elopement during the night.  All told, the requested specialized bed is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Multiple studies of Lovaas-based approaches and early intensive behavioral intervention variants resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Sallows and Graupner). Individual treatment is a defining feature and integral component of ABA. The Individual Program Plan for this patient is constructed to identify all behavioral needs including communication, functional living, self-help skills, social interaction, and recreation. These domains are noted as program components for intensive ABA therapy. All told, the ABA therapy incorporating Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity, is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of an 85-year-old male has requested continuous cardiac monitoring on a telemetry unit in an acute care setting for treatment of his diagnosed acute respiratory failure and anoxic brain damage. Findings:  The physician reviewer found that this patient suffered an out-of-hospital cardiac arrest and was treated with amiodarone medication among other measures.  There were no dysrhythmias while he was monitored on continuous telemetry for several weeks during hospitalization, and the patient was deemed to not be an eligible candidate for an implantable defibrillator given his ongoing anoxic brain damage and poor prognosis.  This recommendation is consistent with current guidelines.  In this circumstance of no dysrhythmias for several weeks after initiation of amiodarone therapy and no plans for implantation of a cardioverter defibrillator due to anoxic brain injury and poor prognosis, continued use of cardiac telemetry is not medically necessary and is not considered standard accepted practice in the medical community.   Current practice guidelines recommend continuation of cardiac telemetry while being evaluated for the cause of the event and while corrective/preventive treatment is being instituted.  In this patients case, corrective/preventive treatment consists of amiodarone and no additional anti-arrhythmic therapy or device placement.  Therefore, since appropriate treatment has been instituted and extended monitoring on treatment has not revealed dysrhythmias, continuous cardiac monitoring on a telemetry unit in an acute care setting is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested Botox injections for treatment of her migraine headaches and neck pain.   Findings:  The physician reviewer found that  Botox injections are not medically necessary for the treatment of this patients chronic migraine as the medical records do not demonstrate that a positive response to previous injections, for example with a reduction in medications. Additionally, the patients medical records do not show an indication for Botox injections. In the medical literature, Matthew and colleagues performed a randomized double blinded, placebo controlled trial on Botulinum toxin type A (Botox) for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache-free days compared to baseline. The authors cautioned that the primary time point difference, however, for Botulinum Type A when compared to placebo was not statistically significant. Silberstein and colleagues studied the safety and efficacy of different concentrations of Botox for prophylactic use in chronic tension type headaches. The efficacy of Botox was demonstrated as more patients than the placebo group had a greater than 50% decrease in tension headache days. For the primary endpoint, however, the mean change from baseline in the number of tension type headache free days per month, there was no statistically significant difference between placebo and four Botox injected groups. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The study concluded that, there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. All told, Botox injections for chronic migraines may provide some relief but a statistically significant difference between treatment groups and placebo groups was not obtained to prove that Botox is medically necessary. Given the lack of a true pathological diagnosis that is considered an indication for Botox injections, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested additional in-school applied behavioral analysis (ABA) therapy for up to 20 hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder. The literature demonstrates that treatment intensity can play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes. A 5-year randomized-controlled study involving 48 children with autism found ABA therapy resulted in significant improvements in IQ, adaptive behaviors and overall autism diagnosis with at least 25 hours of intervention services weekly (Dawson, et al.). A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcomes to typically developing peers and peers with high-functioning ASD. The authors found that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.) Finally, Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. The authors noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week. Review of the submitted clinical documentation demonstrates that this patient exhibits problem behaviors including aggression with hitting and pinching and concerns for safety and elopement. Based upon the patients documented deficits, 20 additional hours per week of in-school applied behavioral analysis is supported by the above-cited literature and is medically necessary for treatment of the patients autism.