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

A 62-year-old female enrollee has requested emergency services for treatment of her skin tear laceration secondary to a cat scratch that occurred two days earlier. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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.At the time of her initial ER visit, this patient was advised that a wound check was required in two days due to the high risk of infection. As cats lick their paws, cat scratches can become infected with the same organisms as cat bites. While the patients condition warranted a follow-up medical evaluation, a reasonable person in this setting would have arranged for follow-up in a setting other than the ER. The follow-up visit did not need to be provided on an emergent basis. There were no concerning signs that would have cause a prudent layperson to seek emergency care for the follow-up visit. A prudent person in this setting would have believed that the necessary wound check could have been provided in a less urgent setting such as a physicians office (the following day) or urgent care center. Thus the patients symptoms did not meet prudent layperson criteria for emergency care and the denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 58-year-old male enrollee has requested acute level of care from long-term acute care for treatment of the enrollees respiratory failure secondary to metastatic sarcoma.  Findings:  The physician reviewer found that long-term acute care hospitals provide 24-hour physician services, access to multiple specialties and routine management of common complications of long-term chronic illnesses, especially those associated with chronic ventilator use. The patient in this case is at the appropriate level of care for his chronic ventilator needs and for his goals of care. The tracheostomy was being done at the long-term care facility (Eskildsen, et al). In contrast, acute care hospitals provide services for patients who have acute illnesses that require care than cannot be met in other settings (Mantone). His providers current plan of care is able to meet this goal as he has no benefit from resuscitation and is in a setting that is well established to meet his ventilator needs and associated complications. The patient is not in a position to benefit from the more advanced diagnostic or therapeutic resources available in an acute hospital. For these reasons, the requested services are not medically necessary for treatment of this patients medical condition and the appropriate level of care is in a long-term acute care facility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested Kuvan for treatment of his tetrahydrobiopterin deficiency and phenylketonuria (PKU). Findings:  The physician reviewer found that in the relevant medical literature, about 2% of patients with phenylketonuria (PKU) have BH4 deficiency. When possible, treatment must begin as early as childhood and a diet low in phenylalanine is essential. In addition, L-Dopa, carbidopa, and serotonin are often supplemented. The addition of BH4 can lower serum levels of phenylalanine, but there is little evidence that the addition of BH4 improves neurologic status. As reported by Levy in his 2007 article, Kuvan has been approved by the Food and Drug Administration (FDA) for patients with PKU who show responsiveness to a BH4 load protocol. However, to date, there are no long-term studies demonstrating the safety or effectiveness of BH4 in this patients condition. As the patient is currently noted to be taking the appropriate dietary measures and supplements, the requested medication has not been established to be medically necessary in the management of this patients care at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for post acute skilled physical, occupational, and speech therapies as well as residential care, behavior modification and psychotherapy counseling for treatment following multiple ischemic strokes.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient has significant functional deficits at one year post-stroke. These outcomes were predictable based upon his status in the early stages post-stroke and in the rehabilitation phases of his illness (Ovbiagele, et al). Further, he has not gained significantly since his discharge from a skilled facility (Kwakkel, et al). At this juncture, the records indicate that he has reached a functional plateau (Heuschmann, et al). The patient continues with neglect of his left side, impulsiveness, and agitation with new information and he is also on a percutaneous endoscopic gastrostomy (PEG) tube. Based on a review of the relevant medical literature, additional gains are not expected or predicted as stroke rehabilitation cannot influence outcome in the absence of continued brain healing. As such, the services at issue have not been demonstrated to be medically necessary in this clinical setting and the denial was therefore appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested for a coronary angiogram with percutaneous coronary intervention for treatment of his triple vessel coronary artery disease.  Findings:  The physician reviewer found that based on the records provided for review, the patient is a 67-year old male with diabetes, provokable silent ischemia on stress testing and three-vessel coronary disease with preserved ventricular function on angiography. The coronary lesions identified are described as amenable to bypass surgery.  In this setting, current guidelines recommend coronary bypass surgery over coronary angiogram with percutaneous coronary intervention due to improved long-term outcomes with bypass surgery in this select group. There is no documentation that coronary artery bypass surgery is either contraindicated in this patient or is associated with excessive increased risk. For patients who do not wish to undergo coronary bypass surgery, aggressive medical therapy is a reasonable alternative approach and is comparable to the requested procedure. Therefore, since coronary artery bypass surgery is the preferred treatment option in this setting and because there is an additional alternative of continued aggressive medical therapy, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested skilled nursing facility (SNF) services for treatment of the enrollees grand mal seizures (poorly controlled) and developmental delays. Findings:  The physician reviewer found that in treating patients with epilepsy, the delivery of high-quality care is complicated by the complexity and diversity of symptoms. Overall, epilepsy has a pervasive impact on the lives of patients with intellectual disabilities and occurs more frequently in this patient population. Children and adolescents offer unique challenges as they are more likely to suffer lifelong intractable epilepsy with multiple seizure types. In addition, the younger patients often cannot clearly express their complaints about antiepileptic drug (AED) side effects, and the caregivers role becomes crucial as the patients advocate. Patients who have both epilepsy and intellectual disability have significant problems requiring skilled health care management. Clinical nurse specialists have the unique opportunity to work with these patients and their families to help them develop self-management and family management skills. Given this patients specialized needs, the requested skilled nursing care should be provided to better to provide her an optimal quality of life. Further, this skilled nursing care will prevent complications from the patients intractable epilepsy during this vulnerable time in the patients current situation. Moreover, the Health Plans criteria defining medical necessity for skilled nursing services provides care for an acute exacerbation of a chronic medical condition. Thus, it is therefore reasonable to extend these benefits to a minor patient who requires the care of a caregiver who is unable to provide such services due to an acute condition affecting the abilities of the caregiver to administer such care. Accordingly, the requested skilled nursing care should be provided this patient until such time that the primary care giver is capable of providing her care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested artificial disc replacement surgery (ProDisc) for treatment of his cervical radiculopathy.  Findings:  Three physician reviewers found that at this time, there is currently insufficient data to adequately assess the performance of total disc replacement. There is a lack of evidence indicating that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented.  In this clinical scenario, standard procedure would be a single-level anterior cervical discectomy and fusion.  The safety and efficacy of a total disc arthroplasty in this setting has not been established.  There is a lack of truly blinded studies establishing the effectiveness of the requested procedure. Thus, the requested artificial disc replacement is not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested for residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that it appears that the enrollee has been making progress toward transitioning to a partial hospitalization program (PHP) level of care. However, at this time she is still in need of care at the residential treatment center (RTC) level in order to prevent relapse. Therefore, the RTC services provided have been shown to be medically necessary as well as coverage for additional services while the patient prepares to transition to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested one-to-one speech therapy three times per week for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that speech-language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective. Therapy is tailored to the individual and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Therefore, the requested speech therapy has been demonstrated to be medically necessary for treatment of this patients medical condition. These services should be provided at a minimum of 60 minutes for 3 days per week until such time that the treating speech therapist does not document any improvements in goals for at least an 8-week period.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.  Findings:  Two physician reviewers found that Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterized by the development of colorectal cancer, endometrial cancer and various other cancers.  Protocols for surveillance in Lynch syndrome include colonoscopy, gynecological examinations, which may include regular ultrasounds and biopsies, and abdominal ultrasound screening.  The American College of Radiology has recognized the increased sensitivity of MRI for high-risk patients.  Clinical situations in which breast MRI may be warranted include patients with BRCA mutations, patients who are untested but who have a first-degree relative with BRCA mutations and patients with a lifetime risk of breast cancer of 20 to 25% or greater as defined by BRCAPRO or other models that are largely dependent on family history. This patient does meet established criteria for breast MRI.  Although the provider states that there is a lifetime risk of breast cancer of approximately 20%, this cannot be established based upon any given model.  All told, the requested MRI of the breast is not likely to be superior over other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested trigger point injections for treatment of her vertebral disc pain. Findings:  Two physician reviewers found that at present, there is a paucity of medical literature providing support for the effectiveness for trigger point injections in patients with fibromyalgia or in the spinal region. Further, Staal and colleagues concluded of their systematic review that trigger point injections failed to show any significant benefits in managing patients with chronic pain. Thus, the requested therapy is not likely to be superior to standard, proven, accepted treatment modalities in this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Class 4 laser treatment sessions for treatment of his neck pain and stiffness. Findings:  Three physician reviewers found that in this clinical scenario, standard treatments include heat, electrical stimulation, massage and stretching.  There is a lack of scientific evidence in the medical literature demonstrating that Class 4 laser treatments are more beneficial for non-specific neck and shoulder pain than these standard treatments. Although some studies have shown a small effect on some types of pain, such as diabetic neuropathy, there is a lack of evidence showing that laser is more effective than conservative treatments. Thus, Class 4 laser treatments provided were not likely to have been superior over other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech and language therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has speech delay and fine motor skills delay requiring speech therapy and occupational therapy. Occupational therapy addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children. In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.  The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorder. In this patients case, the assessment by the speech therapist did not provide prognosis for outcome. However, the provider noted profound delays.  Evaluation and management of individuals with autism spectrum disorder requires a comprehensive, multidisciplinary approach.  All told, speech and language therapy and occupational therapy are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.  She has no complaints or symptoms of pituitary insufficiency and no history of pituitary abnormality.  There is no evidence of growth hormone deficiency.  All told, in this patients case, the requested Genotropin growth hormone therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested a continuous passive motion machine for treatment of his status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that although the use of a continuous passive motion machine after anterior cruciate ligament surgery is often recommended, the practice has long been a source of controversy.  Evidence of the benefit of the equipment at issue in this clinical scenario is limited, and there is need for further study. Early motion is beneficial for reducing pain and decreasing scar formation that can limit motion, but no substantial advantage has been identified for continuous passive motion machine use. Further study is indicated to improve the evidence base. However, until this evidence is available, continued use of continuous passive motion machine cannot be supported.  At this time, there is a lack of support in the medical literature for the use of a continuous passive motion machine in this patients case.  All told, the continuous passive motion machine was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested for two hours per week of individual and/or group (limited to three or fewer children) speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. The authors concluded that, Individuals with mild autism should also receive adequate assessments and appropriate diagnoses.This patient has been documented to present with significant speech and language disorder with deficits in receptive, expressive and social language. A report from the school district speech and language assessment report proposed the IEP include language structure with improvement of spontaneous use of 3-5 word sentences. It was also recommended that the patient read and communicate using verbal language. An in-home applied behavioral therapy report shows that the patient has been meeting his targets or showing improvement. This was all accomplished via a one-to-one structured environment. Given the support for speech therapy in the scientific literature, the requested therapy has been established as medically necessary for this patient and should be provided at a frequency of two 60 minute sessions per week on a one-to-one basis or with no more than three patients per therapist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested perispinal injections (etanercept) for treatment of his back pain.  Findings:  Three physician reviewers found that there is a paucity of peer-reviewed literature supporting etanercept injections for the medical condition in question. There is a lack of high-quality, double-blinded, controlled trials supporting the efficacy of these services.  Cohen and colleagues performed a double-blind, placebo-controlled pilot study to evaluate intradiscal etanercept in patients with chronic discogenic low back pain or lumbosacral radiculopathy. They found no differences in pain scores or disability scores between or within groups for any dose range or subgroup of patients.  Genevay and colleagues conducted a pilot study to explore the efficacy of etanercept in patients with severe sciatica. They observed that the patients within this group had sustained improvement after a short treatment with etanercept that was better than standard care plus a short course of methylprednisolone. They concluded that the results suggest that etanercept is beneficial in the treatment of sciatica and support a pathological role for TNF-alpha in the pathogenesis of sciatica. However, they indicated that their results need to be confirmed by a randomized controlled trial.Tobinick and Davoodfar performed a retrospective clinical review of patients treated with etanercept for back and neck pain at a single private medical clinic in 2003. The review concluded that perispinal etanercept can lead to significant clinical improvement in selected patients with chronic, treatment-refractory, disc-related pain. They noted, however, that generalizability of the study results is limited by the open-label uncontrolled methodology employed. The review concluded that further study of perispinal etanercept injections utilizing double-blind, placebo-controlled methodology is indicated.  In sum, the etanercept injections provided on the date in question were not likely to have been more beneficial than other available treatments in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested laboratory testing for coronary heart disease risk assessment for evaluation of her cardiovascular risk factors. Findings:  The physician reviewer found that guidelines for diagnosis and management of dyslipidemia as it relates to coronary risk have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests, such as the testing in this patients case, in the context of assessing coronary risk. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard clinical risk factor profiling coupled with basic lipid analysis.  Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Likewise, even though elevated lipoprotein(a) and certain LDL subclasses may be considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained elevated levels of these specialized tests in patients with or without known coronary disease.  All told, in this patients case, laboratory testing for coronary heart disease risk assessment performed on on the dates in question was not medically indicated.