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

A 39-year-old male enrollee has requested 20 mg of Ambien, prescribed nightly for treatment of his chronic persistent insomnia. Findings:  The physician reviewer found that this patient was tried on FDA-approved medications for insomnia, and these were not effective. His condition falls into a category of chronic insomnia that has been very recalcitrant to treatment. Current treatment options do not address the needs of difficult-to-treat patients with chronic insomnia, such as the elderly, and those with co-morbid medical and psychiatric conditions (Benca). Sleep and insomnia have been well studied as related to their effect on mood and psychiatric illness. Lack of sleep is well documented to have a deleterious effect on mood. Insomnia is frequently co-morbid with depression, and observational studies suggest that insomnia is a high risk factor for depression. Disturbed sleep is of particular concern in patients with depression, as it can aggravate the symptoms of depression and influence the treatment response to anti-depressants (Wade). Based on the documentation provided, it is apparent that the Ambien 20 mg dose is the only treatment that has been effective for this patients chronic insomnia over the years. Although the requested dose is above the FDA recommended maximum, there appears to be no adverse effects or contraindications to this dosage based on the information provided. While the routine use of Ambien 20 mg nightly for chronic insomnia has not been widely studied, this dosage has been used in some studies and there is little evidence that a 20 mg dose of Ambien has any contraindications due to safety or tolerability issues (Harrison and see Holm). In summary, due to this patients poor response to alternative medications in the past and his success with Ambien 20 mg nightly, I have determined that the medication at issue was and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Hyalgan injections for treatment of her osteoarthritis and severe degeneration of both shoulders.  Findings:  The physician reviewer found that although the use of Hyalgan would be an off-label indication for use in this patient, she has documented severe degeneration in both shoulders. In addition, she has already undergone surgical intervention but continues to experience pain with limitation of function. As there is scientific data supporting the safety and efficacy of Hyalgan for knee osteoarthritis and promise as a modality for the shoulder, it is a clinically reasonable approach to provide the requested treatment to the patient. For the reasons discussed above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for Botox injections for treatment of her migraines.   Findings:  Three physician reviewers found that Botox is not a first-line therapy for treating migraine headache, there is ample literature supporting its use in select patients. An article by Schim notes that the results of a pooled analysis indicated a 57% reduction in acute headache medication use in the 8- to 12-week period following injection of botulinum toxin A. In this patients particular case, she has failed multiple first-line abortive and preventive therapies. In addition, she has benefited from the use of Botox previously with marked worsening while off of Botox therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested  for biofeedback training for treatment of the enrollees abdominal pain. Findings:  Three physician reviewers found that this patient has recurrent abdominal pain. She has had headaches and has been diagnosed with cyclic vomiting syndrome in the past. These are findings suggestive of abdominal migraine. Biofeedback is an accepted modality for treatment of migraines, its use in patients with abdominal migraine is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested a duodenal switch procedure (as opposed to a Roux-en-Y gastric bypass) the for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets generally accepted guidelines for bariatric surgery established by the National Institutes of Health. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The available scientific literature demonstrates the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. As with any weight loss surgery, appropriate presurgical multidisciplinary evaluation (including dietary evaluation and TSH level) should be obtained prior to proceeding with surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested for out-of-Plan referral for laser hair removal for treatment of his skin affected by pilonidal cyst.  Findings:  The physician reviewer found that the patient has persistent problems with recurrence of the cyst, then further surgical management may be warranted, but the requested referral for laser hair removal has not been established to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested for intravenous sedation during dental treatment for treatment of his gag reflex.  Findings:  The physician reviewer found that the patient does have a history of panic disorder and is under psychiatric care for his condition. However from the patients dental history, he has tolerated invasive dental procedures without sedation and related difficulty during these procedures. Performance of sedation is not without risk and the American Dental Association (ADA) mandates that sedation be limited to patients who require that modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a wireless capsule endoscopy for an evaluation of her ischemic colitis. Findings:  Two physician reviewers found that chronic abdominal pain is a common complaint that can evade diagnosis even with an extensive work-up. Wireless capsule endoscopy (WCE) is a new method for visualization of the entire small bowel. To date, there are no randomized controlled trials in the peer reviewed medical literature pertaining to WCE for evaluation of abdominal pain. The clinical data suggests that WCE is approved for the evaluation of patients with obscure gastrointestinal (GI) bleeding, iron deficiency anemia with negative colonoscopy and esophagogastroduodenoscopy (EGD). Further, Voderholzer and colleagues comment that WCE may be helpful in evaluating patients with suspected Crohns disease and other small bowel diseases such as tumors, family polyposis syndrome, and arteriovenous malformation. Bardan and colleagues studied 20 patients with chronic abdominal pain and concluded that WCE lacked significant clinical value in the evaluation of patients with obscure chronic abdominal pain. In another study by Tatar and colleagues, WCE was the most effective diagnostic tool in evaluation of patients with anemia (61%) and diarrhea (36%) and least effective in patients with abdominal pain (17%). Based upon this patients history of abdominal pain and ischemic colitis, the use of WCE was not medically indicated as the etiology of her symptoms was most likely due to ischemic colitis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested the Real-Time Remote Heart Monitor for an evaluation of her palpitations. Findings:  Three physician reviewers found that the relevant scientific literature reveals no benefit to prolonged (30-day) event monitors over conventional Holter monitors in this clinical setting. With presumed normal left ventricle function, the risk of significant arrhythmia would be remote. The patients overall symptoms were non-specific and did not necessitate the use of the equipment at issue. In this clinical circumstance, serial Holter monitoring would have been sufficient for detecting abnormalities. Continuous real-time remote cardiac monitoring is not indicated as an initial strategy in this setting as it does not provide superior benefit over conventional monitoring. The use of a Real-Time Remote Heart Monitor was not likely to be a more efficacious method of evaluation in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested 4-aminopyridine for the treatment of her multiple sclerosis. Findings:  Three physician reviewers found that there is adequate medical literature supporting the use of 4-aminopyridine for patients with multiple sclerosis who have walking disability. Husseini and colleagues reported on a randomized, placebo-controlled, multicenter Phase 3 clinical trial of multiple sclerosis patients. The authors noted that mobility limitation is a frequent clinical symptom of multiple sclerosis which poses a therapeutic challenge. 4-aminopyridine improved axonal excitatory circuits and thus muscular strength in demyelinating diseases. The authors concluded that the study results showed 4-aminopyridine represents a suitable agent for treatment of walking disability in multiple sclerosis patients. This patient has multiple sclerosis and difficulty ambulating. Thus, she is an appropriate candidate for 4-aminopyridine therapy. There are no alternatives available that are likely to result in a better functional outcome for the patient than 4-aminopyridine.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested the use of a continuous passive motion machine for the treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that this patient is status post arthroscopic anterior cruciate ligament reconstruction, partial medial and lateral meniscectomies and removal of loose bodies. Use of the continuous passive motion machine was clinically indicated for this patient. Per Canale and Beaty, use of both active and passive motion modalities is indicated for patients who are status post cruciate ligament repair.  It is common practice to utilize a continuous passive motion machine in this clinical situation to aid in post-operative rehabilitation. Medicare guidelines allow reimbursement for continuous passive motion devices following cruciate ligament repair or total knee replacement when use of the device is commenced with two days following surgery and coverage is limited to a three-week period following surgery. All told, there is adequate evidence to support this patients use of a continuous passive motion device during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested a follow-up neuropsychological evaluation for an evaluation of his neurological condition. Findings:  The physician reviewer found that the literature supports the ability of neuropsychological testing to profile patients with brain injury and help differentiate organic cognitive complaints from those due to depression. It also can allow differentiation of varied causes of dementia such as fronto-temporal dementia. However, in this patients particular clinical situation, there is no evidence that the follow-up neuropsychiatric testing was likely to yield clinically useful information that would affect decision-making regarding the treatment of this patients condition. The patients head injury had occurred approximately five years ago. Furthermore, he had already undergone previous neuropsychological testing which demonstrated significant cognitive deficits. There was no indication for neuropsychological re-evaluation as there is a lack of evidence to support the contention that the results of this testing were likely to affect treatment recommendations. The providers recommendations of participation in adult day treatment and psychiatric intervention for depression could have been made absent the repeat testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested knee brace (CPT code L1845) and knee brace add-ons (CPT codes L2810, L2820, L2830, and L2850) for the treatment of his right knee, status post anterior cruciate ligament (ACL) reconstruction surgery. Findings:  The physician reviewer found that the use of a medial unloader brace was medically necessary for this patients specific clinical situation. Although the medical records do not include a description of the patients knee in reference to genu vera or genu valga, the medical records do document chondroplasty of the medial femoral condyle. This patient, at age 51, is an outlier as far as anterior cruciate repair in patients. The duration of the instability in the knee is important to the development of degenerative osteoarthritis within the joint. This is because cartilage surfacing of the knee joint is strong in compression, but weak in shear. The fact that a chondroplasty was performed on this patient, combined with his age, and further combined with an episode of knee effusion (occurring seven months after his surgery), all suggest not only pathology of an ACL insufficient knee, but of early development of medial compartment degenerative osteoarthritis. The medical literature supports the efficacy of orthotics as a conservative measure in the long-term conservative management of medial compartment degenerative osteoarthritis. The study by Ramsey and colleagues demonstrated that patients utilizing a medial unloader brace (such as was used by this patient) showed an associated reduction in pain. Thus, the knee brace at issue (CPT code L1845) and associated add-ons (CPT codes L2810, L2820, L2830, and L2850) were medically appropriate and necessary for this particular patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested intravitreal injections of pegaptanib sodium for treatment of his proliferative diabetic retinopathy and diabetic macular edema. Findings:  Two physician reviewers found that the use of intravitreal Macugen injections for proliferative diabetic retinopathy with macular edema is not indicated for treatment of neovascular diabetic macular edema. There is a lack of long-term, peer-reviewed, randomized, clinical studies that document that this treatment is more beneficial than standard therapy for this condition. Macugen is indicated for neovascularization of the choroid when associated with age-related macular degeneration. At this time, there is insufficient outcome data demonstrating Macugen is efficacious for neovascular diabetic macular edema. Further studies are needed before conclusions can be drawn regarding the potential efficacy of Macugen in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested coverage for occupational therapy and speech therapy services for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has been receiving occupational therapy and speech therapy services for his diagnosis of autism. Both of his therapists have documented improvement in his skills with these therapies. Specifically, the occupational therapist has documented improvement in functional goals including self help skills such as self feeding, dressing and washing hands. These skills do not typically fall under educational services. The patients functional goals are habilitative or rehabilitative and are considered medical in nature. In addition, the speech therapist also documents decreases in the patients expressive and receptive language skills as well as pragmatic skills. While the speech therapy provided by the educational system may be effective for expressive and receptive language, such therapy does not address communication and socialization in the home and community settings. Thus, from a clinical standpoint, the requested speech therapy services are necessary to adequately address all of the patients needs.  Finally, California Assembly Bill (AB) 88 specifically lists autism spectrum disorders as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. Furthermore, as the above-cited literature demonstrates, occupational and speech therapy are well-accepted as standard treatment for patients with autism. Additionally, the records provided document that this patient has functional skills in both activities of daily living and language that are being affected by his diagnosis of autism and progress with therapy has been noted by his providers. Accordingly, the requested occupational therapy and speech therapy services are medically necessary for treatment of this patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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. This patient presented with six days of ear pain that had peaked four days earlier and was improving. He continued to have a headache, but he had a history of migraine headache. The records noted that the patient was in no distress. Furthermore, the patient did not require any testing or pain medications while he was in the emergency department. While this patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested a neurological exam by a specialist for treatment of her ataxia. Findings:  The physician reviewer found that the patient was diagnosed and has previously been followed at an ataxia specialty clinic by a team that is familiar with this disease. Although the Health Plan states there is no treatment for ataxia which requires follow-up by a neurologist, there are treatments available for symptomatology associated with ataxia. In fact, this patient is on levetiracetam as a specific treatment of ataxia which was initiated by a neurologist at the ataxia specialty clinic. The use of this agent is supported by reports of efficacy in several open-label studies. The patients care requires treatment of the multiple associated symptoms that are unique to hereditary ataxias and a specialist in ataxia is best equipped to evaluate the patient and make recommendations regarding her ongoing treatment. Thus, a neurological exam by a specialist is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested coverage for speech therapy services for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that a literature review by Goldstein examined empirical studies evaluating speech and language intervention procedures applied to children with autism. The author found that speech and language therapy incorporating sign language, discrete-trial training, and milieu teaching procedures have been used successfully to expand the communication repertoires of children with autism. For these reasons, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for a power wheelchair for treatment of her medical condition. Findings:  The physician reviewer found that the use of a power wheelchair in this setting is consistent with Medicare guidelines. This patient has a personal mobility deficit that significantly impairs her participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within her home. Her mobility deficits are not presently ameliorable by a walker, cane, prostheses or manual wheelchair. As such, the patient meets medically necessary criteria for a power wheelchair until such time that she is appropriate for the use of prostheses.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson would have sought immediate medical attention a second time for a complaint of sore throat. A medical emergency is defined as the existence of a medical condition which exhibits symptoms of sufficient severity such that a prudent layperson would reasonably expect that serious impairment of bodily functions or serious dysfunction of any bodily organ or part would occur without immediate medical intervention. This patient had increased pain, but his pain level (5/10) was not severe. His fever was very mild. He was able to breathe, and he had no difficulty handling his own secretions. Furthermore, the patient did not require any parenteral medications. His vital signs did not demonstrate any tachycardia or tachypnea.  His condition was stable on his arrival to the hospital and remained so until his discharge, 34 minutes after he was triaged. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care in this setting to jeopardize his health.