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

A 50-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that the patient was evaluated in the Emergency Department for worsening right shoulder pain for the past week. Her pain had increased over the past two days. The pain radiated down to her elbow. The patient denied any recent trauma, but did admit to heavy lifting on a daily basis. The patient had been using pain medication without relief. She denied chest pain, shortness of breath, headache or neck pain. The patient was alert and appeared in no acute distress. She exhibited tenderness to palpation of the right acromioclavicular joint and right clavicle. No effusion or soft tissue swelling was noted. Strength and neurovascular examinations were normal. The patient was diagnosed with tendonitis and discharged. An emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms had been present for the past week. Although she did report increased severity of her symptoms over the past two days, the patient denied any specific trauma. She denied any acute neurologic problems as well. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patient could have safely waited to be evaluated by her primary care provider. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested chemical dependency residential treatment for treatment of the enrollees polysubstance dependency. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the patient had failed attempts at outpatient treatment for substance use disorders prior to his residential treatment admission. Additionally, his functional impairment was not documented as severe. There were no medical comorbidity issues or severe psychiatric comorbidity. Nor was there documentation of major self-harm issues or major challenges pertaining to the recovery environment. All told, the submitted documentation does not demonstrate the medical necessity for treatment in a residential 24-hour setting. Based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, the patient would be a candidate for a less restrictive treatment environment, such as intensive outpatient services. This is also consistent with American Academy of Child and Adolescent Psychiatry treatment guidelines which recommend treatment in the least restrictive setting and which indicate that community programs, when feasible, may be optimal to residential services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for a dermatology consultation to treat acne for treatment of her acne. Findings:  The physician reviewer found that the patient has moderate acne and has been treated with Retin-A cream without improvement.  The Health Plan guidelines require a failure of conservative treatment, including an eight-week trial of topical antibiotics or a two-month trial of oral antibiotics.  Additionally, if therapy with isotretinoin is indicated, intralesional injections of acne cysts are indicated, or if there is the development of scarring, then dermatology referral is covered.  These criteria are medically reasonable and appropriate, and this patient has not yet met these criteria for referral.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested coverage for growth hormone therapy, Genotropin for treatment of her stated diagnosis of adult growth hormone deficiency. Findings:  Two physician reviewers found that this patient has no documented pituitary disease.  It is unclear why the IGF-1 level was done.  Stimulation tests for growth hormone are more likely to give false positive results in obese patients.  The Endocrine Society Clinical Practice guidelines do not list arginine alone as a preferred test.  Two stimulation tests should be required in this case. In this patients case, growth hormone (Genotropin) is not likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for a duodenal switch for treatment of her morbid obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patient meets generally accepted guidelines for bariatric surgery based on National Institutes of Health criteria. There is no evidence of dietary or behavioral health contraindications to surgery. The duodenal switch procedure is a reasonable and appropriate treatment option for morbid obesity in the well selected candidate. It is a standard primary treatment for morbid obesity, and is approved by the American Colleges of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and the Centers for Medicare and Medicaid Services. The duodenal switch has been shown to be safe and efficacious with excellent long-term outcomes based on 10-year follow-up data. Furthermore, the procedure has been shown to have the best resolution for weight related co-morbid conditions as well as the best weight loss of any surgical procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for Protopic 0.1% for treatment of her lichen simplex chronicus. Findings:  The physician reviewer found that the requested medication is effective and safe for the treatment of pruritic vulvar disorders, as noted by Goldstein and colleagues and Weisshaar and colleagues.  Per Aschoff and colleagues, this has been shown to be effective for lichen simplex chronicus, in particular. Given the location of the disease, long-term use of topical steroids is contraindicated due to risks of atrophy on thin skin.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested liposuction and/or excision of lipoma and excessive tissue of the upper back, posterior neck, back and head for treatment of his lipodystrophy. Findings:  The physician reviewer found that liposuction can be necessary to treat focal lipodystrophy of the neck as a result of taking medically necessary medications to treat a disease. However, as is prudent prior to undertaking any surgical procedure, all reasonable non-operative measures to alleviate symptoms or to improve conditions should be exhausted prior to the procedure. In this patients case, there is no documentation as to any non-surgical measures having been tried and failed (e.g., medications for pain or physical therapy to improve his neck function). Davison and colleagues enumerate some non-operative measures that are appropriate for patients with lipodystrophy. In this case, detailed documentation regarding the characteristics of the lipoma/excess tissue has not been provided and there is no evidence of attempts with non-surgical measures for symptom relief. As such, the medical necessity of the requested service has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested adult psychiatric acute inpatient services for treatment of his bipolar disorder II, cannabis dependence, alcohol abuse, sexual disorder, not otherwise specified and social anxiety. Findings:  The physician reviewer found that this patients three main issues were alcohol and cannabis abuse, mood symptoms and a sexual disorder. All of these issues were addressed in the treatment setting. A factor of paramount importance in determining the appropriate level of care is the patient's ability to stay sober. This patient was sober for three weeks prior to treatment, indicating success with sobriety outside of a controlled environment. This fact, along with the lack of prior treatment, supports a lower level of care than the services that were provided. In addition, the patient was cooperative throughout his treatment. His mood symptoms were very well-controlled early in his stay. He appeared to have some chronic suicidal ideation without any recent self-injurious behaviors. He did not have any dangerous behaviors in treatment. The patients sexual symptoms did not result in grave disability that would warrant an acute inpatient level of care. An evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is useful in determining the appropriate level of care, to ensure the patients level of care meets his individual needs, safely and effectively, in the least restrictive setting possible. Per these guidelines, adult psychiatric acute inpatient services were not indicated. The American Society of Addiction Medicine criteria for level of placement can also be applied to this patient to help determine the appropriate level of care for his needs.  Per these criteria, based upon his symptoms and functional status, the patient was appropriate for outpatient services or an intensive outpatient program during the period at issue. He could have been treated safely and effectively at a less restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for a panniculectomy for treatment of her low back pain.  Findings:  The physician reviewer found that the proposed panniculectomy does not meet the requirements of reconstructive surgery as defined by California law. The submitted documentation does not demonstrate the patients abdominal pannus is an abnormal structure of the body caused by infection, trauma, tumor or disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested for Nuvigil for treatment of his medical condition. Findings:  The physician reviewer found that Nuvigil and Provigil can be (and have been) used for ADD in adults with good effect and a favorable side-effect profile. Symptomatically, this patients excessive sleepiness and cognitive functioning have improved while taking Nuvigil, and had not improved in response to several stimulants/wakefulness promoting agents for narcolepsy
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his metastatic sarcoma to the lungs. Findings:  Three physician reviewers found that local therapy is indicated because the lung is the only site of disease.  Surgery is not an option because further resection would likely severely compromise lung function.  Chemotherapy is a standard treatment for metastatic disease, although patients with sarcoma (particularly relatively indolent sarcomas) respond poorly to chemotherapy. In this clinical situation, the requested CyberKnife stereotactic radiosurgery is likely to be superior to any other therapy available in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the bilateral shoulders for evaluation of her shoulder pain. Findings:  The physician reviewer found that an MRI of the shoulder can be of great value in the diagnosis or grading of many conditions, such as rotator cuff abnormalities, glenoid labral lesions, loose bodies, infections, and tumors.  It is of great value in the evaluation of instability, mechanical symptoms, and limited motion. It is not efficient as a screening procedure, but rather is most useful in concert with other modalities (see Nobuhara). It is necessary to be informed as to the anatomic and pathologic considerations to properly evaluate MRI findings (see Vahlensieck).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech and language delay. Findings:  The physician reviewer found that documentation does not demonstrate the patient has been diagnosed with a pervasive developmental disorder. In the absence of such diagnosis, the need for direct speech therapy is not supported. There is insufficient evidence that direct speech therapy improves outcomes in cases of isolated expressive/receptive speech delay.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested emergency services for 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 had been experiencing a sore throat for three days with subjective fever. He was alert and appeared well. The patients vital signs were normal, and he did not have a fever on presentation. His oxygen saturation was normal, and lungs were clear. The patient was not in any distress. He did not require any treatment in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested continued intravitreal injections of bevacizumab (Avastin) for treatment of her central retinal vein occlusion and macular edema. Findings:  Two physician reviewers found that although there is some scientific evidence demonstrating that intravitreal injections of Avastin may show short-term benefit in some patients who have the diagnosis of non-ischemic central retinal vein occlusion, there is a lack of evidence demonstrating that this treatment is superior over the standard therapy for this condition.  The standard therapy in this clinical situation is laser photocoagulation and/or intravitreal triamcinolone, neither of which was tried on this patient before the use of Avastin. Although it appears this patient might have received some short-term benefit from her Avastin injections, there is a lack of support in the medical literature that demonstrates a long-term benefit of such injections. Furthermore, the use of Avastin in this setting is not supported until standard therapies have been exhausted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for proton beam radiation therapy (PBRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that PBRT is not proven to be superior to external beam radiotherapy or brachytherapy as currently there are no randomized studies comparing treatment modalities for prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 82-year-old female enrollee has requested for a follow-up colonoscopy for screening of her medical condition. Findings:  The physician reviewer found that the guidelines also state that if a follow-up colonoscopy is normal, or even if it shows one or two tubular adenomas, then the next colonoscopy should be in five years time. Thus, based on national guidelines, and the lack of objective data regarding her recent change in condition, a follow-up colonoscopy is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested daily Lovenox injections for treatment of her pregnancy. Findings:  Three physician reviewers found that the thrombophilia/autoimmune panel performed after this patients pregnancy loss is a common panel of its type in these situations. However, recent evidence (Branch) disproves any association with any of the common thrombophilias and common adverse pregnancy outcomes, particularly recurrent first-trimester losses. Along these lines, only anticardiolipin antibodies have been definitively associated with recurrent pregnancy loss, warranting prophylactic therapy for pregnancy support consisting of heparin (preferably LMWH) and low-dose aspirin. For other thrombophilias, including the prothrombin gene and factor V Leiden mutations, published data does not support heparin prophylaxis of any type (standard or LMWH) for this indication. Among the potential thrombophilias, the MTHFR mutation has been shown to not be associated with any adverse pregnancy outcomes (ACOG and Said and colleagues). In fact, the study by Said and colleagues suggests that the MTHFR mutation may actually be protective for pregnancy. In addition, as a folate metabolism pathway mutation, there is no biochemical explanation for why heparin would be effective to correct an MTHFR mutation; at most, folate supplementation would be more appropriate biochemically, but not for an individual who was only heterozygous for a mutation. Prevailing opinion is that these MTHFR mutations are actually not abnormalities, but polymorphisms, that is, biologic variants with little clinical impact at all. Therefore, no treatment is indicated for them in this or any context, and the ACOG Practice Bulletin states that they should no longer be tested for. The fact that a different polymorphism for the MTHFR gene was identified heterozygously in this patient than the one in the ACOG paper is not clinically significant; none of these mutations are worse than any other, but some are more common than others. Although prophylactic heparinization with Lovenox would be appropriate if there was documentation of positive anti-phospholipid antibodies in conjunction with recurrent losses, such is not the case with this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for skilled nursing facility services for treatment of her multiple sclerosis. Findings:  The physician reviewer found that therapy with occupational therapy and physical therapy are well accepted as beneficial in reducing disability, but have not been effective in this case in restoring strength or function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Roux-en-y gastric bypass and cholecystectomy for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set by the National Institutes of Health for surgical treatment of morbid obesity with a BMI of 47 and multiple co-morbid conditions that will likely be ameliorated or eliminated by bariatric surgery. With regard to the Health Plans contention that medical weight loss is a viable treatment option for morbid obesity, there is no scientific evidence demonstrating that structured diet and/or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best and most durable long-term outcome for the morbidly obese. However, although medically the patient meets criteria for weight loss surgery, it does not appear that she has obtained psychological clearance for the procedure. Therefore, the patient should obtain psychological clearance before weight loss surgery is authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his morbid obesity. Findings:  Three physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Furthermore, this patient has several unique clinical issues that make the choice of the laparoscopic sleeve gastrectomy a better option as compared to laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic gastric banding (Lap-Band). The patient is status post cardiac transplant and is on immunosuppressive medications and therefore the Lap-Band is a relative contraindication given the risk associated with a foreign body. The patient is also taking non-steroidal anti-inflammatory drugs (NSAIDs) and steroids which are a relative contraindication for LRYGBP as both will promote ulcer formation. The laparoscopic sleeve gastrectomy does not involve the use of a foreign body or malabsorption of vitamins or medications, making it the best clinical option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for chelation therapy for treatment of her lead and mercury toxicity.  Findings:  The physician reviewer found that this patient has not had blood metal testing for any toxin. In the absence of documentation of blood testing for lead and/or mercury levels, there is no evidence that the patient met clinical indications for chelation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his low back pain.   Findings:  Three physician reviewers found that the use of artificial disc replacement has not yet been adequately supported by Level I and Level II studies of sufficient duration to resolve current outstanding issues concerning the use of this technology. It is known through studies of knee and hip total replacement that there is a predictable need for revision over time and the same sequence of events is likely following total disc replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for EpiCeram Skin Barrier Emulsion for treatment of her atopic dermatitis/eczema. Findings:  The physician reviewer found that the use of EpiCeram in this patient is justifiable for the following reasons: she has moderate to severe atopic dermatitis (see Elias and Schmuth); her disease did not respond to the over-the-counter formulation (CeraVe); she has tried two topical corticosteroids of different groups, mometasone and triamcinolone (see Sugarman and Parish); and EpiCeram has been safely and successfully used to treat atopic dermatitis.