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

The parent of a 12-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) as an adjuvant therapy along with cognitive behavioral therapy for treatment of the enrollees post traumatic stress disorder (PTSD).  Findings:  The physician reviewer found that review of the submitted documentation and peer-reviewed literature demonstrates the medical necessity of the requested therapy. Trauma-focused cognitive behavioral therapy has the best evidence in the peer-reviewed medical literature for the treatment of PTSD in adolescence. Although there are no definitive studies illustrating the effectiveness of EMDR in this population, EMDR is an established non-invasive therapeutic intervention for adults diagnosed with PTSD, and is included in the American Academy of Child and Adolescent Psychiatrys practice parameter for treatment of children and adolescents with PTSD.  Considering this recognition, coupled with the fact that this patient with profound psychiatric impairment has responded well to the therapy, utilizing EMDR as an adjunctive modality is safe and reasonable in this particular case, and thus medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested a surgical consult for bariatric surgery and follow-up for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The medical records note a body mass index of 48.42.  This patient has several comorbid conditions, including degenerative joint disease and sleep apnea.  She has failed dietary efforts and is an appropriate candidate to undergo a bariatric surgery consult.  The current medical evidence supports the requested services in this setting.  All told, the requested consult for bariatric surgery and follow-up are medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Nuvigil for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that there have been mixed results in well designed clinical trials on the efficacy and safety of Nuvigil for multiple sclerosis. In addition, there have been no well designed clinical studies demonstrating the long-term safety and effectiveness of Nuvigil for patients with multiple sclerosis. Given the lack of adequate evidence for Nuvigil in patients with fatigue related to multiple sclerosis, its use is not likely to be more beneficial than other therapies for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Botox injections for treatment of her urinary frequency and urge incontinence.  Findings:  Two physician reviewers found that in this patients case, the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The clinical notes do not include a complete medical and urologic history and physical examination supporting the requested services in this case.  Additionally, details regarding the type and duration of prior therapies were not provided.  Although Botox injections may be indicated for the treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition, there is no documentation of a neurologic condition requiring Botox injections in this case.  Therefore, Botox injections are not likely to be more effective than other treatment modalities in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested TEC System (Iceless cold compression device) for treatment of his lumbar stenosis, spondylolisthesis, and intractable radiculopathy.  Findings:  Three physician reviewers found that this patient has been prescribed a treatment for his post-operative care, the TEC System. Overall, there is a paucity of clinical data demonstrating superior health outcomes in patients following spinal surgery. This system and similar devices have shown some success in the care of post-operative knee and hip patients (Woolf, et al; Su, et al). However, there is a lack of documentation, indications, and evidence of the effectiveness of the TEC System for post-operative spinal care. Therefore, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested right ear keloid excision for treatment of his mass on his right ear lobe.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The patient has an enlarging, painful keloid that developed behind the right ear. Keloids tend to grow but not to spontaneously regress, and can be associated with pain. As keloids often recur following excision, which produces further trauma to the skin, surgical excision is not considered first-line therapy. Keloids can be effectively treated or reduced in size to lessen pain, with intralesional steroid injections, cryotherapy or injectable 5-fluorouracil, in combination with external pressure application (Weshahy and Abdel; Love and Kundu). As there is no evidence that other conservative measures have been attempted, the request for coverage of excision is not medically necessary. The patient should pursue other treatment options first, as larger keloids can result after surgical excision. For the reasons set forth above, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested sacroiliac joint fusion for treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  Previously, she has undergone a multilevel laminectomy and fusion procedure at L3-S1.  Per the medical records, sacroiliac joint radiofrequency ablation did not provide relief.  In this case, the diagnosis of sacroiliac degenerative disease is not well-supported by the documentation provided, and the requested services are not likely to relieve this patients chronic back pain.  There is a lack of support for the requested services in this case.  Thus, the requested sacroiliac joint fusion is not likely to be of greater benefit than other options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Tylenol with codeine for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Medications with a high risk of dependence and tolerance, such as Tylenol with codeine, are not recommended.  The current medical literature does not support the requested medication in this clinical setting.  Baron and McDonald noted that high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting condition.  Short-acting opiates with high-dose acetaminophen are more likely to cause adverse outcomes.  Ballantyne and Mao noted that prolonged use of high-dose and short-acting opiates might induce abnormal pain sensitivity.  All told, the requested Tylenol with codeine is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested 30 days of continued substance abuse treatment at the partial hospitalization program (PHP) level of care for treatment of his bipolar disorder and substance abuse.  Findings:  The physician reviewer found that the patient was admitted to a treatment facility for his substance abuse problems. His psychiatric condition was complicated by his drug use and has been considered to be a result of his drug use. His problems have been persistent and he has relapsed soon after discharge from a residential treatment program. Applying the American Society of Addiction Medicine (ASAM) placement criteria, the patient needs to be transitioned to a more appropriate treatment environment in an outpatient setting. The records indicate that intensive outpatient program (IOP) services would be safe and effective in treating this patients medical condition. Therefore, the requested 30 days of continued substance abuse treatment at the PHP level of care is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested duodenal switch surgery for treatment of her obesity.  Findings:  The physician reviewer found that this patient has a BMI of 43 and is a potential candidate for any standard primary weight loss procedure including the laparoscopic gastric banding, laparoscopic Roux-en-Y gastric bypass, laparoscopic vertical sleeve gastrectomy, and duodenal switch. The National Institutes of Health (NIH) consensus guidelines indicate that psychological clearance must be obtained. The remainder of a multidisciplinary evaluation includes medical clearance, evidence of dietary efforts, and dietary clearance, which were not provided. Therefore, the medical necessity for the requested duodenal switch is not determined at this time for failure to document failed weight loss efforts, and completion of a thorough multidisciplinary evaluation without barriers to surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested Gardasil (HPV vaccine) for treatment of his Crohns disease.  Findings:  The physician reviewer found that the current Centers for Disease Control (CDC) recommendations for the HPV vaccine include use in males aged 9 to 26 years of age. The vaccine is less immunogenic among patients ages 16 to 26 than in those 9 to 15 years of age. The CDC recommendations also note the increased risk for infection and the associated anal cancer among homosexual males. This patient is at higher risk of infection with HPV as a homosexual male but is at relatively low risk since he is monogamous. He might have a lessened immune response to the vaccine as a result of his immune suppression from the Remicade. However, based on the guidelines from CDC, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested gastric bypass surgery for treatment of her obstructive sleep apnea and obesity.  Findings:  The physician reviewer found that based on review of the available records, although the patient does not have documentation of six months of consecutive supervised weight loss, the patient does meet standard nationally accepted guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. This patient has a BMI that is greater than 40, or at least 35 with one or more serious co-morbid conditions. The records indicate the patient has a BMI of 53 as well as several weight related co-morbid conditions. In addition, she completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary or behavioral, or medical barriers to surgery. She has failed weight loss efforts in the past and lost pre-operative weight as requested by her provider to clear her for bariatric surgery. Consistent with these findings, the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A parent of a five-year-old female enrollee has requested a referral to an ear, nose and throat (ENT) specialist for evaluation of her tonsillar hypertrophy.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested service. Adenotonsillar hypertrophy is not a benign condition. According to Tatlipinar and colleagues, Patients with adenoid and tonsil hypertrophy are at a higher risk for cardiopulmonary complications, poorer quality of life, and more severe upper airway obstruction (UAO) symptoms and should have priority for surgical treatment to prevent cardiopulmonary complications. This patient has had persistent cough, exacerbation of her asthma and clinical obstructive sleep apnea with an examination revealing hypertrophic tonsils. The peer-reviewed literature supports ENT evaluation with potential intervention in cases such as this patient, to prevent long-term complications. For the reasons provided above, the requested referral to an ENT specialist is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Botox injections for treatment of her temporomandibular joint disorder (TMJ).  Findings:  Three physician reviewers found that review of the submitted documentation and literature fails to demonstrate that the services at issue were likely to be more beneficial for treatment of the patients medical condition than standard therapies. Review of the medical literature available does not provide conclusive results that Botox is a safe and effective treatment for TMJ. Although the U.S. Food and Drug Administration (FDA) have approved Botox for migraine headache and cervical dystonia, it has not approved its use for TMJ, (National Institute of Dental and Craniofacial Research). In addition, the American Dental Association has not established a standard of care concerning the off brand use of Botox to treat TMJ. For the reasons set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy based on the available research.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested gender reassignment procedure, bilateral mastectomy for treatment of her medical condition.  Findings:  The physician reviewer found that this patient has a significant psychiatric history of anorexia nervosa, schizoaffective disorder, and possible borderline personality disorder. She has been assessed with gender identity disorder and wishes to undergo bilateral mastectomy. The patients contention that she would be better served by bilateral mastectomy is negated by her variable compliance with much of her previous treatment. In light of the variable participation in PHP, the patient is unlikely to attend to her post-operative care as required by her provider. Further, given the patients ongoing struggle with anorexia nervosa and other psychiatric conditions, gender reassignment surgery is not clinically appropriate at this time. Considering the patients comorbid psychiatric illnesses, the requested bilateral mastectomy is not necessary for treatment of this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old male enrollee has requested Gralise 600mg for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  He has tried and failed to benefit from standard therapy, including medications and physical therapy.  The medical records noted that generic gabapentin caused gastrointestinal distress.  The current medical evidence supports the use of Gralise in this clinical setting.  The requested medication is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions.  This patient demonstrates neuropathic pain per the clinical notes.  All told, Gralise 600mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a Functional Neuromuscular Electrical Stimulator (FES) Cycle RT300 Rehabilitation Therapy System for treatment of her paraplegia. Findings:  Two physician reviewers found that there is sufficient support for the requested equipment in this patients case.  She has experienced secondary complications from her spinal cord injury.  Although the studies to date are small for functional electrical stimulation, this is due to the relative rarity of the condition.  Additionally, the studies to date demonstrate a consistent improvement in bone density, muscular maintenance, spasticity, and cardiovascular status with the use of this equipment.  The current evidence supports the requested equipment in this setting.  Therefore, the requested Functional Neuromuscular Electrical Stimulator (FES) Cycle RT300 Rehabilitation Therapy System is likely to be of greater benefit than other treatment alternatives in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A parent of an eight-year-old female enrollee has requested repeated esophageal dilation procedures within her local community, rather than at a facility that is approximately 130 miles/3 hours from her residence for treatment of the enrollees recessive dystrophic epidermolysis bullosa and recurrent esophageal stricture. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services. Epidermolysis bullosa represents a collection of disorders characterized by development of blisters with trauma and worsening in warm weather. This patient suffers from the recessive dystrophic type, involving severe blistering and scarring, including involvement of the gastrointestinal tract and urologic system. This is the most incapacitating of the disorders because of the mucous membrane involvement and impact on nutrition and growth. Flexion contractures and cutaneous carcinomas may eventually develop, requiring removal and tissue release. Special skin grafts and bone marrow transplantation may offer relieve in some cases. This patient has failed stem cell transplantation. The health plan has referred the enrollee to another facility because their local institutions are not equipped to deal with the care that she requires. While the facility in question has a well-respected and recognized clinic that specializes in epidermolysis bullosa, the commute is 3-4 hours each way. Obstruction due to esophageal structure is a semi-emergent situation requiring rapid dilation for relief. In addition, due to the severity of her disease, such a long drive is intolerable and may exacerbate her condition. She has been involved with a pediatric gastroenterologist locally that understands the intricacies of her care. It is medically necessary to provide this patient local treatment with a subspecialist that knows her well. Therefore, it is medically necessary and appropriate for this patient to continue to receive esophageal dilation procedures within her community.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested services on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. This patient had pain in her knee that could not be explained by any recent injury. The patients pain had persisted for six hours prior to her presenting to the emergency room to have it evaluated. Moreover, the patients pain rated as 7 out of 10, and this level qualifies as severe pain. A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. Therefore, the patients symptoms on the said date met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested balloon sinuplasty for treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that this patient has reactive airway disease with history of asthma and chronic allergic rhinitis. These are not entities that will be cured by sinus surgery. Endoscopic sinus surgery, whether done with or without balloon instrumentation will not resolve congestion or rhinitis. It is not clear as to what medical therapy this patient has received and over what course of time.  It is recommended that patients with this type of disease undergo evaluation by an allergist in order to maximize medical therapy prior to considering surgical intervention. Consistent with these findings, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depression and anorexia nervosa.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Clinical guidelines and patient placement criteria have been developed to assist with determining the appropriate level of care and length of stay.  In this patients case, considering her depressive symptomatologies with suicidal ideation and strained marital dynamics, acute inpatient hospitalization was initially indicated.  However, the medical records do not support continued acute hospitalization from the time frame specified.  On the date in question, the patient had a family therapy session.  She had resumed her psychotropic medications, and there were no modifications to the regimen being considered.  By the subsequent date, there was no acute psychiatric syndrome.  As of the subsequent date, although the patient required ongoing care, she could have been safely and effectively treated in a partial hospitalization program or intensive outpatient community-based program grounded in dialectical behavioral therapy, psychodynamic therapy, and marital therapy.  All told, acute inpatient psychiatric services provided from the time frame specified were not medically indicated for the treatment of this patient.