Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested reimbursement for 44 sessions of transcranial magnetic stimulation (TMS). The Health Plan has denied this request indicating that the therapy at issue was considered investigational for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has an approximate 15-year history of clinically significant affective symptomatologies that have been diagnosed both as unilateral depression and bipolar disorder. The patients symptom complex consists of feeling depressed, profound negativity and occasional catatonic like symptoms, along with poor concentration, increased appetite, middle insomnia and episodic suicidal ideations. Her depressive symptoms tend to improve as the day progresses.  The patient has a history of pressured thoughts and speech and grandiosity.  In the medical documentation provided, there is no evidence of a course of an evidence-based psychotherapy or treatment with electroconvulsive therapy (ECT).  The patient has pursued multiple psychotropic medication trials. Psychopharmacotherapy has been reportedly hindered by poor efficacy, lack of sustained clinical effect, and tolerability issues. The patient eventually pursued transcranial magnetic stimulation (TMS) and engaged the treatment modality during an approximate one-month period.  The Health Plan has denied the patients request for reimbursement for this therapy.In 2008, TMS was cleared by the Food and Drug Administration (FDA) as a treatment for major depressive disorder. Subsequent to the FDA clearance, the American Psychiatric Association (APA) investigated this treatment and the available literature.  The outcome of the investigation in 2010 was APA endorsement of TMS for the acute phase treatment of major depressive disorder. The recommendation, however, does not extend to bipolar disorder.  Review of the submitted documentation indicates that this patient was diagnosed with bipolar II disorder by a specialist in bipolarity. Further, her treating psychiatrists diagnoses included rapid cycling as one of the major indicators of the patients diagnosis. There was no evidence provided to refute the diagnosis of bipolar disorder or explanation included to refine the clinical formulation, thus it appears that TMS was used for the depressed phase of bipolar disorder in this case. TMS is not indicated for such use, and accordingly, the use of TMS was not likely to be more beneficial than any available standard therapy in this particular scenario.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested an MRI of the lumbar spine for evaluation of her back and leg pain and irregular menstrual bleeding.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient indeed had low back pain with radicular features, however, there was no proven neurological deficit. While the patient had significant discomfort, there was no documented attempt at traditional physical therapy and the medical records do not document that an appropriate course of anti-inflammatory medication was completed. Moreover, this patient had a prior history of similar findings of back and leg pain on an episodic basis. Finally, there is insufficient evidence regarding concerns for malignancy to support the use of MRI in this setting. In this case, the medical necessity of an MRI of the lumbar spine has not been established, as there was no documented neurological deficit and conservative treatment had not been exhausted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested Xifaxan (rifaximin)for treatment of his small intestinal bowel overgrowth (SIBO).    Findings:  The physician reviewer found that based on review of the available records, not testing for SIBO with glucose or Lactulose breath test was reasonable given this patients clinical history. However, the patient should first be treated with an adequate trial of more standard, proven antibiotic agents prior to use of Xifaxan. In the medical literature, medications such as tetracycline, metronidazole, ampicillin, and TMP/SMX have all been shown to be effective for treatment of SIBO. Since the patient has no documented allergies to any of these drugs, the use of Xifaxan is not medically necessary in this patients care and was appropriately denied.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature.  Findings:  The physician reviewer found that the symptoms reported by the patient and documented in the emergency department records indicate that the sudden onset of symptoms was severe enough to cause a person with an average knowledge of health and medicine to reasonably expect that not receiving immediate medical attention would put his health at serious risk. Although the patient had symptoms of sinus congestion and possible infection, the acute onset of worsening headache could also have been a sign of a complication of sinusitis (abscess) or of another potentially life threatening cause of headache such as subarachnoid hemorrhage. Given his symptoms, it was reasonable for the patient to seek emergency medical care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for speech therapy services in a small group setting, physical therapy services and occupational therapy services for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the medical literature strongly supports speech therapy in patients with articulation defects. Papers by Tyler and Sharp and Hillenbrand state that reviews of the literature indicate the necessity and effectiveness of speech therapy in children over the age of three with articulation defects. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. In accordance with the occupational therapy evaluation findings, the patients delays are not severe enough to warrant the need for occupational therapy at this time. The recommendation of physical therapy was for a right foot sprain and the physical therapy treatment plan indicated weekly therapy. However, many months have elapsed since the initial recommendation and there is no indication that the patient continues to experience functional difficulties secondary to the foot sprain. Therefore, the requested physical therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested  residential treatment center services for treatment of the enrollees serious emotional disturbance.  Findings:  The physician reviewer found that this patient with a history of multiple behavioral problems including: major depressive disorder, recurrent, severe, in partial remission, polysubstance dependence including hallucinogens, cannabis and opiates, conduct disorder, parent-child relational problems, tic disorder not otherwise specified (NOS), anxiety disorder NOS and personality disorder NOS including narcissistic, antisocial and schizotypal was placed in the residential treatment facility for control of his behaviors which had previously been difficult to manage. Based upon the documentation provided, the patients symptoms and behaviors represented a deterioration from his usual performance status and included self injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24-hour structured setting. Therefore, the patient required the intensity of service of residential treatment level of care and could not have been treated in a lesser intensity environment during the disputed period.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for emergency transport services indicating that her condition was emergent in nature. Findings:  The physician reviewer found that the patient complained of persistent cough/congestion that had been getting worse. Per the ambulance records, she had no complaints of chest pain, shortness of breath, nausea/vomiting or trauma. The evidence demonstrates that the patient did not have a condition that would lead a prudent layperson to believe that he or she required immediate medical attention or ambulance transport since the patient was not short of breath, experiencing chest pain or toxic in appearance. It typically takes at least 48 hours to see improvement in bronchitis symptoms when on antibiotics. The fact that the patient had not improved within a 24-hour period would not be considered a reason to seek immediate medical attention by a prudent layperson. Furthermore, the fact that the patient left the emergency room without being seen suggests that her symptoms were not severe
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested acute inpatient mental health services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that utilizing the American Society of Addiction Medicine (ASAM) criteria for a Level III residential treatment center (RTC) this patient was not described to be at risk for withdrawal. In addition, he did not require medical monitoring and he did not attend the groups as would be expected. As such, during the said time frame, the patients psychiatric condition did not require the 24-hour structured setting in a RTC and treatment could have been provided at a lower level of care. Consistent with these findings, the acute inpatient hospitalization for stabilization during this time met the criteria set forth by the ASAM as medically necessary. However, the patient did not meet the ASAM criteria for the Level III RTC facility from the said dates and could have been treated in a less restrictive environment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested a spinal disc add-on of L5-S1 and fusion of L4-L5 surgical procedure for treatment of her L5-S1 and L4-5 degenerative disc disease and lumbar radiculopathy.  Findings:  Three physician reviewers found that the issue in this case is whether lumbar disc replacement and fusion are likely to be more beneficial for treatment of the patients severe low back and leg numbness than any available standard therapy. There is currently a paucity of data demonstrating the long-term safety and efficacy of lumbar disc replacement.  Additionally, The ProDisc-L is only FDA approved for patients with single level disease.  This patient has multi-level disease. The patient has been diagnosed with cauda equina syndrome and this diagnosis has been used as an additional justification for disc replacement. However, there is no objective evidence in the providers notes to support a cauda equina syndrome diagnosis. Even if the diagnosis of cauda equina syndrome is confirmed, the standard treatment is urgent decompression. There is no evidence that disc arthroplasty is appropriate in the setting of cauda equine syndrome. Lumbar disc arthroplasty and fusion remains of unproven efficacy at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Nuvigil for treatment of his traumatic brain injury.  Findings:  Three physician reviewers found that as supported by the clinical studies and approved by the FDA, Nuvigil is indicated to improve wakefulness in adult patients with excessive sleepiness associated with obstructive sleep apnea, narcolepsy and shift work disorder. Currently there is a paucity of reliable scientific data demonstrating an improvement in quality of life in terms of concentration and memory problems due to head trauma in patients treated with Nuvigil. As such, large, prospective, randomized controlled clinical trials evaluating the potential benefits and side effects are required to define the clinical role of Nuvigil and to establish patient selection criteria. Accordingly, its use in the management of this patients condition is not likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a biological knee replacement for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that biological knee replacement is a term utilized by orthopedic surgeons advocating the methods of meniscus transplantation, application of articular cartilage paste grafting and ligament replacement in an effort to delay total joint arthroplasty. It is described as any combination of meniscus transplantation, application of articular cartilage stem cell paste grafting or ligament reconstruction. These methods utilize allograft material. The issue to be decided in this case is whether it is medically necessary for this patient to receive a biological knee replacement, i.e., autologous chondrocyte implantation through cartilage paste and meniscal replacement. The patient appears to have bicondylar tricompartmental degenerative osteoarthritis. At age 57, the use of the techniques described above is supported by level three and level four studies which are considered lower level evidence. Such studies are not adequate to support biological knee replacement over conservative care with subsequent total joint replacement. The patients current management reflects the standard of care for this patients disorder. The use of biological knee replacement for treatment of this patients condition remains the subject of debate. The requested procedure has not been proven in the currently available peer-reviewed medical literature to be safe or efficacious for the treatment of this patients medical condition. Therefore, the  denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her bulimia nervosa. Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, as of initial denied date of service this patient was medically stable, no suicidality was present that would require 24-hour monitoring, her weight was 80% of what was expected, her motivation to recover was partial, she was cooperative with treatment and her co-morbid disorders could be managed safely in a partial hospital program setting. She was able to display some degree of control in purging behaviors and had made gains during her stay at the RTC facility.  All told, the RTC services provided during the time period at issue were not medically necessary for the treatment of the patients condition. Rather a step-down to a partial hospital program setting was medically necessary for the patients continued treatment.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson would have sought immediate medical attention? Under Health and Safety Code 1317.1, `Emergency medical condition` means 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 patient's health in serious jeopardy. (2) Serious impairment to bodily functions. (3) Serious dysfunction of any bodily organ or part.  Under 28 CCR 1300.67, `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area. Review of the submitted documentation indicates that the patient attempted to see his new primary care physician but was told that the first available appointment was two weeks later.  Waiting until that date to be seen would have constituted a delay in diagnosis/treatment of two weeks. This patients condition had been ongoing for approximately a week and a half with a low pain level and thus was not an emergent problem. However, it did present an urgent problem, as his pain was not improving and could have been indicative of a serious underlying condition that needed to be addressed. Thus, a prudent layperson would believe that he was experiencing an urgent medical condition and needed to be seen earlier than the next available appointment in two weeks.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested acute level of care services for treatment of her depressive disorder.  Findings:  The physician reviewer found that this patient was admitted to an acute inpatient hospitalization unit on the date in question. Her mental status exam was noted to show her to be pleasant and cooperative. She appeared disheveled. Her mood was depressed and her affect congruent, yet in a normal range, stable and not tearful. Her thought process was organized and she did show a thought content of neural-vegetative anxiety and depression with insomnia. At the time of her admission, the patient had suicidal ideation without an active plan and no auditory or visual hallucinations. She has a history of chemical abuse/dependency. Although the patient had been experiencing suicidal thoughts leading up to her admission and during the initial period of her stay, by the said date she was showing less depression and there was no evidence of active suicidal ideation with intent or plan. As of the said timeframe, the patient did not meet medical necessity criteria for continued acute inpatient level of care services, as she was not an imminent danger to herself and/or others, nor was she noted to be severely unstable. The medically necessary level of care during this time was step down to a partial hospitalization program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested a PET/CT scan for evaluation of his colon cancer.  Findings:  Three physician reviewers found that this patient has a history of stage IV colon cancer and is currently undergoing treatment with chemotherapy.  Clinically, the patient is stable.  PET studies for patients with a history of colon cancer have been shown to be useful in the initial staging, to evaluate initial response to chemotherapy, for re-staging following completion of chemotherapy and/or radiation therapy, and to evaluate for suspected recurrent disease.  A review of the peer-reviewed literature found insufficient support for the use of PET scans for surveillance of patients in this clinical situation.  The National Comprehensive Cancer Network guidelines do not recommend PET scans for evaluation of response to chemotherapy. At this time, there is insufficient clinical evidence to support the requested PET/CT scan so the PET/CT scan is not likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested decompression with fusion at the L4-5 level for treatment of her stenosis at L4-5.  Findings:  The physician reviewer found that based on review of the available records, this patient has chronic back pain both from age related degeneration and from hook pullout from her scoliosis surgery. She has abnormalities on her CT and MRI scan at multiple levels but there is no convincing medical evidence that the L4-5 level is her pain generator. Her provider reports that the patient has retrolisthesis at L4-5. However, applying the criteria for fusion as reported in the Milliman Care Guidelines for lumbar fusion and from Bambakidis and colleagues, there has no evidence of significant instability, scoliosis, angulation, spondylolysis, infection, fracture or tumor to warrant surgical fusion at L4-5. Consistent with these recommended indications for fusion surgery this patient does not meet the medical necessity criteria and therefore the requested surgery was appropriately denied.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested past and future coverage for inpatient residential care services provided, and re-admittance to residential level of care.  Findings:  The physician reviewer found that at the time of admittance to the residential treatment facility, this patient was actively depressed and alcohol dependent. The patient was undergoing numerous travails in his personal life and had access to a loaded weapon that he contemplated using to commit suicide a few days prior to admission. The patients relapse risk was thus intensified in potential outcome severity. He was unable to maintain sobriety as an outpatient and his living situation was not supportive of recovery. Although he did not require an inpatient level of care for withdrawal, he did require a safe structured inpatient setting to establish stability and safety before an outpatient program could be safely and effectively utilized. Thus, the services provided were medically necessary for treatment of the patients alcohol dependence. The patient was discharged from the treatment facility with after care instructions. No additional medical records have been provided since the patients discharge to support the current request for re-admittance to residential level of care. Therefore, future inpatient residential treatment services are not medically necessary at this time. However, the patient should receive an immediate psychiatric evaluation to determine the level of care that is appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for acute inpatient mental health services for treatment of the enrollees panic disorder, Aspergers syndrome, and generalized anxiety disorder versus oppositional defiant disorder. Findings:  The physician reviewer found that American Psychiatric Association practice guidelines indicate that patients should be managed in the least effective setting which is likely to prove to be safe and effective. The data reviewed suggest that the patient could not have been safely and effectively managed in a less restrictive setting. All told, acute inpatient mental health services were medically indicated for the treatment of this patient.