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

An 18-year-old female enrollee has requested residential mental health treatment for her depression and eating disorder.  Findings:  The physician reviewer found that from a psychodynamic perspective, the patient was underdeveloped in terms of self-esteem, the ability to self-soothe, accept her imperfections, and develop and maintain meaningful relationships. This enduring schema birthed pathological coping strategies to negotiate the often turbulent developmental task of a healthy second individuation.  She was on a path of role diffusion, rather than sound identity formation, which would have surely fueled continued behavioral dysregulation, intrapsychic conflict, substance use and societal misconduct. Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, was the most appropriate disposition and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy. With regard to the course of care, the patient had a positive therapy trend until the most recent entry on the date specified as well as a reassuring provider evaluation on the date specified. There was no documentation of medical compromise due to her eating disorder or severe behavioral dysregulation. There was no further clinical documentation or provider justification for continued care at the residential setting. In conclusion, considering the clinical presentation, patient history, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care was safe, appropriate and consistent with good medical practice. However, based on the documentation provided, transition to a less restrictive setting by the date specified would have been reasonable. Thus, the request for residential mental health treatment from the date specified and forward is not supported as medically necessary. Therefore, the residential mental health treatment from the time frame specified was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old male has requested non-emergency medical transportation for treatment of his deformational plagiocephaly.   Findings:  The physician reviewer found that the requested non-emergent medical transport to primary care, subspecialty, therapy, and diagnostic appointments, specifically physical therapy and the orthotic clinic involved in creating the helmet for positional cranial molding is not medically necessary. The letter submitted by the provider describes his plan of care for the patient. However, there is no indication that the patients medical condition limits his ability to take private or public transportation. Further, the records do not include documentation of any impaired mobility, as the only mention of special equipment is the helmet to help correct the patients positional plagiocephaly. All told, the requested non-emergent medical transportation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested a knee brace for treatment of his right knee injury.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the knee brace in this patients case.  The current medical evidence does not support the equipment at issue in this clinical setting.  An orthotic hinged brace is not indicated for a patient with a meniscal tear in the absence of any ligamentous instability.  Per the submitted medical records, this patients clinical examination revealed no instability or laxity to the ligamentous structures.  A hinged knee brace is unlikely to provide a positive effect in this setting.  All told, the knee brace was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested the prescription drug Forteo for treatment of her osteoporosis with bilateral hip fractures.   Findings:  The physician reviewer found that osteoporosis is a skeletal disorder characterized by a loss of bone osteoid that reduces bone integrity, resulting in an increased risk for fracture.  Treatment of osteoporosis involves general measures such as increased calcium in the diet, Vitamin D supplementation, and high impact physical activity.  Forteo stimulates the production of new collagenous bone matrix that must be mineralized.  Patients taking Forteo must have sufficient intake of Vitamin D and calcium.  This medication can increase bone density in most bones.  Following a course of Forteo, a course of bisphosphonates is often considered in order to retain the improved bone density.  This patient has a documented history of osteoporosis and is status post bilateral hip fractures.  Forteo has been recommended to promote bone healing.  The requested medication is an appropriate bone building osteoporosis treatment.  All told, the prescription drug Forteo is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of TMS therapy in this patients case.  TMS therapy has been endorsed by the American Psychiatric Association, and there is a growing base of evidence-based studies supporting its utility and efficacy for adults with depression.  However, at this time, there is a lack of well-designed clinical studies in the peer-reviewed medical literature with significant statistical power demonstrating similar outcomes in the adolescent population.  Per the current medical evidence, TMS is not routinely prescribed in this clinical setting.  In the adolescent population, TMS does not align with generally accepted standards of medical practice, and its clinical appropriateness for those with anxiety and eating disorder has not been demonstrated in the scientific literature.  All told, the requested TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees Aspergers syndrome.  Findings:  The physician reviewer found that speech therapy is medically necessary for this patient with autism spectrum disorder-pervasive developmental disorder not otherwise specified. On evaluation, this patient displayed significant social skills deficits and a history of pragmatic language delays. Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Volmar and Weisner). Goldstein reviewed the available communication interventions for patients with autism in peer-reviewed research articles published over the past 20 years. The authors reported that the evidence supports the claim that effective interventions exist to teach communication skills to children with autism. The goal of teaching social skills is to improve the quality of life. Research and clinical experience have also demonstrated that social skills impairments affect optimal functioning in all areas of life for patients with PDD-NOS (Countryman). This patient has a history of poor peer interaction and significant social and emotional deficits. All told, this patient will benefit from speech therapy emphasizing pragmatic speech and social interaction skills. In addition, a thorough speech evaluation with emphasis on standardized testing for pragmatics is recommended.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old female  has requested coverage for emergency services provided. Findings:  The physician reviewer found that the patient had a history of endometriosis and ovarian cysts and was status post left oophorectomy. She presented to the emergency room (ER) with a chief complaint of heavy menstrual bleeding for 11 days. Per the ER records, the patient was not in any pain (pain level was documented as 0 on a scale of 1 to 10) but did feel a bit dizzy.  Upon physical exam it was noted that the patient did not appear to be in any obvious distress, the abdomen was benign, and the pelvic exam was benign with minimal blood present. The patients vital signs were normal, she was not pregnant, and she was not anemic. She was diagnosed with dysfunctional vaginal bleeding. No treatment was rendered in the ER or at the time of discharge, and the patient was instructed to follow-up with her primary care provider the next day. The patient flew to Hungary the day after presenting to the ER where her symptoms continued. One week after having been seen in the ER, she was admitted to a hospital in Hungary where dilation and curettage (D&C) was performed. The diagnosis was metrorrhagia (dysfunctional vaginal bleeding). The D&C was effective in stopping the patients uterine bleeding. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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 evidence demonstrates that the patient had prolonged menstrual bleeding diagnosed by her medical providers at both the ER and at the hospital in Hungary. The submitted medical records indicate that at the time she was seen in the ER she was not in pain, did not have a fever, and was not passing out. The patients husband reports that he and his wife were leaving on a trip to Hungary the next day and therefore they wanted a physician to check the patients condition prior to proceeding with their travel plans. The patients examination could have taken place in an alternate setting and did not require immediate medical attention in an emergency department. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date at issue.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 38-year-old male has requested coverage for emergency services provided.  Findings:  The physician reviewer found that the patient presented to the emergency department with complaint of recurring headaches. The patient had previously received treatment in the emergency department three days prior to this admission for a severe migraine and returned to the emergency department on the date at issue due to a recurrence of his migraine headache. The patient states that during his previous visit, he was instructed to return in three days for an MRI if he experienced additional migraines. The patient states he had additional migraine headaches and therefore returned to the emergency department as directed.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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 evidence demonstrates that a prudent layperson would have sought immediate medical attention on the date of service in question. The patient presented previously with acute symptoms of headache, visual loss, and extremity numbness. The patient had been instructed to return to the ED on the date in question for an MRI if his symptoms persisted. The patient reports that he experienced additional migraine headaches and therefore returned to the emergency department as directed.  All told, a prudent layperson in these circumstances would have sought immediate medical attention on the date in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male has requested coverage for past and future transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  The physician reviewer found that based on review of the available records, this patients depression is treatment resistant as multiple antidepressants and augmentation strategies have not successfully brought on remission. In the medical literature, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. The APA Practice Guidelines for treatment of depression state that the (A)cute phase treatment may include TMS. Connolly and colleagues found that, TMS was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Carpenter and colleagues reported that, TMS is an effective treatment for those unable to benefit from initial antidepressant medication with a response rate of 58.0% and a remission rate of 37.1%. Thus, although relatively new, TMS is an effective treatment as demonstrated in the referenced evidence based literature, and is FDA approved for the treatment of treatment resistant major depressive disorder. Consistent with these findings, TMS treatment from the date at issue and forward was and is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy, CPT codes 90867 (1), 90868 (36), and 90869 (1) for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical literature supports TMS therapy in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies and remains symptomatic.  Considering the medical records and the expanding peer-reviewed literature base, TMS therapy is appropriate to treat this patients depressive symptoms.  All told, the requested TMS therapy, CPT codes 90867 (1), 90868 (36), and 90869 (1), is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested the Caris study for her diagnosis with stage IV colon cancer. Findings: Two physician reviewers found that the requested testing is not likely to be more efficacious than other modalities for evaluating this patient.  She has progressive metastatic colon cancer.  The Caris assay tests for the presence of multiple molecular markers which are believed to be of relevance to the pathogenesis of colon cancer and in the prediction of response to various chemotherapeutic agents.  However, there is insufficient evidence supporting the requested testing in this clinical setting.  Currently, the superior efficacy of the requested testing for predicting response to drugs has not been established by the current medical evidence.  In sum, the requested Caris study is not likely to be more beneficial than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested continued occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that occupational therapy is medically indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Volmar and Wiesner and Case-Smith). The research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of a childs performance to develop intervention strategies when delays are noted. This patient has documented delays in adaptive and fine motor skills and occupational therapy is a medically necessary treatment for such impairments. Occupational therapy has also been recommended for the patients neuro-sensory delays. A systemic review by Polatajko found that no firm conclusions can be made regarding the efficacy of sensory integration occupational therapy techniques due to poor study quality and great variability in interventions and populations. While sensory processing concerns are noted in this patient, evidence-based research supporting a sensory-based occupational therapy program does not exist at this time. As such, although continued occupational therapy is medically necessary to address the patients adaptive and fine motor delays, treatment of neuro-sensory delays should not be included in the patients occupational therapy regimen. An updated occupational therapy evaluation which includes appropriate standardized testing should be obtained in order to measure the patients progress.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested intensity modulated radiation therapy (IMRT) for treatment of large B-cell lymphoma.   Findings:  Two physician reviewers found that the patient presents with non-Hodgkins lymphoma with a bulky epigastric mass, which was diagnosed approximately two years ago. She underwent chemotherapy with R-CHOP and had a response with no signs of progressive disease after eight cycles. Following chemotherapy, she was treated with tomotherapy over 18 fractions to a total dose of 36 Gy to her initial site of bulky disease. There is no evidence in this patients records to suggest that standard treatment with 3D conformal technique to deliver radiotherapy would result in more side effects than expected with IMRT. Further, because lymphoma is a relatively radiosensitive tumor, the dose prescribed in this case was 36 Gy. At the prescribed dose of 36 Gy, it is unlikely that an IMRT treatment plan would result in any clinically meaningful decrease to the surrounding normal structures compared to a 3D conformal plan. Therefore, treatment with IMRT was not likely to be more beneficial than the standard therapy of 3D conformal radiotherapy in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested 1.5% Pennsaid Gel for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication for the treatment of this patient.  The medical records do not demonstrate an indication for the use of 1.5% Pennsaid Gel in this patients case.  The clinical records do not provide details regarding the efficacy of the requested medication for this patient.  Additionally, medical records pertaining to the initiation of this medication were not submitted for review.  There were no laboratory studies provided to document this patients renal function.  The clinical documentation does not provide details regarding the stated diagnosis of osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested radiofrequency ablation of the sacroiliac (SI) joints and lateral branch nerves for treatment of his bilateral SI joint dysfunction.   Findings:  Two physician reviewers found that the patient presents with low back pain. The patient has a history of fusion at S1 and bilateral hip replacement. The record indicates the patient has a history of back and buttock pain as well as anterior thigh numbness. A computed tomography (CT) guided medial branch injection demonstrated mild bilateral anterior lipping at the sacroiliac (SI) joints with mild scoliosis on the iliac side of the SI joint bilaterally. One provider reports the patients pain was dramatically improved with spinal facet joint injections, but the relief was transient and the patient now requires radiofrequency ablation (RFA) at the same facet joints. Another provider states that in patients who receive adequate, but short-term relief benefit from steroid injections into the SI joint, it is reasonable to pursue RFA of the SI joint for long-term benefit. Radiofrequency ablation of the SI joint is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records the patient had a spinal fusion in the area to be treated with RFA. The medical literature does not support the efficacy of RFA at levels in which the medial/lateral branches are already disrupted such as that which may occur in spinal fusions. As noted by Aydin and colleagues, Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested a T1-rho cartilage scan for evaluation of her patellofemoral pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  T1-rho mapping has been shown to be effective in visualizing early changes in osteoarthritis, and is a promising technique for evaluating early cartilage damage.  Along with other new techniques, it may be of value in characterizing changes in articular cartilage, and may be eventually helpful in detecting morphological cartilaginous changes earlier than conventional MRI.  However, this method of evaluation has been used primarily in the research setting.  At this time, there is a paucity of reported clinical information to support the technique.  All told, the requested T1-rho cartilage scan is not medically indicated for the evaluation of this patient.