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

A 46-year-old male enrollee has requested for facet joint injections for treatment of his back pain.  Findings:  The physician reviewer found that the treatment plan of an isolated specific targeted low risk diagnostic facet injection is reasonable and will provide valuable diagnostic and potentially therapeutic relief that will allow further elucidation of a comprehensive management plan including medication and physical modalities. All told, the patient meets all reasonable criteria for facet injection, described as axial non-radicular, has no evidence of compressive lesion or neurologic sequelae, and has no contraindication to the block. The patient has also failed conservative management and has had no previous posterior fusion at the affected level. Therefore, the requested diagnostic facet injection should be approved for this patient based on medical necessity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for residential treatment level of care services for treatment of her multiple mental health conditions. Findings:  The physician reviewer found that it is rather uncommon for a patient inactive in treatment to transition directly to the residential setting.  Residential placement is most often utilized as a step-down from acute psychiatric hospitalization or a step up for those who have failed less restrictive interventions such as outpatient therapy or partial hospitalization.  Intensive outpatient care or partial hospitalization would have been appropriate and consistent with accepted medical practice in the United States.  In sum, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested coverage for past use of a continuous passive motion device for treatment following shoulder surgery.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  The value of continuous passive motion after shoulder surgery is a subject of controversy, with some reports showing favorable results, and other reports showing no effect at 3-month follow-up.  In a study by Michlovitz and colleagues, continuous passive motion showed no better results than passive range of motion exercises after rotator cuff repair. As noted by Lee and colleagues, aggressive early motion was felt to be a possible cause of anatomic failure after repair.  Immediate passive motion was found to be detrimental, and was noted to possibly cause increased scar formation in the subacromial space, per Peltz and colleagues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the current medical evidence does not support the requested gastric Lap-band procedure in this clinical setting.  For patients with a body mass index of 35 or less, bariatric surgery may be indicated if the patient has obesity-related comorbid diseases.  The submitted medical records do not demonstrate that this patient has obesity-related comorbid disease.  In addition, the patient has not completed essential aspects of a pre-surgical program prior to bariatric surgery, including medically supervised attempts at weight loss.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested authorization and coverage for Ef3-Wave Unit (interferential stimulation device) for home therapy for treatment of the enrollees shoulder pain.  Findings:  Two physician reviewers found that the patient has chronic bilateral shoulder pain.  An x-ray of her left shoulder revealed degenerative changes of the left acromioclavicular joint, normal glenohumeral joint, and mild calcific tendinitis.  She has received physical therapy, including manual therapy, exercises, and electrical stimulation.  The patient has requested coverage for Ef3-Wave Unit (interferential stimulation device) for home therapy.  The Health Plan has denied this request and reported that the requested device is investigational for the treatment of this patient.  In this patients case, the current medical evidence does not support the requested interferential stimulation device for home use.  The medical literature does not demonstrate that interferential stimulation is more beneficial for this patients calcific tendonitis than standard treatments.  Although there is limited evidence suggesting some benefit from interferential stimulation, the pain-relieving properties appear to be transient.  There is a lack of evidence showing that the requested device is likely to be more effective in controlling chronic pain than conventional types of treatment.  All told, the requested Ef3-Wave Unit (interferential stimulation device) for home therapy is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested reimbursement for skin treatment services for treatment of the enrollees skin lesions.  Findings:  The physician reviewer found that pigmented skin lesions are among the most common skin lesions. Among them, melanocytic proliferations are morphologically diverse, and their behavior may be difficult to discern with certainty. It may not be possible to distinguish melanocytic from non-melanocytic pigmented skin lesions and, in particular, benign from malignant lesions. Solar lentigines are benign, hyperpigmented lesions that present a significant cosmetic nuisance for many middle-aged and elderly patients with chronic accumulated sun exposure (de Giorgi, et al). Cryosurgery (freezing) is a highly effective treatment for a broad range of benign skin problems. Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most non-hair-bearing areas of the body. Spray methods include the timed spot freeze technique, the rotary or spiral pattern, and the paintbrush method. Benign skin lesions that are suitable for freezing include actinic keratosis and solar lentigo skin lesions, and often can be treated in a single session, although some require several treatments (Andrews, et al). Lentigo maligna is a premalignant melanocytic neoplasm occurring on the sun-exposed skin of the middle-aged and elderly. It is believed to represent the in situ phase of lentigo maligna melanoma, thus cure is usually the aim of treatment. Presentation may be quite subtle, and delayed diagnosis is common. The estimated lifetime risk of lentigo maligna progressing to lentigo maligna melanoma is 5%. Surgical excision is the treatment of choice to obtain clinical and histologic clearance, but cryotherapy also yields good results, with recurrence rates in the order of 7-10%. Cure rates for lentigo maligna is reportedly 96% (McKenna, et al). Since it can be difficult to clinically differentiate lentigo from lentigo maligna, the providers plan was to destroy the lesion and perform biopsy if the lesion returns, which would be suggestive of lentigo maligna. Therefore, the patient might have lentigo maligna. For these reasons, the service was not cosmetic in nature, but clinically indicated. As such, the service at issue was medically necessary as within the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested for whole body skin photography for evaluation of his hyperpigmented macules. Findings:  Two physician reviewers found that patients with this condition have a higher risk for developing melanoma.  While isolated lesions can be biopsied, this becomes problematic in patients with numerous nevi or large, clinically atypical nevi.  Effective approaches to early melanoma detection should identify and evaluate both new and changing nevi.  Whole Body Skin Photography is a standard of care approach to early diagnosis of melanoma in such patients.  In this clinical setting, Whole Body Skin Photography was likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested authorization and coverage for L5-S1 decompression and instrumented fusion with interbody cage for treatment of the enrollees multilevel degenerative disc disease, facet arthropathy, and multilevel neuroforaminal narrowing.  Findings:  The physician reviewer found that in the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. The authors noted that, References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified. However, neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified. The first treatment option states that lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. Specifically, this option indicates the requested fusion is not recommended in this patient. The American Pain Society (APS) has also developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain (Chou, et al). The panel developed a total of 8 recommendations. Recommendation number 7 pertains to this patient, which states that, In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, it is recommended that clinicians discuss risks and benefits of surgery as an option. However, the authors state that, For persistent and disabling radiculopathy due to herniated lumbar disc, standard open discectomy and microdiscectomy are associated with moderate short-term (through 6 to 12 weeks) benefits compared to nonsurgical therapy, though differences in outcomes in some trials are diminished or no longer present after 1 to 2 years. Based on these two comprehensive literature reviews, surgical fusion at the L5-S1 level is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female has requested Rituxan for treatment of her autoimmune hearing loss.  Findings:  Three physician reviewers found that the patient has had a progressive fluctuating hearing loss in her left ear since the 1990s. On work-up, she was diagnosed as having autoimmune inner ear disease. The diagnosis was based on her response both to transtympanic and systemic steroids. She did not reportedly respond to other available immunosuppressive medications. Her left ear continues to decline, and treatment with Rituxan has been proposed. There are data supporting the use of Rituxan for some autoimmune conditions, and the study from Cohen and colleagues suggests this medication may be effective in autoimmune inner ear disease. This patient may be a candidate for a structured clinical trial of Rituxan. However, its use has not been established by appropriately designed, randomized, and double-blinded clinical trials to be expected to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for prolotherapy for treatment of her left knee pain.  Findings:  Three physician reviewers found that the peer-reviewed medical literature, prolotherapy is not adequately supported in well designed, randomized, prospective, double-blind studies. The study by Reeves and Hassanein only evaluated a small number of knees and there was a different cohort protocol for the study group versus the control group. Uthman reviewed the medical literature from 1968 to 2002 and found a lack of convincing or reproducible evidence to support intra-articular therapies including prolotherapy as altering the course of osteoarthritis of the knee. there is a paucity of data supporting the superiority or equivalence of prolotherapy in treating osteoarthritis of the knee. Therefore, the requested therapy is not likely to be more beneficial than standard therapies in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested an MRI of the cervical spine for evaluation of her neck pain.  Findings:  The physician reviewer found that this patient had not had any history of malignancy, abnormal laboratory values, neurologic or radicular symptoms, or any significant trauma. Additionally, there is no indication that the patient has had x-rays to evaluate her neck pain prior to the request for evaluation with MRI. According to the American College of Radiology imaging guidelines, patients with chronic neck pain should initially undergo five-view radiographic imaging and if there are no neurologic signs or symptoms further imaging is not needed (Daffner, et al.) Further, in the setting of neck pain, MRI of the cervical spine is acceptable when all of the following criteria are met: neck pain lasting longer than six weeks, no red flags and there is no response to conservative management. Based upon the information provided, this patient does not meet the above criteria, as there is a lack of evidence that conservative management has been attempted or plain x-rays have been obtained. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female has requested surgery to remove excess thigh skin.   Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of the requested procedure.  There is no documentation of office visits for or treatment of a skin condition related to the excess thigh skin.  The submitted medical records do not include a physical examination describing the extent of any such skin condition.  The patients condition does not constitute an abnormal structure of the body, given the lack of medical record documentation of a functional deficit or skin condition related to the excess thigh buttock skin.  The photographs do not demonstrate an excess of skin that would be sufficient to prevent ambulation.  The requested surgery would be performed to improve appearance, but not function.  The requested surgery does not meet the expanded concept of medically necessary reconstructive surgery defined in California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male has requested Egrifta for treatment of his lipodystrophy secondary to HIV medications.  Findings:  The physician reviewer found that abdominal lipodystrophy constitutes an abnormal collection of adipose tissue. In this patients case, the lipodystrophy may be related to taking the medications for treatment of HIV. Currently, as stated in the press release from the FDA, Egrifta is noted to decrease abdominal fat. However, functional improvement has not been clearly studied or shown as judged by the FDA. As noted by Falutz and colleagues, tesamorelin (Egrifta) might be useful for the treatment of HIV-infected patients who have an increase in abdominal girth and dyslipidemia in the context of receiving antiretroviral therapy. Some data suggest that Egrifta may also improve lipids in HIV-infected patients with excess abdominal fat accumulation, but these findings need to be confirmed. Based on the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible. This patient is documented to have a severe condition of abdominal protuberance without significant subcutaneous fat. He has a severely abnormal condition that may be related to an increase in visceral adipose tissue (VAT) from treatment of his HIV disease. This abnormal condition is demonstrated in the photographs provided for review. A confirmatory CT scan is appropriate to document that the major contribution to this condition is from VAT and not from other causes, as recommended by the treating provider. On confirmation that the patients condition is from VAT, then Egrifta should be authorized as reconstructive and therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested an MRI of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the lumbar spine in this patients case.  The peer-reviewed medical literature indicates that advanced imaging of the spine, such as MRI, should be reserved for select patient populations.  This includes patients with suspected infection, patients with suspected metastatic disease, patients with neurological deficits, and patients with a history of recent significant trauma.  For patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma, and no neurological deficits), it is medically appropriate to undergo a trial of conservative therapy, including non-steroidal anti-inflammatory medications (NSAIDs) and physical therapy, prior to advanced imaging, such as MRI.  This patient has back pain with no neurological deficits.  There is no documentation of conservative therapy, including NSAIDs and physical therapy.  There is no clinical concern of infection or metastatic disease, and there is no history of recent trauma.  All told, the requested MRI of the lumbar spine is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-month-old female enrollee has requested for Synagis vaccine for treatment of the enrollees prematurity and respiratory distress due to transient tachypnea of newborn.  Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in infants born at 32-35 weeks gestation, up to 12 months of age. The most notable of these factors is a birth weight less than 2500 grams (Holman, et al). In addition, Horn and Smout analyzed retrospective data from 304 infants less than 1 year of age with bronchiolitis or RSV pneumonia admitted to the hospital. Data were subdivided by gestational age (less than 32 weeks, 33-35 weeks, and greater than 36 weeks) and compared, looking at rates of intubation and ICU admission, as well as length of stay. The authors found that infants less than 1 year of age born at 33-35 gestational age (GA) fared worse than those born more prematurely over all measures. Specifically, the authors concluded that, Premature birth during this critical period of lung development (32-35 weeks GA) may result in significant alteration in lung function and physiology. The IMpact-RSV Study Group evaluated the effect of palivizumab prophylaxis on severity of illness in premature infants and reported a significant decrease in hospitalization rate for all infants. For infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness, and is thus medically necessary for this patient for the 2011-12 RSV season.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old male has requested Narrow Band UVB therapy for treatment of his urticaria pigmentosa/mastocytosis.  Findings:  The physician reviewer found that published works provide evidence that NBUVB phototherapy can be useful for the treatment of urticaria pigmentosa. As noted by Loubevres and colleagues, mastocytosis is a heterogeneous group of conditions characterized by an increased number of mast cells in the skin or, less frequently, in other organs such as the liver, spleen, lymph nodes, bone marrow, lungs and gastrointestinal system. The most common clinical skin forms are urticaria pigmentosa, solitary mastocytoma, diffuse cutaneous mastocytosis and telangiectasia macularis eruptiva perstans. Bunimovich and colleagues noted that treatment of urticaria pigmentosa usually starts with elimination of all things that might trigger histamine release. Cutaneous mastocytosis is treated with topical emollients, topical glucocorticoids, and calcineurin inhibitors. Systemic steroids are occasionally used, mainly for aggressive systemic mastocytosis. To treat cutaneous lesions, psoralen UVA or UVA1 without psoralen have been shown to be effective (Castells, et al). A few reports in the literature, including one study from Prignano and colleagues, provide preliminary evidence that NBUVB is beneficial for treatment of urticaria pigmentosa. Since this patients urticaria pigmentosa had previously responded to NBUVB following failure with various medical therapies, it has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that her symptoms include severe depression, anxiety, insomnia, poor concentration, poor energy, fatigue, feelings of hopelessness, and intermittent suicidal ideation.  She has been tried on multiple medications, including Cymbalta, Abilify, Seroquel, Elavil, Lexapro, Prozac, Effexor, Remeron, clomipramine, nortriptyline, Luvox, Zoloft, Desyrel, Celexa, Paxil, Wellbutrin, and Pristiq.  She is currently in psychotherapy and has received cognitive therapy, with minimal to no response.  This patient has major depressive disorder which is been refractory to numerous medication trials and psychotherapy, including cognitive therapy.  Her treating provider has recommended transcranial magnetic stimulation.  The current medical literature has demonstrated the benefit of transcranial magnetic stimulation.  This patient has not responded to conventional medications or procedures for the treatment of her sustained depression.  Transcranial magnetic stimulation has been shown to improve patients with this condition.  In this clinical setting, transcranial magnetic stimulation is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested Roux-en-Y gastric bypass for treatment of his obesity.  Findings:  The physician reviewer found that this patient has a documented medical comorbidity of hypertension.  On the date in question, the documentation noted that he had completed 4 of 7 classes, but he had not undergone psychological evaluation.  He had not completed support group and seminar attendance or detailed journal recording of dietary intake. The available evidence suggests that completion of each component will increase the success of the bariatric surgery.  Most programs utilize a comprehensive preoperative approach for the benefit of the patient.  This patient has not completed these aspects, and he has not demonstrated suitability for the surgical procedure.  All told, the requested Roux-en-Y gastric bypass is not medically necessary for the treatment of this patient.