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

A 62-year-old female is requesting Restor lenses for treatment of her glaucoma.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient has a history of diabetes and previous Lasik treatment. She was found to have decreased visual acuity and cataracts on examination. The provider recommended cataract surgery with Restor lens implant and this was done. The use of multifocal intraocular lens implant (IOL) in her treatment was not medically necessary even considering her history of previous Lasik surgery. The relevant medical literature, including the references cited above, suggest that cataract surgery using a standard (monofocal) IOL is likely to result in equivalent outcomes when compared to multifocal IOL devices. Further, the purpose of implanting the Restor IOL was apparently attempted to provide the patient with less dependence on glasses after the cataract surgery. However, the additional benefits of Restor IOL are for the patients convenience and are not medically necessary to improve the outcome of the procedure. For this reason, the Health Plans characterization of the cataract surgery with Restor IOL placement as cosmetic is appropriate and the scientific data does not suggest that Restor IOL is necessary for management of her condition due to her history of Lasik.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested IVIG therapy for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that the submitted documentation does not document prior treatment trials, time course, rate of exacerbations, degree of progressive dysfunction, current status or disability.  She is said to have history of chronic infection for which immunomodulatory therapy would not be appropriate.  Standard multiple sclerosis platform medications have been shown to reduce attacks and progressive disability, and although they alter immune function, they are not contraindicated in general for individuals with a history of chronic infection. Preventive management of relapses is the cornerstone of relapsing-remitting multiple sclerosis (RRMS) treatment, and disease modulator therapies are considered platform treatment.  In this patients case, the submitted medical records do not document trial, intolerability, failure or contraindication to standard therapies. Thus, IVIG therapy has not been shown in this case to be more beneficial than standard therapies for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a hysteroscopy, biopsy, and laparoscopy for treatment of her pelvic pain and vaginal bleeding. Findings:  The physician reviewer found that it is possible that this patient would benefit from pathologic treatment including a D&C, and visual evaluation of her endometrial lining with a hysteroscopy. However, prior to surgery a more complete gynecologic workup is indicated, and if already done simply needs to be documented. Specifically, tissue diagnosis of the endometrium would be helpful to exclude hyperplasia in a patient of her age with suspected menorrhagia. As recommended by the American College of Obstetricians and Gynecologists (ACOG), an office endometrial biopsy, or an outpatient D&C would be a reasonable treatment option. Conversely, proceeding with a hysteroscopy without tissue diagnosis or assessment of the uterine cavity by sonogram to better assess the uterine shape, size, possible pathology is not clinically justified. Further, given the lack of data regarding the cyst, more information is needed to ascertain the need for a laparoscopy. Therefore, the requested D&C procedure and visual hysteroscopy are medically necessary while the laparoscopic evaluation of the pelvis is not indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested an MRI of the left knee for evaluation of his knee pain. Findings:  The physician reviewer found that this patient has ongoing left knee pain following arthroscopic repair of the left knee.  Recent physical examination showed clinical signs of a lateral meniscal tear.  It is not uncommon for patients to develop a repeat meniscal tear following arthroscopic repair of a torn meniscus.  There is ample support in the peer-reviewed literature for MRI of the knee for suspected meniscal tear.  The American College of Radiology guidelines support the use of MRI when there is suspected internal derangement of the knee.  This patient has a documented abnormal physical examination of the left knee, with examination suggesting a meniscal tear.  As documented by the patients physician, the MRI has been requested to determine the exact cause of the patients pain so that a proper treatment plan can be developed.  All told, the requested MRI of the left knee is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested  speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the relevant medical literature, Nelson and colleagues concluded that speech and language development is considered to be a useful indicator of a childs overall development and cognitive ability. Moreover, the authors commented that young patients with speech and language delays tend to have more difficulties with written language. The authors warn that in some cases these problems may lead to lower IQ scores that may persist into young adulthood. From this detailed account, it is clear that speech and language delay in young children can result in substantial long-term consequences. This patient is a young child with a history of mild receptive language delay and moderate to severe expressive language delay, with residual mild deficits despite improvements made with speech therapy. Her skills remain below those of her peers despite intervention. These deficits negatively impacted her ability to communicate effectively with children and adult caregivers; thus the speech therapy services provided to this patient have been established to have been medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain. Findings:  The physician reviewer found that with the exception of x-rays, imaging has not been done.  Whole body MRI is not medically indicated for this patient since there is no history of malignancy. Whole body MRI, although not widely available, is generally reserved for the detection of skeletal metastases as well as other organ involvement.  This patient has a history of a foot neuroma.  Due to the fact that imaging of her feet has not been done despite symptoms which have persisted for over one year, bilateral MRI of the feet is medically indicated for the evaluation of this patient.  All told, in this patients case, evaluation with bilateral MRI of the feet is medically appropriate given her symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested prolotherapy treatments for treatment of her chronic low back pain, left greater than right, and sacroiliac joint arthropathy.  Findings:  Three physician reviewers found that prolotherapy was not and is not likely to be the most beneficial treatment for this patients chronic low back pain and sacroiliac joint arthropathy.  There is insufficient evidence in the literature to support the efficacy of prolotherapy for the treatment of the patients chronic medical condition. Additionally, there are alternative therapies which are supported by the medical literature which may be effective in treating the patients chronic pain condition.Yelland and colleagues published a randomized control trial on prolotherapy injections, saline injections, and exercise for chronic low back pain. The objective was to assess the efficacy of prolotherapy injections and exercise protocol in the treatment of chronic nonspecific low back pain. The  hypothesis concluded that prolotherapy injections and exercise was no more effective than the control treatment.  Dagenais and colleagues conducted a critical review of the literature on prolotherapy for spinal pain. The review found that most clinical studies reported positive results, such as decreased pain or disability. Differences, however, between treatment and control groups did not always reach statistical significance. They concluded that there were great variations in the injection and treatment protocols for prolotherapy that preclude definite conclusions. They further asserted that future research should focus on those solutions and protocols that are most commonly used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment.  All told, the superior efficacy of the services at issue has not been established at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Two physician reviewers found that weight-related comorbid conditions include hypertension, diabetes and sleep apnea. The patient has a history of hypothyroidism and is on medication. Cardiac clearance was obtained. A dietary evaluation did not reveal any barriers to surgery. A behavioral evaluation did not reveal any obvious barriers to surgery. The patient has failed dietary efforts in the past. This patient has morbid obesity, has failed reasonable weight loss attempts and does not have any obvious metabolic, medical, dietary or behavioral barriers to surgery. Thus, she meets all generally accepted criteria for bariatric surgery.  A laparoscopic sleeve gastrectomy is an appropriate primary treatment of morbid obesity in the well-selected patient.  The current medical literature has documented the safety and efficacy of this procedure.  Therefore, in this patients case, the requested laparoscopic sleeve gastrectomy is likely to be superior over all other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested onabotulinumtoxin-A (Botox) injection therapy for treatment of her anterior cervical fusion at C5-6 and C6-7.   Findings:  Three physician reviewers found that in the past the patient has received trigger point injections. Recently, the patient has requested the use of Botox injections in addition to her typical injections. There is no definitive evidence that Botox injections are likely to provide benefit in the treatment of this patients condition. Currently there are no randomized clinical trials that demonstrate the usefulness of Botox for cervical pain disorders. To use Botox over more standard injections is therefore not indicated in this instance. Although the patient states that Botox injections helped her headaches, Botox would not be considered a first-line therapy over more standard treatment modalities. As reported, documentation of failure of standard of care for headache disorders should be demonstrated prior to treatment with Botox. As this patients records do not demonstrate failure with standard therapies, a course of Botox would be investigational at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested toenail removal for treatment of his onychomycosis.  Findings:  The physician reviewer found that the requested toenail removal is medically indicated for the treatment of this patient.  Per the submitted documentation, the patients toenail is thick and mycotic.  Additionally, the patient has pain due to the ingrowing nail borders. These findings constitute the necessity for toenail removal. Toenail removal for thick and ingrowing toenails is a commonly performed procedure well within the standard of care for this ailment.  All told, the submitted documentation has demonstrated the medical necessity for the requested service in this patients case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. Several of the major reasons complained of by the enrollee's parent including abdominal pain, inability to walk or eat, are not supported in the documentation provided based on physical examination by the treating nurses, physician assistant, and supervising physician. The acute onset of severe abdominal pain, inability to ambulate, or dysphagia are all symptoms that would lead a reasonably prudent layperson to seek care at the ED. However none of these symptoms are documented in this patients history of present illness, review of systems, physical exam, diagnostic tests, assessment, plan, or instruction section of the ED visit note. The records document a patient with nasal congestion without difficulty breathing, vomiting, diarrhea, or abdominal pain. The patient presented with normal vital signs and was described as alert, attentive, smiling, active, and playful on examination. In the absence of medical documentation to support severe abdominal pain, inability to ambulate, or inability to eat as the reason for emergent medical care, this patients situation does not meet the definition of an emergency medical condition as set forth by California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested bilateral knee Synvisc One injections for treatment of her osteoarthritis.  Findings:  The physician reviewer found that in the medical literature, Waddell and colleagues indicated that the usefulness of viscosupplementation in the treatment of osteoarthritis of the knee has been generally accepted, although some questions have been raised. Bellamy and colleagues discussed some comparative studies evaluating different products with regard to their relative value but found inadequate evidence supporting the superiority among the different available hyaluronic acid formulations. In addition, Wang and colleagues concluded that additional well-designed, randomized, controlled trials are still needed to resolve the uncertainties regarding the effects of different products in varied clinical situations and patient populations. Since there is a lack of evidence supporting the increased efficacy of the requested Supartz One injections over standard alternatives, its use has not been demonstrated as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested brachytherapy for treatment of his pancreatic cancer. Findings:  Two physician reviewers found that brachytherapy is a procedure in which a radioactive source is placed near the tumor or target.  Interstitial brachytherapy implies the insertion of the sources into tissue.  There is little data on the use of interstitial brachytherapy for pancreatic cancer.  The available published literature tends to involve interstitial brachytherapy for locally advanced, inoperable pancreatic cancer. In those cases, the seeds are placed within the visible/palpable tumor, often as part of a multi-modality therapy, including external beam radiation and/or chemotherapy. There is a lack of evidence supporting its use as additional therapy for resected pancreatic cancer. Nori and colleagues described interstitial brachytherapy for intact pancreatic tumors (i.e. not after resection).  The submitted literature does not apply to this patients case, in which the tumor was resected. Therefore, there is a lack of literature supporting the use of interstitial brachytherapy in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested laparoscopic Roux-en-Y bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has clinically severe obesity and has failed prior weight loss attempts. She completed a thorough multidisciplinary evaluation that did not reveal any obvious psychological, dietary or medical barriers to surgery. The patient meets all generally accepted guidelines for bariatric surgery, including National Institutes of Health consensus guidelines. The current medical evidence supports weight loss surgery in this clinical scenario.  This patient has failed dietary efforts that span over the past several years.  All told, the requested laparoscopic Roux-en-Y bariatric surgery is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested Phenergan injections and hydromorphone with Dilaudid for treatment of her migraines.  Findings:  The physician reviewer found that there are many prophylactic migraine treatments that are available to treat migraine.  There are several new techniques with trigger point injections. Phenergan and Dilaudid injections are not part of routine care and provide only very short-term relief, with no long-term benefit.  There are oral dissolvable 5-HT receptor agonists, injectable triptans and oral dissolvable triptans that offer superior efficacy and less addictive alternatives for migraine treatment, with better long-term outcomes.  In truly refractory cases, referral to a headache center with comprehensive services that offer psychological, pharmacological, and physiologically appropriate regimens including injection therapy are more beneficial for long-term help in migraine conditions.  All told, the requested Phenergan injections and hydromorphone with Dilaudid are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested pulsed radiofrequency neurolysis treatments for treatment of her peripheral neuropathy. Findings:  Two physician reviewers found that on reviewing the medical literature, Day and colleagues evaluated the role of sympathetic blocks and neurolysis for chronic pain syndromes including neuropathic pain and found that the efficacy of these treatments in providing analgesia for various sympathetic mediated pain syndromes is sparse in the literature. Further, many case reports and case series have been published but few placebo-controlled, blinded studies have been conducted to reliably ascertain its effectiveness. Additional treatment for peripheral neuropathy includes antidepressant therapy. It remains one of the standard therapies for peripheral neuropathy of all types including diabetic, HIV, and idiopathic neuropathy. Max and colleagues performed randomized, double-blinded, cross-over studies in patients with painful diabetic neuropathy, comparing amitriptyline with desipramine. The authors concluded that desipramine relieves pain caused by diabetic neuropathy with similar efficacy to amitriptyline, offering alternatives to patients unable to tolerate one of the two medications. The mechanism of action in antidepressant analgesia for painful neuropathy include blockade of norepinephrine reuptake.This patient may have received some benefit from pulsed radiofrequency neuromodulation of the lumbar sympathetic plexus, however, it is difficult to make argument for reimbursement of the procedures because they are still considered investigational in the medical literature. Thus, the use of pulsed radiofrequency neuromodulation was not and is not likely to be more beneficial for treatment of this patients peripheral neuropathy since the patient has not exhausted all available standard therapies and its use was appropriately determined to be investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for Lyrica for the stated diagnosis of polyneuropathy for treatment of her medical condition.  Findings:  The physician reviewer found that this patients records demonstrate that she has failed treatment with numerous medications. In addition, she has undergone radiofrequency neuromodulation of the sympathetic chain. The patient reports that a trial of Lyrica provided her relief from her neuropathic pain. Although use of Lyrica in the treatment of peripheral neuropathy would be an off-label use of the medication, this patient has tried other treatments without success and she has had a positive response on a trial of the drug. Although officially approved only for diabetic neuropathy, post herpetic neuralgia, and fibromyalgia, many medications are used off-label with successful outcomes. Moreover, a literature search shows that studies support Lyrica as efficacious for various types of neuropathic pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested cold therapy machine and continuous passive motion machine for treatment of his right knee status post arthroplasty.  Findings:  Three physician reviewers found that in a review of the current medical literature, Harvey and colleagues discussed use of CPM devices following total knee replacement surgery. The authors examined a number of end points including active and passive knee flexion, active and passive knee extension, length of hospital stay and the incidence of the need for manipulation under anesthesia. After reviewing 20 randomized controlled trials of 1335 patients, the authors concluded that range of motion (ROM) effects were too small to justify use of CPM status post knee replacement. Further, Bruun-Olsen and colleagues offered similar results when reporting on 63 patients treated with active exercise or CPM and active exercise following total knee replacement. Overall, the authors concluded that the addition of CPM to active exercise did not restore pre-operative ROM and stair climbing capacity had actually decreased in both groups. Moreover, Smith and colleagues evaluated the efficacy of cold therapy compared to compression bandaging after total knee replacement. The study focused on 84 post-operative unilateral knee replacement patients randomized into patients treated with compression bandages versus those undergoing treatment with cryo-pad technology without significant differences between the groups in terms of measured outcomes. In summary, CPM and mechanical cryotherapy remain controversial. Despite use of both modalities following total knee replacement, the objective scientific data does not support the use of either CPM or cryotherapy as opposed to standard applications of ice, early mobilization, and active physical therapy. Based upon the information set forth above, I have determined the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.