Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 73-year-old female has requested coverage for surgical intervention and related services provided.    Findings:  The physician reviewer found that the patient was treated in Mexico for pelvic organ prolapse. She underwent extensive work-up including colonoscopy, barium enema, colonic transit study, pelvic and abdominal ultrasound, and blood work. She also underwent surgery for what is described as an emergent situation due to rectal bleeding. The patient underwent cystocele repair, rectopexy, and lifting of the pelvic floor. She remained in the hospital for approximately three days. There is no documentation of any other preceding treatment or evaluation in the United States to confirm reports that the patients physicians could not determine the etiology of her problem.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.It is reasonable to conclude that a prudent layperson would have sought immediate evaluation for rectal bleeding. However, other than the colonoscopy, the remaining work-up would be considered elective and unrelated to the bleeding. Furthermore, the subsequent diagnoses were most likely not a cause of any sort of significant rectal bleeding and the surgical procedures performed were elective and not related to any emergent procedure. As such, while a prudent layperson would have sought immediate medical attention for rectal bleeding, once the colonoscopy was performed, a prudent layperson in this situation would not have reasonably believed immediate surgical intervention and related workup was required.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a Tennant Biomodulator for treatment of her cervicocranial syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  There is a lack of published high-grade evidence to support the efficacy of the Tennant Biomodulator in this clinical setting.  The medical records noted a history of neck and upper back pain, and the provider noted the diagnosis of cervicocranial syndrome.  The current medical literature has not demonstrated the effectiveness of the device at issue.  The literature has not established the efficacy of electrotherapy modalities in the setting of cervicogenic pain.  No significant clinical improvement beyond a placebo effect would have been expected.  All told, the Tennant Biomodulator provided on on the said date was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested Suboxone MIS Film for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  Suboxone is not indicated for the treatment of chronic pain.  This patient reported that he benefitted from methadone in the past.  In this case, methadone or buprenorphine are appropriate alternatives.  The current medical evidence does not support the use of Suboxone MIS Film in this patients case.  Myers and colleagues provide some support for the use of buprenorphine in this clinical setting.  All told, Suboxone MIS Film is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested partial removal of the tongue (glossectomy) for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is insufficient evidence to support the safety, efficacy, and long-term outcome of the requested surgery in this clinical setting.  Although some studies regarding the requested services are encouraging, there is a paucity of data supporting the clinical use of this surgical intervention in this case.  This patient has already undergone prior surgery, including tonsillectomy and uvulopalatopharyngoplasty.  The patient has been documented to have 15 episodes of apnea/hypopnea per hour of sleep which is eliminated with the use of nasal CPAP at 7 cm of water pressure.  Symptoms of snoring and hypoxemia were also eliminated.  In order to establish the medical necessity of the requested services, the record must document an inability to adequately address the patients sleep apnea with conservative approaches.  However, this patients records document excellent improvement of obstructive sleep apnea symptoms using conservative medical approaches with the use of CPAP therapy.  All told, the requested partial removal of the tongue (glossectomy) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested intravenous immune globulin (IVIG) therapy for treatment of her chronic inflammatory demyelinating polyneuropathy (CIDP).  Findings:  The physician reviewer found that a medical literature review indicates that diagnosis of CIDP is made based on history, examination, and electrodiagnostic study. The preferred therapies for CIDP include IVIG, steroids, and plasmapheresis. An evidence-based guideline from the American Academy of Neurology (AAN) states that, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). CIDP is disabling, and good results would include freedom from symptoms, and normal neurologic examination findings. This patient has had IVIG treatment, with such success that she is active, and has a normal neurological examination. Thus, continued IVIG at the doses provided should be continued to avoid the patients disease from worsening. For these reasons, the requested therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested occupational therapy and physical therapy for treatment of his status post right middle cerebral artery stroke.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had a severe stroke, with residual deficits six months post event.  He is status post craniotomy and cranioplasty.  The medical literature shows that recovery from severe stroke is facilitated by formal physical therapy, and that neuroplastic changes associated with functional improvements can continue for months to years.  However, the current medical evidence indicates that most of the motor recovery occurs within three months after stroke onset.  Balaban and colleagues performed a retrospective study to evaluate functional outcome in patients with middle cerebral artery stroke.  The authors noted that patients do not always experience increased functional improvement with increased duration of inpatient therapy.  In this patients case, while the clinical records indicate improvements post stroke, the therapy notes do not document significant functional improvements post cranioplasty.  All told, continued occupational therapy and physical therapy from the date specified and forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia and continued pelvic pain.  Findings:  The physician reviewer found that this patient has a chronic pain syndrome related to lumbar spine surgery. Several providers noted multiple trigger points and include a diagnosis of fibromyalgia. While the records do not outline a formal description that confirms a diagnosis of fibromyalgia as defined by the American College of Rheumatology, the patient reportedly has multiple trigger points. The patient has had good pain control with Lyrica. Further, the records indicate the patient has failed tricyclic antidepressants and an anticonvulsant. Given a diagnosis of fibromyalgia, the fact that Lyrica is indicated for fibromyalgia and the patient has experienced a proven response without significant side effects, Lyrica is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested computer-assisted surgical navigational procedure for musculoskeletal procedures (CPT 20985) for treatment of her left hip pain.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  The patient has severe left hip pain and a left total hip arthroplasty is planned.  Although cup inclination may be more consistent with the use of computer navigation, there is a lack of clinical data supporting its use.  Per the current medical literature, outcomes have not been shown to be improved with this technology over standard techniques.  Of note, computer navigated procedures often involve an increase in operative time.  All told, computer-assisted surgical navigational procedure for musculoskeletal procedures (CPT 20985) is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested a series of Orthovisc injections to the right knee for treatment of his osteoarthritis. Findings:  The physician reviewer found that this patient previously received intra-articular viscosupplementation injections. The current medical evidence does not support the requested series of Orthovisc injections to the right knee at this time.  The requested injections are not likely to be beneficial in this clinical setting.  Double-blinded, well-designed, placebo-controlled studies have not demonstrated a clinical benefit for the requested services in this setting.  All told, the requested series of Orthovisc injections to the right knee is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested artificial disc replacement surgery and subsequent hospitalization for the treatment of her neck pain. Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  At this time, the potential problems that may occur with longer follow-up have not been fully documented.  Total disc replacement has been associated with a high rate of re-operations.  This patient has severe cervical spondylosis with foraminal impingement.  The standard procedure in this setting would be a single level anterior cervical discectomy and fusion.  There is a lack of truly blinded studies establishing the efficacy of the services at issue in this setting, and the results are short-term at best.  All told, the services at issue were not likely to have been more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested Butrans (buprenorphine) for his cervicalgia, degeneration of cervical intervertebral disc, and chronic pain syndrome. Findings:  The physician reviewer found that given the lack of documentation that the patient is taking high levels of opioid medications, as well as the absence of documentation of prior opioid dependence, prior misuse, prior attempts with Duragesic, and prior attempts with morphine sulfate extended-release products, the medical necessity of Butrans is not supported.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested a three-pack of inhalers for treatment of the enrollees asthma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity in this patients case.  On the date indicated, the documentation noted that the patients asthma was well-controlled if he used Albuterol prior to exertion.  His respiratory examination was normal.  The patient was prescribed prednisone for asthma exacerbations.  The Health Plan has agreed to provide coverage for one inhaler at a time, and this is medically appropriate.  According to current guidelines, the use of albuterol more than a couple of times per week, except for exercise, is an indication of poor asthmatic control.  Per the submitted documentation, this patient has mild intermittent asthma from exercise.  Based upon the medical records, a three-pack of inhalers is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Nutropin growth hormone therapy for treatment of the enrollees short stature. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  The current medical evidence supports growth hormone therapy in this clinical setting.  This patients height is more than 2 standard deviations below normal.  Additionally, his growth velocity is poor.  The results of provocative growth hormone testing show a poor peak growth hormone response.  Per the clinical notes, the patients predicted adult height is far below the mid-parental target height.  The medical records indicate that other causes of poor growth have been ruled out.  All told, Nutropin growth hormone therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a lumbar home traction unit for treatment of his low back pain. Findings:  The physician reviewer found that there is insufficient evidence from peer-reviewed published studies to conclude that spinal unloading devices such as lumbar traction devices are clinically effective in the management of chronic mechanical low back pain.  Fritz and colleagues noted that there may be a subgroup of patients that may benefit from mechanical lumbar traction.  This subgroup was reported to consist of patients with leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise.  This study, however, was a small controlled trial with multiple limitations.  The literature that has been published in favor of use of the device includes case studies and other low-grade literature that does not establish clinical efficacy.  Overall, home lumbar traction has not been demonstrated to improve pain, health or functional outcomes for the condition of chronic mechanical low back pain.  All told, the requested lumbar home traction unit is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this clinical setting.  This patients height is more than two standard deviations below the mean for age and gender.  Her growth velocity is poor for mid-puberty.  The patient has low growth factors despite having a normal weight for height ratio, and her adult predicted height is well below the genetic target height. According to Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet specific criteria.  This criteria includes height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile, growth velocity less than the 25th percentile for bone age, bone age more than two standard deviations below the mean for age, low serum IGF-1 and/or IGFBP-3, and other clinical features suggestive of growth hormone deficiency.  Based upon the current medical evidence, the requested Genotropin growth hormone therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested Norco and Soma for treatment of his lumbar spondylosis and chronic pain syndrome.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing a patients pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. It is in the patients best interest to wean off the Norco and Soma. For these reasons, the requested Norco and Soma are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a replacement infusion pump for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested replacement infusion pump.  In general, opioid intrathecal pump infusion is not recommended for chronic pain associated with posterior lumbar spine fusion.  Per the clinical records, this patient may benefit more from removal of the intrathecal pump and weaning off opioids, as her symptoms of increased pain may be the result of opioid-induced hyperalgesia.  Angst and Clark presented a systematic review on opioid-induced hyperalgesia.  The authors observed that very high doses of certain opioids can produce allodynia and possibly hyperaglesia.  Per the authors, the hyperalgesic state can be aggravated when the dose of the opioid agonist is increased.  The current medical evidence does not support the requested equipment in this clinical setting.  All told, the requested replacement infusion pump is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested surgical removal of a painful lump for treatment of her mass on her forehead. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Generally, skin lesions that bleed or have ulcerated surfaces, are large, show recent signs of malignant degeneration, are associated with satellite lesions, or have variegated colors should be biopsied to rule out malignant degeneration.  In the absence of a suspicion of malignancy or a functional problem such as infection, bleeding, or obstruction of movement, the removal of a skin lesion or subcutaneous cyst is not medically indicated.  Thus, the requested services are not medically indicated for the treatment of this patient.  These cysts are common and the condition does not constitute an abnormal structure of the body.  In the absence of infection, inflammation or impaired range of motion or function related to the cyst, its removal would not be expected to improve function.  All told, the requested services are not reconstructive in nature and are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested general anesthesia for dental procedure (Tori removal) for treatment of his dental anxiety. Findings: The physician reviewer found that based on review of the available records, general anesthesia for extensive dental services and a high level of anxiety is not medically necessary. This patient does not present with a significant history that would require monitored anesthesia care. Additionally, there is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for general anesthesia. In the medical literature, Shabanie reported that sedation could be categorized into minimal, moderate. or deep sedation with general anesthesia. Sedation may add a new dimension to procedures by compromising the patients normal protective mechanisms and carries the potential of cardiac, respiratory, and cognitive complications. The author stated that interventional procedures could be performed under local anesthesia, with or without sedation, or under general anesthesia. The choice generally depends on patient factors such as age, cardiovascular stability, pain tolerance, and procedural factors such as complexity, extent, and degree of induced pain. In longer and more extensive procedures on more fragile patients, the assistance of an anesthesiologist will be required. Hausman and Reich noted that not all procedures are well suited for the office with sedation. Examples of such procedures would include those associated with significant fluid shifts, postoperative pain, bleeding, or procedures of long duration. However, relatively non-invasive procedures, those of short duration, and those not associated with either fluid shifts or significant post-procedure discomfort, are well suited to office-based practice without sedation. Consistent with these findings, the requested general anesthesia for Tori removal is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested removal of moles from the chest for treatment of the enrollees skin lesions.  Findings:  The physician reviewer found that given the possibility that an atypical melanocytic nevus can harbor premalignant or malignant cells, excisional biopsy of the lesion is warranted. Careful analysis of histologic features as well as the additional information provided by immunohistochemistry is needed for a correct diagnosis in most cases of melanoma in children. The lesion should be entirely excised to assure that no abnormal cells are left in the skin. Further, the expertise of a plastic surgeon is indicated to prevent scarring on the patients chest. This diagnostic, rather than cosmetic procedure is therefore medically necessary for treatment of this patients medical condition.