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

A 48-year-old female enrollee has requested laparoscopic gastric band placement (CPT 43770) or laparoscopic sleeve gastrectomy (CPT 43775) for treatment of her obesity.  Findings:  Two physician reviewers found that the records indicate that she has failed self-attempted diets and weight loss programs and was seen in consultation for weight loss surgery. The provider noted the patient was an appropriate candidate for weight reduction surgery and recommended laparoscopic gastric band placement and if not feasible, laparoscopic sleeve gastrectomy. The patient also sought orthopedic consultation for left knee pain and was diagnosed with probable degenerative meniscus tear and non-ideal BMI. Weight reduction surgery is indicated for patients with a BMI greater than 40, or a BMI greater than 35 with significant medical co-morbidities. As defined by the American Society of Metabolic and Bariatric Surgery (ASMBS) guidelines such co-morbid conditions include coronary disease, hypertension, respiratory issues, arthritis, and metabolic diseases including diabetes or hyperlipidemia. The medical literature has demonstrated that patients with one or more of these co-morbidities may experience improvement or resolution of those conditions after weight reduction. This patient presents with knee pain, however she has not been diagnosed with any of the clinically significant co-morbidities discussed by the ASMBS. Additionally, the records do not show that she has undergone any specific therapy for the knee pain such as physical therapy or non-steroidal anti-inflammatory drugs (NSAIDs). Currently, the patient does not meet the criteria for weight reduction surgery set forth by the ASMBS and the requested surgery was appropriately deemed investigational in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a CT of the pelvis and abdomen on an emergent basis for evaluation of his left lower abdominal pain. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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.This patient had been experiencing abdominal pain for three to four days. His pain was not related to acute trauma. He had no other symptoms of acute illness, such as fever or vomiting. The only laboratory abnormalities noted were minimally elevated liver transaminases. This is a nonspecific finding for which a CT scan is not indicated. While the patients symptoms may have warranted a medical evaluation, there was no indication for a CT scan to be obtained on an emergent basis. The patients symptoms on the date of service in question did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested a custom knee brace for treatment of his medical condition status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that given this patients plan to return to cutting, twisting and pivoting sports, his providers decision to provide a custom orthotic or ACL brace was clinically appropriate. Although the general use of orthotics after ACL reconstruction remains controversial, this patients provider noted specific reasons for the use of a custom brace instead of a standard device. The authors suggested the conclusions of their skiers can be generalized to other sports involving cutting, twisting and pivoting. Considering that this patient was to return to sports with similar movements as the skiers, (Sterett, et al.), the rationale for this providers approach in prescribing a custom orthotic for his patient was reasonable. In Wright and Fetzer, the authors reviewed 12 randomized controlled trials and found varying accounts on whether pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. However, in the article authored by Sterett and colleagues, a total of 820 skiers who had had ACL reconstruction were divided into a cohort that used functional knee bracing during skiing. The non-braced skiers were found to be 2.74 times more likely to suffer subsequent injury than braced skiers. . In summary, the custom orthotic was in the best interest of the patients recovery and it was therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that according to the American Academy of Neurology guidelines, botulinum neurotoxin injections should not be considered in patients with episodic migraine and chronic tension-type headaches.  Shuhendler and colleagues noted that the use of botulinum toxin A for the prophylactic treatment of episodic migraine headaches was not significantly different from placebo, both from a clinical and statistical perspective.  At this time, the medical evidence does not support the use of Botox in this clinical scenario.  In this patients case, Botox injections are not likely to be superior over all other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested removal of a cyst for treatment of the enrollees epidermal inclusion cyst. Findings:  The physician reviewer found that the submitted medical records document an increase in the size of the cyst. The medical records noted that the cyst was 2 x 2 mm. A few months later, the cyst measured 6 x 6 mm.  The only effective, definitive treatment for epidermal inclusion cysts is surgical excision(Pandya and Radke).  The patient was experiencing associated symptoms, namely, an increase in the size of the lesion.  Thus, the removal of the cyst was indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested mental health outpatient therapy for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the psychiatric evaluation is incomplete and the patients diagnosis is mild depression. There is no history of inpatient treatment and no indication that the patient could not be managed safely and effectively with therapy once weekly. The American Psychiatric Association (APA) practice guidelines for treating patients with suicidal behavior recommend treatment in the least intensive setting that is likely to be safe and effective. Furthermore, the APA practice guidelines for treating patients with major depressive disorders indicate that patients should be treated in the most appropriate setting given their symptoms. For these reasons, therapy three times per week is not the most appropriate intensity of treatment for this patient given the data submitted for review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested pelvic floor physical therapy for treatment of her pelvic floor dysfunction.  Findings:  The physician reviewer found that at several of her PT sessions, the patients records described her as relatively asymptomatic. Although she was being treated for presumed pelvic floor dysfunction, the records indicate that that condition was not consistently causing her problems. In addition, the patient noted to her gynecologist that she was not finding the PT treatments helpful. Overall, the sessions at issue do not meet the published criteria for PT as they were not being provided to achieve a specific diagnosis-related goal and were not likely to increase the patients function. As such, the medical necessity of the therapy at issue has not been demonstrated in the records provided for review. Accordingly, I have determined that the therapy at issue was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) and intensive behavioral intervention (IBI) services for treatment of the enrollees autism. Findings:  Two physician reviewers found that the patient has a series of diagnoses including autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and serious behavioral problems of peer combativeness, authority conflict, and hiding. The literature shows that ABA therapy has at least a 40 year record of improvement in autistic children. The contention that ABA therapy is unproven or investigational is no longer prevailing opinion based upon multiple studies. While ABA therapy is a medically appropriate and indicated modality in this setting, based on the level of functional delays documented in the submitted records as well as his age, this patient does not require the frequency of therapy that has been requested. The proposed 20 hours of ABA therapy is generally indicated as early intensive intervention for younger patients. ABA therapy at a frequency of 10 hours per week is appropriate for this patient who has experienced some gains with treatment, but continues to have behavioral issues and problems with social interaction. A request has also been made for coverage of the patients participation in a six-week therapeutic summer camp program. The proposed program utilizes principles of intensive behavioral intervention (IBI) in an attempt to help children who experience social and behavioral difficulties. While there is little data studying the effects of such programs in this setting, given the patients documented issues with social interaction and acting out behaviors, his participation in a highly organized program directed at treating children with social and behavioral difficulties is a medically reasonable approach to treatment. Thus, the patient should also be covered for participation in the six-week therapeutic summer camp.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested home lumbar traction unit, CPT code E0890 for treatment of her pain. Findings:  Three physician reviewers found that there is insufficient evidence in the medical literature to support the efficacy of traction for the treatment of low back pain.  Although it is used as empiric therapy in clinical practice, there is a lack of evidence demonstrating that it is more beneficial for the treatment of low back pain than other standard available interventions.  All told, the superior efficacy of the home lumbar traction unit has not been established in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine or chronic headaches, there is ample literature supporting its use in refractory cases.  In this particular case, the patient has failed multiple first-line therapies for headache and now has frequent disabling symptoms. Furthermore, the patient may now also have medication-induced rebound headaches and has responded to treatment with Botox in the past. Thus, a trial of Botox is a reasonable treatment strategy for this particular patient and may provide a bridge to minimize the overuse of other medications.  A reassessment of the necessity of Botox use after 12 months should be implemented to ensure that the therapy continues to be beneficial for reduction in the frequency and severity of her headaches.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested continued residential treatment center care. Findings: The physician reviewer found that this patient is not showing any signs of her binging or purging behaviors. Her current treatment plan shows this patient to be steadily progressing, with appropriate weight gain. It does not appear that this patient requires the restrictive setting of a residential treatment care (RTC) facility. The literature documents conflicting reports as to the efficacy of treatment of anorexia nervosa in a patient such as this who currently is undergoing a steady gain in weight. It appears that she could be treated in a lesser restricted environment, such as the outpatient setting. This patient had previously been treated at this same RTC with good results having been achieved upon her discharge. The skills that she had gained from that previous admission, and the ability to continue advancement in her weight without intense interventions demonstrates that this patient no longer required this level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested mental health outpatient therapy sessions with a psychiatrist three times per week for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the psychiatric progress notes suggest that the patient had initially made some improvements in therapy. However, the most recent progress note indicates that she had worsened symptoms in a majority of the measurable domains that are documented in the progress notes; these include worsening of: depression, anxiety, sleep; panic; and hopelessness. Overall, it appears that the patient has experienced deterioration in her condition with her current therapy. While it is often the case that a patient's symptoms can worsen during the initial phases of therapy, after nine months of intensive therapy, some improvement should be evident. According to the relevant literature, a patient is likely to have improvement or remission within six months of therapy for PTSD using EMDR - `At 6-month follow-up, 75% of the adult-onset (compared with 33% of the childhood-onset) patients receiving EMDR achieved remission as compared to none of the patients receiving fluoxetine.` (van der Kolk and colleagues). All told, it does not appear that the patient is showing improvement with her current therapy regimen of three visits per week. Given the lack of improvement in the patients condition, the medical necessity of the requested frequency of service is not supported.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 1-year-old male enrollee has requested  emergency services for treatment of the enrollee's complaints of coughing.  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.  This case does not meet the prudent layperson criteria for emergent care. The patients acute symptoms of watery eyes and a runny nose do not constitute an emergency. The cough had been going on for four months and was not associated with worrisome acute symptoms like wheezing or fever. The laboratory tests and chest x-ray did not reveal evidence of significant disease. The treatment rendered (intramuscular Decadron) was non-specific and not needed emergently. In addition, the providers final clinical impression was that of a benign URI. In addition, there was no evidence that the patient was in pain. For these reasons, the services rendered in the ED could have been rendered at a later time by his primary care provider or a pediatric clinic without any risk to the patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 7-year-old female enrollee has requested 2 dorsiflexion Dynasplints for treatment of the enrollees idiopathic toe walking with mild heel corcontractures. Findings:  Three physician reviewers found that the provider notes the patient was born at 35 weeks gestation and was diagnosed before birth with intrauterine growth retardation. Her provider documented that her toe walking has resulted in mild heel cord contracture that required treatment with bilateral Dynasplints. The patient was also treated with physical therapy (PT) and provided the Dynasplints to promote dorsiflexion at night. To date, medical studies have not shown ankle dorsiflexion Dynasplints to be effective in treating persistent joint stiffness. Although some research shows that patient outcomes are improved with splinting, the majority of the literature does not support these findings. Most of the current data indicates that night splinting does not increase ankle range of motion or stretch the plantar flexors. Moreover, most of the articles suggest that conservative splinting does not improve equinus type gait. Consequently, the equipment at issue was not likely to be more beneficial for management of this patients condition than standard, proven alternative modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested Tekturna for treatment of her proteinuria.  Findings:  The physician reviewer found that the patient has minimal change disease (MCD) with significant proteinuria and hypertension (HTN), which is best treated initially with an angiotensin converting enzyme (ACE) inhibitor) and if blood pressure allows, an ARB. The role of Tekturna in treatment of HTN is still unclear, given that outcome studies have not yet been performed and clinical experience is limited concerning possible side effects. Specific to treatment of HTN in MCD, the use of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) seems a reasonable option for blood pressure reduction, and may have the added benefit of reducing urinary protein excretion. Thus, the use of Tekturna in this setting is not the standard of care. While it might provide some reduction of blood pressure and proteinuria if an additional antihypertensive agent is required, the use of an ARB should be attempted prior to the use of Tekturna.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested all-male group therapy for treatment of the enrollees eating disorder.  Findings:  Three physician reviewers found that the patient is receiving ongoing treatment incorporating standard therapeutic interventions. A psychiatric assessment notes the patient has made significant progress with the eating disorder. Additionally individual therapy note from this therapist reports the patient was following his meal plan, was cooperative and motivated, and denied any purging. Given the patients positive response to therapeutic interventions currently in place, there is no evidence to indicate than an all male group for treatment of his eating disorder is likely to be more effective than standard available therapy. Articles in peer reviewed medical literature, including the text from Herpertz-Dahlman and Hebebrand, and the American Psychiatric Association (APA), have not identified an all male eating disorder group as more efficacious than other available therapeutic modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-month-old male enrollee has requested skilled nursing services for treatment of the enrollees congenital dislocation of the right knee. Findings:  The physician reviewer found that a congenital dislocation of the knee is a rare medical condition. There is a lack of support in the medical literature documenting a requirement for skilled nursing services during preoperative or postoperative care in these patients.  Based on the medical documentation provided, the services at issue were not medically indicated. During the orthopedic visits, an assessment was provided by the clinic nurse. During the time of serial casting, prior to surgery, the patient was taking ibuprofen for pain.  Postoperatively, the patient was taking Tylenol with codeine. There are no other specific nursing procedures prescribed by the physician. The submitted nursing notes document custodial care and standard cast care for this patient.  The patient did not require documentation of vital signs.  Standard cast care, both with serial casting and postoperative care, typically does not require the services of a skilled nurse.  Pain management with the medications prescribed in this patients case does not typically require nursing supervision.  Therefore, the care provided by the nurse would be considered custodial in nature.  All told, skilled nursing services were not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient had documented a BMI greater than 35 last year with a weight of 206 pounds and with a BMI of 34.7 thereafter (2 pounds away from a BMI of 35). She also had significant co-morbid conditions including hypertension and secondary cardiovascular disease. The patient had failed prior dietary efforts, completed a multidisciplinary evaluation and was determined to be an appropriate candidate for bariatric surgery. The submitted evidence demonstrates the patient had clinically severe obesity and her BMI rounded to 35, which was the number used by the surgeon and evaluation team to determine her appropriateness for weight loss surgery. All told, the lap band procedure was medically appropriate and necessary for this patient who was unlikely to achieve adequate weight loss results without surgical intervention.