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

The guardian of a 33-year-old male enrollee has requested the medication Banzel for the treatment of the enrollees seizure disorder secondary to isodicentric chromosome 15q duplication syndrome. Findings:  The physician reviewer found that this patient has refractory seizure disorder, and uncontrolled seizures pose a hazard. He has an underlying chromosomal abnormality, likely the etiology for his seizure disorder. Prior anticonvulsants have been ineffective for treatment of his condition. His current anticonvulsant regimen has been more beneficial than prior treatments. Per the literature, Banzel is the most recent antiepileptic drug to have shown efficacy in the treatment of Lennox-Gastaut syndrome (LGS). This patients condition is similar to LGS. Although the evidence supporting the use of available treatments for LGS is not robust, there is evidence demonstrating the efficacy of Banzel and the clinical evidence in this case demonstrates it has been effective for this patient. Topamax has an uncertain chance of success and a trial of such is not necessary. The current regimen is medically indicated and is more likely to be beneficial than Topamax or other treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential treatment care for the treatment of the enrollees mental health condition. Findings:  The physician reviewer found that an analysis indicates medical necessity for residential treatment existed. The factors in this case are consistent with CALOCUS and American Academy of Child and Adolescent Psychiatry practice guidelines. The patient had a history of high-risk behavior, the presence of major comorbid psychiatric disorders, a stressful recovery environment, conflict with parents, a need for ongoing multidisciplinary staff structure and interventions, and a need for careful medication monitoring.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested nasal repair surgery and related surgical procedures for the treatment of his obstructive sleep apnea and septal deviation. Findings:  The physician reviewer found that the records provided do not document that the requested surgical procedures are medically indicated or necessary. There is no documentation of an anatomically significant septal deviation and there is no documentation of any trials of medical allergy treatment for the patients congestion. The Health Plan has authorized UPPP and tonsillectomy for this patient. There is no evidence that he is likely to obtain added benefit from the other proposed procedures. Even with multilevel surgery, he may continue to have sleep apnea, daytime sleepiness and hypertension. All told, the patients clinical findings do not support the necessity of the surgical procedures in dispute.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested cognitive skills therapy for the treatment of the enrollees Aspergers disorder. Findings:  Two physician reviewers found that this patient has a diagnosis of Aspergers disorder with impairment in social functioning, impulse control, attention focusing and encopresis. Aspergers disorder and attention deficit/hyperactivity disorder are complex neurodevelopmental disorders that require various treatment modalities to maximize functioning and to address core difficulties. A trial on a psychostimulant was unsuccessful. Cognitive skills therapy was utilized to target multiple areas of impairment. This is a widely used and accepted approach in the community for the treatment of core symptoms of autism spectrum disorder. This approach is consistent with the American Academy of Child and Adolescent Psychiatry guidelines and the current literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patients language development appears normal. A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills. The submitted clinical documentation does not demonstrate that the patient had deficits in speech and language which necessitated speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. While school services are essential, they are not sufficient for children with the severity of deficits as seen in this patient. The more aggressively these deficits are targeted, the better chance this patient has for developing adequate skills to function in the community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism and mixed receptive/expressive language disorder. Findings:  The physician reviewer found that this autistic patient has profound speech delay, yet has developed some academic skills close to age level, which would imply normal or close to normal intellectual capacity. This implies that the possibility of language and communication skills to improve does exist. He presently is functioning at the 1st percentile for both receptive and expressive language.  He has failed to improve communication skills despite fairly intensive speech therapy. Myers and colleagues recommend extensive speech therapy for autistic children. The paper notes that the traditional, low-intensity pull-out service delivery models often are ineffective. Goldsteins paper deals with the potential success of various speech therapy techniques in improving communication skills in the autistic population. This patients pediatrician has been following the patient for at least two years and has recently recommended an increase in the intensity and frequency of speech therapy.  Speech therapy was medically indicated for this patient. Future speech therapy is also medically appropriate, and the patient should be reevaluated in one year to evaluate progress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the coccyx for an evaluation of her coccygeal pain. Findings:  The physician reviewer found that tumors in and around the sacrococcygeal area can present with coccygeal pain. Plain x-rays typically will not be very helpful because of the complex anatomy of this region. A patient presenting with persistent pain in this area warrants further diagnostic investigation and an MRI is likely to be helpful in diagnosing the source of the patients pain and could affect the plan of treatment. The clinical utility of MRI in this setting is well established, and as such, the study should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a 65-year-old male enrollee has requested continued stay at a skilled nursing facility (SNF) level of care for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that this patient required and continues to require the services of a skilled physical and occupational therapist to maintain and advance his functional status as he recovers from a ruptured Achilles Tendon and scapular fracture. These treatments could not be provided by alternative unskilled providers, and therefore are medically necessary. Skilled therapy services are needed on a daily basis, and given the extent of his impairments and the presence of multiple co-morbidities, these services are most appropriately provided in an inpatient setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 86-year-old male enrollee has requested a PET/CT scan for an evaluation of his adenocarcinoma of the lung. Findings:  Three physician reviewers found that the follow-up of adenocarcinoma is a known, acceptable, and reasonable use of a PET/CT scan. The patients PET/CT was not performed after the patients last cycle of chemotherapy was completely finished, but that does not negate its usefulness in this case. Studies support the clinical utility of PET/CT in this setting. All told, the PET/CT at issue aided in decision-making in terms of the ongoing care and management of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) scan for an evaluation of her osteopenia. Findings:  The physician reviewer found that even if this patient only has osteopenia at this time, the progression to osteoporosis can be prevented and risk for fracture decreased with the proper evaluation and pharmacological treatment. It is a good standard of care in the United States to order a DEXA scan in a postmenopausal woman with risk factors of osteoporosis. It is the gold standard among physicians who treat patients with osteoporosis to order a baseline bone density study at the onset of menopause and then order follow up scans to determine any progression into osteopenia.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 4-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. The patient in this case had developed a fever and upper respiratory symptoms the day prior. Although he reported neck pain, his neck was described as supple and the patient appeared well, and in no distress. It was noted that he in fact was ambulatory, and walking outside the exam room during his observation period in the emergency department. The patient required only pharyngeal swab testing and oral medication during his visit. The patients symptoms were not acute in onset. While a high fever and neck pain in a three-year-old patient might prompt a parent to seek care from a medical professional, immediate medical attention was not required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested revision of prior bariatric surgery for the treatment of her weight gain status post Lap Band surgery. Findings:  The physician reviewer found that the average weight loss under the best of circumstances with adjustable gastric banding (Lap Band) is 50% of excess body weight loss (EBWL).  The patient underwent Lap Band when she had a BMI of 52.6. She did not achieve adequate results with the Lap Band procedure. With a current BMI over 50, the patient is an appropriate candidate for revisional bariatric surgery with Roux-en-Y gastric bypass, which is medically indicated in this case to achieve adequate weight loss results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested follow-up services with her current podiatrist for the treatment of her fractured toe. Findings:  The physician reviewer found that this patient has several podiatric conditions which appear to be active from a review of the submitted medical records. Specifically, she has a recent fracture of her right 5th toe, a Morton's neuroma of her right foot, and bilateral heel spurs with secondary pain. The patient continues to be symptomatic. Thus, continued follow-up with the patients current podiatrist is medically appropriate and indicated given the patients combined foot impairments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan for an evaluation of her migraines and vertigo. Findings:  The physician reviewer found that this patient has had years of headache and dizziness. She has been diagnosed as having migraine, vertigo and tinnitus. Ear, nose, and throat testing had not suggested a retro-cochlear lesion. Prior imaging of the brain was normal. Evidence-based guidelines support the use of brain imaging in individuals with recent onset headache, with distinct change in headache pattern, or with abnormal findings on neurologic exam. Here, a neurologic exam is not recorded. The need for subsequent imaging of the brain is not supported by factors such as documented exam abnormalities, or unexplained change in headache pattern. All told, the necessity of the imaging studies performed are not documented in the clinical records provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested Lovaza for the treatment of his IgA nephropathy. Findings:  The physician reviewer found that the FDA approved indication of Lovaza is for adult patients with very high (greater than 500mg/dL) triglyceride levels. This patient had a normal level of creatinine and a low amount of proteinuria. All told, there is insufficient that Lovaza is medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested continued coverage of cancer treatment with a breast cancer specialist for her follow-up care for breast cancer. Findings:  The physician reviewer found that the negative features associated with triple negative state breast cancer and given her family history, the patient is likely to receive greater benefit from follow-up care with a breast cancer specialist who is knowledgeable regarding the clinical management of triple negative breast cancer. Furthermore, such a specialist is likely to be more knowledgeable of therapies for this subset of breast cancer patients and better informed of potential clinical trials for which she may be eligible should the need arise. Thus, the patient would be best served by a breast cancer specialist versus a primary care physician or gynecologist as proposed in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a total thyroidectomy by an ear, nose, throat (ENT) surgical specialist in the treatment of complex re-operative thyroid procedures that has a high volume of experience for the treatment of her multi-nodal goiter. Findings:  The physician reviewer found that this patients surgery is high-risk and should be carried out at a center specializing in the treatment of complex re-operative thyroid procedures that has a high volume of experience. The other issue at question is whether the surgery should be performed by an ENT surgical specialist or a general surgeon. Although both are trained in thyroid surgery, there is a possibility that this patient may also require a neck dissection. Thus, it is appropriate that she be referred to an ENT surgical specialist, as the volume of neck dissections performed by ENT surgeons is far greater than that performed by general surgeons.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested an osteochondral allograft transplant of the right ankle for the treatment of her right ankle condition. Findings:  Two physician reviewers found that the use of allograft transplant for such an extensive lesion is not supported by Level I-III evidence. While in such a difficult case ongoing problems after arthrodesis are likely, the proposed allograft transplant is not likely to be result in a superior outcome for this patient and will likely fail with subsequent need for further procedures.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees autistic spectrum disorder. Findings:  The physician reviewer found that the requested speech therapy is medically indicated for treatment of this patient. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health.  Specific treatment, including speech therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. All told, speech therapy for this patient at the frequency requested is necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that this patient has been receiving speech therapy in a pull-out public school setting. During this time, the patient made no advancement in language development as demonstrated by two testing agencies. Myers and colleagues noted that the low intensity pull-out speech therapy delivery model is often ineffective. Speech therapy is medically indicated and appropriate for this patient, and Goldsteins paper cites the success of such programs. Myers and colleagues also noted that occupational therapy for autistic children is difficult to research due to difficulties in setting up double-blinded studies. In this patients case, occupational therapy is medically indicated at this time, and the need for continued occupational therapy should be evaluated in one year.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested thighplasty and suprapubic area plasty with skin excision for the treatment of her chronic skin ulcerations status post bariatric surgery. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested surgery is reconstructive in nature. The patient has generalized skin laxity associated with weight loss. The photographs provided do not demonstrate that the degree of excess skin is so severe as to constitute an abnormal structure of the body. In the absence of evidence that the patients excess skin condition constitutes an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed surgery does not meet the definition of reconstructive surgery as defined by California law. Concerning the medical necessity of the proposed surgery, there is insufficient evidence of a functional impairment to support a thighplasty and suprapublic area plasty. The requested surgery has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patients history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of infections in the thigh folds. Furthermore, photographs documenting cellulitis, ulcerations or rashes were not submitted. The plastic surgeons office notes describes a history of thigh and mons pubic infections but do not document any medically supervised attempts at conservative management of this condition. The medical records do not provide any documentation in the form of frequent physician visits to the patients primary care physician or plastic surgeon for the management of ongoing clinically significant dermatologic problems that have either: 1) never responded to topical therapy; or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that autism is believed to be a congenital dysfunction of brain circuitry resulting in profound communication defects and lack of social development. Effective interventional therapy involves one-on-one speech therapy as well as occupational therapy.  Autism is a recognized neurological disorder and requires medical therapy. This patients language and sensory deficiencies have been fully documented. The speech and occupational therapies requested for this patient are medically indicated. This should be continued for one year, and the patients progress should be reevaluated at the end of the year to determine progress and the need to continue services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested inpatient treatment at a neuropsychiatric hospital for the treatment of the enrollees psychosis, not otherwise specified.  Findings:  The physician reviewer found that this patient presents with complex symptomatology. There is limited documentation of an evaluative child psychiatry workup. At the present time, it is not safe to transfer this patient home. She presents a danger to others, especially her sibling. She remains severely disturbed and continues to possibly be psychotic. There is a real and compelling danger that she will decompensate further without continued care and proper supervision. Accordingly, the patient should remain in an acute inpatient psychiatric hospital until an appropriate less restrictive setting is found. Until the patient is able to be transferred to an appropriate less intensive level of care, evaluation and titration of medications should be continued as an inpatient, under the direction of a child and adolescent psychopharmacologist and psychiatrist, if possible.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested meniscal allograft transplantation of the knee, osteochondral autograft, arthroscopic lavage and arthroscopic debridement for the treatment of her osteoarthritis of the knee. Findings:  Two physician reviewers found that meniscal allograft transplantation is an accepted procedure for this subgroup of patients. Although long-term outcomes remain unproven, the alternatives (unicondylar knee replacement and total knee replacement) are even less well understood in the young patient. Given the severity of the patients condition, and the absence of more effective alternatives, meniscal allograft transplantation and associated procedures were an appropriate option for the patient and should be covered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested cyclophosphamide for the treatment of her systemic scleroderma. Findings:  Two physician reviewers found that this patient has scleroderma which is becoming more severe. She is quite ill and there are no guidelines for treatment in this particular setting. It is stated in the literature that Cytoxan for one year may be of some help in treating the lung disease associated with scleroderma. However, the patient has already received Cytoxan. In addition, there is no evidence that Cytoxan can improve the gastrointestinal involvement. All told, there is inadequate evidence that additional use of Cytoxan is likely to be efficacious in this setting.