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

The parent of a 16-year-old female enrollee has requested adolescent psychiatric residential treatment services for the treatment of the enrollees mood disorder, not otherwise specified, and polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has had outpatient treatment, which she left prior to completing. She has also intermittently taken Wellbutrin. There is no evidence the patient had any other outpatient treatment, partial hospital treatment or intensive outpatient treatment prior to her admission to the residential treatment center. Based upon the psychiatric evaluation, medical management notes, monthly resident review and milieu progress noted, the patient has had no psychotic symptoms during her inpatient admission and there is no evidence she is at risk of harm to self or others. As of a recent progress note, the patient had not been prescribed any psychotropic medication. All told, the medical necessity of adolescent psychiatric residential treatment services has not been established. This patient could have been effectively and safely treated at a lower level of care
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency involves acute symptoms of such severity that a prudent layperson would believe that her health would be at risk without immediate medical attention. This patient presented with swelling and redness of her right knee. Her symptoms had been worsening over the course of one week. Her physician was concerned that the patient may have developed a recurrent deep vein thrombosis. It was appropriate for this patient to have been emergently evaluated, including an INR check and venous Doppler exam. A prudent layperson in this situation would have reasonably believed her health was in serious jeopardy without immediate medical attention. With regard to the acute hospital care provided on some of the dates of service in question, the submitted documentation does not demonstrate that these services were medically necessary. The venous Dopplers were negative for deep vein thrombosis, and the patients white blood cell count was normal. The elevated INR in and of itself did not require inpatient treatment for adjustment of the patients Coumadin dose, as the patient was not exhibiting signs of active bleeding. There is no documentation that the cellulitis was circumferential or involved more than 50% of the involved extremity. The patient had not failed a trial of outpatient antibiotics. Her vital signs were stable during the entire course of her stay. All told, the patient was appropriate for outpatient treatment with oral antibiotics during the dates of service at issue. Thus, the patients symptoms on the initial date of service met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health. However, acute hospital care services provided on the additional dates of service were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested continued treatment with Aciphex 20mg for the treatment of his severe laryngopharyngeal reflux disease. Findings:  The physician reviewer found that the Health Plan has formulary proton pump inhibitors (omeprazole, Prevacid and Nexium) that are at least as potent and efficacious as Aciphex. The Health Plans requirement that the patient attempt an eight-week course of two of the three formulary proton pump inhibitors (omeprazole, Prevacid and Nexium) is a reasonable requirement for assessing the effect of such medication. The submitted medical records do not demonstrate that the patient has tried the preferred proton pump inhibitors for eight weeks. As such, the patient should attempt appropriate trials of two of the formulary proton pump inhibitors as recommended by the Health Plan. If the patient does not respond to the preferred proton pump inhibitors, then treatment with Aciphex 20mg would be medically indicated.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she 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 suffering from emesis (vomiting) for two days and diarrhea for one day prior to her visit. Although she had nausea, there is no indication that she was continuing to experience vomiting on the day she presented to the emergency department. She denied any hemorrhage or abdominal pain. Her vital signs were described as normal. Her physical exam was unremarkable. The only testing performed was a urinalysis. No blood testing was ordered. There is no documentation that the patient was dehydrated or unstable, either by vital signs or lab data. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe she was at risk of serious jeopardy to her health, serious impairment to bodily function, or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet Californias definition of an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Lap-Band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 40. This meets the recommendations set by the National Institutes of Health for weight loss surgery. The patient has also documented multiple attempts at weight loss, including numerous diets, over-the-counter pills and phentermine. Weight loss surgery has been demonstrated to be superior to diet and exercise plan for the treatment of morbid obesity. It is not likely that the patient will achieve and maintain adequate weight loss without surgical intervention. This patient is an appropriate candidate for the Lap-Band procedure, and the procedure is medically indicated to treat her morbid obesity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested a PET scan for an evaluation of her gastrointestinal stromal tumor. Findings:  Two physician reviewers found that gastrointestinal stromal tumors are rare malignancies, but recent literature indicates a vital role of PET imaging in the staging and evaluation of treatment for recurrence. There is peer-reviewed literature concerning this particular tumor and the use of PET imaging. The American Cancer Society has stated that PET imaging is the most promising tool to date for the detection of such a tumor. In this patients case, CT of the liver was equivocal. The use of PET scan would not only allow for the evaluation of possible hepatic metastasis, but also allow for a way to evaluate the response to therapy given to date.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested continuation of psychotherapy treatment for the treatment of his panic disorder. Findings:  The physician reviewer found that this patient appears to be finalizing his treatment which has been beneficial. The goals for the final phase of treatment should include continued efforts to confront his fears, continued application of acquired skills and treatment gains, reduction of dependence on his treating provider, transference resolution, and termination of treatment. In consideration of the long-term treatment effort and relationship with his treating provider, it would not be appropriate to simply transfer the patient to another in-network provider to complete treatment. This final phase of treatment can reasonably be completed within six months of the date of this decision and should involve no more than 26 additional treatment sessions with his current provider. If the patient regresses and becomes more symptomatic during this final phase of treatment or subsequent to termination, an alternative treatment course should be pursued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested photodynamic therapy and Visudyne for the treatment of his central serous retinopathy. Findings:  The physician reviewer found that  the standard of care in the treatment of CSR is still observation. Studies have shown that the final visual outcome is essentially the same whether the retina is treated with laser or just observed. There is evidence that the eye treated with laser has a better chance of recovering more quickly than observation, but unless there is a significant reason the patient requires a faster recovery (i.e., bilateral involvement with poor vision in the better eye), observation is still considered the standard of care. Recent studies have suggested that low dose PDT with Visudyne can result in safely reducing the subretinal fluid in patients with CSR more quickly than observation. That said, there has not been a large, prospective, randomized study showing that the final visual outcomes are better in patients treated with low dose PDT with Visudyne compared to those who received no treatment. If patients present with poor vision in both eyes, PDT is medically appropriate, however, this patients vision was 20/20 to 20/25 in the left eye. In sum, low dose PDT with Visudyne is not the standard of care, nor has it been shown in large prospective studies to be better than the standard of care of observation in patients with CSR.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-month old female enrollee has requested a custom remolding orthotic (pediatric/custom cranial device) for the treatment of the enrollees positional plagiocephaly. Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface (such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy) for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position (e.g., the American Academy of Pediatrics Back to Sleep recommendations). Brachycephaly is generally defined as a cephalic index of greater than 81%. This patient has a cephalic index of 89.5%. The most frequent cause is constant supine positioning during infancy. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (see Biggs). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. The American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants and found, Management of deformational plagiocephaly involves preventive counseling of parents, mechanical adjustments, and exercises  Skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. Surgery is rarely necessary but may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis. This patient was born with cranial asymmetry as a result of intrauterine positioning. Her cephalic index of 89.5% meets the definition of brachycephaly, and approximates the severe range of deformation. She has failed standard treatment recommendations for positioning. Her cranial asymmetry is exacerbated by plagiocephaly and macrocephaly, resulting in significant deformity. Based on the standard of care described above, the custom orthotic device was medically necessary and appropriate for this infant to prevent future complications and permanent deformity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that although the patient stated he did not intend to hurt himself or others, this was not necessarily the case given his documented ODD and history of lying. Many patients falsely deny such feelings. Thus, it is necessary to consider the actions of the patient rather than to solely rely on his statements. It is clear from the attending notes that the treatment team felt that the patients actions showed him to be at risk until the date of discharge. There were valid reasons for his inpatient level of care including the need to assess this patient in a setting away from home by trained observers in order to properly diagnose his problems and assess his response to treatment. This patient had multiple problems, especially his severe PTSD. His feelings towards his father and brother were clouded by his PTSD symptoms. Only through observation by skilled professionals in a structured environment was it possible for the treatment team to sort out the various influences affecting the patient, and develop an appropriate treatment plan. Furthermore, this patients high risk of relapse from a premature discharge was a clinical indication for continued acute inpatient psychiatric care. In summary, the patient was not appropriate for treatment at a less intensive level of care during the period in question.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested emergency services for her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she 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. The submitted medical records indicate the patients symptoms had commenced one week prior to her exam. Her symptoms consisted of vaginal itching. She did not report any abdominal pain, vomiting, fever, or any other ominous symptoms. The patients physical exam was unremarkable, and she did not require any medications in the emergency department. The records provided do not document the presence of severe vaginal discharge or pain that would likely preclude one from driving. Further, although the patient reports no history of yeast infections, prior to presenting to the emergency department she had tried an over-the-counter medication for yeast infection which had provided some relief. All told, a prudent layperson in this patients circumstances would not reasonably expect the absence of immediate medical attention to result in serious jeopardy to her health, impairment to bodily function or serious dysfunction of a bodily organ or part. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis. This patients symptoms do not meet the criteria for an emergency medical condition under California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested adolescent substance residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that residential placement was not medically necessary. The records indicate there were no detoxification risks or co-occurring medical issues that required monitoring. In addition, according to the treating psychiatrist and the Intake Assessment, the patient did not have prior consistent treatment for substance abuse and had not demonstrated an inability to address his substance abuse issues in a less restrictive setting. Furthermore, the patient was without any suicidal or dangerous ideation on admission or at any time during this stay. He demonstrated no safety issues that required 24 hour monitoring or supervision.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested physical therapy for the treatment of her neck and back injury. Findings:  The physician reviewer found that this patient continues to have neck and back pain secondary to trauma. Physical therapy is standard practice for the patient's injuries and resulting functional impairment. The specific interventions proposed by the physical therapist are appropriate for the patient's condition. Specific goals for the treatment sessions have been well-documented, and these goals appear obtainable in a reasonable and predictable period of time. Since the patient continues to respond and progress with the proposed treatments and failed an attempt at a home exercise program, additional skilled services by a physical therapist were and are medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a repeat colonoscopy for an evaluation of her risk for colon cancer. Findings:  The physician reviewer found that this patient is recommended to have a repeat colonoscopy every five years since she falls in the high-risk category based on her family history and personal history of cancer. Winawer and colleagues guidelines suggest that patients with first degree relatives who have colon cancer should be screened starting at 40 years of age and with follow-up testing every 5 years thereafter. In addition, patients with a personal history of cancer may also be at an increased risk for colon cancer and should be followed accordingly. This patient has a family history of colon cancer and a personal history of breast cancer. In congruence with the American Gastroenterological Association (AGA) guidelines discussed by Winawer and colleagues, this patient should have a repeat screening for evaluation of her risk for colon cancer, and as such, the procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested gastric electrical stimulation for the treatment of her severe gastroparesis. Findings:  Two physician reviewers found that the alternative treatments available in this setting including parenteral nutritional support and surgical intervention are inappropriately invasive at this juncture. The GES is a widely accepted treatment for refractory gastroparesis. Mearin and colleagues note that, For several years, treatment in the most severe cases has consisted of implantation of a gastric pacemaker. Although the results are far from perfect, new data were presented that allow better patient selection to achieve greater symptom control. This statement is consistent with the conclusion by Patrick and Epstein as well as Waseems comment that the GES will offer benefit to patients with refractory gastroparesis. All told, the GES has been proven to be safe and effective in the scientific literature and is appropriate for use in patients such as this patient with documented refractory gastroparesis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested Avastin for the treatment of his progressive metastatic schwannomas with hearing loss. Findings:  The physician reviewer found that this patient has been diagnosed with recurrent schwannomas. There is a lack of compendium-listed treatment options for refractory schwannomas. The use of Avastin for treatment of this disease has been studied in a peer-reviewed, published, clinical trial and was found to be tolerable and effective. The study by Plotkin and colleagues concluded that Avastin was associated with a reduction in the volume of most growing vestibular schwannomas and improved hearing in some patients. Based on the rarity of the disease, the lack of other treatment options and the proven efficacy in a clinical trial, the use of Avastin is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a colonoscopy for an evaluation of his risk of colorectal cancer. Findings:  The physician reviewer found that the American Gastroenterological Association (AGA) clinical guidelines and rationale for colorectal cancer screening, patients with only 1 or 2 small (measuring less than 1 cm) tubular adenomas with only low-grade dysplasia should have a repeat colonoscopy every 5 -10 years. These criteria are reiterated by the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG). This patient had one polyp measuring less than 1 cm identified as adenomatous, which was non-dysplastic. This patient does however have a family history of colorectal cancer. Therefore, the clinically appropriate management would be to perform a follow-up colonoscopy five years after the initial screening with polyp removal.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested speech therapy for the treatment of her autism. Findings:  The physician reviewer found that this patient meets general pediatric practice guidelines for continued speech therapy services. The services are requested to treat autism, which is considered an illness. Further, this patient is making progress toward specific goals as documented in the records provided for review. This patient requires the expertise of a skilled speech and language pathologist who is trained to facilitate patients optimization of speech and language skills, especially in those patients with autism. As noted by Paul in his recent publication, Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words. Aman agrees that the clinical data suggests that patients with autism spectrum disorders obtain lifelong gains in functioning as a result of early intervention with speech and language therapy.