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

A 57-year-old male has requested proton beam radiation therapy for treatment of his adenocarcinoma of the prostate.   Findings:  Three physician reviewers found that the patient has a recent diagnosis of low-risk, early-stage prostate cancer.  Per the medical records, his pretreatment prostate specific-antigen (PSA) was 4.1, and core biopsy demonstrated Gleason 6/10 adenocarcinoma involving 4 of 7 cores from the right side.  The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability. Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies, are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.  Proton beam radiation therapy is an accepted, safe and effective treatment modality for prostate cancer.    However, the current medical literature has not demonstrated the superior efficacy of proton beam radiation therapy in this clinical setting.  Vargas and colleagues noted that proton beam radiation therapy yielded improved normal tissue sparing as compared to intensity modulated radiation therapy.  However, other accepted technologies, such as image-guided radiation therapy, with daily CT, and imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing, and these technologies were not investigated in that paper.  Some assert that that proton therapy could lower the risk of second radiation-associated malignancies.  However, there is a lack of published clinical data that demonstrate this.  Thus, the superior effectiveness of proton beam radiation therapy over intensity modulated radiation therapy in reducing radiation-associated malignancies has not been established.  In sum, there is a lack of data demonstrating that proton beam radiation therapy is likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested approval for 90 days of residential chemical dependency treatment or admission to residential chemical dependency treatment for treatment of her chemical dependency.   Findings:  The physician reviewer found that based on review of the available records, this patient presents without an acute medical or psychiatric condition. She has been successfully treated in an outpatient setting in the past. In addition, she completed a 30 day rehabilitation program but did not comply with her outpatient care recommendation to live in a sober house. She now agreed to a residential program to avoid further legal difficulties. The requested services are not medically based and are not supported by current placement criteria or practice guidelines from the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested coverage for spine surgery for treatment of the enrollees neck pain and arm pain. Findings:  The physician reviewer found that anterior cervical decompression and fusion may improve cervical radicular symptoms in patients who have pain and loss of strength and sensation who have not responded to conservative management.  Many patients with cervical spondylotic myelopathy respond to conservative treatment, especially those with mild signs.  However, there is a lack of evidence in the medical literature supporting surgery, as opposed to conservative management, with regard to long-term benefits for patients with degenerative radiculopathy or myelopathy.  At this time, further large-scale randomized trials are needed.  In this patients case, there is a paucity of documentation to support the diagnoses of myelopathy and radiculopathy.  The electromyography/nerve conduction velocity studies do not indicate the presence of an acute process.  The reports of the CT scans do not document the presence of an anatomic change over time.  The providers report of an MRI showing a large herniation at C5-6 is not accompanied by reports of neurologic findings on examination.  There is a lack of documentation of any conservative care since the initial surgical procedure.  All told, the requested spine surgery is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old male has requested coverage for emergency services.   Findings:  The physician reviewer found that the patient presented to the emergency department for evaluation of a dry cough for two weeks that was not improving. A medical screening exam was performed which revealed that he was afebrile with a normal respiratory rate, heart rate, and pulse oximetry on room air. Testing was performed to include an EKG, lab tests and a chest x-ray, but the patient left the emergency department prior to being seen by the physician on duty. Subsequently, he went to an Extended Hours Clinic and was seen by a physician assistant. Again, the patient was noted to be afebrile with a normal pulse, respiratory rate and pulse oximetry. Pain was not a presenting complaint, and no pain level was documented. The patient reported he had a dry cough for four weeks that was not improving, and felt short of breath. A history of asthma was noted. The physical examination was noted to be normal including that he was in no apparent distress, and the results of the studies obtained a few hours earlier at the emergency department were reviewed. The EKG and labs tests were unremarkable, but the chest x-ray showed lingular atelectasis versus an infiltrate compatible with pneumonia. The patient was diagnosed with pneumonia and cough and discharged from the clinic with prescriptions for Levaquin, Robitussin, and Tessalon Perles. He was instructed to follow-up with his primary care provider in one to two days.  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.Review of the submitted evidence demonstrates that the patient had a dry cough for approximately two to four weeks. It was not associated with fever or chest pain, and the associated shortness of breath was not documented to be severe. The patients temperature, respiratory rate, and pulse oximetry were normal, and the patient was noted to be in no apparent distress. While the patient was diagnosed with pneumonia and did require medical attention, the submitted documentation does not demonstrate he was experiencing acute symptoms that required immediate attention. The fact that the patient left the emergency department without being seen by a physician is not consistent with the actions of an individual who believed he or she was experiencing a medical emergency. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention in an emergency department.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male has requested coverage for past sub-acute substance abuse residential treatment provided for treatment of his alcohol dependence.   Findings:  The physician reviewer found that the patient has a history of alcohol dependence.   His pattern of drinking was causing family discord.  However, his spouse was listed in the record as supportive.  The patient denied any physical complaints or history of complicated withdrawal, seizures, or delirium tremens.  At the time of presentation, the patient had been sober for four days and was not taking any medication.  The submitted documentation fails to demonstrate the medical necessity of the services at issue.  The documentation provided did not include severity-of-illness and level-of-function multidimensional assessments that would justify residential services.  Per the American Psychiatric Association, residential treatment is indicated for patients who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack substance-free social supports or sufficient motivation to remain abstinent in an ambulatory setting.  In this patients case, he was motivated for care.  He had good family support.  Aside from irregular participation in Alcoholics Anonymous, he had not trialed any less restrictive interventions.  The current medical evidence does not support the services at issue in this clinical setting.  Considering these factors, intensive outpatient or partial hospitalization program level of care would have been medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer status post cyst removal and biopsy.  Findings:  Two physician reviewers found that the patient has a history of bilateral reduction mammaplasty, and right breast surgical excision. Magnetic resonance imaging (MRI) of the breast was last performed a year ago, with indication of routine follow-up due to increased risk of breast cancer. The patient has heterogeneously dense breasts on mammography. There is no documented family history of breast or ovarian cancer. The patients MRI was BIRADS-0, and the provider noted that both breasts require further evaluation with a second look ultrasound. On the left side, there was a 6 mm enhancing nodule retroareolar region. a month subsequent, a second look ultrasound was performed and stated that MRI findings correlated to benign nodules. A six month follow-up ultrasound was performed, which was BIRADS-2, and a routine mammogram was recommended in six months. The American College of Radiology (ACR) criteria recognize the increased sensitivity of MRI in the screening of high risk patients. Based on the records provided for review, the patient is not considered high risk. Therefore, the patient does not meet the ACR criteria for 20-25% risk and the requested MRI is not clinically indicated for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male has requested Ambien CR 25mg (12.5mg x 2 tablets per day) and Adderall XR 75mg (25mg x 3 capsules per day for treatment of his attention deficit/hyperactivity disorder and insomnia.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities.  In this patients case, the dosage of these medications exceeds the recommended limits established by the United States Food and Drug Administration.  The patient weighs 270 pounds and reportedly requires two Ambien CR tablets to sleep as well as high-dose, long-acting stimulant for his attention deficit/hyperactivity disorder due to a 4-hour to 5-hour duration of effect of his medication.  There is a lack of well-developed studies in the peer-reviewed literature that supports treatment with Adderall XR at a dose of 75mg daily.  The fact that a common side effect of stimulant medication is insomnia supports the notion that the current dosing of Adderall XR may be generating the need for the high-dose Ambien.  Additionally, there is a lack of well-developed studies in the peer-reviewed literature that demonstrates both superiority and safety of Ambien CR 25mg (12.5mg x 2 tablets per day).  In this case, the specific outcomes of previous systematic medication trials and non-medication therapies, such as cognitive behavioral therapy for insomnia, are unknown.  In the absence of evidence-based literature supporting this particular regimen, the requested medication quantities are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 21-month-old female enrollee has requested coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she demonstrates expressive language skills below those of her peers, limiting her ability to communicate effectively.  The current medical literature supports speech therapy in this clinical setting.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested coverage for past and future transcranial magnetic stimulation and maintenance every two months or as needed for treatment of his mental health conditions.   Findings:  Three physician reviewers found that the patient has a history of mood and anxiety symptoms.  Per the medical records, he has a history of alcohol dependency and was reportedly in remission.  Last year, his treating psychiatrist noted the diagnosis of bipolar disorder.  His symptom complex consisted of low energy, anhedonia, depressed and sad mood, feelings of worthlessness, excessive pessimism, hypersomnia, and suicidal ideation.  The patient had trialed multiple medications, including Remeron, Paxil, Cymbalta, Lexapro, Wellbutrin, Lamictal, Depakote, Strattera, Klonopin, propranolol, Provigil, topiramate, Ritalin, Concerta, Adderall, and Vyvanse.  As noted by the provider, psychopharmacotherapy has not achieved remission.    The superior efficacy of transcranial magnetic stimulation has not been established in this patients case.  The patient was diagnosed with bipolar disorder.  There is a lack of well-controlled and adequately powered exploratory and confirmatory studies supporting the use of transcranial magnetic stimulation for patients with this condition.  Therapeutically, there was no mention of intermediate treatment settings, such as intensive outpatient or partial hospitalization programming.  This patient has trialed multiple medications, but he has not exhausted commonly utilized augmentative strategies, such as lithium, buspirone, thyroid hormone, quetiapine, or aripiprazole.  Further, he has not trialed antidepressants from alternative classes.  Finally, there is no reported contraindication to electroconvulsive therapy.  Electroconvulsive therapy remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured.  There is a lack of well-designed studies demonstrating the superior effectiveness of transcranial magnetic stimulation as compared to electroconvulsive therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested nipple AlloDerm insertion for treatment of her medical condition status post bilateral mastectomy.  Findings:  The physician reviewer found that the patient underwent bilateral skin sparing mastectomy for breast cancer four years agowith removal of the nipples.  She now has bilateral silicone breast implants under the muscle.  Multiple attempts at nipple reconstruction have been made.  The submitted photographs show symmastia, joining of the inframammary folds across the midline, horizontal scars in the outer half of each reconstruction with the right one being indented, a small barely protruding right nipple, and a left nipple that is only visible because of its difference in color versus the surrounding skin.  The submitted photographs support the medical necessity of the requested nipple AlloDerm insertion.  This patients condition constitutes an abnormal structure of the body caused by the surgical treatment of cancer.  Per the photographs, the nipples have not been adequately reconstructed.  A number of reconstructive techniques have been described for nipple reconstruction, including skin grafts, composite grafts, and various local flaps.  As noted in the current literature, the use of AlloDerm in nipple reconstruction can lessen or prevent flattening of reconstructed nipples and produce projection.  Of note, the medical literature supports the use of AlloDerm to bolster skin flap reconstruction.  As long as this patients surrounding tissue will sustain a local flap, then the requested services are indicated.  There is a lack of support for the use of AlloDerm to create or preserve nipple projection in the absence of such a local flap.  All told, the requested nipple AlloDerm insertion is reconstructive in nature and is medically necessary for the treatment of this patient
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a then three-year-old male has requested coverage for past emergency services provided.   Findings:  The physician reviewer found that the patient, a then three-year-old male, was brought to the emergency department with a chief complaint of right earache for two days which woke him from sleep acutely on the day of presentation. He had a history of bilateral ear tubes.  The patients parents had noted bloody purulent drainage from the right ear. Vital signs included temperature 99.9, pulse 132, respirations 28, and oxygen saturation at 98% on room air. The physician noted that the right tympanic membrane showed decreased landmarks and erythema and the patient was diagnosed with otitis media and was prescribed an antibiotic and pain medication.At issue in this case is whether a prudent layperson would have sought immediate medical attention for the patient 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.Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention for this patient given his symptoms of acute severe ear pain, purulent and bloody drainage from his ear, and history of significant ear problems in the past. The patients symptoms were concerning for serious impairment of hearing and worsening infection. Based upon the severity of the patients symptoms and their sudden worsening in the middle of the night, the parents decision to seek immediate medical attention for the patient was consistent with the response of a prudent layperson in this situation.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 33-year-old female has requested coverage for past emergency services.   Findings:  The physician reviewer found that the patient presented to the emergency department with chief complaint of severe left ear pain, fever, difficulty hearing out of the left ear and cough for 14 days. The emergency department triage records indicate the patient began experiencing a fever earlier that day and had severe pain as well as difficulty hearing out of her left ear. The patient reported her pain as a 9 on a scale of 1 to 10. The patients vital signs included temperature 99.9 degrees, pulse 90, respirations 16, and oxygen saturation 100% on room air. The patient was assessed with upper respiratory infection and otitis media left ear. She was prescribed Z-Pak and Vicodin and was discharged from the emergency department.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.A prudent layperson would have sought immediate medical attention on the disputed date of service due to symptoms including severe ear pain, fever, and cough. The submitted medical records document the patients pain level as 9 on a scale of 1 to 10. Based upon the definition of emergency medical condition stated above, the presence of severe pain is an appropriate indication for seeking immediate medical attention. Further, the absence of immediate medical attention in this setting had the potential to result in serious impairment of hearing, worsening infection and risk for sepsis, meningitis and other infectious complications. All told, the patients decision to seek immediate medical attention was consistent with the response of a prudent layperson in this situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male has requested continued treatment/monitoring by an orthopedic oncologist, as opposed to an oncologist with a specialization in hematology for treatment of his status post curettage and cementation of a low-grade chondrosarcoma of the left proximal humerus.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  The Health Plan has offered follow-up care by an in-network oncologist.  Based upon the medical records, this alternative treatment is medically appropriate.  This patient has no active disease, and his current surveillance consists of regular CT scans.  At this time, the in-network provider can adequately manage this patients care.  Presently, this patient is at low-risk and can undergo surveillance within the Health Plans provider network.  However, if there is evidence for a local recurrence, then follow-up with the orthopedic oncologist would be appropriate.  All told, the requested continued treatment/monitoring by an orthopedic oncologist, as opposed to an oncologist with a specialization in hematology, is not medically indicated in this patients case at this time.