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

A 48-year-old male enrollee has requested for endovenous laser ablation of the accessory greater saphenous vein of the left leg for treatment of his varicose veins.  Findings:  Three physician reviewers found that EVLT is often useful for large branches, particularly when they are long, straight segments that are essentially part of a paired saphenous system. Neovascularization is a recognized phenomenon, particularly following saphenofemoral junction dissection. However, there is limited data pertaining to the use of EVLT for accessory veins (i.e., not one of the major saphenous branches). The alternative standard treatment for accessory veins is to remove the branch via stripping or phlebectomy, or to use some form of sclerotherapy, although this tends to have a high rate of recurrence. With the appropriate anatomy, an endovenous approach does tend to be associated with less morbidity. Thus, the use of EVLT for accessory veins which are essentially acting as the greater or small saphenous vein is medically reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for speech therapy for treatment of her dysarthria and aphasia secondary to stroke.   Findings:  Three physician reviewers found that the submitted clinical evidence demonstrates this patient experienced a stroke with resultant deficits in language and speech. Speech therapy is a vital part of the rehabilitative process. As this patient has aphasia, this indicates a language processing problem that is best treated with speech therapy. By definition, all language issues, including verbal and auditory memory, are affected by left-hemispheric strokes in the left middle cerebral distribution. The records indicate the proper use of typical and standard speech therapy techniques in treating this aphasic patient. The type of speech therapy utilized in this case includes some cognitive techniques and is appropriate to treat the patients speech disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested Botox injections for the treatment of her jaw pain status post traumatic injury. Findings:  Three physician reviewers found that Botox works by paralysis of the muscle tissue. The theory behind its use in patients with TMD is that it will decrease muscle tonicity and relax overactive muscles associated with the TMJ to alleviate hyperactive muscle pain and tension on the TMJ. The National Institute of Dental and Craniofacial Research assert that Botox is not approved by the U.S. Food and Drug Administration (FDA) for TMD and studies are currently ongoing. Further, Botox is not discussed in detail in these recommendations, rather the lack of medical literature proving the safety of Botox for this condition was addressed. Ultimately, the scientific data does not support Botox as an established therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a laparoscopic partial hysterectomy for the treatment of her menorrhagia. Findings:  The physician reviewer found that this patient has debilitating menorrhagia and menstrual pain despite using oral contraceptives. She has already attempted hormonal treatment for her condition. The patient has also had an endometrial evaluation via biopsy showing weakly proliferative phase endometrium. Given this result, and the finding of a very thin endometrium on ultrasound, a hysteroscopy or a dilation and curettage would not be useful, and would only add surgical risk without anticipated benefit if performed in this case. As noted in the American College of Obstetricians and Gynecologists (ACOG) Guidelines for Womens Healthcare, women with anovulatory uterine bleeding who have failed medical therapy and no longer desire future childbearing are candidates for endometrial ablation or hysterectomy. Although endometrial ablation is an option that could be pursued for treatment of the patients heavy periods, it is not likely to be as effective for treatment of her menstrual pain as partial hysterectomy. In this patients case, a laparoscopic partial hysterectomy is more appropriate than the alternatives specified by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested a knee ligament stabilizing brace for treatment of her left knee condition status post anterior cruciate ligament (ACL) surgery. Findings:  The physician reviewer found that a functional knee brace for the purpose of protection of the knee in high impact athletic sports injury for a period of one year after an anterior cruciate reconstruction has not been demonstrated to be beneficial in the medical literature. Wright and Fetzer noted that the use of bracing did not demonstrate improved outcomes in pain, range of motion, graft stability or protection from injury. Sterett and colleagues showed that high demand skiers who had had bracing after ACL reconstruction (compared with non-braced skiers) did receive protection from re-injury to a degree of statistical significance. However, the authors questioned whether these findings could be generalized to other high impact sports activities. McDevitt and colleagues studied a young, active population status post ACL reconstruction and found that no benefit could be detected from the use of functional bracing. The braced group was instructed to wear an off-the-shelf functional knee brace for all cutting, pivoting, or jumping activities for the first year after surgery. The conclusion was that post-operative bracing does not appear to change the clinical outcomes after ACL reconstruction.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested brachy radiation for treatment of her condition status post excision of pterygium with conjunctival autograft.  Findings:  The physician reviewer found that the use of additional prophylactic therapy for a primary pterygium, such as Beta irradiation, is not the standard of care due to associated risks including scleral melting with possible secondary infection. Further, the scientific literature lends support to the use of supplementary therapies such as Beta irradiation only when a patient later requires removal of a recurrent pterygium. The standard of care remains primary pterygium surgery with a conjunctival autograft without prophylactic Beta irradiation therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested neuromuscular junction testing for evaluation of his chronic bilateral heel pain. Findings:  The physician reviewer found that standard ultrasound or magnetic resonance imaging (MRI) scan can document chronic inflammation of the proximal plantar fascia that can predispose the lateral plantar nerve to entrapment. There is no evidence that neuromuscular junction testing is more appropriate than these diagnostic modalities. In fact, review of the medical literature reveals no peer reviewed outcome data from large scale, randomized, controlled studies supporting the diagnostic value of neuromuscular junction testing in this setting. At this time, there is inadequate evidence demonstrating that the proposed testing will influence therapy or result in an improved outcome in this case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe their child 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 presented to a hospitals emergency room after two to three episodes of clear emesis (vomiting). He had potentially been exposed to human feces in a swimming pool earlier in the day. His symptoms had resolved, and he was in no distress upon presentation to the emergency room. Vitals were stable. He did not have diarrhea or bloody stool. The patient was described by the triage nurse as happy, smiling, playful, and comfortable. While the patients symptoms may have warranted a medical evaluation, that evaluation did not need to be provided on an emergency basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the Rabkin study concludes, LapDS [duodenal switch] is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated. Thus, the available scientific literature demonstrates the duodenal switch procedure is an accepted procedure and is clinically indicated for this patient. It is considered to be an appropriate and standard primary treatment for obesity, and is approved by the American Colleges of Surgeons, ASMBS, SAGES and CMS based on available medical evidence and long-term follow-up of over 10 years.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested for aquatic physical therapy for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that there is a lack of long-term controlled studies on physical therapy for osteoporosis or chronic pain from metastases of lymphoma, there are studies that document good reduction in pain with short-term therapy. The patients physical therapist documented improved strength to near normal or normal and reported no pain at rest. However, the patient continues to have pain after periods of movement. Thus, pain reduction continues to be an active goal. Additionally, all of the patients physicians are in support of continued aquatic physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for vertical sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Three physician reviewers found that there is insufficient data demonstrating that it is likely to be more efficacious than conventional surgical alternatives for patients such as this patient. In this case, the patient does not require a staged procedure based on her moderate BMI, and she has no significant co-morbidities. As such, conventional options such as LGB are medically appropriate in this setting. As noted by DeMaria and Jamal, LGB is an internationally supported procedure that is a reversible method for achieving significant weight loss. Fielding and Ren confirmed that mid-term results show LGB to live up to its early promise as an effective tool.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested  for acupuncture treatments for treatment of the enrollees eczema.  Findings:  Three physician reviewers found that the standard of care of eczema is topical steroids and non-steroidal anti-inflammatory agents such as pimecrolimus. Other conventional options include non-prescription measures such as the use of moisturizer, gentle soap, and fragrance free detergent. All patients with eczema should also be evaluated by a dermatologist. Pfab and colleagues suggest that acupuncture may be helpful in eczema, however, large scale, double-blinded, placebo-controlled studies are currently lacking. Since the available data is anecdotal at best and inadequate to establish the safety and effectiveness of acupuncture as a treatment modality for atopic dermatitis or eczema, the therapy remains investigational.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.   Findings:  Two physician reviewers found that the study by Frietag and colleagues found that Botox was statistically superior to placebo for the primary endpoint of reduction in migraine headache episodes. The authors further indicate Botox showed numerical superiority to placebo for acute medication use and Migraine Disability Assessment Scores. Adverse events were rare. Although Botox is not a first-line therapy for migraine headaches, there is clear indication for its use in patients with chronic headache states that are resistant to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for speech/language therapy for treatment of the enrollees expressive language disorder. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. They noted that intervention services are helpful at a young age when chances for improvement are best. The long-term consequences of speech and language delay may be substantial. Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested for Genotropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the scientific literature does not demonstrate that Genotropin is associated with better outcomes, fewer side effects or confers added benefit among this patient population as compared to the Health Plan formulary alternatives. Nor is there evidence that Humatrope and Nutropin are contraindicated for use by this patient. All told, the alternative medications offered by the Health Plan are medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for adult inpatient treatment for treatment of her alcohol dependence and major depressive disorder. Findings:  The physician reviewer found that the patient was not precluded from active participation in an outpatient program due to biomedical concerns. Further, the patients emotional status was stable; destructive and/or impulsive behaviors were not sufficient to block processing of treatment goals. In sum, there is no indication in the medical records provided that the patient required the level of medical and nursing supervision provided by a PHP level of care.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had an exacerbation of a pre-existing problem that did not produce a fever, fluid loss through vomiting or diarrhea, or pain documented as being sufficiently severe to be worrisome for placing the patients health in serious jeopardy. Nothing in the patients labs or imaging were concerning and the patient remained hemodynamically stable throughout her stay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for an eating disorder intensive outpatient program for treatment of her eating disorder.  Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) practice guidelines for the treatment of patients with eating disorders, this patient is a candidate for treatment in a less restrictive setting. Wilson and colleagues also endorse the efficacy of outpatient treatment modalities. Without evidence of significant co-morbid conditions, the patient may well benefit through outpatient therapy, but her condition does not require the intensive services offered through an IOP.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for vertical banded gastroplasty for treatment of her obesity. Findings:  Two physician reviewers found that the Lap-Band requires frequent adjustments and support therapy. Additionally, bleeding is possible if band erosions occur. The ghrelin factor is not reduced, anti-inflammatory medicine is not well-tolerated, and marginal ulcers can occur. This is not so with the sleeve gastrectomy. Existing gastroesophageal reflux disease is improved after the first year with this procedure. Furthermore, the peer-reviewed literature shows that revisional surgery is much easier to perform if it becomes necessary. In this patients case, sleeve gastrectomy is likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for Norditropin NordiFlex for treatment of the enrollees stated diagnosis of isolated growth hormone deficiency. Findings:  The physician reviewer found that while he has been experiencing declining growth rate, this could be related to his pubertal delay. This patients growth hormone dependent IGF-1 level was normal for gender and stage of development. His mid-parental height expectation is 59.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested for a bilateral breast reduction/lump removal for treatment of his gynecomastia.  Findings:  The physician reviewer found that this patients tender gynecomastia has a clinically significant impact on his activities of daily life. Moreover, the tissue involved is glandular in nature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins.  Findings:  Three physician reviewers found that the literature does not favor sclerotherapy over standard of care treatments for refluxing veins. Corabian and Harstall reviewed the available literature and commented that in the short-term follow up, sclerotherapy shows promise, but the authors favored surgery over sclerotherapy after a two- to three-year follow up period. This patients records do not demonstrate that the sclerotherapy sessions were intended to treat lifestyle limiting symptoms, nor is there documentation of a concerted effort to try conservative treatment prior to treatment with sclerotherapy
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for partial breast irradiation using MammoSite brachytherapy for treatment her breast cancer. Findings:  Three physician reviewers found that partial breast irradiation with MammoSite is safe and effective when used to treat women with low risk breast cancer, there is insufficient data to support that it is superior to whole breast irradiation for patients.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for dynamic surface electromyography, physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements for treatment of her medical condition.   Findings:  Three physician reviewers found that review of the literature shows that gait analysis testing is standard in optimizing ambulation in a variety of conditions, including after amputation, as well as post stroke, post trauma, and multiple sclerosis. As a result of her gait analysis, the patient was fitted with ambulatory prosthetics, with resultant improvement in her gait. The diagnostic testing that was performed (gait analysis with surface EMG and physician interpretation) was not experimental or investigational in nature for this patients particular clinical situation and was clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested an electron beam computed tomography (CPT Code 0144T) for an evaluation of his ventricular septal defect and hyperlipidemia. Findings:  Three physician reviewers found that based on the records provided, the patient has little documented coronary risk due to his well controlled hyperlipidemia, atypical non-exertional chest discomfort, and no provokable ischemia on recent exercise stress testing. A small ventricular septal defect does not affect coronary risk. In this circumstance, the patient has very low likelihood of significant coronary disease, such that additional evaluation with coronary calcium scoring is not medically indicated and not considered the standard of practice within the medical community. Greenland and colleagues discussed the current guidelines that are endorsed by several national organizations and do not recommend routine coronary calcium scoring in most situations. These guidelines further suggest that the requested testing is even less indicated in patients with low coronary risk with no provokable ischemia on stress testing. Moreover, there is insufficient evidence in the scientific literature that treatment changes based on coronary calcium scoring favorably effects cardiac outcome when compared to treatment guided by traditional risk factor profiling.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a pain management specialist for treatment of her right shoulder impingement syndrome. Findings:  The physician reviewer found that the American Academy of Orthopedic Surgeons (AAOS) recommends initial management of shoulder impingement syndrome with ice packs, rest, avoidance of overhead activities, NSAIDs, stretching exercises, steroid injections, as well as supervised physical therapy. Only some of these treatments have been utilized by this patient. This patient has a history of persistent shoulder pain and a radiograph that may suggest a spur versus a loose intra-articular body. A referral to a pain management specialist for this patient is not medically necessary at this time due to the absence of a clear orthopedic diagnosis and the lack of evidence demonstrating the patient has completed an adequate course of conservative therapy.