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

The parent of a 4-year-old male enrollee has requested a 3-6 month trial of intravenous immune globulin (IVIG) treatment for treatment of the enrollees inflammatory disorder with fevers.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested IVIG therapy. Intravenous immunoglobulin is a pooled blood product containing a broad range of antibodies against pathogens and foreign antigens that can be used to modulate immunodeficiency and autoimmune disorders. The U.S. Food and Drug Administration (FDA) has approved its use for treatment of the following disorders: primary immunodeficiency disease, idiopathic thrombocytopenic purpura, Kawasaki disease, chronic lymphocytic leukemia with frequent infections, bone marrow transplantation, pediatric human immunodeficiency virus to prevent other infections and chronic inflammatory demyelinating polyneuropathy. Detailed guidelines have been developed to ensure safe administration of both intravenous and subcutaneous use. IVIG has been used off-label for treatment of PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), Guillain-Barre syndrome, multifocal motor neuropathy, autoimmune mucocutaneous blistering diseases such as Stevens-Johnson syndrome and toxic epidermal necrolysis, multiple sclerosis, systemic lupus erythematosus and other autoimmune vasculitis, and myasthenia gravis, to name but a few. The scope of IVIG use has expanded beyond treatment of patients with primary immunodeficiencies and its administration has had life-saving and life-altering effects in a number of patients. For many patients with well-defined clinical conditions, guidelines either exist or are being developed for administration of IVIG. For patients with conditions that remain undiagnosed, but yet who possess many signs and symptoms consistent with inflammatory and autoimmune dysfunction, a trial of IVIG is medically appropriate. Such is the case with this patient. Thus, a 6 month trial of IVIG is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Synvisc injections for treatment of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The current medical literature does not support the requested Synvisc injections in this patients case.  Hsieh and colleagues compared the efficacy of intra-articular hyaluronic acid injections with physical therapy versus physical therapy alone for patients with adhesive capsulitis.  The authors reported that hyaluronic acid injections did not provide additional benefit for patients who were already receiving physical therapy.  Colen and colleagues conducted a systematic review of the use of hyaluronic for joints other than the knee.  The authors noted that there is a lack of evidence demonstrating that hyaluronic acid is superior over corticosteroids or other conservative therapies.  All told, the requested Synvisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature and DiGeorge syndrome.  Findings:  The physician reviewer found that in a study analyzing 61 patients with DiGeorge syndrome to determine the frequency of endocrine abnormalities in this population, Choi and colleagues reported that 16% of patients were below the 3rd percentile in height, but serum IGF-1 level was normal in 9 of 10 of these patients. Further, GH deficiency is not commonly seen in association with DiGeorge syndrome. All told, other causes of short stature have not been ruled out prior to considering a trial of GH therapy. Therefore, the requested therapy is not supported as medically necessary for treatment of this patients medical condition based on the records provided for review.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested CPT codes 83090 (homocysteine) and 86141 (C-reactive protein) for evaluation of his family history of coronary artery disease.  Findings:  Two physician reviewers found that in this patients case, C-reactive protein and homocysteine testing performed on the date in question were not likely to have been superior over other available methods of evaluation.  There is a lack of evidence demonstrating that lowering homocysteine levels in this clinical setting improves cardiac outcome.  Per the medical records, this patient was on statin therapy on the said date.  Although there is some evidence supporting evaluation with C-reactive protein levels in patients on statin therapy, these studies tend to involve patients with existing atherosclerotic heart disease, and not patients on statin therapy for primary prevention, such as in this case.  Therefore, the superior efficacy of the services at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a power wheelchair for treatment of his chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records indicate that he has normal strength in the limbs and no range of motion deficits in the limbs that would preclude ambulation or use of a manual wheelchair.  Additionally, it is not clear from the current documentation that the patients home is accessible to a power mobility device.  However, manual wheelchairs provide superior accessibility in these types of environments.  This patient has multiple chronic health conditions, such as hypertension and chronic obstructive pulmonary disease, which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested 61 external urethral clamps per year for treatment of his urinary incontinence.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The manufacturer of C3, male continence device, suggests that the device be discarded after approximately one week of use. The manufacturer instructions further point that it should not be cleaned or washed as this will compromise its effectiveness. In my professional experience, clamps generally last longer than a week. In this patients case, the Health Plans approval of 52 clamps per year (4 clamps a month) is reasonable and medically necessary. Therefore, the requested 61 external urethral clamps per year are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her stage III endometrial cancer.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the therapy at issue. Given the significant amount of toxicity with concurrent chemotherapy and pelvic three-dimensional conformal radiation therapy (3DCRT), it is appropriate to seek less toxic ways to deliver radiotherapy. The typical dose delivered for whole pelvic radiotherapy is above the dose tolerance for both small bowel and bone marrow. The medical literature includes studies that have demonstrated that IMRT had improved target coverage versus 3DCRT (Bouchard et al). Jhingran and colleagues reported a 28% rate of grade 2+ bowel toxicity compared to a historical rate of 40% with 3DCRT. Furthermore, the safety and efficacy of pelvic IMRT has been supported by multiple medical studies. For the reasons set forth above, IMRT was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  inpatient acute psychiatric treatment with evaluation by a forensic psychologist for treatment of the enrollees anxiety, major depression, and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that the patient does have a formidable symptom complex, the etiology of which has been difficult to determine. The aggression is of particular concern since it is considered to be a relatively stable trait, and aggression in childhood often predicts continuation or even escalation of behavior problems over time (Newcorn, et al). Considering the patients refractivity to comprehensive treatment and the recommendation from the psychological consultation on the date specified, evaluation by an outpatient forensic psychologist is medically necessary. The potential benefits of a consultation with a forensic psychologist would include a definitive assessment of dangerousness, an additional diagnostic opinion, and clinical recommendations for the treatment plan. For these reasons, the requested evaluation by a forensic psychologist is supported as medically necessary while the resumption of inpatient acute psychiatric treatment is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested intravenous immunoglobulin (IVIG) Gammagard 400mg/kg per visit, six visits every four weeks for six months for treatment of her selective antibody deficiency.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested therapy.  The medical records demonstrate that this patient has an immune deficiency.  The pattern of her infections suggests humoral deficiency, and this includes upper and lower respiratory tract infections, arthropathy, and sicca syndrome.  This patient has failed prophylactic antibiotics. The current medical evidence supports IVIG therapy in this clinical setting.  The use of replacement immunoglobulin is supported by the relevant scientific literature.  All told, IVIG Gammagard 400mg/kg per visit, six visits every four weeks for six months is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested weekly individual sessions with a counselor for treatment of his panic disorder with agoraphobia.  Findings:  The physician reviewer found that cognitive behavioral therapy is a trusted therapeutic intervention for individuals with panic disorder.  Its safety and efficacy is supported by many well-designed studies and years of clinical experience.  Considering its chronicity, it is not uncommon for an individual with panic disorder to receive multiple treatments of cognitive behavioral therapy.  In the case of panic disorder refractory to first-line treatments, there is evidence supporting panic-focused psychodynamic psychotherapy, which is delivered individually.  The medical records offer no contraindication to individual sessions.  Based on the current peer-reviewed literature, individual therapy is medically indicated in this case considering the longitudinal course of illness coupled with the patients current presentation.  Thus, a course of 12 individual sessions delivered on a weekly basis is indicated.  However, a diagnostic reassessment to compare the clinical status with the pre-determined therapy goals and objectives following these 12 sessions is needed in order to establish the medical necessity of additional weekly individual sessions with a counselor.  All told, a portion of the requested weekly sessions with a counselor is medically indicated in this patients case
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature continues to demonstrate positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice.  In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness, and therefore, medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections for treatment of her chronic migraines.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature supports the use of Botox in this clinical setting. A review of the medical records indicates a diagnosis of chronic migraine. The definition of chronic migraine requires 15 or more headache days a month with at least eight being migrainous. While a migraine by definition lasts at least four hours, it is still defined as migraine if the headache has features of migraine, and is aborted by a migraine specific treatment such as Imitrex, even if it does not last a full four hours. Also, acute treatment has a goal of complete headache relief within two hours. The medical records document that the patient has more than 14 headaches days a month, most of which are migrainous. Although the patient has other headaches that are not migrainous, that does not change the diagnosis of chronic migraine. The medical literature cited above supports the safety and efficacy of Botox injections for the treatment of chronic migraine. Therefore, Botox injections were and are likely to be more beneficial than standard medical therapy and are appropriate treatment for the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that typically, the medical communitys customary prescription for an autistic child would be ABA therapy. The medical literature strongly supports the treatment of autism with ABA therapy in children. However, this patient does not readily nor traditionally diagnose as autistic. The patient has moderate intellectual disability with a full-scale IQ of 58. A diagnosis of pervasive developmental delay is usually reserved for severely to profoundly intellectually disabled patients with some autistic features that cannot be clearly called autistic. In this patients case he has made significant progress, now functioning in a special day 10th grade class and demonstrating some academic skills. The patients major functional deficit is socialization with same age peers and poor pragmatic (social) language. Based upon the documentation provided, the patients presentation does not appear consistent with high functioning autism or PDD-NOS. In light of this fact, coupled with the patients relatively high level of function with significant progress functioning in a special day class as well as demonstrated academic skills, ABA therapy is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested hydrocodone-acetaminophen 7.5/750mg (Vicodin ES 7.5/750mg), quantity 100 and morphine ER 30mg, quantity 180 for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this patients case.  Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  Opiates are considered adjunctive to this treatment.  The current medical evidence does not support the requested medications in this clinical setting.  Baron and McDonald reported that the use of high-dose opiates may contribute to pain sensitization.  High-dose opiates are more likely to cause adverse outcomes.  Ballantyne and Mao noted that use of high-dose opiates may result in abnormal pain sensitivity and tolerance.  All told, hydrocodone-acetaminophen 7.5/750mg (Vicodin ES 7.5/750mg), quantity 100 and morphine ER 30mg, quantity 180 are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested urgent care services.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the said date. 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 on the date in question. In this case, the patients presenting signs and symptoms were painful urination, blood clots in urine, frequency, urgency, back pain, abdominal pain, and yellow appearing skin. The patients symptoms were consistent with several medical conditions that could have resulted in serious jeopardy to the patients health such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction, and others.  Thus, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Xenazine (tetrabenazine) for treatment of his Huntingtons disease.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Xenazine is the standard of care for treating chorea in Huntingtons disease and the U.S. Food and Drug Administration approved Xenazine for that indication. This patient has a diagnosis of Huntingtons disease and has documented failure of risperidone and his neurologist reports that he previously tried and failed Haldol. This patient has severe chorea affecting his activities of daily living including the ability to feed himself. In addition, this patient has been gradually titrated to an appropriate dose of Xenazine by his neurologist. For the reasons set forth above, Xenazine is approved in this clinical setting and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested panniculectomy and abdominoplasty for treatment of her symptomatic abdominal pannus.  Findings:  The physician reviewer found that based on review of the available records, there is adequate documentation describing a functional impairment likely related to the lower abdominal overhang. A panniculectomy may correct this lower abdominal overhang. The American Society of Plastic Surgeons (ASPS) stated that, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Manahan and colleagues noted that, the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This patient reports typical symptoms including skin rashes and periodic open sores associated with redundant skin overlap. She is documented to have treated these problems with multiple topical medications, which have failed. Her examination and photographs are consistent with this clinical picture of a functional impairment related to the significant lower abdominal overlap. Consistent with these findings, the requested panniculectomy is supported as medically necessary for treatment of this patients medical condition. However, it is not likely that a functional impairment is related to this the patients diastasis rectus. There is conflicting data whether correction of rectus diastasis may serve a functional purpose. Coriddi and colleagues evaluated patients functional status following abdominoplasty and reported that, rectus plication did not significantly improve functional outcomes. Overall, a functional purpose for correction of diastasis is not reported with sufficient detail to support surgical correction. Thus, the requested abdominoplasty, which treats the upper abdomen and corrects diastasis recti, is not a medically necessary procedure for treatment of this patients medical condition. The patients functional impairment is likely related to the lower abdomen and not the upper abdomen. In summary, the requested panniculectomy has been shown to be medically necessary while the requested abdominoplasty is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested diazepam (Valium) 5mg, and lorazepam (Ativan) 1mg for treatment of her anxiety disorder.  Findings:  The physician reviewer found that Benzodiazepines carry the very serious risk of tolerance and dependence. This patients records reference a history of drug dependence. Prescribing three different medications, clonazepam, Ativan and Valium, from the same potentially addictive class is not consistent with the recommendations in the medical literature. Standard of care in this setting requires a slow taper, over a 6-12 month course, of benzodiazepines with at least part of this process performed in a medically supervised setting as a robust or poorly coordinated reduction could lead to life-threatening symptoms. Thus, the Valium, which is mid-level potency and long-acting, is medically necessary as part of a slow taper. However, the documentation provided does not support the medical necessity for the medications in the treatment of her anxiety disorder. There are standard treatments including serotonergic enhancing medications and cognitive behavioral, psychodynamic or interpersonal therapy for management of her anxiety. As part of a slow-taper, the requested Valium is medically necessary for treatment of the patients drug dependence, while the Ativan is not medically necessary.