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

A 48-year-old male enrollee has requested Yttrium-90 microsphere brachytherapy/selective internal radiation therapy for treatment of his metastatic pancreatic neuroendocrine carcinoma.Findings:  Three physician reviewers found that per current National Comprehensive Cancer Network guidelines for neuroendocrine tumors metastatic to the liver, for patients deemed unresectable, hepatic regional therapy (arterial embolization, chemoembolization, radioembolization), or local ablative treatment, including radiofrequency, microwave, and cryotherapy, are viable treatment options.  Given that this patient has been treated with Xeloda and Temodar, together with localized pancreatic radiation therapy and hepatic artery embolization, and given that the only residual disease is the one focus in the liver that is deemed unresectable, selective internal radiation therapy certainly was appropriate per current National Comprehensive Cancer Network guidelines. In this patients case, Yttrium-90 microsphere brachytherapy/selective internal radiation therapy was likely to have been the most beneficial treatment option.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that this patients developmental history included some slight delays, as he was not sitting until age 12 months and was not walking until age 24 months. The remainder of his development has been normal. There is no documentation suggesting that the patient did not catch up from a gross motor and fine motor standpoint of his delays.  There is a lack of recent studies showing the benefit of speech therapy for articulation disorders at this age. Additionally, based upon the norms for the development of language and articulation, the delays noted in the submitted documentation are within functional limits for his age. In this patients case, speech therapy is not medically indicated.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested emergency services for treatment of his medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergency medical condition requiring emergency medical services. An emergency medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. With regard to this patient, he presented with a fever, body aches, and cold symptoms that had persisted for two days prior and had no chronic medical conditions. On physical evaluation, the patient was in no acute distress with a dry cough. His vital signs and pulse oximetry were within normal limits on arrival except for a temperature of 101.8 degrees. The patient did not have any concerning signs such as lethargy, vomiting, chest pain, seizure activity or decreased responsiveness. The patient had a common viral syndrome that is very common in this age group. The patient had been to urgent care only 24 hours earlier and received antibiotics and cough medicine. Although he indicates that he was instructed to go to the ER if his symptoms worsened, the evidence does not demonstrate that he experienced significant deterioration in his condition since being seen at the urgent care facility. Thus, to a layperson with an average knowledge of medicine, this patients signs and symptoms would not equate to an emergent condition. A prudent layperson would not believe these symptoms would place his health in serious danger, serious impairment to bodily functions, or cause serious bodily dysfunction without immediate treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested localized hyperthermia with low dose radiation treatment for treatment of her breast cancer. Findings:  Three physician reviewers found that this patient is requesting low dose radiation for the treatment of an early stage breast cancer. Per the submitted documentation, it appears as if the patient has decided to avoid standard oncologic care. The use of hyperthermia with radiation is limited to chest wall recurrences and metastatic disease. It is not meant to replace standard treatment, including surgery, radiation therapy, chemotherapy and hormonal therapy when indicated. Current National Comprehensive Cancer Network guidelines do not support the requested services in this clinical scenario. Thus, the requested localized hyperthermia with low dose radiation treatment is not likely to be the most efficacious treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested computed tomography (CT) scan of the chest, abdomen and pelvis for evaluation of her medical condition. Findings:  The physician reviewer found that the patient states that she needs multiple CT scans of her chest, abdomen and pelvis to help define the cause or causes of her medical state. However, these imaging modalities are useful for vastly different clinical entities. A CT scan of the abdomen/pelvis is appropriate for evaluating a patient with acute abdominal pain or pelvic pain in the outpatient (especially emergency room) setting (i.e., appendicitis, bowel torsion, renal calculi, and intussusceptions; all life threatening, and imaged extremely accurately by a CT scan). There is no evidence of acute abdominal/pelvic pain in the records provided. A CT scan of the chest is indicated to evaluate shadows or densities within the thorax cavity, when chest x-rays show densities of unclear origin (i.e., bronchogenic tumors, diseases of the pleura, metastatic tumors of the lung and pericardium are extremely well visualized by CT of the chest). On this basis, there is no clinical indication for the requested CT study in this particular setting. Furthermore, researchers have become mindful of the risk of the radiation to the patient who undergoes CT examination. There now is a link to CT radiation exposure and the future increased risk of many different cancers. For all the above reason, the requested CT scans of the chest, abdomen, and pelvis are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested stereotactic body radiation therapy (SBRT) to a spleen lesion for treatment of her recurrent metastatic ovarian cancer. Findings:  Two physician reviewers found that SBRT has been shown to provide localized tumor control in a variety of different clinical settings, including both primary and metastatic lung lesions, primary and metastatic liver lesions and spinal metastases. However, there is no evidence for efficacy in ovarian cancer.  Furthermore, imaging modalities have demonstrated complete treatment by the salvage chemotherapy. Therefore, the indication for treatment remains ambiguous. Surgical resection remains the standard of care for recurrence of ovarian cancer following salvage chemotherapy. Given resolution of the lesions by PET and CT scanning, there is a lack of evidence for benefit from SBRT in this clinical situation. The efficacy of SBRT to prevent disease recurrence or prolong disease control has not been established. Thus, SBRT to the spleen lesion is not likely to be more beneficial than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested participation in Clinical Trial #NCT00738582 using MORAb-009 for treatment of his pleural mesothelioma. Findings:  Two physician reviewers found that the standard of care for unresectable mesothelioma is a platinum drug such as cisplatin in combination with pemetrexed (Alimta). This conventional treatment regimen is based on a randomized controlled clinical trial which demonstrated improvement in survival and quality of life and was reported by the National Comprehensive Cancer Network (NCCN). This patient wishes to participate in a clinical trial with cisplatin and Alimta along with the experimental compound MORAb-009. As MORAb-009 is being tested in this Phase II clinical trial, no outcome data is yet available showing its potential benefit.  As noted above, the literature offers adequate evidence in favor of treatment with cisplatin and Alimta as likely to result in better health outcomes in this patient with mesothelioma. Thus, the requested services are not likely to benefit the patient more than treatment with accepted standard therapies in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested continued acupuncture treatment for treatment of her low back and hip pain. Findings:  The physician reviewer found that acupuncture can be very effective in the management of chronic low back pain.  Patients who respond well to an initial course of treatment remain at risk of a recurrence of the pain. In those individuals, a repeat course of acupuncture is clinically indicated. In this patients case, she has chronic low back pain that was resistant to most interventions. She has tried physical therapy and chiropractic care, with no improvement.  Per a note from the treating physician, the patient benefitted from prior acupuncture services provided. A few weeks later, the patient reported limited ability to work due to continued pain, and she noted that acupuncture treatment aids in alleviating her pain. Thus, continued acupuncture services were and are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested biofeedback sessions for treatment of his chronic constipation. Findings:  The physician reviewer found that while the medial information submitted for review is sparse, there is technically adequate documentation to support biofeedback for management of what is likely a defecatory disorder in this patient. The patient does not appear by clinical criteria to have slow transit constipation and it is documented that the patient has not sustained anorectal trauma and does not have symptoms suspicious of neurological disease. It is documented that the patient takes adequate dietary fiber. Thus, there is no reason to expect that medications that increase colonic motility will result in improvement in his symptoms. Since the patients problem appears to be dysfunction in the initiation of a bowel movement he will likely respond to defecation training with biofeedback therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female enrollee has requested the medication Lunesta for treatment of her insomnia. Findings:  The physician reviewer found that newer agents for insomnia have been shown to be more effective and cause fewer side effects than benzodiazepines and other older agents. One such newer agent is zolpidem. Zolpidem is not indicated for long-term use and has been shown to cause headaches, dizziness, and tiredness in the daytime (Lieberman). Another new agent is eszopiclone. Eszopiclone has the longest half life of the newer sleep agents and can last from 7 to 9 hours in duration in the patients age group. It is unique in that dependence does not develop, and most experts believe it is safe and effective for long-term use. Improvement in quality of life and improved job performance has been seen in studies lasting six months for both eszopiclone and long-acting zolpidem (Walsh and colleagues). In summary, given this patients co-morbid conditions (trigeminal neuralgia, ocular migraine, and chronic major depression), the poor results she obtained with trazodone and standard release generic Ambien (zolpidem) and the data from peer reviewed clinical trials on Lunesta and its long half life as well as its effectiveness for the  long-term treatment of insomnia, Lunesta is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female has requested ten or more additional sessions of intensive outpatient treatment for treatment of her bulimia nervosa. Findings:  The physician reviewer found that the literature supports the fact that patients generally remained at their discharge level of recovery over time, as noted by Zeeck and colleagues.  Her prior treatments appeared to have inadequately controlled her eating disorder symptoms. In this patients case, ten additional sessions of intensive outpatient treatment are medically indicated.  She meets the American Psychiatric Association criteria for intensive outpatient treatment. The patient will likely deteriorate at a lower level of care, and she needs further intensive services due to her comorbid conditions.  A reassessment after ten intensive outpatient program sessions is needed in order to determine the medical necessity of future services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested orthotic foot inserts L3020 x 2-foot longitude/metatarsal support (removable foot inserts) for treatment of her foot pain. Findings:  The physician reviewer found that the requested orthotic foot inserts are indicated for this patients continued pain.  Limited documentation was submitted for review. However, in a letter, the patients podiatrist noted that the patient has ongoing symptoms of tendonitis and neuritis in the foot and ankle which have not resolved completely. He also noted that the patient has had injections.  She has been diagnosed with plantar fasciitis, neuritis and painful hallux valgus. These painful foot conditions can be treated conservatively and successfully with the use of custom triplanar orthotics. In this patients case, orthotic foot inserts L3020 x 2-foot longitude/metatarsal support (removable foot inserts) are medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested acute inpatient treatment services, partial hospital program services, as well as prospective services at either level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the medical records submitted do not support the medical necessity of acute inpatient services for the dates of service at issue. While the patient continued to be underweight, the records indicate that she was stable for partial hospitalization program (PHP) level of care as of her admission date, and in fact, this was the recommended level of care at the time of the patients planned discharge from the hospital. The record does not reflect her ideal body weight, but she had gained four pounds over the preceding week and a half and there was no indication of physiological compromise. Therefore, American Psychiatric Association (APA) and National Eating Disorders Association (NEDA) criteria for the acute residential treatment center level of care were not met as there was no evidence that the patient was psychiatrically impaired and unable to respond to PHP or outpatient treatment. PHP was the recommended level of care and the information submitted does not indicate that the patient could not have been safely and effectively treated at this level as of the admission date. In regards to partial hospitalization program services provided the following month, there was no clinical data submitted for the services provided during this time period. Therefore, the records fail to support the contention that the patient was in need of daily assessment of physiological and mental status; that her eating disorder was impairing her functioning to the extent that she was unable to function in normal social educational or vocational situations; that she was engaging in daily binge eating, purging, fasting, or other pathogenic weight control techniques; or that she was seriously underweight and in need of structured programming to gain a significant amount of weight. Thus, there is no evidence that the patient met APA or NEDA medically necessity criteria for PHP services during this time period. The patient clearly has been struggling with a serious eating disorder and was significantly compromised to the point of requiring inpatient treatment for approximately one month. Eating disorders tend to be chronic in nature. At the time of her planned discharge, the patient continued to be underweight. However, there has been no recent data submitted which establishes a current need for treatment with a reasonable degree of certainty. Medically necessary services at any given time will depend on the patients current psychiatric and medical condition, along with any additional co-morbid conditions which may arise. Given the absence of evidence of such, the medical necessity of future acute inpatient or PHP levels of care has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  The physician reviewer found that with a BMI of 38 and the presence of significant co-morbidities (i.e., hypertension), the patient is an appropriate candidate for weight loss surgery based on generally accepted guidelines. The laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for clinically severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested Dysport injections (300 units every three months for one year) for treatment of his chronic pain.  Findings:  Two physician reviewers found that the patient has been diagnosed with refractory thoracic pain and myofascial pain. He has had a variety of standard therapies which have reportedly not been satisfactory in addressing his pain. Dysport (abobotulinumtoxinA) injections have been provided in order to reduce his complaints of pain. Review of the peer-reviewed literature shows potential benefit of Botox (onabotulinumtoxinA) for back pain. However, there is little to no peer-reviewed literature regarding the use of abobotulinumtoxinA for the treatment of back pain or myofascial pain. Moreover, there is no literature showing therapeutic equivalence between differing neurotoxins (onabotulinumtoxinA versus abobotulinumtoxinA) for the treatment of chronic pain. As such, there is a lack of published prospective randomized trials that have shown that the use of abobotulinumtoxinA for the treatment of back pain is as good as or better than generally accepted treatment modalities for this type of pain. Given the absence of adequate outcome data establishing the efficacy of abobotulinumtoxinA in this setting, there is insufficient support for its use by this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested emergency services for 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 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 patient had a cough with a runny nose and cold symptoms for three days prior and had no chronic medical conditions. Vital signs and pulse oximetry were normal on arrival, except for a slightly elevated temperature of 100.5 and a pulse of 130.   The patient did not have any concerning signs such as lethargy, vomiting, seizure activity or decreased responsiveness.  On physical examination, the physician noted the lungs were clear, without rales or rhonchi.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested therapy for treatment of his neck and back pain. Findings:  Two physician reviewers found that the medical notes state that the patient received facet joints and/or trigger point injections. The descriptions do not illustrate that the patient underwent injections of the facet joints.  While areas around the facet joints were marked, the notes do not describe if the injections in fact entered the facet joints or if medial branch or facet joint nerve blocks were performed. Thus, it appears that these injections were trigger points or infiltration around the facet joints rather than intraarticular or medial branch blocks. The services performed are consistent with trigger point or ligament injections. Such treatment is within the standard of care in this setting. Considering the patient has neck and low back pain, ligament or trigger point injections were indicated and were likely to be more efficacious than alternative treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 46-year-old deceased female has requested accessories for the speech generating device associated with the Eye Gaze System for treatment of the enrollees amyotrophic lateral sclerosis. Findings:  The physician reviewer found that an add-on is medically indicated when it is designed to compensate for a specific impairment and enhance the functional independence of that individual. The Tash microlight switch, a device that allows for feather light touch activation, was medically necessary for the patient because it facilitated her communication in the setting of extreme motor weakness. The series 5 wireless compact flash allowed for connection to a wireless network and the XGA display upgrade provided enhanced video graphics. Neither of these two add-ons was adaptive or specifically designed to compensate for impairments secondary to amyotrophic lateral sclerosis.  Thus, the Tash microlight switch was medically indicated for this patient. The series 5 wireless compact flash and service charge for display, XGA were not medically indicated for this patient.