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

The parent of a nine-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the scientific data suggests that the plasticity of the developing brain enables the retraining of neural circuitry not compromised by the underlying pathogenetic processes that give rise to ASD including speech and language delay. As noted by Paul, young patients with ASD, benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Thus specific treatment, including speech and language therapy, can be used to help induce brain plasticity with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and the associated developmental delays. In conclusion, there is adequate evidence demonstrating that speech and language therapy in an individualized setting can have a positive outcome on development of useful speech. Accordingly, I have concluded that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested for artificial disc replacement for treatment of his low back pain.   Findings:  Two physician reviewers found that spinal fusion has been the standard for surgical management of low back instability and pain, but the theoretic advantages of removal of the painful disc while preserving motion has led to increasing interest in total disc arthroplasty. Early results have been encouraging, but the long-term benefit of arthroplasty over fusion remains to be determined (see Lin and Wang). A high rate of re-operations has been reported, and potential problems over the long-term have not been addressed (see de Kleuver and colleagues). Nor has the effect of these implants on adjacent segment degeneration been clarified (see German and Foley). No statistical difference between fusion and disc arthroplasty has been demonstrated in clinical outcomes or adjacent level motion (see Guyer and colleagues). The role of total disc arthroplasty is not yet defined. Long-term studies may clarify whether it is appropriate in selected patients (see Madigan and colleagues). However, at this time, total disc arthroplasty has not been shown to be better than fusion. There is uncertainty as to the preservation of motion or modification of adjacent segment disease, and the long-term efficacy and safety of the procedure needs further study (see Resnick and Watters).
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:  Two physician reviewers found that there is inadequate evidence in the scientific literature that branch vein ablation is superior to standard therapies. Endovenous ablation has been primarily studied in the setting of great and small saphenous veins. It is not appropriate to extrapolate the results of such studies to predict superior results with accessory vein ablation. Further, there is no evidence that endovenous ablation of the accessory branch provides any advantage over standard therapy, such as stab phlebectomy, which would also allow treatment of other varicosities on the same leg at that time. As stated previously, ablation also carries the risk of skin burning if the branch is superficial, which is not present with stab phlebectomy.All told, the submitted duplex images do not demonstrate a contraindication to standard treatment options available in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested additional physical therapy at a skilled care facility for treatment of her medical condition. Findings:  The physician reviewer found that there is general agreement that skilled rehabilitation is appropriate for individuals with a hip fracture. However, there is no consensus on the effectiveness of different therapeutic programs (i.e., in terms of intensity, duration, and frequency). The need for continued skilled rehabilitation depends on the individuals response to therapy and whether further gains are likely. This patients weight bearing status was toe-touch weight bearing. The patient required minimal assistance with her bed mobility, transfers, and walking. She required moderate assistance in most activities of daily living. The patient was independent in bed mobility and transfers on and required stand-by-assistance with walking (using a front-wheeled walker). The records indicate the patient either required stand-by-assistance or was independent in her activities of daily living. Per the physical therapy note, the patient had met her goals by ambulating greater than 100 feet with stand-by-assistance with her walker and was independent with her bed mobility and transfers. She had also met her occupational therapy goals. The patient was trained in safety and exercises and instructed on how to follow her weight bearing precautions. The physical therapy notes conclude by stating that the patient was ready to be discharged. All told, the patient made significant progress in her rehabilitation program. Although she required stand-by-assistance with ambulation, and likely still requires this level of assistance with ambulation, it is not necessary for this assistance to be provided by skilled therapists. The submitted evidence does not demonstrate that the patient has functional deficits that require additional skilled physical therapy at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested adult psychiatric acute inpatient services for the treatment of her behavioral health issues. Findings:  The physician reviewer found that the documentation indicates that from the date of service in question forward, the patient was cooperative and stable with no risk of harm to self or others. The providers progress note indicates no withdrawal symptoms and her mood had much improved. Her anxiety and depression were rated a 4 of 10. Based on the level of care utilization system for psychiatric and addiction services (LOCUS), and the American Psychiatric Association (APA) guidelines, this patient would have been a candidate for treatment at a less restrictive level of care than acute inpatient treatment. Since the patient was on a medical detoxification protocol, the services provided before the time period in question were medically necessary. However, the medical records provided do not support the medical necessity for the services provided during the time period in question.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a WalkAide functional electrical stimulator for the treatment of her right foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that the literature reveals a number of publications that suggest WalkAide is a promising device for patients with foot drop resulting from upper motor neuron disorders.  Wieler and colleagues reported that although the studies are small and not blinded, the results are encouraging in terms of decreased energy expenditure and increased walking speed. However, with regard to proven long-term safety and efficacy, the WalkAide FES has not been demonstrated to be as effective, or superior to a standard ankle foot orthosis (AFO). These authors concluded that the WalkAide is a reasonable option for patients who have failed traditional treatment for foot drop including physical therapy and standard AFO. The patients records do not document the strength of her dorsiflexion or whether she has tried physical therapy, or an AFO since her recent decline in mobility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for enhanced external counterpulsation for treatment of his chest pain. Findings:  The physician reviewer found that the documentation is not supportive of coronary ischemia or angina. An electrocardiogram revealed normal left ventricular systolic function. Based on these findings, clinical indications for enhanced external counterpulsation have not been met.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for Nuvigil 250 mg for treatment of her idiopathic hypersomnia.  Findings:  The physician reviewer found that Nuvigil has the same clinical indications for use as Provigil, and the latter is widely used for typical narcolepsy confirmed by pathologic sleepiness on MSLT, and for idiopathic hypersomnolence which is another disorder of sleepiness. Thus, although a formal diagnosis of narcolepsy could not be confirmed with diagnostic testing in this patient, based on her MSLT results, the diagnosis should not be entirely excluded. The medical literature reveals that approximately one-third of narcoleptic patients do not have all of the typical features of the disorder, with the exception of excessive daytime sleepiness, as is the case with this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested cold/compression therapy for the treatment of the enrollee, who is status post knee surgery. Findings:  Two physician reviewers found that there is insufficient scientific literature documenting significant clinical benefit of cold/compression therapy over standard ice packs following outpatient knee surgery. The medical literature does not demonstrate an advantage of cold/compression therapy over ice packs in terms of functional outcomes and clinical assessments at each follow-up examination. Conflicting studies with relatively short-term follow-up exist in the literature. There is a lack of high quality demonstrating that cold therapy is better than intermittent ice pack use with respect to improving mid-term and long-term functional outcomes. As such, cold/compression therapy was not likely to be more efficacious for this patient than other available treatment options.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patient presented with nose pain of one months duration. Her pain was not severe and she was not in distress. She had not sustained any acute injury. She was not short of breath. There was no acute or sudden change in her condition. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. A prudent layperson in the patients circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department with a fever, cough and sore throat. Upon arrival to the Emergency Department, his vital signs were normal. His temperature was 99.3. The medical records note that the patient appeared happy, playful and smiling. The patient had received antipyretics nine hours prior to admission. Physical examination revealed breath sounds were clear and equal bilaterally. Flu swab was positive for influenza A, and the patient was discharged on Tamiflu in stable condition. An emergency medical condition is defined as a medical condition which manifests itself by acute symptoms of sufficient severity, including pain, such that the absence of immediate medical attention would reasonably be expected to result in placing the patients health in serious jeopardy, or causing serious impairment to bodily functions or serious dysfunction of any bodily organ or part. There is no documentation in the submitted medical records that the patients condition met this definition. The patient was in stable condition on arrival to the Emergency Department and did not exhibit any signs or symptoms of serious illness. He did not have a high fever, cold sweats or convulsions while in the Emergency Department. He was noted to be in no acute distress and appeared well. The patients symptoms upon presentation were not such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize the patients health in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for percutaneous tibial nerve stimulation (PTNS) for treatment of her bladder dysfunction.   Findings:  Three physician reviewers found that the efficacy of PTNS remains unproven at this time. A review of the literature does not reveal validated studies showing this technique to be better than other standard treatments. While PTNS appears promising (a validated sham technique was recently published by Peters, et al.), the evidence currently available is not sufficient to demonstrate the superiority of PTNS over standard therapy, which does not appear to have been exhausted in this case. At this time, there is inadequate medical literature supporting the use of PTNS to treat this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested for laboratory testing (code 83525, insulin, and code 85384, fibrinogen activity) for evaluation of the enrollees cardiovascular risk. Findings:  The physician reviewer found that this patient underwent laboratory testing consisting of insulin and fibrinogen activity for screening to assess cardiovascular risk.  Guidelines for the evaluation and management of cardiovascular risk have been established and are periodically updated by expert committees. These guidelines are endorsed by several national organizations and do not currently recommend routine performance of specialized tests such as insulin and fibrinogen levels.  Treatment change or addition based on the results of routine screening with these specialized tests has not been shown to improve outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Additionally, diabetes guidelines also do not recommend routine screening performance of specialized tests such as insulin levels because outcomes based on treatment change from the results of these tests have not been shown to be improved compared to outcomes achievable using treatment based on standard risk factor profiling.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested for laboratory testing (code 82172 apolipoprotein, code 83090 homocysteine, code 83695 lipoprotein(a), code 83698 lipoprotein-associated phospholipase A2, code 83701 lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed, code 86141 C-reactive protein, high sensitivity hsCRP and code 82664 electrophoretic testing) for evaluation of the enrollees cardiovascular risk. Findings:  Two physician reviewers found that there is evidence in the medical literature indicating that there is statistical association between levels of the various requested blood measurements and coronary disease.  However, the bulk of evidence indicates that the availability of such detailed measurements does not lead to more effective therapy for hyperlipidemia-associated risks or improve clinical outcomes. Screening for levels of these entities is not beneficial unless the patient has failed to respond to standard therapy, or because of family history or other risk factors, is regarded as being at unusually high risk of developing coronary artery disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested Flonase for treatment of her allergic rhinitis. Findings:  The physician reviewer found that the mainstay of treatment for perennial allergic rhinitis includes a nasal steroid. The Health Plans requirement of recent trial and failure of a preferred generic nasal corticosteroid (fluticasone) and a preferred brand nasal corticosteroid (Nasonex) prior to authorization of Flonase is medically appropriate in this clinical situation and consistent with the standard of care. While the patient and her provider indicate that the patient has tried and failed fluticasone, the prior authorization form submitted by the patients provider indicates that the patient has not had a trial of Nasonex in the previous 180 days. Nor is there documentation in the submitted medical records of a trial of Nasonex within this time period. In the absence of objective evidence of unsuccessful treatment with both of the nasal corticosteroids included on the Health Plans formulary list, the medical necessity of Flonase is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a deceased 44-year-old male enrollee has requested for insulin potentiation therapy (IPT) for treatment of the enrollees esophageal cancer.  Findings:  The physician reviewer found that there is no reliable scientific data to support the use of IPT in the treatment of cancer. At this time, IPT has no known clinical benefit. According to the American Cancer Society, there are concerns about using lower doses of chemotherapy drugs. When chemotherapy drugs are tested in clinical trials, their effects are carefully monitored to learn which dose will best balance the need to kill cancer cells with the goal of keeping the side effects at a tolerable level. There is no evidence that chemotherapy at a fraction of the recommended and tested dose can produce the same effect as the full dose if used with insulin. The American Cancer Society also noted that despite supporters' claims that IPT has been well researched, scientific studies that show safety and effectiveness, have not been published.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a cardiology consultation and stress testing for evaluation of his irregular heartbeat, shortness of breath and dizziness.  Findings:  The physician reviewer found that the patients records indicate the presence of some cardiac risk including a family history of coronary artery disease (CAD), in addition to hypertension and a normal appearing electrocardiogram. The patients symptoms of exertional dyspnea and palpitations are concerning for an ischemic equivalent. In this clinical setting, further evaluation with stress testing is reasonable, appropriate, and considered within the accepted standard practice in the medical community. The current guidelines, as discussed by Gibbons and colleagues, are endorsed by several national organizations including the American College of Cardiology (ACC) and the American Heart Association (AHA). The recommendations consider stress testing appropriate in the clinical circumstance of a patient with cardiac risk and symptoms of dyspnea suggestive of an ischemic equivalent.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for an MRI of the lumbar spine for evaluation of her lower back pain. Findings:  The physician reviewer found that if there are no radicular symptoms, conservative treatment with physical therapy and anti-inflammatories is appropriate and an MRI is not necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested subcutaneous hormone replacement therapy for the treatment of her menopausal symptoms. Findings:  Three physician reviewers found that there is no documentation indicating that this patient has tried other forms of hormone replacement therapy to treat her symptoms. The medical literature does not demonstrate that subcutaneous hormone replacement pellet implants are superior to traditional forms of hormone replacement therapy. Additionally, the medical literature does not demonstrate that bioidentical hormones such as those at issue in this case are superior to traditional hormone replacement therapy, or that they have a superior safety profile. All told, there is inadequate evidence supporting the contention that the subcutaneous hormone replacement therapy at issue is more efficacious for the patients symptomatology than standard hormone replacement therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a knee brace for treatment of the enrollee, who is status post anterior cruciate ligament repair. Findings:  The physician reviewer found that Wright and colleagues review of the literature, 12 randomized controlled studies noted no evidence that pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. All told, postoperative bracing is not likely to change the clinical outcome after anterior cruciate ligament reconstruction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested reimbursement for laboratory testing,codes 83890, 83896, 83898 and 83912, for evaluation of the enrollees abdominal pain. Findings:  Two physician reviewers found that Celiac disease is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. This can result in typical malabsorption syndrome (chronic diarrhea, weight loss and abdominal distention) and a spectrum of symptoms potentially affecting any organ or body system, including chronic abdominal pain and constipation. Fasano and Catassi (2005) recommended the use of serological genetic celiac disease tests in order to identify these cases in a timely fashion to prevent serious complications secondary to untreated celiac disease. Underdiagnosis and misdiagnosis of celiac disease are common and can result in protracted and unnecessary morbidity. Hin and colleagues reported that serological screening uncovers a large proportion of patients with this condition and should be considered more frequently, especially when there is a family history of celiac disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for laboratory testing, codes 83520 and 88347, for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that code 83520 included evaluation of antigliadin antibodies and tissue transglutaminase testing. Code 88347 included endomysial antibody testing. Celiac disease presents with non-classical features such as abdominal pain and constipation. In order for the diagnosis to be confirmed, there must be a positive serological marker present. The testing at issue was performed to look for this marker.