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

The parent of a four-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA therapy is supported as superior to special education or standardized care in improving the outcome in patients with autism. Given the current standards of practice, the requested ABA services should be provided at a frequency of 30 hours per week. The patient should begin with the requested 30 hours of ABA therapy with evaluations every 6 months, in order to assess the necessity of the number of hours required to adequately address this patients individual needs. In sum, the requested services have been demonstrated to be medically necessary in this instance and should be approved.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested emergency services for 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.Second degree burns are more serious than first degree burns due to the loss of tissue.  Hand injuries are also at higher risk for infection and complications than other parts of the body. In general, patients with burns should receive immediate medical attention. This patient reasonably believed she had a medical condition including significant pain and potential body part impairment and/or serious dysfunction of her hand which justified follow up in the ED on the date of service in question as instructed by the emergency physician who examined her the day before. In light of the discharge instructions the patient received during her initial ED visit indicating that she should return to the ED the following day, the patient met prudent layperson criteria for emergency care.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested urgent care services for the treatment of her spotting and vaginal discomfort. Findings:  The physician reviewer found that the issue to be decided is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would have believed she was experiencing an urgent medical condition on the date of service in question. Urgently needed services are those services necessary to prevent serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plan's service area.  In this patients case, she presented on the date of service in question with complaints of cramps, spotting and discomfort. These complaints, in a young sexually active woman, can reasonably be considered urgently needed services. The patients symptoms would be sufficient to cause a prudent layperson to seek services while out of the Plans service area.  Based on the acute nature of the symptoms the patient was experiencing, the patient reasonably believed she was experiencing an urgent medical condition on the date in question.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that documentation has been provided which demonstrates that this patient failed multiple abortive and preventive headache therapies. Additionally, the documentation indicates the patient had a previous positive response to Botox therapy. This new data supports the continued use of Botox to help manage this patients headaches. In this particular case, given the patients failure to respond to multiple standard headache therapies, the use of Botox is likely to be more beneficial for treatment of the patients headaches than continued attempts with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested gynecomastia surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before or near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence.  The use of mastectomy for gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty, as in this patients case, is not considered an acceptable alternative to nonsurgical forms of treatment.  In this patients case, the surgery at issue was not medically indicated. Additionally, the patients condition did not constitute an abnormal structure of the body and may have resolved at the conclusion of puberty. All told, gynecomastia surgery was not reconstructive in nature and was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested inpatient treatment for treatment of his substance use disorder.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient, although challenged to stay abstinent from prescription drugs and alcohol, could have accessed and benefited from intensive rehabilitation services for his addictions on an outpatient basis. This patients previous attempts at detoxification and rehabilitation were greater than two years prior to this entry to care. While the patient reported work-related challenges related to his substance use disorder, no description of legal, family, or acute medical concerns necessitating an inpatient level of care were presented. Moreover, no withdrawal symptoms were noted in the records provided for review. Consistent with the references cited above, this patients substance use disorder could have adequately been managed in an outpatient program or chemical dependency partial hospitalization program (PHP). The PHP would offer this patient ongoing therapeutic intensity and structure for his continued recovery. The PHP also allows patients to receive intensive treatment during the day and practice recovery skills while living in a supportive structured environment. Less-restrictive settings promote recovery in a natural and least restrictive a setting as possible. As such, inpatient rehabilitation services were not medically necessary for care for this patient during the dates of care at issue as he could have been safely and adequately treated on an outpatient or PHP basis.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested emergency services for treatment of his medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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 patients symptoms were not sudden in onset or severe. He reported sore throat and ear pain as well as a rash. The patient specifically denied fever, vomiting, trouble eating or any other symptoms of a more serious or life-threatening nature. He had already started a course of antibiotics. While the patients symptoms warranted a medical evaluation, this service did not need to be provided on an emergent basis. 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 his health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested spinal fusion surgery at L-4 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation for treatment of his lower back pain.  Findings:  The physician reviewer found that the additional records do not demonstrate a medical indication for the requested procedure. The reports provide no new rationale for the proposed procedure. Fusion is indicated for instability or abnormal movement, with pain or neurological deficit, but rarely in the presence of abnormal radiographic studies without appropriate clinical findings. Diffuse low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain with degenerative changes, fusion is no more effective than intensive rehabilitation, as noted by Chou and colleagues.  Fusion has a poor success rate when used to treat multilevel degeneration as seen on MRI. Thus, at this time, there continues to be a lack of documentation of clinical indications for the requested procedure. All told, the requested spinal fusion surgery at L-4 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation is not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, 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: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. Given this patients history, he reasonably believed he needed to return for a wound check within 24-48 hours as he had been instructed on his discharge summary from the hospital. Specifically, after his wound had been treated, the emergency provider had instructed him to return for a wound check in two days. There is nothing in the discharge summary informing the patient to return only if there were signs of infection such as redness, swelling and pain. Thus, the patient followed the providers directions and presented to the ER for a wound check as advised. For these reasons, the patients decision to seek treatment in the ER for the wound check as recommended by the emergency provider was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested anesthesia and hospital services for extraction of wisdom teeth for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has Goldenhar syndrome and is need of having her wisdom teeth removed. Given that her oral surgeon has recommended that the procedure be accomplished under general anesthesia rather than local anesthesia, performance of this procedure in a setting with an available anesthesiologist is prudent and consistent with sound clinical judgment. Goldenhar syndrome is a rare congenital deformity which has associated facial and oral anomalies that have been known to cause airway management challenges. Involving an anesthesiologist is appropriate in the event a complication secondary to airway management develops.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a transfer to an acute rehabilitation unit for treatment of her metastatic breast cancer to the brain. Findings:  The physician reviewer found that from a review of the available records, it appears that the patient is now ready for treatment at a lower level of care and requires the services available at a skilled nursing facility. She is currently an inpatient, but in order to transfer to an acute rehabilitation unit, a patient needs to have good rehabilitation potential and must be able to tolerate intensive rehabilitation on a daily basis. This patients records show that as an inpatient she had occupational and physical therapy evaluations that demonstrated the inability to ambulate, extreme weakness and multiple other deficits. At this time, the patient has very low potential for rehabilitation and could not tolerate the amount of therapy expected at an acute rehabilitation facility. In addition, there is no indication in the records that a physician or other provider has recommended or ordered the requested transfer to an acute rehabilitation unit. For these reasons, a skilled nursing facility is the most appropriate level of care for this patient at this time considering her current medical status and lack of potential.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 76-year-old male enrollee has requested stereotactic radiosurgery (CyberKnife) for treatment of his high grade prostate cancer.  Findings:  Three physician reviewers found that while CyberKnife is a treatment option, it is not standard therapy for prostate cancer. In a report from King and colleagues, the authors acknowledge that their results are not mature enough. In addition, short follow-up is also an issue with the study by Madsen and colleagues which treated patients with hypofractionated radiation, though not with CyberKnife. Despite these shortcomings, the studies demonstrate that hypofractionated radiation is effective with respect to biochemical control (Katz, et al). However, none of the studies referenced above discusses the use of CyberKnife/SBRT as a boost treatment.  In fact, the paucity of studies suggests that such an approach has not been investigated. Furthermore, there is no literature for the use of SBRT as palliative therapy (i.e. treating the prostate in the setting of metastatic disease).All told, IMRT as a boost treatment is likely no less effective, and perhaps yields a lower risk of late toxicity due to the fractional dose delivery when compared to CyberKnife. As such, there is no compelling clinical rationale for this patient to be treated with CyberKnife and there is no proven benefit of CyberKnife treatment over standard prostate radiation therapy options including IMRT or 3D-conformal radiotherapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested chiropractic care/physical therapy for treatment of her low back pain.  Findings:  The physician reviewer found that chiropractic techniques are commonly applied for the treatment of back and neck pain and have been rated very helpful by patients.  The literature supports the effectiveness of manual therapy/spinal manipulative therapy for the management of chronic back pain. In this case, the patient has a history of chronic back pain. The records indicate that she responded to manual therapy with gradual improvement in her pain rating scores. The treatments were consistent with standard practice and have benefitted the patient. All told, past chiropractic care/physical therapy was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested a left total hip arthroplasty for treatment of his arthritis of the left hip.  Findings:  The physician reviewer found that total hip replacement is recognized as an effective procedure for the relief of pain and improvement of function in the hip. This reconstructive procedure is indicated in patients with a failure to respond to conservative management. Although evidence of osteoarthritis on x-ray is a necessary indication for the operation, the severity of radiographic stage does not correlate with postoperative outcome. More important are the severity of the pain and the degree of interference with daily activities.  In this patients case, there is a lack of documentation of any conservative management, with no documentation of the patients response to medications, therapy, or assistive devices. The presence of osteoarthritis in the left hip is noted on x-ray, but there is no documentation of any findings on examination.  Based upon the submitted documentation, a left total hip arthroplasty is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested testosterone CYP injections 200mg/mL 2MLH, intramuscularly every month for treatment of his decreased libido and fatigue.  Findings:  The physician reviewer found that the patient is not currently osteoporotic.  Recent testing shows osteopenia in the hip and normal, age-appropriate, bone density in the lumbar spine.  The current medical literature does not recommend testosterone therapy for osteoporosis in a patient that is not hypogonadal (low testosterone).  If the patient was osteoporotic one year ago before starting therapy, then he has shown a good response to current treatment. He had one set of laboratory tests that showed a normal total testosterone and low free testosterone, but a subsequent test showed a normal free testosterone.  Thus, at this time, the patient is not hypogonadal.  All told, the requested testosterone CYP injections 200mg/mL 2MLH, intramuscularly every month, are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested plasma injections for treatment of her plantar fasciitis.  Findings:  Three physician reviewers found that the patient has failed conservative treatment consisting of stretching, icing, custom orthotics, night splints, immobilizing boot, physical therapy and steroid injections. The provider recommended an autologous platelet-rich plasma injection to the painful heel.    Most of the studies on platelet-rich plasma therapy note some efficacy.  However, these reports note that further investigation is necessary.  There is a lack of large, double-blind, placebo-controlled studies for this treatment modality.  Currently, the minimally invasive endoscopic plantar fasciotomy demonstrates a 90% cure rate.  At this time, the superior efficacy of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested general anesthesia during esophagogastroduodenoscopy and colonoscopy procedures for evaluation of her medical condition.  Findings:  The physician reviewer found that the applicable medical literature suggests that monitored anesthesia care is medically necessary in a patient with anticipated intolerance to standard sedatives. The patient in this case has a history of requiring a larger dose of sedatives to achieve the same result as the average person. Clearly, the actual dose of Propofol administered the patient during the procedures was substantial. In fact, the dose was the equivalent of about three times the normal dose for most patients her age and size. It was therefore likely and foreseeable that she would not have tolerated conscious sedation well. For these reasons, the choice to administer monitored anesthesia care during the EGD and colonoscopy procedures on the date in question was medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a duodenal switch for treatment of her obesity.  Findings:  The physician reviewer found that this patient is morbidly obese and has failed supervised weight loss programs in the past. She has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery.  A duodenal switch procedure is a standard procedure for the treatment of morbid obesity that is approved by the American Society for Metabolic and Bariatric Surgery. The duodenal switch procedure is a medically appropriate standard primary treatment for morbid obesity. The submitted documentation provides adequate support for the requested procedure in this clinical scenario.  All told, the requested duodenal switch is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female is has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depression.  Findings:  Two physician reviewers found that as reported by Janicak and colleagues, the use of TMS for that treatment of major depressive disorder (MDD) is supported in the scientific literature with favorable assessments of its safety and effectiveness. Consistent with this, Demitrack and Thase noted that the value of TMS in the treatment of MDD is widely recognized as a clinically significant treatment option in patients resistant to other treatments. Thus, the TMS is currently within the standard of care in the treatment of depression in well selected patients and is used at leading academic institutions as well as in the private practice environment. With regard to this patient, multiple attempts at treatment with antidepressants and psychotherapy. These treatment modalities were tried and were either discontinued due to side effects or were insufficient to produce an adequate clinical response although administered in adequate dosages and for sufficient durations. Therefore, in the presence of continuing depression, it was reasonable to provide the patient with a trial of therapy with TMS, given the published support for its safety and efficacy in the treatment of patients with refractory MDD. Accordingly, the use of TMS in the management of this patients condition should not be considered investigational and was likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a myomectomy, cystectomy, dilation and curettage and possible total hysterectomy including bilateral salpingo-oophorectomy for treatment of her uterine fibroids. Findings: The physician reviewer found that based upon the submitted documentation, surgery is not indicated. This is a patient who presented for a routine gynecologic examination, with no gynecologic complaints. An ultrasound revealed the incidental findings of small ovarian cysts, minimal fibroids, and an endometrial lining that was 1 cm thick, on said date of her cycle.  This degree of endometrial thickness is normal on of the said date of her cycle, as are the small cysts, including small complex hemorrhagic cysts. Fibroids are found in 50 to 80% of women by the time they are 50, so the incidental discovery of small fibroids is of no clinical significance and does not require further evaluation or treatment.