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

A 60-year-old female has requested approval for a positron emission tomography (PET) scan for evaluation of her breast cancer.    Findings:  Two physician reviewers found that the patient was found to have stage I left breast cancer nine months ago. She underwent a bilateral mastectomy. At surgery, axillary lymph node dissection on the left showed 7 of 15 positive lymph nodes. The patient had a PET/CT showing no hypermetabolic foci. No current physical or laboratory values reportedly indicate recurrence at this time. In light of the number of positive nodes and risk of recurrence or metastasis the provider has recommended a follow-up PET/CT.  The National Comprehensive Cancer Network (NCCN) guidelines offer wide latitude to clinicians who are concerned about early tumor recurrence of breast cancer based upon initial presentation, staging and biology of the tumor. The NCCN specify that PET/CT is indicated if tumor recurrence is considered likely. Although the original scan was negative, 7 of 15 axillary lymph nodes were positive at surgery. This ratio indicates the risk of recurrence is fairly high. So, in an effort to detect likely or highly possible tumor recurrence as early as possible to improve patient outcome, the use of PET/CT is the most accurate modality. By contrast, conventional imaging would not provide such advantages.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating the services at issue were not required on an emergent basis. Findings:  The physician reviewer found that The patient presented to the emergency department with chief complaint of sore throat of four days duration associated with cough, headache, runny nose, joint pain and muscle aches. The patient reported experiencing a fever of 105 degrees at home. Upon presentation to the emergency department, the patient reported the severity of her symptoms as a 9 on a scale of 1 to 10. Vital signs included temperature 100.2 degrees, pulse 122, respirations 22, and oxygen saturation 99% on room air. The patient was diagnosed with influenza A and fever and Tylenol and Norco were administered in the emergency department. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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 documentation demonstrates that on the date in question the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to seek immediate medical attention. Specifically, the patient had acute symptoms of high fever prior to presenting to the emergency room, headache, muscle aches, and sore throat. Given these symptoms, the patient was at risk for significant morbidity and mortality related to possible infectious complications including sepsis, meningitis and others. All told, a prudent layperson in these circumstances would have reasonably believed they were experiencing an emergency medical condition and would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female has requested continued residential services for treatment of her bipolar disorder, post-traumatic stress disorder, polysubstance dependence, impulse control disorder, borderline personality disorder generalized anxiety disorder and eating disorder not otherwise specified.  Findings:  The physician reviewer found that this case encompasses significant affective, anxiety and addictive influences in addition to being steeped in psychodynamic theory. It appears the patients characterological organization and family dynamics fuel a cyclical pattern of maladaptive behaviors which in turn exacerbates the psychiatric pathology. A previous independent medical review determined that residential treatment level of care was medically necessary for this patient, and the patients treatment team indicates that residential care will be complete by the date at issue. Based on the documentation provided, there is continuing evidence of persistently severe suicidality and mood symptoms, along with substance abuse and global impairment which were unresponsive to less restrictive treatment settings prior to admission. Such symptomatology is more than likely to result in undue morbidity and possible psychiatric hospitalization if the patient is discharged prematurely. Affording the patient a planned discharge on the date at issue will provide her with the best chance for success in the outpatient setting.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a then eight-year-old female enrollee has requested coverage for emergency services.  Findings:  The physician reviewer found that the patient was seen in the emergency department with a history of right ear pain for a couple of days associated with a fever, cough, vomiting, and a discharge from the right ear. At the time of the emergency department visit, the pain was rated as moderate. The physical examination revealed a temperature of 100.4 degrees, petechial lesions on the palate, and erythema of both tympanic membranes with blisters on the right tympanic membrane. No perforation of the tympanic membrane or discharge was noted in the medical records. The patient was treated with ibuprofen orally and Auralgan ear drops in the ear canal for pain. The diagnoses were otitis media and bullous otitis.  The patient was given prescriptions for ibuprofen for pain and Zithromax (an antibacterial antibiotic) for a presumed bacterial infection of the ears. The patient was discharged to follow-up with her primary care physician. Subsequent to the emergency department visit, the patients father reported that his daughter had mild pain prior to the day of the emergency department visit but developed severe pain associated with a bloody discharge from the right ear on the date in question which prompted the emergency department visit. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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 documentation demonstrates the patient had pain that was described by her father as severe, although in the emergency department it was rated as moderate. If, in fact, the tympanic membrane had perforated at home, that would account for the patients transient severe pain and also account for the bloody discharge from the ear as reported by her father and which was noted in the emergency department record as discharge. Although the severe pain and discharge might not have been present by the time the patient arrived at the emergency department, the patient did have a fever and physical evidence of a bacterial infection of the right tympanic membrane. The blisters were diagnostic of bullous otitis which is caused by a bacterium and warranted treatment with an appropriate antibiotic. All told, a prudent layperson would have thought the patient to be experiencing an emergency medical condition on the date in question and would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male has requested a Fentanyl patch for treatment of his back pain and HIV.   Findings:  The physician reviewer found that the relevant scientific evidence includes a literature review to assess the effectiveness of controlled release opiates over short-acting opiates in patients with chronic pain (Rauck). The author states that opioids have long been an important option in the management of moderate to severe chronic pain. The author concluded that many patients receiving long-acting opioid formulations show improved treatment responses and better perception of quality of life. In addition, the sustained reductions in pain seen with long-acting opioid formulations may promote the patients focus on daily activities rather than on their pain, thereby improving therapy adherence and reducing pain-related anxieties.In the case of this patient, the use of the long-acting Fentanyl patch is supported by the scientific literature and is medically necessary for treatment of his chronic pain. The patient has a chronic pain condition due to degenerative disc disease of the lumbar spine and lumbar radiculopathy. Additionally, the patient has HIV and hepatitis B, with fatty liver. As a result, the patient must avoid products containing acetaminophen, non-steroidals and most medications metabolized by the liver. Further, the Fentanyl patch has a high safety profile in patients with liver failure as well as very little interaction with anti-retroviral medications. All told, the Fentanyl patch is an appropriate opioid medication to control the patients chronic pain and is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female has requested MaterniT21 test for evaluation of her fetus for Trisomy 21.  Findings:  Two physician reviewers found that the patient has chronic hypertension. The records indicate that she underwent sequential screening for fetal aneuploidy, which reportedly revealed an increased risk for Down syndrome.  While noninvasive detection of fetal aneuploidy by free fetal DNA in the maternal circulation has been shown to be an effective screen, diagnostic testing with amniocentesis remains the gold standard. Based on the current peer-reviewed medical literature and practice guidelines, free fetal DNA testing is not supported to be as effective as standard testing. Since amniocentesis is available and the requested testing is not more beneficial than amniocentesis, the MaterniT21 is not likely to provide novel and useful data relevant in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male has requested bilateral hip arthroscopy performed in a single surgery to correct bilateral femoroacetabular impingement for treatment of his hip pain.  Findings:  The physician reviewer found that the surgical treatment of femoroacetabular impingement has become more widely accepted despite the lack of high quality evidence demonstrating its efficacy. With regard to whether the performance of bilateral hip arthroscopies during a single operative session is medically necessary compared to staged procedures, the evidence is sparse and for the most part anecdotal. One recent paper indicates the intra-operative complication rate was no different than in staged procedures, and the outcome was no different in the near-term (Mei-Dan, et al.). Results over the longer-term are not yet available.  At this time, there is no peer-reviewed evidence demonstrating that the performance of bilateral hip arthroscopies during a single operative intervention is superior to staged procedures in terms of outcome, rehabilitation or complications. As such, the medical necessity of the proposed services for treatment of this patients bilateral femoroacetabular impingement has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested coverage for the medication phentermine 37.5 mg for treatment her obesity. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates the patient has been diagnosed with obesity. Phentermine is an FDA-approved medication for obesity and has been used with good results in some patients. The documentation provided does not demonstrate any contraindications to the use of phentermine in this case. Thus, a course of phentermine is a medically appropriate and reasonable option for this patient. However, the patient will require a prescribing and supervising physician to monitor her for potential risks and complications. In addition, the medication is not indicated for long-term use over three months without a break in treatment. In sum, a three-month course of phentermine 37.5 mg is medically necessary for treatment of this patients obesity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male has requested intravenous IVIG for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that this patient has had progressive upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The current medical literature indicates that the diagnosis of chronic inflammatory demyelinating polyneuropathy is made based on history, examination, electrodiagnostic study, and may be supplemented by cerebrospinal fluid examination and relevant biopsies.  The current medical evidence supports intravenous IVIG treatment for the treatment of chronic inflammatory demyelinating polyneuropathy.  As IVIG is shown to be appropriate for chronic inflammatory demyelinating polyneuropathy, and this patient has had findings which are consistent with this diagnosis, IVIG treatment is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female has requested participation in a weight loss program for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Obesity is associated with diabetes, hypertension, hyperlipidemia, cancer, osteoarthritis, obstructive sleep apnea, cardiovascular disease, and asthma.  The prevention of obesity involves both increasing physical activity and dietary modification to reduce caloric intake.  Lifestyle modification, including diet, physical activity, and behavior therapy, have been shown to induce clinically significant weight loss.  Weight loss strategies that use dietary, physical activity or behavioral interventions can produce significant improvement and long-term weight loss results.  The medical documentation indicates the patient had significant weight loss with the structured diet program provided by a medical center.  Her potential for significant and sustained weight loss will improve with the present program.  All told, the requested participation in a weight loss program at the center is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested laparoscopic adjustable gastric banding for treatment of her obesity.  Findings:  The physician reviewer found that based upon the patients most recently documented BMI of 32.8, she does not currently meet the criteria set forth by nationally accepted guidelines for weight loss surgery. According to the National Institutes of Health Consensus Guidelines, an individual must have a BMI of at least 35 along with significant co-morbidities to be considered an appropriate candidate for bariatric surgery. In this case, the patient lost a significant amount of weight following her surgical consultation in February 2012 and no longer appears to have a BMI of 35 or above. Given the patients sustained weight loss, the risks of bariatric surgery outweigh the potential benefits of surgery at this time. It is likely an individual in this patients circumstances will be able to achieve adequate weight loss using conservative weight loss methods such as diet and exercise.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested coverage for Synvisc One injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that upon review of the relevant scientific evidence, the medical necessity of an additional series of hyaluronan injections is not established for this patient. The above cited literature does not support a positive effect from hyaluronan in osteoarthritis of the knee. While there is an advantage to delaying joint replacement as long as possible, the use of repeated hyaluronan injections is not without risk with possible allergic reaction or infection as complications. Moreover, there is no evidence that one brand of hyaluronan injections is more effective than another. At this time, the use of hyaluronan injections in individuals with osteoarthritis of the knee is poorly supported by double-blinded studies and also has a low but present risk of complications. The possibility that the hyaluronic acid molecule will disrupt the effect of inflammatory cytokines affecting osteoblastic and osteoclastic and chondrolytic changes within the knee joint is unlikely. As such, the process of chronic inflammation is not likely to be altered by the hyaluronic acid macromolecule. Further, in the article authored by Colen  et al. which reviewed the use of hyaluronic acid in joints other than the knee joint, it was concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. All told, there is insufficient evidence that an additional course of Synvisc One injections is medically necessary for treatment of the patients knee osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male has requested approval for long-term residential treatment (or higher level of care services) for treatment of his behavioral health issues.    Findings:  The physician reviewer found that based on review of the available records, RTC level of care is indicated. This patient is not so suicidal or homicidal that he requires acute hospitalization. However, he is chronically non-compliant and a danger to himself and others, and has markedly impaired level of functioning with refusal to attend school, as well as many oppositional behaviors when he does attend school. Yet he is able to regroup shortly when he is in the hospital. He has had multiple hospital admissions and ED visits within the past six months, with relapses sometimes within one or two days of discharge. This patient requires long-term RTC placement to help him acquire appropriate skills and maintain them long enough so that they will generalize when he is discharged. In addition, he has been given multiple opportunities to engage in outpatient therapies, and either refuses to attend completely or relapses quickly in this setting. All told, long-term RTC is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female  has requested approval for breast cancer surgery to be performed by a breast cancer surgical oncologist versus a general surgeon, and breast cancer surgery in a treatment facility that specializes in cancer treatment versus a standard surgical environment for treatment of her right breast carcinoma.   Findings:  The physician reviewer found that currently, there is inadequate data that breast cancer patients who are treated by breast surgeons experience superior outcomes when compared with treatment provided by general surgeons. Further, there is no indication that care provided in specialty centers is superior to that provided in general practices. One of the four surgeons offered by the Health Plan is a trained surgical oncologist, and the other three providers are general surgeons. Certification by the American Board of Surgery (ABS) includes assessment of competency in breast cancer care. In addition, there is nothing about this patient that is unusual or complex other than a second adjacent benign lesion that should be excised at the same time as the definitive surgery for the DCIS.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female has requested approval for past magnetic resonance imaging (MRI) of the breast for evaluation of her heterogeneously dense breast tissue with multiple cystic lesions.   Findings:  Three physician reviewers found that the patient has a family history of postmenopausal breast cancer. No positive physical findings. The patients mammogram and ultrasound reports have been very equivocal. This has led to MRI evaluation of the breasts where the report was also equivocal and recommendation was made for short-term follow-up with MRI due to abnormal enhancement within several areas. A repeat or follow-up MRI was requested and denied by the Health Plan as being investigational since there is no evidence of increased risk of breast cancer. Conventional imaging including mammography and targeted ultrasound have been equivocal in this patient therefore her provider recommended further evaluation with MRI, which was done. This examination showed some abnormal findings including enhancement patterns that can only be followed with MRI. Since an abnormal MRI was documented in the records, a repeat MRI was the appropriate imaging modality for accurate change, especially considering the enhancement findings. Repeat targeted ultrasound would not provide such analysis. MRI in this instance is the standard of care.  All told, MRI is the most sensitive means for early detection of breast cancer in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female has requested residential treatment center (RTC) services for treatment of her behavioral health issues.    Findings:  The physician reviewer found that based on review of the available records, this patient was admitted to RTC level of care primarily because she had run away from home and was considered a flight risk. However, she was already in the juvenile system and there were legal constraints placed upon her. The records indicate that she had little previous substance abuse treatment for her daily use of cannabis. She refused all medications to treat her ADHD, mood and anxiety, and only accepted medication to help her sleep. The milieu notes indicate that she has not exhibited any serious behavior problems, such as threatening to run away or hurt herself or others. Her main problems in the milieu were arguing when told to do something and becoming upset over small matters. Although the treatment team states that she was at high risk because of her previous runaway behavior and suicide attempt, there is no evidence that she contemplated escaping from her program. All told, the RTC level of care services provided from the date at issue and forward are not supported as medically necessary for treatment of this patients medical condition.