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

The parent of a 17-year-old male enrollee has requested residential treatment for treatment of the enrollees cannabis dependence and alcohol abuse. Findings:  The physician reviewer found that this patient had escalating substance abuse for the past several months.  He was unsuccessful in treatment on an outpatient basis and in a wilderness treatment program as well.  During his treatment, he admitted to many of the behaviors that his mother had suspected him of prior to treatment.  He admitted that his substance use was also likely worse than anyone had suspected.  It appears he had not adequately dealt with the death of a close family member, and this was causing continued stress and substance abuse. Per the submitted documentation, the patient had improvement in his symptoms during treatment at the residential treatment center. In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System is indispensable in determining the necessary level of care for children and to insure the level of care meets individual needs in the least restrictive setting possible.  Per these guidelines, non-secure 24-hour psychiatric monitoring was medically indicated at the time of admission.  Thus, the patient met criteria for residential treatment services at the time of admission. The patient made progress in treatment and after approximately eight weeks was no longer reporting any mood symptoms.  He also has a history of failed treatments in the past at an outpatient level of care. However, he had no attempts at less restrictive settings, such as an intensive outpatient program. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.  Based upon the submitted documentation, the residential treatment center level of care was the least restrictive setting indicated for his treatment from the date of admission for approximately eight weeks. As of the following day, this patients mood stabilized, and it appears he could have transitioned to a less restrictive setting.  Thus, residential treatment provided from the admission date for approximately eight weeks was medically indicated.  Residential treatment was not medically indicated from the following date of service through the discharge date.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested Rituxan (rituximab) infusions for treatment of her neuromyelitis optica. Findings:  The physician reviewer found that neuromyelitis optica (NMO) is an inflammatory demyelinating disorder of the central nervous system that almost exclusively affects the optic nerves and spinal cord. Because pathological and serological studies suggest that NMO appears to be, at least in part, a B-cell mediated disease Rituxan has been considered a potentially effective treatment. However, studies to date have been small and not controlled. Well-designed clinical trials are needed to assess treatment effects in this rare disorder. The safety and tolerability of Rituxan in NMO is currently the subject of a clinical trial. Given the unproven efficacy of Rituxan in this setting, its use is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested diagnostic testing (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile) for evaluation of her pregnancy. Findings:  The physician reviewer found that per the submitted documentation, this patient had a high-risk pregnancy. Her high-risk conditions included polyhydramnios, cholestasis of pregnancy with elevated liver enzymes, and elevated bile salts. The patient had symptoms of itching which is very typical with cholestasis of pregnancy. She underwent diagnostic testing (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile).The medical community has been paying increasing attention to cholestasis of pregnancy, which is a potentially serious pregnancy-related liver disorder. The primary symptom of intrahepatic cholestasis of pregnancy is severe itching. The itching generally progresses in severity, and may develop to the point that it interferes with a womans daily activities, including sleep. Although the itching sensation can be present on any part of the womans body, it is most commonly felt on the palms of the hands or the soles of the feet. There is an increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy and polyhydramnios. The patient started to receive biweekly fetal testing as well as kick counts. On the date in question, the patient had a follow-up growth scan and antenatal testing which included an amniotic fluid index and biophysical profile. The timing since her previous sonogram to check growth was appropriate, and the patient received the biophysical profile as part of her biweekly antenatal assessment for cholestasis of pregnancy and polyhydramnios. These are considered standard of care. The fetus is monitored closely during the pregnancy to ensure normal fetal development is taking place. In this patients case, the diagnostic testing provided (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile) were medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that a breast MRI can either be performed as a screening exam or as a diagnostic study. The breast MRI performed was a diagnostic study performed as a short-term follow-up exam. Both mammograms and breast MRI studies are given a BIRAD classification, which includes recommendations for follow-up interval or need for a biopsy. When there is a finding that is probably benign, then a recommendation for short-term follow-up is given. Most short-term follow-up studies are performed in six months.  If an abnormality that is probably benign is found on a mammogram, then the short-term follow-up study would be a mammogram. Similarly, if a probably benign finding is only identified on breast MRI, then the short-term follow-up study needs to be a breast MRI. As this patients probably benign finding was only visualized on breast MRI, a follow-up breast MRI would be indicated. Thus, the breast MRI was medically appropriate and likely to be more reliable than a follow-up mammogram.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested ProDisc-C artificial disc replacement surgery (C5-6 anterior cervical discectomy and artificial disc replacement using ProDisc-C and C6-7 anterior cervical discectomy and fusion using plate fixation and allograft) for treatment of her cervical spondylosis and degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement surgery in the cervical spine in the attempt to limit adjacent segment disc disease has been employed with some early encouraging results. However, the maintenance of these results over the long-term has not yet been determined (Murrey and colleagues). The effectiveness of these implants is still uncertain, and the progression of degenerative change at the adjacent levels of standard fusion surgery may represent physiological progression of the natural history of the process, rather than being related to the surgery (Denaro and colleagues). In addition, heterotopic ossification has been reported after artificial disc replacement (Mehren and colleagues) and a significant frequency of spontaneous fusion in replacement surgery should be anticipated during long-term follow-up (Suchomel and colleagues). The need for long-term evaluation of artificial disc replacement surgery was recognized in the original approval of the ProDisc-C by the Food and Drug Administration for single-level replacement. Thus, an additional period of surveillance was required, a period which has not yet been completed. Finally, the utilization of an artificial disc implant at more than one level has been attempted (Ozturk and colleagues), as has the insertion of an implant at one level with fusion at another (as is the case with this patient, Lee and colleagues), but the reported studies have limited numbers and lack long-term outcomes.Because there are many unanswered questions regarding the efficacy of total artificial disc replacement surgery in the cervical spine, particularly when combined with fusion, it remains an unproven procedure at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity. Findings:  Two physician reviewers found that the patient is seeking a laparoscopic sleeve gastrectomy. The Health Plan has denied authorization for the procedure on the basis that it is considered experimental and is not as good as or better than laparoscopic gastric band (LGB) or laparoscopic Roux-en-Y gastric bypass (LRYGBP) according to the literature. Laparoscopic sleeve gastrectomy is widely accepted in the literature as both a standalone procedure and as the first phase of a two-stage procedure (followed by duodenal switch). Recent trials and reviews of five and eight year-data clearly show that laparoscopic sleeve gastrectomy is as good as or even better than LRYGBP. In the case of this patient, she has a history of peptic ulcer disease, is on lifelong anti-coagulation therapy, and takes non-steroidal anti-inflammatory drugs (NSAIDS) which significantly increases her risk for bleeding. She had a gastric polyp removed. With LRYGBP, the gastric remnant would make future endoscopic evaluation impossible. In addition, the patients dosage deliverance and absorption of her medication is critical and with LRYGBP this will be very unpredictable because of the rapid push to the distal small bowel. Furthermore, management of the patients anemia and vitamin deficiencies would be more difficult with LRYGBP.With regard to LGB, a study by Uglioni, et al. found that that after 5 years, 39% of LGB treated patients either had their bands removed or had insufficient weight loss. Recent studies also show that longer-term weight loss is much better with sleeve gastrectomy than with LGB, and the former results in greater improvement of co-morbidities. Moreover, band erosion while on anti-coagulant therapy would be very problematic.All told, given the patients medical history and current need for medications, sleeve gastrectomy is more appropriate than any other available weight loss procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that this patient has a long history of substance abuse problems.  She has been to numerous treatment centers for a variety of substance and psychiatric issues. She had serious difficulty maintaining her sobriety in the past. There is limited information in the submitted progress notes as to her status in treatment. The notes largely consist of statements about her group attendance and other brief statements. Based upon the submitted documentation, her motivation was limited, and this is considered a major factor in treatment success. In cases such as this, an evidence-based instrument such as the Level of Care Utilization System is useful in determining the necessary level of care to insure the level of care meets individual needs safely and effectively, in the least restrictive setting possible.  Based upon these guidelines, medically monitored residential services were medically indicated at the time of admission to the residential treatment center as the patient was at moderate risk of harm, her functional status was seriously impaired, and she had significant co-morbidities. The current minimum standard for this level of care is four weeks of treatment on an inpatient basis. It appears this length of treatment was warranted for this patient. A treatment length longer than this is not supported by the submitted documentation. Thus, residential treatment services during the initial four weeks were medically indicated. The medical necessity of residential treatment services provided after the initial four weeks has not been established, and the patient could have been treated safely and effectively at a less restrictive setting during these dates.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for autologous platelet concentrate for treatment of her knee pain. Findings:  Two physician reviewers found that there is a lack of well-controlled, randomized studies supporting the use of platelet rich plasma injections for this patients medical condition. Studies showing promising results were laboratory studies, poorly designed clinical studies or clinical studies with significant limitations. In this patients case, autologous platelet concentrate is not likely to be the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested Xolair for treatment of her asthma. Findings:  The physician reviewer found that the medical literature provides sufficient scientific data on the long-term (greater than two years) safety and effectiveness of Xolair in patients with higher IgE levels than this patient. Further, Wahn and colleagues found that pre-treatment allergen-specific IgE levels was not a reliable prognosis factor in selecting patients most likely to benefit from treatment with Xolair. Moreover, Lowe and colleagues concluded that, Although currently approved dosing tables are close to optimal, it should be possible to treat patients with higher levels of baseline IgE if higher doses can be administered. Thus, this patients elevated IgE level should not be considered a contraindication to her being treated with Xolair, and it is clinically appropriate for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  The physician reviewer found that although the treating OT provider has documented functional goals for this patient, the goals are not easily quantifiable. The patient has been receiving occupational therapy on and off for over two years, yet the submitted records provide no documentation demonstrating benefit of the therapy over time. The treating provider has not performed standardized assessments documenting the need for these services. Although the in-network OT evaluation utilized a standard evaluation (the Peabody Developmental Motor Scale (PDMS)), no attempt was made to use a standardized assessment to measure issues with sensory processing, which is a common issue with young patients with autism. All told, the submitted clinical evidence fails to establish a treatment baseline, does not articulate specific functional goals, and does not objectively document the patients progress toward goals. Thus, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested a bilateral mastectomy for treatment of his gynecomastia. Findings:  The physician reviewer found that with regard to whether the proposed procedure is reconstructive in nature, based upon the documentation provided, the patients condition is not considered an abnormal structure of the body. Gynecomastia is quite common among adolescent males. It often occurs during puberty and most males experience natural regression of the breast tissue over time. The submitted photographs demonstrate grade I to III gynecomastia with little or no excess skin on either side. In sum, the submitted evidence does not demonstrate that the patients condition is so severe that it constitutes an abnormal structure of the body. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning the medical necessity of the proposed procedure, the submitted evidence does not demonstrate that the patients condition results in a functional impairment. There is no medical record documentation of reports of pain that is refractory to standard therapies. In the absence of objective evidence of pain or discomfort that persists despite the use of conservative therapies (e.g., non-steroidal anti-inflammatory drugs or analgesics) or the existence of a physical functional impairment, the medical necessity of bilateral mastectomy is not established. All told, the documentation submitted in this case does not demonstrate the requested procedure is necessary from a medical standpoint.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  Three physician reviewers found that given the predicted adult height estimate from the information provided, this patient would not qualify for GH therapy on the basis of idiopathic short stature according to the Food and Drug Administration (FDA) guidelines of July 2003. Moreover, the scientific data do not support the use of GH therapy in combination with gonadotropin-releasing hormone agonist (GnRH) therapy, as utilized for management of this patients condition. While some studies report positive results with this combination therapy, the patient numbers were small and the outcomes were deemed insignificant. For these reasons, the therapy remains investigational for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a full body PET scan for evaluation of his stage IV renal cell carcinoma. Findings:  Two physician reviewers found that the American College of Radiology notes that PET scanning may be helpful for establishing metastatic disease in lesions detected by MRI, CT or bone scan. Additionally, PET scan may be used to detect unsuspected metastases in high-risk patients. This patient is undergoing relatively toxic therapy, and he is being considered for ablation. PET scanning was initially used to establish the diagnosis and extent of disease.  At this time, it is medically reasonable to evaluate the response to treatment in order to determine treatment options, especially since the patient is experiencing toxicity to Sutent. A PET scan will provide structural information and establish metabolic activity of the disease. In this patients case, the requested full body PET scan is likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested proton beam therapy for treatment of his esophageal cancer. Findings:  The physician reviewer found that proton beam therapy is an FDA-approved tool available to clinicians to treat patients with radiotherapy. For distal esophageal/gastroesophageal junction cancer, proton beam therapy is one of several options. At this time, proton beam therapy is not considered medically necessary in this setting as there is limited data to support its use; and while there are some dosimetric advantages, there are also dosimetric disadvantages. For this particular patient, the dosimetric advantage was not in the maximal doses to critical organs such as heart, liver and esophagus, but rather the mean and lower integral dose delivery, which may not be clinically meaningful. There is inadequate evidence that proton beam therapy was a superior option compared to IMRT or conventional 3-D radiation, which are considered the standard therapies for the treatment of this patients disease. As such, proton beam therapy was not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested gastrointestinal biofeedback for treatment of her pelvic floor dysfunction. Findings:  The physician reviewer found that this patient meets generally accepted criteria used to determine appropriateness for biofeedback therapy for chronic constipation with defecation dysfunction. While she may or may not have dyssynergic defection, she clearly has tried and failed standard approaches for treatment of chronic constipation, including laxatives used for longer than three months and she meets the ROME III criteria for functional constipation. Objective evidence of her possible dyssynergic constipation includes below normal squeeze pressures (which likely represent an abnormality of relaxation of the puborectalis muscle, a requirement for the diagnosis of dyssynergic constipation) and inadequate propulsive force. The abnormal colon transit study likely represented colonic atony, and often accompanies dyssynergic defecation disorder. In this patients case, there is medical justification and necessity for a trial of biofeedback therapy prior to proctectomy with permanent ileostomy. If the trial of biofeedback therapy proves to be successful, it will allow the patient to avoid permanent ileostomy. While there is limited literature supporting the use of biofeedback in this particular setting, given the refractory nature of the patients condition as well as the lack of desirable surgical options, a trial of feedback therapy is medically necessary in this patients case for the treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested partial hospital program (PHP) care for treatment of her behavioral health condition. Findings:  The physician reviewer found that the records submitted do not establish medical necessity for the PHP services provided on the dates of service at issue as they do indicate that the patient required these services. The records indicate that the patient was seen for three one-and-one half-hour group therapy sessions, along with one or two physician visits during the time period in question. PHP services typically are a minimum of 3-4 hours daily. The patients high GAF score, along with the physicians note and treatment plan, indicated that the patient was essentially in or close to complete remission. The patient presented with diagnoses of panic disorder and bipolar disorder. National practice guidelines indicate that hospitalization or partial hospitalization program services are only required for very severe cases of panic disorder with agoraphobia, when administration of outpatient treatment has been ineffective or is impractical. In this patients case there was no evidence submitted indicating that outpatient treatment had been ineffective or impractical for her. To the contrary, outpatient treatment appears to have been very effective as evidenced by the patients near or complete remission. Moreover, American Psychiatric Association guidelines do not indicate that PHP services are appropriate or medically necessary for the treatment of patients with bipolar disorder who are in remission.