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

A 62-year-old female enrollee has requested laser therapy for the treatment of her degenerative disc disease and stenosis of the cervical spine. Findings:  Three physician reviewers found that the available medical literature does not support the use of laser therapy in this case. The available medical studies do not show the efficacy of this therapy over other available modalities or treatment. It is unclear how long the treatment benefits last or whether there is any practical carry-over or carry-over that can be applied towards activities of daily life (strength, range of motion, and pain-relief). Whatever local, temporary increase in blood circulation that laser therapy provides can be replicated with other, commonly used modalities such as ice, massage, and exercise. These modalities would also have the same effect (providing temporary relief) as laser treatments would on muscle pain and stiffness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-and-10-month-old male enrollee has requested for applied behavioral analysis (ABA), speech therapy, occupational therapy and neuropsychological evaluation for treatment of the enrollees autistic spectrum disorder and developmental delay. Findings:  The physician reviewer found that all of the services being requested by the patients parent are now the standard recommendations for autistic children; 26 hours of ABA (which includes 5 hours of supervision), 2 hours of occupational therapy, and 2 hours of speech therapy are now the recommendations of most centers treating autistic children. The need for a neuropsychologist would be to monitor changes or the lack of improvement in these programs. These interventions are all medical and are not instructional, remedial, or caretaking procedures. The programs are directed toward improving the patients communicative skills, socialization, and physical fine motor abilities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested for Cialis for treatment of his condition. Findings:  The physician reviewer found that Cialis is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. It is medically appropriate to treat complaints of erectile dysfunction empirically with Cialis. Cialis has no impact on desire or sensation. Thus, this medication would not be reasonably requested by patients who do not have erectile dysfunction. This medications high safety profile in all except those taking nitrates has been established and justifies empiric use. Since erectile dysfunction is self-reported, the history of erectile dysfunction is the prime indication for its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old male enrollee has requested for a consultation for no needles technique for cataract surgery for treatment of her condition. Findings:  The physician reviewer found that the patient desires to have his surgery performed using the small incision, topical anesthesia technique. This technique has become the standard of care for the past ten to fifteen years because of decreased complication rates, faster recovery and diminished pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has for speech therapy for treatment of her central auditory processing disorder (CAPD).   Findings:  The physician reviewer found that this patient has a central auditory processing disorder. Despite this receptive language handicap, the patient has an above-normal intellect.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Lyrica for treatment of her condition. Findings:  The physician reviewer found that the medical literature does not support the use of Lyrica for post-stroke pain. A systematic review of the literature on the pharmacologic treatment of central post-stroke pain showed that amitriptyline and lamotrigine are the only oral medications that have proven to be effective in the treatment of central post-stroke pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for hemi-implant arthroplasty for treatment of her condition.   Findings:  Two physician reviewers found that Hemi-implant arthroplasty is experimental for the treatment of hallux limitus. The standard of care is a cheilectomy or a joint fusion procedure. There are no long-term outcomes studies to support this procedure. The efficacy and complications in the long-term remain unknown.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for artificial disc replacement L4-L5 for treatment of her condition.   Findings:  Two physician reviewers found that artificial disc replacement is also not indicated in light of shortened pedicles, hypertrophy of flavum and significant disc bulge. Decompression, decompression and discectomy and/or fusion are alternatives that are likely to be more efficacious for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that there is no scientific data that support the required 6 months waiting period. There are no outcome studies that show any benefit of this requirement, short-term or long-term.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested residential treatment for the treatment of the enrollees condition. Findings:  The physician reviewer found that as of the date in question, the patients need for 24/7 residential case was not established. He was not overtly aggressive, psychotic, homicidal or suicidal. There is no mention that his drug problem was a major difficulty at that time, and his treatment plan was vague. Continued care for this patients medical needs could have been established at a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a total disc replacement for the treatment of her cervical spine pain. Findings:  Two physician reviewers found that artificial disc replacement surgery has been the subject of much study, and at present there is good evidence of early results showing safety and satisfactory outcomes. These early studies have led to FDA approval of this procedure in patients with disease at a single spinal level, after failure of conservative measures used for a period of time. As a result of a lack of data in the adequacy of the prostheses over time, studies over several years were mandated, but have not yet been reported. Thus, this procedure remains under study for its long-term prospects. In addition, for this patient, studies and scans indicate that she has degenerative changes in multi-levels of her cervical spine, and thus, is not appropriate for the artificial disc replacement surgery that she requested.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that it is possible that in this case the GERD and the articulation problems of the patient are related. Serious reflux can frequently result in aspiration through the larynx which in turn would cause insult to the vocal cords. Dysfunction of the vocal cords at a critical time in the neurological development of speech could readily result in disarticulation. There are many special exercises and therapies that help control vocal cord dysfunction. Speech therapy is a very important part of the treatment for vocal cord dysfunction. Special exercises can increase the patients awareness of abdominal breathing and relax the throat muscles. This enables the patient to have more control of the vocal folds and throat. Exercises are aimed at overcoming abnormal vocal cord movements, controlling the vocal folds with the breath stream, and improving airflow into the lungs. Speech therapy in this case, for this patient is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Xolair for the treatment of her condition. Findings:  The physician reviewer found that systemic steroids over a long period of time reduce serum immunoglobulin levels. This is one reason why the total IgG is not elevated to a significant degree. Xolair is medically appropriate considering both the documented atopy and the severity of her disease. The Health Plans denial is not appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested Rituximab infusions for the treatment of his progressive polymyositis. Findings:  Three physician reviewers found that the patient has a severe disease, polymyositis, that has not been responsive to standard therapies. Several articles have been published in peer-reviewed journals documenting a favorable response to Rituximab in similar patients. The patient appears to be an appropriate candidate for Rituximab. Given the failure of standard treatments in this case, the use of Rituximab is medically reasonable and appropriate option. In fact, the submitted documentation demonstrates the patient has already benefitted from a trial of the therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested Xifaxan for the treatment of her condition. Findings:  The physician reviewer found that the use of Xifaxan is appropriate in this case to treat this patients symptoms of gas and bloating. The use of the medication for these symptoms is the community standard at this point even though the FDA approval is for the diagnosis of travelers diarrhea. The medical records support this course of treatment for this patients unexplained symptoms of gas and bloating.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested an Oasis Neuromonics device for the treatment of her tinnitus. Findings:  Two physician reviewers found that tinnitus is a common condition and is associated with hearing loss of varying degrees, as well as certain medications. While many medical and surgical treatments have been developed and tried over the years, there is no consistently beneficial therapy. Tinnitus is an entirely subjective symptom, which means that there is no way to accurately quantify the degree of tinnitus that the patient suffers from other than their own description of the severity, and how it affects their quality of life. The vast majority of tinnitus sufferers learn to accommodate the symptom, while a much smaller number learn to cope with the help of tranquilizers or sleep aids. The Oasis Neuromonics device is one of many that are offered to the small number of patients who seek alternatives for treatment of their symptoms. The article supplied by the patient for this device is a small study of only 35 patients, many of whom noted relief with this device. At this time, sufficient medical studies do not exist to show that the device significantly improves outcomes better than standard alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for Erbitux chemotherapy in combination with Taxotere for treatment of his condition.   Findings:  Two physician reviewers found that Erbitux is one of a newer group of drugs that appear to work by inhibition of epithelial growth factors. It has been approved in certain situations in metastatic colon cancer, as well as cancer of the head and neck. In the latter type of cancer, Erbitux did appear to increase survival when combined with radiation therapy in patients with locally or regionally advanced disease. One study has been published using single agent Erbitux in patients in whom prior therapy with cisplatinum had failed. This demonstrated a 13% response rate with a median duration of response of 5.8 months. Being a single arm study, there was no way to determine its efficacy relative to other possible therapies. There is no good data to indicate that Erbitux adds efficacy to the use of Taxotere in patients such as this patient. This is investigational and of no proven benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Procrit injections for treatment of his metastatic neuroendocrine tumor. Findings:  The physician reviewer found that Procrit is used very restrictively in patients with cancer by their oncologists. Those with hemoglobin levels below 10 must not be getting potentially curative chemotherapy, and must have their iron stores evaluated to determine if they would be able to respond to the Procrit. The use of Procrit was a reasonable maneuver in an attempt to obviate this need, and it was successful. As such, in this clinical situation, the use of Procrit seems to be more appropriate than any other approach available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for the Flexitouch Lymphedema System for treatment of her lymphedema (secondary to breast cancer). Findings:  The physician reviewer found that Bio-compression devices usually only offer a one size fits all jacket for truncal edema where the Flexitouch system is adjustable. In addition, the Flexitouch system offers variability in pressure settings making it safe and more effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for partial hospitalization services for treatment of her condition. Findings:  The physician reviewer found that there appears to be nothing to argue that she needed something as intensive as partial hospitalization.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a keloid and scar removal procedure for the treatment of her condition. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the procedure at issue was reconstructive in nature. This patient presented with keloid scars following breast reduction for macromastia. Thus, she had an abnormal structure caused by trauma, specifically, breast reduction surgery. However, the procedure at issue was not likely to result in more than a minimal improvement in the appearance of the patient as surgical excision of a keloid without postoperative steroid injections carries a significant chance of recurrence. Thus, the procedure at issue does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the procedure, a myriad of different interventions have been recommended for the treatment of keloids, ranging from simple pressure to surgery and radiation therapy. In general, more invasive treatments should be restricted to patients who have failed conservative treatment. Furthermore, there is a relatively high recurrence rate for patients who undergo surgical excision alone. For this patient, the records do not document a reasonable trial of more conservative treatments prior to proceeding to surgical management.  In the absence of a trial of less invasive treatment and given the likelihood of recurrence associated with surgical excision of the keloids, the procedure at issue was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested biofeedback for the treatment of her pelvic floor dysfunction. Findings:  Three physician reviewers found that this patient has tried other treatment options, but they have failed. The articles provided tend to show that biofeedback therapy is the superior treatment option for pelvic floor dysfunction. The only surgical treatment option for this patient is an iliocolostomy which would be a drastic measure without exhausting all other conservative treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Lexapro for the treatment of her depression. Findings:  The physician reviewer found that Lexapro has been effective and helpful for this patient and she appears to be compliant with it, and free of side-effects from it. The Health Plans alternative therapy recommendation is Celexa, which is known to have more side effects (e.g., somnolence and daytime fatigue) than Lexapro. Lexapro is a superior agent for side-effect sensitive patients such as this one. The patient in this case would most likely relapse rapidly if forced to return to generic citalopram (Celexa).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a ductogram, ductoscopy and excisional biopsy for the treatment of her condition. Findings:  The physician reviewer found that a ductoscopy in the management of ductal lesions has been shown to be a useful tool in the evaluation of patients with nipple discharge per the study by Kapenhas-Valdes and colleagues. In that article, the authors concluded that many deeper intraductal abnormalities could be missed by blind surgical excision.  Ductoscopy has a role in the evaluation of women with abnormal nipple discharge and abnormal radiologic findings suspicious for a ductal origin.  The services at issue were medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of an 85-year-old female enrollee has requested continued care at a skilled nursing facility for the treatment of the enrollees condition. Findings:  The physician reviewer found that the feeding tube is generally recognized as a skilled service. The patient is in the skilled nursing facility because of the totality of her custodial needs, not because she requires inpatient skilled care in a skilled nursing facility. It is possible for her to receive her feeding tube and be safe in other settings, including home. She does not have daily skilled care needs that require a skilled nursing facility stay. The Health Plans denial is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a panniculectomy and/or abdominoplasty for the treatment of her excess skin condition. Findings:  The physician reviewer found that the requested panniculectomy/abdominoplasty is not reconstructive in nature. The patients excess skin condition is not so severe as to constitute an abnormal structure of the body. The requested procedure would not be performed to improve function or create a normal appearance to the extent possible. The patient would still have obesity with cellulite and lipodystrophy and the preferred procedure would offer no more than a minimal improvement in the appearance of the patient. Thus, the patient does not meet the criteria of Californias reconstructive surgery law. Furthermore, there is no evidence to support the medical necessity of the proposed panniculectomy/abdominoplasty in this particular setting. The record lacks documentation of a stable weight for a period of at least six months. In addition, there is a lack of documentation of rashes, intertrigo, or skin ulcerations which have been diagnosed, treated with conservative management and failed conservative treatment over a period of time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested growth hormone therapy (Genotropin) for the treatment of the enrollees growth failure. Findings:  The physician reviewer found that the requested growth hormone therapy is medically necessary for this patient in this case. Her familial and idiopathic short stature is such that she is destined to become a short adult (less than 4 feet 11 inches) without growth hormone therapy (Genotropin). In addition, she is under the appropriate care of a supervising endocrinologist, and other causes for her poor growth have been excluded.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested artificial intervertebral disc replacement surgery for the treatment of her lower back pain. Findings:  Three physician reviewers found that lumbar artificial disc replacement is still experimental for the treatment of lumbar degenerative disc conditions. There are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long term. Fusion or non-operative management remains the gold standard treatment and standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested an electron beam computed tomography (EBCT) scan for an evaluation of her heart. Findings:  Three physician reviewers found that there was no documentation provided necessitating the requested EBCT. There is no evidence that the patient has undergone any standard stress testing. EBCT is not considered a screening tool for the diagnosis of coronary artery disease. To date, there are no controlled, prospective trials of EBCT as a predictor of actual disease events. The patient has complaints of chest pain and shortness of breath and per the recommendations of the American Heart Association, the data are insufficient to recommend EBCT instead of stress testing generally for patients with chest pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Botox injections for the treatment of her hypertonicity of her pelvic floor musculature. Findings:  The physician reviewer found that there are a very small number of peer-reviewed articles reporting the use of botulinum toxin type A for the treatment of chronic pelvic pain. There are some scattered case reports as well as a couple of original research studies. In a 2004 pilot study from Australia of women with chronic pelvic pain and demonstrable spasm in the pelvic floor muscles, a reduction in pressure was found when botulinum toxin type A was injected, and a diminution of pain symptoms were noted. A follow-up study with a small patient number was performed by the same research group in 2006 to evaluate the treatments effect on pelvic floor pressure, pain response, and the impact on quality of life. Women with chronic pelvic pain and pelvic floor muscle spasm were randomized to receive botulinum toxin type A or placebo injections to the pelvic floor muscles. The use of botulinum toxin type A, which blocks cholinergic transmission at the neuromuscular junction, is reported to decrease pain and improve function in cervical dystonia, limb spasticity after a cerebrovascular accident, and headaches. In this double-blind, placebo-controlled study, significant intergroup differences for individual pain scores were not demonstrated. A significant placebo effect was noted. There were significant intragroup differences in pain, but it can be concluded that there is no significant treatment effect when compared to placebo. The use of botulinum toxin may hold future promise for this indication. However, further trials are needed to confirm its effectiveness in the treatment of chronic pelvic pain.