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

An 18-year-old female enrollee has requested an abdominoplasty for the treatment of her abdominal rhytids. Findings:  The physician reviewer found that abdominoplasty (CPT 15847) is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases, tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. The result is frequently improved by liposuction performed during the same operation. Some patients have so much excess tissue that the low transverse incision has to be extended around to the back. This is known as an extended abdominoplasty, which is the procedure that the patients surgeon has proposed. When the excess skin is such that the ends of the transverse incision meet around the back, the procedure is called a belt lipectomy. Panniculectomy is a lesser procedure (CPT 15830) that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It is considered medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, etc. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus does not make its removal medically necessary. However, in this case the weight of this patients pannus is tearing the skin at the lateral ends of the transverse infraumbilical skin crease. Although it is unclear if conservative treatments have been attempted for the skin tearing, unlike an infection related to hygiene, this problem is mechanical due to the excess weight of the pannus and cannot be relieved with conservative measures. The patients condition of torn skin constitutes an abnormal structure of the body caused by the trauma of the heavy pannus pulling on the body during activities of daily living. A panniculectomy would appropriately address this issue as it is likely to improve function and offers more than minimal improvement in appearance and function. Abdominoplasty (extended or standard) is a cosmetic adjunct to the panniculectomy procedure and is not required to treat the patients condition. For the reasons stated above, I have determined that although an abdominoplasty is cosmetic rather than reconstructive in nature and not medically necessary, a panniculectomy is considered a reconstructive procedure for treatment of the patients medical condition and is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Supartz injection to the knee for the treatment of her bilateral knee arthritis. Findings:  The physician reviewer found that this patient has a history of advanced degenerative disease of both knees. She has received viscosupplementation therapy in the past with reasonable relief of her knee discomfort. Viscosupplementation has a low-risk profile. The patients morbid obesity places her at a higher than normal risk of side effects with the ongoing use of NSAIDs. Intraarticular steroids, another option in this setting, have a different mechanism of action and are more effective in a knee with an acute effusion. In addition, intraarticular steroids can have some systemic effect, and should be avoided in patients with comorbidities. Based on the patients previous positive response to viscosupplementation and her lack of complications from this therapy, the request for treatment with Supartz is medically appropriate and indicated.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested urgent medical and laboratory services for the treatment of her medical condition. Findings:  The physician reviewer found that according to California regulations, urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plans service area. The Health Plan defines urgent needed care as any otherwise covered medical service that a reasonable person with average knowledge of health and medicine would seek for treatment of an injury, unexpected illness or complication of an existing condition, including pregnancy to prevent serious deterioration of his or her health, but which does not qualify as Emergency Care.  This patient presented with amenorrhea after discontinuation of oral contraceptive. She sought examination with an out-of-network provider. There is no objective documentation of pelvic or abdominal pain and no evidence of an evaluation of pain. There is no evidence of an urgent or emergent problem. The laboratory tests ordered were not of an urgent or emergent nature. The submitted clinical evidence does not demonstrate the presence of an unforeseen illness, injury, or complication of an existing condition. Further, the services provided were not necessary to prevent serious deterioration of the patients health and could have been delayed until the patient returned to the Plans service area.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient was experiencing an acute exacerbation of her chronic restless leg syndrome. The submitted medical records do not document that the patient was experiencing extreme pain. She had not sustained any injury. Since the patient had a long-standing history of restless leg syndrome, she would have reasonably known that her symptoms did not represent a danger to her health. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. She could have been evaluated on a routine basis for a medication adjustment. Because this patients symptoms were not sudden in onset and she had not sustained an acute injury, her symptoms do not meet criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested for a magnetic resonance imaging of the pelvis/uterus for evaluation of her uterine anomaly.  Findings:  The physician reviewer found that Olpin and Heilbrun, MRI is the best imaging method available because of its superior ability to reliably visualize complex uterovaginal anatomy. MRI has emerged as the universally accepted standard in the imaging evaluation of Mullerian duct anomalies. Overall, MRI provides excellent delineation of both internal and external uterine anatomy with accuracies of up to 100% in the evaluation of Mullerian duct anomalies. One of the most valuable features of MRI in the evaluation of pelvic anatomy is the multiplanar imaging capability which allows the contour of the uterine fundus to be visualized. This data is essential for the evaluation of Mullerian duct anomalies. T2-weighted images provide excellent detail regarding uterine zonal anatomy and are considered the mainstay of pelvic imaging. The endometrium is uniformly hyperintense on T2-weighted images. The junctional zone surrounds the endometrium, and is readily identified as a hypointense band measuring between 8 to 10 mm in thickness. The uterine myometrium surrounds the junctional zone and is of intermediate signal intensity on T2-weighted images. T1-weighted sequences are used to identify blood products, which can be very helpful when obstructed Mullerian duct anomalies result in hematometrocolpos.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested gastric revision surgery from the previously provided Lap-Band to Roux-en-Y gastric bypass for treatment of her obesity.  Findings:  The physician reviewer found that the patient underwent Lap-Band for treatment of morbid obesity. Lap-Band is a restrictive procedure. There is a lack of published data that suggests that Roux-en-Y gastric bypass is more successful long-term when compared to the Lap-Band. OBrien and colleagues reported similar weight loss medium-term when comparing the Lap-Band to gastric bypass. The pouch of the Lap-Band and the gastric bypass operations are of very similar sizes. Significant weight loss with a procedure that causes the same degree of restriction as the Lap-Band procedure is not likely. Revision to another restrictive procedure is not indicated for this patient given its low probability of success.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that this patient wanted a medical evaluation to prevent pregnancy following sexual intercourse after the failure of a prophylactic. Despite her history of blood clots, there was no immediate danger to her health. Oral hormone therapy can lower the risk of pregnancy to one or two percent if taken within five days after unprotected sexual intercourse. Oral hormone therapy preparations such as Plan B are FDA-approved and available on an over-the-counter basis. This patient could have been evaluated on a non-emergent basis. While her situation may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for residential rehabilitation treatment for treatment of her polysubstance abuse. Findings:  The physician reviewer found that APA substance treatment guidelines state that patients who step down to a partial day hospitalization program (which is the next least restrictive setting after the RTC level of care) do require intensive care, but that they have a reasonable probability of refraining from illicit use of substances outside of a restricted setting (see Kleber).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested the WalkAide Functional Electrical Stimulator for treatment of her footdrop. Findings:  Two physician reviewers found that the footdrop is managed with either plastic molded ankle foot orthoses or double-metal upright ankle foot orthoses, depending on various clinical factors. In certain instances, patients with footdrop may have significantly improved gait mechanics with use of a functional electrical stimulator unit like the WalkAide when compared with standard ankle foot orthoses(Hausdorff and Ring). When this is found to be the case, a functional electrical stimulator unit is medically justified. Recently, this equipment has been increasingly used for both gait training and as an adaptive device to improve functional gait.  In the case under review, the patient's gait was significantly enhanced by the device when compared with the use of standard ankle foot orthoses.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested for a consultation with a neurologist for treatment of his back and leg pain and nerve pain. Findings:  The physician reviewer found that there are no neurological complaints or deficits. Given these factors, neurological evaluation is unlikely to add any new information regarding this patients symptoms. Neurological testing including electrodiagnostic testing (EMG/NCV) is also unlikely to add any significant information in the absence of any neurological deficits since there is little correlation between electrophysiological findings and actual pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested authorization and coverage for left total ankle replacement with Salto Talaris ankle prosthesis for treatment of his advanced post-traumatic arthritis. Findings:  Two physician reviewers found that the specific prosthesis requested by this patient has been approved by the Food and Drug Administration for treatment of patients with advanced ankle arthritis. The results of total ankle replacement are comparable to the results of ankle fusion with respect to the alleviation of pain and improvement in function. Furthermore, total ankle replacement avoids the most severe complication of ankle fusion which is the development of premature degenerative disease in other joints of the foot including, but not limited to, the subtalar joint and the first metatarsal phalangeal joint. Thus, total ankle replacement is likely to be a more efficacious option for this patient. The procedure offers a strong likelihood of pain relief comparable to that of ankle fusion, without the associated complications of developing premature arthritis in other joints of the foot that would be even more debilitating. This patient already demonstrates decreased motion in the subtalar joint which would likely be aggravated by ankle fusion.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested intravitreal Avastin injections for treatment of her diabetic retinopathy.  Findings:  Two physician reviewers found that the use of Avastin therapy for proliferative diabetic retinopathy and diabetic macular edema has been well documented in the literature as a very effective means of therapy and in many clinical situations is the standard of care. Schwartz indicated that Avastin given before panretinal laser was excellent treatment for patients with persistent neovascular tissue despite extensive laser therapy. The new approach with Avastin prevents the cascade of severe ischemia, poor circulation and massive neovascularization. Patients with an increased risk for visual loss with focal laser and vitrectomy that are given a pre-laser injection with Avastin may eliminate the tractional complication. Avastin given before panretinal laser treatment may be beneficial in preventing laser-induced visual dysfunction and foveal thickening(Mason and colleagues). Moradian concurred that Avastin has a significant therapeutic effect on active progressive proliferative retinopathy. Arevalo found that Avastin resulted in a marked regression in retina neovascularization in patients with proliferative retinopathy with previous laser treatment and results in rapid resolution of vitreous hemorrhage. Avastin is a well-proven therapy that has provided significant benefit to patients with various forms of diabetic retinopathy. The scientific data demonstrates the beneficial effects including prevention of some of the laser-induced visual dysfunction and foveal thickening. The therapy significantly helps patients to maintain vision, prevent some post-laser complications and is associated with vision stability.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested for emergency ambulance transportation services at issue were not required on an emergent basis and were not medically necessary. Findings:  The physician reviewer found that the patient was ambulatory at home per the ambulance report, had normal vital signs except for mild hypertension, and had no evidence of cauda equina syndrome. No lab tests were performed and he was treated with intramuscular and intravenous pain medications. The patients pain improved and he was sent home with a prescription for pain and muscle relaxation medications. There is no evidence that the patients symptoms would cause a prudent layperson to believe emergency ambulance transportation was necessary to prevent serious harm or injury.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested IVIG therapy for treatment of her dermatomyositis. Findings:  The physician reviewer found that the medical records indicate that she was in a wheelchair prior to high-dose IVIG and that she failed multiple steroid-sparing therapies prior to initiation of IVIG. IVIG is a well-established therapy for refractory polymyositis and dermatomyositis and has been used successfully for years(Dalakas and colleagues). In the Dalakas trial, IVIG resulted in clinical improvement in inflammatory myopathy, but the duration of benefit was short and repeated treatments were needed. Review of the literature failed to find evidence for an optimal length of treatment with immune globulin. Thus, duration of treatment depends upon the clinical findings in an individual patient. Therefore, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested laparoscopic adjustable gastric banding surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patients chart demonstrates that she has tried many diets in the past but was unable to maintain the weight loss. Several years ago she did lose some weight, but in the past couple of years, both her weight and BMI have increased. The American Society of Bariatric Surgery (ASBS) 2004 consensus conference statement, As long as a candidate has tried to lose weight by various means they should not be required to complete formal non-operative obesity therapy as a precondition for bariatric surgery(Buchwald). The authors also commented that, Long-term weight loss is difficult to achieve with diet, exercise, and pharmacotherapy. Most patients who present for bariatric surgery have already failed multiple attempts to achieve a sustained weight loss by using nonsurgical treatment options. Jamal and colleagues have also demonstrated that mandated pre-operative dietary counseling is an obstacle to patients access for surgical treatment of morbid obesity and has no impact on weight loss outcome or post-operative compliance. Applying the basic criteria set forth by the ASBS, the 1991 National Institutes of Health (NIH) consensus conference weight criteria for bariatric surgery of a BMI greater than 40 is still reasonable today.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested a biopsy of penile papules for treatment of his medical condition. Findings:  The physician reviewer found that this patient presents with penile lesions of unknown etiology. While sebaceous gland hyperplasia is suspected, other possible causes have not been excluded. The lesions may be due to human papillomavirus infection. Although the STD work-up was normal, this does not rule out human papillomavirus infection as a possible source of the patients lesions. As such, it is medically necessary to biopsy one or two of these lesions to ensure that the lesions do not represent a human papillomavirus infection.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) bone density scan for evaluation of her risk for osteoporosis.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists (AACE) state in their osteoporosis guidelines that BMD measurements should be performed for risk assessment in peri-menopausal or post-menopausal women who have risk factors for fractures and are willing to consider available interventions. The AACE further comments that testing is appropriate for establishing skeletal stability and monitoring therapeutic response in women receiving treatment for osteoporosis. To this end, obtaining baseline measurements prior to intervention in all women 40 years and older who have sustained a fracture is recommended.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for Xyrem for treatment of his obstructive sleep apnea and idiopathic hypersomnia. Findings:  The physician reviewer found that Xyrem is known to increase the amount of N3 stage of sleep, but based on the patients sleep study results, it is not necessary here. The sleep study also showed some reduction of REM sleep which can be associated with untreated sleep apnea, as well as the effect of medications.Based on diagnostic criteria, this patients pathologic sleepiness cannot be categorized as a separate disorder such as idiopathic hypersomnolence (i.e., this patient has untreated sleep apnea, which is the primary cause of his sleepiness). The disorder of sleepiness or narcolepsy can only be diagnosed when other sleep disorders are being treated. In a test interpretation, the patients provider did not make a diagnosis of narcolepsy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for growth hormone (GH) therapy (Nutropin AQ) for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patient has markedly delayed puberty; it appears his predicted adult height will be in normal range. If there is objective evidence of his low growth rate (1.2 cm per year), he would be an appropriate candidate for GH therapy. However in this case, no longitudinal growth records have been provided to substantiate that the patient has had falling growth rates. If longitudinal data is submitted (such as a plotted growth chart) demonstrating a low rate of growth, GH therapy would be medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for laparoscopic adjustable gastric banding and a Nissen fundoplication for treatment of the her obesity.  Findings:  The physician reviewer found that the National Institutes of Health (NIH) consensus guidelines do not consider GERD to be a life-threatening weight-related comorbid condition. Another condition such as diabetes, hypertension or sleep apnea is necessary in patients with a BMI of less than 40 to meet criteria of clinically severe obesity. In the case of this patient, there is no evidence a sleep study has been performed documenting obstructive sleep apnea and there is no medical note documenting sleep apnea outside of the consulting surgeons history and physical.