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

A 59-year-old male enrollee has requested test strips and lancets for a home international normalized ratio (INR) monitor for treatment of his primary hypercoagulable state treated with warfarin. Findings:  The physician reviewer found that the patient will likely require long-term treatment with warfarin anticoagulation due to his history of PE secondary to a hypercoagulable state. The peer reviewed medical literature suggests that home INR monitoring offers several advantages over clinical laboratory testing including more frequent testing and therefore better INR target achievement. As reported by Heneghan and colleagues, data collected on patients conducting in home INR testing reveals significantly fewer adverse events and an overall lower mortality rate due to under and over anticoagulation. Moreover, the Centers for Medicare and Medicaid Services (CMS) guidelines require an integrated home education program for the INR monitor and provide coverage for testing strips and lancets to facilitate appropriate usage of the device. Based on these considerations and the reasonable anticipation that this patient will require for the long-term use of warfarin, the requested equipment is medically indicated and appropriate for monitoring and management of his condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested inpatient hospital treatment for treatment of the enrollees major depression and polysubstance abuse. Findings:  The physician reviewer found that this patient continued to meet criteria for inpatient treatment given the severe disturbance of affect, feelings of hopeless and helplessness, and fleeting suicidal ideation.  He was at risk for escalation of symptoms at a lower level of care and could not have been managed safely in a less restrictive environment. When determining level of care, comorbidity must be considered, such as depression, substance abuse and severe functional impairment, which were all noted in this case. The level of care provided was consistent with community standards of practice and American Academy of Child and Adolescent Psychiatry practice parameters.  All told, inpatient hospital treatment provided during the time period at issue was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested osteochondral allograft transplantation for the ankle and its associated services (codes 20680, 20690, 20692, 20902 and 27700) for treatment of her ankle pain. Findings:  Three physician reviewers found that although ankle arthrodesis remains the standard treatment for ankle arthritis, the associated problems have led to interest in other approaches, such as joint replacement and allograft transplantation. Short-terms results of allograft transplantation have been encouraging, but longer follow-up is needed to confirm these initial results. Follow-up radiographs have shown narrowing and sclerosis, even in cases with good clinical status. A high failure rate has been reported to be associated with this procedure.  At this time, the superior efficacy of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested bariatric surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that the National Institutes of Health (NIH) bariatric surgery consensus guidelines recommend bariatric surgery for patients with well selected patients with morbid obesity. These criteria are met with a BMI of at least 40 or clinically severe obesity with a BMI of 35-40 with one or more serious weight related conditions such as diabetes, hypertension, coronary artery disease, or sleep apnea. This patient has GERD and has been given intermittent proton pump inhibitor (PPI) with some relief of her substernal pain. However, she has no evidence of diabetes, hypertension, coronary artery disease, or sleep apnea. At this time, the guidelines suggest that patients with a BMI of 35-40 without a serious weight related co-morbid condition should undergo bariatric surgery within the setting of a clinical trial. For these reasons, this patient does not meet the NIH consensus guideline criteria for clinically severe obesity and the requested surgery is therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested minimally invasive endoscopic spinal surgery for treatment of his neck pain. Findings:  The physician reviewer found that scientific proof of the efficacy of laser disc decompression remains poor, and well-designed studies are needed, as noted by Schenk and colleagues. At this time, there is a lack of controlled studies in the literature. While some studies have been encouraging, the published data are not sufficient to conclude that efficacy has been established. Despite the numerous procedures performed, there continues to be a paucity of published randomized clinical trials. All told, the requested minimally invasive endoscopic spinal surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested testing for evaluation of her medical condition. Findings:  The physician reviewer found that Review of the submitted clinical evidence demonstrates that this patient has had a variety of symptoms including cramping and muscle pain. Myotonic dystrophy has been considered in the diagnosis. The patients physical exam and EMG have not revealed any muscle weakness or myotonic activity. Per a literature review, myotonic dystrophy type 2 (DM2) is characterized by myotonia (90% of affected individuals) and muscle dysfunction (weakness, pain, and stiffness) (82%), and less commonly by cardiac conduction defects, iridescent posterior subcapsular cataracts, insulin insensitive type 2 diabetes mellitus, and testicular failure. Although myotonia (involuntary muscle contraction with delayed relaxation) has been reported during the first decade, onset is typically in the third decade, most commonly with fluctuating or episodic muscle pain that can be debilitating and weakness of the neck flexors and finger flexors. Subsequently, weakness occurs in the elbow extensors and the hip flexors and extensors. Facial weakness and weakness of the ankle dorsiflexors are less common.The literature also reveals that absent or minimal myotonic discharges on EMG do not exclude myotonic dystrophy type 2. This patients symptoms and exam could potentially represent early features of myotonic dystrophy, and knowledge of this diagnosis would impact her long-term care. Consequently, genetic testing for myotonic dystrophy type 2 is relevant and medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 26-year-old male enrollee has requested residential treatment for treatment of the enrollees schizophrenia. Findings:  The physician reviewer found that although the RTC may have provided intensive and useful services, the records provided do not support a finding of medical necessity of this intensive level of care during the period at issue. It appears that the patient presented with symptoms of depression, anxiety and psychotic symptoms of his serious mental illness. However, the records do not indicate that he posed a risk of harm to him self or others. The patients Clozaril levels obtained were within therapeutic range (nor=29, cloz=473). Overall, the records do not support the need for 24-hour monitoring and care in a locked psychiatric facility as the patients symptoms were not described as severe enough to warrant constant supervision to intervene with his behavioral issues. For these reasons, the RTC services provided from during the period at issue have not been established as medically necessary and the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested Epiduo gel for treatment of the enrollees acne. Findings:  The physician reviewer found that this patient has a history of acne. She has responded well to topical therapy with Epiduo, a combination topical agent that contains a retinoid cream (adapalene) and a topical antibacterial agent (benzoyl peroxide).  Use of both topical retinoid creams and topical antibiotics are useful and effective for acne treatment, as noted by Eichenfield and Gold. However, preferred formulary alternatives are available which have not been tried, including tretinoin and benzoyl peroxide-erythromycin. Based upon the submitted documentation, the medical necessity of Epiduo gel has not been established.  All told, Epiduo gel is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for evaluation as the enrollee has a personal history of thyroid cancer. Findings:  The physician reviewer found that breast MRI has become increasingly useful in the work-up of many equivocal findings seen with conventional mammographic and ultrasound examinations of the breast.  However, as discussed by the American College of Radiology (ACR) practice guidelines, the presence of microcalcifications is not one of the indications for breast MRI. The negative predictive value for MRI is not sufficient to rule out ductal carcinoma in situ (DCIS). In this patients radiology report, the interpreting provider commented on the limitation of MRI in this particular set of circumstances. Overall, when calcifications are considered suspicious, MRI should not be used in lieu of the more invasive and revealing sampling by biopsy. For these reasons, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested an occipital nerve stimulator trial for treatment of her occipital neuralgia. Findings:  The physician reviewer found that the facts probative of the medical necessity of the requested device for this patient include the severity and refractory nature of the headaches, her young age, the duration of symptoms, and disability due to the condition. At only 27-years of age, this patient has an 8-year history of refractory and severely disabling headaches that have completely interfered with her quality of life. She has had a comprehensive multimodal approach to therapy, with physical and medical therapies, interventional and conservative management attempts, that have failed to produce any long-term results. She responds very well to occipital nerve blocks, but this treatment only lasts about two months. Therefore, this patient would benefit from at least a trial of ONS with temporary leads. If the patient responds well with significant reduction in headache frequency and severity, then the permanent implant would be appropriate. Given this patients severe and frequent refractory headaches, an ONS trial is both necessary and justified based on an evidence-based review of the case, the applicable standards of care and relevant medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested acupuncture for treatment of her myofascial pain syndrome, lumbosacral pain (with associated myofascial neuropathic pain) and chronic multifocal arthralgias.  Findings:  Two physician reviewers found that the medical literature does not establish that acupuncture is an effective intervention in the setting of chronic pain, including multifocal arthralgias and myofascial pain. There is insufficient medical literature demonstrating that acupuncture improves health and/or pain compared to conventional care consisting of exercise, rest, palliative modalities and pharmacotherapy as needed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a colonoscopy for evaluation of his medical condition.Findings:  The physician reviewer found that major national guideline-making bodies, including the United States Preventive Services Task Force (USPSTF) and the American Cancer Society-United States Multisociety Task Force (ACS-MSTF) recommend various efficacious tests for colorectal cancer screening. These include annual high sensitivity fecal occult blood testing (FOBT) including immunochemical tests, flexible sigmoidoscopy or double-contrast barium enema every 5 years, and colonoscopy every 10 years. The ACS-MSTF also includes computed tomography colonography every 5 years as a screening option. A positive result of an FOBT, flexible sigmoidoscopy, double-contrast barium enema, or computed tomography colonography should be followed by a colonoscopy. Before the emergence of colonoscopy, FOBT and flexible sigmoidoscopy were the most widely used screening tests for the general population. Colonoscopy soon replaced these tests as the most utilized screening method. Colonoscopy is currently the preferred test for colon cancer screening. As per the American College of Gastroenterology Guidelines, the preferred colorectal cancer prevention test is colonoscopy every 10 years, beginning at age 50. Thus, this patient should be approved for colonoscopy for screening as this procedure is considered the standard of care in the gastroenterology community. Screening colonoscopy is graded level of evidence 1B which means a strong recommendation with moderate quality evidence and the benefits clearly outweigh the risks and burdens.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested removal of saline breast implants for treatment of her ruptured implant.  Findings:  The physician reviewer found that this patients records and photographs demonstrate that although the right breast implant was deflated and the skin wrinkled, there were no abnormalities affecting the right breast itself. Even if the breast with the ruptured implant was considered an abnormal structure of the body, the etiology of the abnormality was not due to congenital defect, developmental abnormality, trauma, infection, tumor or disease. Rather, the condition was secondary to an elective cosmetic procedure. The contention that the abnormality was made more severe due to weight loss associated with the patients colitis is not persuasive. Excess breast tissue due to weight loss is not considered an indication for reconstructive breast surgery by the American Society of Plastic Surgeons. Further, even if the patients condition was in fact exacerbated by weight loss due to colitis, removal of the implants would not create a normal appearance to the extent possible or improve function. As such, the patient does not meet criteria for reconstructive surgery as defined by California law. With regard to whether removal of the ruptured implant was medically necessary, the records document that the ruptured implant was a saline implant. Whereas removal of ruptured gel implants is necessary because the free gel can cause medical problems, a ruptured saline implant does not carry such risk. Moreover, there is no evidence the patient had experienced a Baker class IV contracture. All told, I find that the removal of the patients breast implants was a cosmetic procedure and not reconstructive or medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested real-time cardiac monitoring for evaluation of his palpitations. Findings:  Three physician reviewers found that the submitted documentation does not demonstrate that the patient is at high-risk for serious arrhythmia, given the absence of syncope or presyncope, the demonstrated normal cardiac structure and function, and the absence of any episode of sustained arrhythmia.  In addition, given the frequency of the patients symptoms, a standard Holter recording would have been the appropriate next step.  All told, real-time cardiac monitoring was not likely to have been the most beneficial method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a PET/CT scan (code 78815) for evaluation of his pancreatic carcinoma. Findings:  Three physician reviewers found that the PET/CT results provided necessary information for patient management. There was no other way to establish the diagnosis of tumor recurrence short of laparotomy or laparoscopy.  All told, the PET/CT scan performed was likely to have been superior over all alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested social cognitive speech and language therapy, sensory integration (auditory, tactile and oral motor), and occupational therapy (tactile, vestibular, and proprioceptive functions) for treatment of the enrollees autism. Findings:  The physician reviewer found that social cognitive speech and language therapy, sensory integration, and occupational therapy are well-established modalities for the treatment of autism. Myers and colleagues state in their seminal paper that, Most children with ASD can develop useful speech. Goldstein and colleagues discussed the various speech therapy modalities and their effectiveness in autistic children. Turner and colleagues reported that the earlier and more intensive speech therapy an autistic child receives, the better the prognosis for normalized speech. Similarly, Paul and Sutherland emphasize that early intervention and intensity of speech therapy is essential for young autistic patients to develop meaningful speech. Of further note, Schaaf and Miller document the support in the medical literature for the effectiveness of sensory integration and occupational therapy in the autistic patient. They conclude that improvement in the ability to process and integrate sensory input will influence adaptive behavior and occupational performance. Furthermore, a case study by Roberts, et al. reported on improved behavior regulation following treatment with classical sensory integration therapy. The paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population.In conclusion, given the severity of this patients documented deficits, he is an appropriate candidate for major intervention involving multiple modalities. For these reasons, the requested social cognitive speech and language therapy, sensory integration, and occupational therapy services are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested epidural injections for treatment of his lumbar degenerative disc disease and left sided radiculopathy. Findings:  The physician reviewer found that the patients medical records shows he received an initial epidural steroid injection and had a 90% reduction in his pain. The patient had two additional epidural steroid injections, however they were not medically necessary for the patients medical condition because the patient reported a great reduction in pain following the initial injection. There is inadequate medical evidence that repeated epidural steroid injections are required to achieve pain reduction greater than 90%. Thus, the two additional epidural injections performed following the initial treatment were not medically necessary for the patients medical condition. Although the patient reported a 90% reduction in pain following the initial injection, the scientific data does not support repeated epidural steroid injections over a single successful injection.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested lorazepam 1mg for treatment of her anxiety disorder. Findings:  The physician reviewer found that the notes indicate a pattern of drug-seeking behavior.  Her history is significant for an overdose of medication with near fatal results, requiring more than 10 days of treatment.  Lorazepam has addictive qualities. Michel and Lang reviewed some of the forensic aspects of this medication and noted that the adverse effects of benzodiazepines have been well-known for several decades. They include drowsiness, behavioral disinhibition, hostility, rage and addiction.  This patient has been offered safer medication alternatives, which she has declined. All told, lorazepam 1mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested speech and language therapy for treatment of the enrollees possible infantile spasms.  Findings:  The physician reviewer found that recently, the Infantile Spasms Working Group (ISWG) established guidelines for diagnosis and treatment of patients with this condition. The ISWG found a need for a comprehensive approach for optimal management of children with IS, including access to and evaluation by a variety of professionals, including child neurologists, pediatricians, psychiatrists, rehabilitation services (physical, occupational and speech therapy), nurses, vocational rehabilitation counselors, neuropsychologists, social workers, and pharmacists. As such, speech and language therapy is an important part of a thorough treatment regimen for patients with IS. This patient faces significant barriers to effective communication in social, educational and home environments due to disabilities resulting from infantile spasms and seizure disorder. A work-up has not revealed an etiology of these problems, but she certainly has neurological deficits as a result, including profound speech and language delay. However, speech and language therapy offered in the school setting usually focuses on educational goals. Thus, private speech and language therapy, provided by professionals with expertise in working with young patients with IS generally offers a more widespread approach. These experienced providers address communication skills in all aspects of daily living. Since functional language skills are essential to help these children express their needs and wants in a variety of environments, the requested speech and language therapy is medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested Cymbalta, 30 mg daily for treatment of her fibromyalgia and cervical disc disease with radiculopathy. Findings:  The physician reviewer found that this patient tried Neurontin and it made her drowsy. Sedation is an intolerable side effect for this patient, given her lifestyle. She reportedly had inadequate relief with gabapentin yet Cymbalta has been effective. In addition, Cymbalta is approved by the Food and Drug Administration (FDA) for treatment of fibromyalgia. Thus, Cymbalta, 30 mg is medically necessary for management of this patients medical conditions of fibromyalgia and cervical radiculitis and the denial was not appropriate.