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

An 18-year-old male enrollee has requested ictal single photon emission computed tomography (SPECT) scan with video EEG monitoring for evaluation of his intractable epilepsy.  Findings:  Three physician reviewers found that the requested SPECT scan has been requested to localize the seizure focus, and if surgery is required, the provider will be able resect as little brain cortex as possible. As Goffin notes, Correct localization of the onset zone with the use of SPECT or PET is associated with a better surgical outcome. There are aspects of both SPECT and PET that are important. It is better to image the patient during a seizure (ictal imaging) as opposed to when the patient is not actively seizing (inter-ictal imaging). One will generally stop seizure medications, and have the tracer readily available to inject as soon as the seizure activity appears. Since the half-life of 99mTc (used for SPECT scans) is six hours and the half-life of 18FDG (used for PET) is less than two hours, it is easier to perform a SPECT scan. There is further literature that suggests that SPECT is actually preferable to PET. Desai and colleagues reported that ictal subtraction SPECT appears to be more sensitive than interictal PET in this patient population. This preference for SPECT over PET is confirmed by Kim and Mountz who noted that SPECT has the practical capacity to image blood flow functional changes that occur during seizures in the routine clinical setting. In conclusion, this patient is being treated in a dedicated epilepsy center that can effectively utilize SPECT scanning to help localize the seizure focus as well as possible. A SPECT scan, if obtained during an active seizure, should help in the decision making regarding the patients future treatment. Therefore, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested axial lumbar interbody fusion through a minimally invasive approach for treatment of her low back pain.  Findings:  Three physician reviewers found that Tian and colleagues conducted a meta-analysis of studies comparing the radiological and clinical efficacy of minimally invasive and conventional open transforaminal lumbar interbody fusion.  The authors noted that the minimally invasive approach increased intraoperative radiation exposure.  They reported that additional randomized controlled trials are needed to compare these two surgical procedures.  Kaloostian and Gokaslan also noted that there is a need for randomized controlled trials comparing these two approaches.  The current medical evidence has not demonstrated the superior efficacy of minimally invasive fusion approaches as compared to standard open fusion procedures. All told, the requested services are not likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested real time heart telemetry monitor services for evaluation of her atrial fibrillation and shortness of breath.  Findings:  Two physician reviewers found that this patient presented with a history of paroxysmal atrial fibrillation and symptoms of palpitations. In this circumstance, non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring is able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Similarly, self-activated non-real time and non-continuous monitoring devices (event recorders) are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and Holter monitors appropriate for initial evaluation of supraventricular dysrhythmias. There is no documentation to indicate the patient was not able to effectively manage a standard monitoring device or that these devices have been previously obtained to evaluate the patients symptoms. All told, continuous real-time monitoring by telemetry services was not likely to have been more beneficial than standard off-line patient activated or auto-triggered devices in this patients work-up.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested CardioDx testing for evaluation of her history of chest pain.  Findings:  Three physician reviewers found that the evaluation of patients for possible coronary artery disease is often based upon established clinical risk factors as well as diagnostic tests with varying levels of sensitivity, specificity, and predictive value.  At this time, gene expression testing is not a standard approach to the evaluation of patients with suspected coronary artery disease.  There is a lack of data demonstrating that the results of testing at issue will improve patient outcomes.  Current medical guidelines do not support the testing at issue in this patients case.  She presented with chest discomfort, palpitations, and dyspnea in the setting of risk factors of hypertension, hyperlipidemia, and a family history of premature ischemic heart disease.  The documentation noted a normal nuclear stress test.  In this patients case, CardioDx testing provided on the said date was not likely to be more beneficial than other options for evaluation this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested intravenous (IV) rituximab (Rituxan) for treatment of her Hashimotos encephalitis.  Findings:  Three physician reviewers found that there is a paucity of medical literature supporting the safety and efficacy of rituximab for this patients diagnosis. Although rituximab will lower antibody titers, there is no data suggesting this treatment will have the same impact as other treatments that aim to accomplish a reduction in antibody titers and have been used in treating Hashimotos encephalitis, such as steroids, cyclosporine, intravenous immunoglobulin (IVIG), and plasmapheresis. Given the lack of supporting data establishing improved health outcomes with IV rituximab in this patient population, the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy beneficial than other treatments including steroids, cyclosporine, and IVIG.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested emergency services.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the said date. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation demonstrates the patient had a sore throat for one day at the time she presented to the ED. She did not have a fever and her pain level is not documented in the medical records provided. Although the patient received antibiotics in the ED, her diagnosis was pharyngitis. While the patient indicates she has asthma and was concerned about potential breathing difficulties, she was not noted to be in respiratory distress in the ED and a diagnosis of asthma is not noted in her medical history. Based on the available documentation, the severity of the patients symptoms on the date in question were not such that they would cause a prudent layperson to believe she required immediate medical attention to avoid serious harm.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested 52 hours per month of applied behavioral analysis (ABA) therapy and six hours of supervision per month for treatment of his autism.  Findings:  The physician reviewer found that to be medically necessary, a service must be in accordance of generally accepted standards of medical practice, which means it must have support in peer-reviewed literature. Overall, there is a paucity of evidence for providing ABA therapy to adults. The compiled data stresses the importance of early intervention and treatment in the first several years of life. Additionally, it is not clear how the five specific behaviors identified by the functional behavioral assessment would respond to continued ABA. The evaluator noted that the problem of inappropriate touching occurs only when the patient is not closely supervised. The problem of inappropriate exposure occurs on an infrequent basis, reportedly once per year. The problems of food preference, swallowing pills, and fear of dogs are not issues that are best addressed by ABA treatment. In sum, the proposed ABA therapy is not an appropriate modality to address these concerns. All told, the requested 52 hours of ABA treatment each month and six hours of supervision each month is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested knee arthroscopy with osteochondral allograft transplant (OATS) procedure for treatment of the enrollees osteochondritis dissecans lesion.  Findings:  Three physician reviewers found that it is in the patients best interest to proceed with the providers recommendation for the OATS procedure as further treatment for the patients condition of osteochondritis dissecans lesion of the knee. This patient has already undergone a first-line treatment option of surgical intervention consisting of drilling the lesion (Wall, et al). This was unsuccessful and the provider has noted an area of necrotic bone beneath the lesion. This poorly vascularized necrotic bone is not capable of supporting fibrocartilaginous ingrowth. Both the patients continued symptoms and the identification of poorly vascularized bone provide a reasonable indication for the use of the OATS procedure. Unless bone and cartilage plugs are utilized, the underlying poorly vascularized bone cannot be expected to support a stable solution to the osteochondritis. Miniaci and Tytherleigh-Strong used autogenous osteochondral grafting rather than allograft and demonstrated both clinical results and MRI evaluation evidence of significant healing. Given the peer-reviewed medical literature supporting the use of osteochondral transplant, either allograft or autogenous, the requested procedure is considered appropriate and likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested weekly individual psychotherapy services for treatment of her major depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients with major depressive disorder.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which weekly or even twice-weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In this patients case, the submitted documentation does not support the medical necessity of the services at issue.  In a letter, the provider noted that the patient has made progress and treatment duration is indeterminate.  A comprehensive treatment plan was not provided. Information such as developmental history, treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination, and supportive community interventions are needed to determine if the increased frequency and duration of sessions are bolstering autonomy and resiliency while mobilizing the patient towards remission.  The Health Plan approved continued outpatient combined medication management/individual psychotherapy sessions at a frequency of once every two weeks from the said date forward.  The treatment frequency recommended by the Health Plan was medically appropriate.  All told, weekly individual psychotherapy services from the date in question forward were not and are not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Provigil for treatment of her depression.  Findings:  Two physician reviewers found that provigil is indicated for augmentation of treatment for major depression as it has been shown most useful to treat the adverse side effects of selective serotonin reuptake inhibitors (SSRIs) particularly sedation and impaired concentration as well as cognitive impairment. In addition, her successful use for over four years makes it contraindicated to discontinue and would risk worsening her clinical condition. For these reasons, the requested medication is likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee has requested occupational therapy (8 sessions, with a frequency and duration of 45 to 60 minutes per session over the next 8-10 weeks) for treatment of the enrollees lack of coordination and development of fine and gross motor praxis.  Findings:  The physician reviewer found that the occupational therapist also noted difficulties in sensory modulation and recommended remedial therapy. Sensory integration therapy was introduced by Ayres many years ago, on the assumption that behaviors could be modified by alteration of the established sensory developmental patterns that were in place. Lane and Schaaf explore the evolution of the scientific supporting evidence that behaviors can be modified by sensory input. Miller and colleagues support the efficacy of sensory modulation. Additionally, partial acceptance of sensory modulation is expressed in the report of the American Academy of Pediatrics, which states that there is no universal accepted framework for diagnosis of sensory integrative disorders (Zimmer, et al.). In sum, there is adequate evidence of the efficacy of sensory modulation techniques to support its use in this setting. Based upon the documentation provided, the patient has a significant motor problem and requires therapy in an attempt to improve his fine motor performance. All told, it is medically necessary that the patient receive the requested occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy (CPT code H2019) and 15 hours of supervision per month (CPT code H0032) and 5 hours of treatment planning per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. The medical communitys customary and usual prescription for an autistic child is ABA therapy. ABA therapy is well-documented as being an effective therapy to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. The efficacy of ABA as the only effective behavioral treatment has been documented by many authors (Vismara and Rogers).When reviewing ABA as effectively applied and continued with older children, there is limited literature substantiating its favorable effect on this continuing impaired population. Thus, the clinical circumstances of each patient must be considered to determine the appropriateness of continuing ABA therapy. In this case, there are several clinical features that are relevant. When ABA therapy was discontinued the patients behavioral control deteriorated and he became more aggressive. This would imply that the ABA therapy did have a positive effect on his personal skills and behavior. When reintroduced, over limited hours, the patient demonstrated improved social and behavioral skills. ABA services did have a positive although limited behavioral effect during the three months when it was reintroduced. However, ABA therapy has not substantially improved the patients overall communicative, social, and self-help skills during the nearly four years of treatment. Thus, the numbers of hours of ABA therapy should be adequate to prevent regression of the patients presently acquired skills; 2 hour daily should be adequate to prevent loss of his present abilities, along with daily school attendance. In conclusion, it is medically necessary for this patient to receive 10 hours per week of ABA therapy and 4 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested  speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that in this patients case, he has received 8-10 hours per week of individual and group speech therapy since 2011. The patient was 4-5 years old during the period of the disputed services. Although the CELF testing has confirmed significant improvement over the period of intensive speech therapy, the hours of therapy were excessive, particularly as the patient was developing sentences by age 212 which suggests less than severe impairment. Most recommendations for speech therapy for autistic children are for 1 to 2 hours per week of individual speech therapy. By the beginning of the disputed period, the patient had received 50 speech therapy sessions in 2012. Based on this patients deficits during the disputed period, 1 hour per week of individual speech therapy was medically necessary from the remainder of the speech therapy services provided during this period were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested suprapubic liposuction for treatment of his lipodystrophy.  Findings:  The physician reviewer found that based upon the submitted documentation, liposuction is not medically necessary for this patient and is not reconstructive in nature. The condition of buried penis can be complicated by skin rashes, intertrigo, recurrent urinary tract infections, voiding dysfunction, erectile dysfunction or pain with erection - all of which would require medically necessary surgery. This patient does not present with any of these symptoms and his condition is not so severe that the penile shaft is not visible. Liposuction alone is not recommended for the treatment of buried penis because it alone does not remove all of the hanging tissue covering the penis and its supporting structures. Although the patients condition of buried penis is not severe it does constitute an abnormal structure of the body caused by obesity. However, the requested liposuction surgery alone will not alleviate his complaints. The patients elevation of the pannus that does alleviate the symptoms is not a simulation of the results of liposuction and liposuction alone will not improve function or create a normal appearance to the extent possible. Furthermore, if the patient does have an inguinal hernia as opined by the urologist, liposuction will not correct that condition. All told, the medical necessity of the requested procedure has not been established, as it will not relieve the patients symptoms. Nor does the requested procedure meet criteria for reconstructive surgery.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested  emergency services for treatment of her abdominal pain and gross hematuria.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patient had a history of UTIs and had experienced the rapid onset of symptoms of a UTI on the disputed date of service. Untreated, this uncomplicated infection could have ascended the urinary tract to involve the kidney and thus could have become a serious, life-threatening infection. Waiting until the next day to seek diagnosis and treatment for this obvious infection would not have been prudent. In addition, the patients pain level was 7/10 (a level compatible with severe pain). In sum, a prudent layperson would have thought the patients symptoms represented an emergency medical condition and would have sought immediate medical attention on the date in question.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested emergency services provided for treatment of his abscess.  Findings:  The physician reviewer found that the patient presented to the emergency department on the date indicated because he was instructed to return to the emergency department to have his packing removed. However, the very nature of this recheck makes it a planned, non-emergency visit. The patient was not in severe pain (pain level was 3/10), it was a weekday, and he could have had the packing removed in an urgent care facility or by his primary care provider via a scheduled appointment. A prudent layperson would not have thought this to be an emergency medical condition for which immediate medical attention was required in order to avoid serious harm.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested follow up care with a pediatric cardiologist for treatment of his Shones syndrome.  Findings:  The physician reviewer found that current guidelines recommend that just over half of adult congenital heart disease patients should be seen by a cardiologist with specific congenital heart disease expertise because they are at risk for serious complications (e.g., reoperation and/or arrhythmias) and premature mortality (Sable, et al.). Their expertise in treating these patients is far greater than the average adult cardiologist who receives limited training in congenital heart defects. As noted by Kovacs and Verstappen, Adult physicians have not been educated about the complexity of the adult with a congenitally malformed heart. In sum, it is medically necessary for this patient to be followed by a pediatric cardiologist who understands the natural history of congenital heart defects. As such, the medical necessity of the requested services has been established.