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

The parent of a three-year-old male has requested speech therapy for treatment of his expressive language delay.  Findings:  The physician reviewer found that the patient has an identified expressive speech delay of approximately 50%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient has made significant progress in his receptive language skills with intervention and is likely to benefit from continued therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested for the transcranial magnetic stimulation (TMS) therapy for treatment of his depression. Findings:  The physician reviewer found that the Mayo Clinic has stated It's not yet known if transcranial magnetic stimulation can be used to treat depression for the long term, or whether you can have periodic maintenance treatments to prevent depression symptoms from returning. The effectiveness of transcranial magnetic stimulation may improve as researchers learn more about techniques, the number of stimulations required and the best sites on the brain to stimulate. TMS is certainly indicated for the treatment of acute phase unilateral depression.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested emergency services.  Findings:  The physician reviewer found that the patient  presented to the Emergency Department (ED) with complaints of itching all over for three weeks.  The patient was uncomfortable, but was in no acute distress.   Her vital signs were normal. She was triaged with an acuity level of 4. She was evaluated by the physician and treated with oral Benadryl.  Blood tests including electrolytes and liver functions tests were unremarkable. The itching was relieved and the patient was discharged to follow up with her family doctor.At issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention on the date in question. 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.The patient had the symptoms for three weeks prior to her visit to the emergency department.  She had not sought medical attention during that time.  The patients vital signs were normal.  She did not describe any difficulty breathing. She was described as uncomfortable, but in no acute distress. She was treated with oral medications with relief.  The patient was not experiencing an emergency medical condition, as her life was not in serious jeopardy and that there was no serious impairment to bodily functions or serious dysfunction to any bodily organ or part.  The denial should be upheld. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested past and future coverage for home health services for treatment of her Parkinsons disease.  Findings:  The physician reviewer found that treatment for Parkinsons disease includes medical therapy, surgical measures, and brain stimulation.  This patient has advanced idiopathic Parkinsons disease.  She has undergone multiple neurology evaluations and has been tried on multiple medications.  Per the submitted documentation, there is increased dystonia with increased on-off phenomena, making any ambulation difficult.  In addition, she has bladder involvement, requiring regular self-catheterization, and mild constipation.  The documentation from her treating providers indicates that she requires regular daily assistance with activities of daily living, including bathing, dressing, and toileting.  The submitted documentation demonstrates the medical necessity of the services at issue in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for physical pulmonary exercise stress test for evaluation of his dyspnea on exertion. Findings:  The physician reviewer found that this patient has undergone an extensive cardiac workup that has demonstrated that his symptoms are of non-cardiac origin.  The physical pulmonary exercise stress test testing can potentially provide some helpful information as to this patients exercise intolerance and unexplained dyspnea on exertion.  For patients with unexplained dyspnea and for whom initial test results are non-diagnostic, the weight of evidence suggests that the requested testing is a useful tool in identifying cardiac and pulmonary causes, mitochondrial myopathy, psychological factors, or deconditioning.  Results from the physical pulmonary exercise stress test may efficiently direct further diagnostic testing to target the suspected organ system involved.  All told, the requested physical pulmonary exercise stress test is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested coverage for past blood testing for food allergies with IgG allergy testing for evaluation of his allergies.  Findings:  Three physician reviewers found that the patient has a medical history of hypertension and ADAM syndrome. The patient has symptoms of abdominal bloating and diarrhea for several months. No laboratory or imaging data is available for review. The provider recommended evaluation for gluten intolerance. The provider ordered IgG Food Antibody Assessment with IgE Foods an IgE Inhalants. Gluten intolerance or gluten enteropathy is a diagnosis based on history, physical examination, and specific laboratory testing including serum celiac panel (IgG anti tissue transglutaminase antibodies, IgG endomysial antibodies, and/or IgG deamidated gliadin peptide). The diagnosis is confirmed with small bowel biopsy. If the above tests are positive, a trial gluten-free diet can be initiated with observation for clinical improvement. However, the diagnosis is not made with the use of IgG and IgE Food Antibody testing. Food allergy testing is based on a very specific history, food challenge, skin prick test and measurement of specific IgE antibodies to food extracts, individual allergens, or allergenic peptides. Indiscriminate testing is not helpful and yields a rate of high false positive results. In the peer-reviewed medical literature, food specific IgG and IgG4 testing is not supported as a first-line evaluation modality. Specifically, it does not detect true food hypersensitivity and may actually be a marker for development of tolerance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old female has requested the RT300-SLSA FES integrated cycle system for treatment of her tetraplegia.  Findings:  Two physician reviewers found that the patient has C5 tetraplegia as a result of the onset of transverse myelitis.  Per the submitted documentation, the patient has utilized the requested device, with favorable results.  In this clinical setting, the requested device is likely to be superior over other available treatment options.  Functional electrical stimulation (FES) cycle ergometry has been shown to have positive physiological effects on spinal cord patients which translate into reduced long-term complications.  Multiple studies have shown that FES ergometry can increase muscle volume, improve venous return, and improve cardiac output and endurance with improved oxygen uptake. Some studies also report an increase in bone mineral density.  The pre-morbid functional and fitness level of this patient make her an ideal candidate for requested device.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mammogram and a breast magnetic resonance imaging (MRI) every 6 months for evaluation of the enrollees risk for breast cancer.  Findings:  Two physician reviewers found that the patient has a strong family history of breast cancer in her sister who was diagnosed with invasive ductal breast cancer at the age of 30. The patient has had prior mammograms and breast MRI studies that have shown extremely dense breast tissue. BRCA testing was negative. The patient had a screening breast MRI on and is requesting reimbursement for this study as well as future coverage for a mammogram and breast MRI every 6 months. The American Cancer Society (ACS) does not advocate for screening breast MRI for patients with dense breast tissue. Review of the peer-reviewed medical literature did not find an exact formula or risk factor for patients with this patient's heritage. Using the Breast Cancer Risk Assessment Tool (also known as the Gail model) this patients lifetime risk for developing breast cancer is approximately 17.6% including the patients positive family history of breast cancer in her sister. It is well documented in the medical literature that a yearly screening breast MRI is medically appropriate for patients with a calculated life time risk of greater than 20%. The American Society of Breast Surgeons recommends breast MRI, [a]s part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. At this time, there is insufficient clinical evidence to support the use of screening breast MRI in this patient. This is primarily because the patients calculated risk of developing breast cancer is less than 20%. For these reasons, breast MRI and mammogram are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy at the requested frequency.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested for emergency services were required on an emergent basis. Findings:  The physician reviewer found that a prudent layperson would have sought medical attention for an increased low back pain following a recent fall. However, the patient did not have an emergency medical condition that placed him in serious jeopardy if he did not undergo surgery. He did not have a serious impairment of bodily function or a serious dysfunction of any bodily organ or part. Failure to have performed his surgery would not have harmed him. The medical records fail to indicate any evidence of instability, angulation, spondylolysis, spondylolisthesis, fracture, tumor, or infection.  The patients symptoms met prudent layperson criteria for emergency care. However, the hospital admission and services provided did not meet prudent layperson criteria for emergency care.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for emergency services at issue were not required on an emergent basis. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention. 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.A prudent layperson would reasonably seek immediate medical attention for acute-on-chronic polysubstance use relapse in the context of a post-operative state and peri-surgical infection combined with multiple medical problems, including hypertension and hypothyroidism. The American Psychiatric Association (APA) Clinical Practice Guidelines states ambulatory detoxification with co-occurring general medical conditions may be unsafe.  Therefore, seeking immediate medical attention was reasonable in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested for a Melody pulmonary valve replacement via catheter for treatment of his pulmonary regurgitation. Findings:  Three physician reviewers found that there have been clinical trials examining the use of transcatheter pulmonary valve replacement as an alternative to open heart surgery. The peer reviewed medical literature has demonstrated that this procedure has been found to be beneficial at one year in follow-up studies, with minimal complications. Although there is a paucity of long-term follow-up data with use of the Melody valve replacement procedure via catheterization, there is less chance of complication during the procedure than with a standard surgical re-intervention. Thus, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested for an international normalized ratio (INR) machine for evaluation her Coumadin. Findings:  The physician reviewer found that this patient is on chronic Coumadin therapy to help reduce thromboembolic risk. The documentation indicates that the patients caregiver can operate a home INR monitoring device and that testing with the device would not be expected to occur more frequently than weekly since current laboratory INR draws are not occurring more frequently than once weekly.  The requested INR machine is medically indicated in this clinical setting. All told, the requested INR machine is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for lumbar medial branch radiofrequency at L4, L5, and S1 for treatment of her history of low back pain. Findings:  Two physician reviewers found that the patient has tried standard therapies, including medications, which failed to reduce her pain.  The patient has lumbar radicular pain that was responsive to lumbar transforaminal steroid injections.  Additionally, she has lumbar spondylosis resulting in facet arthropathy.  In this clinical setting, the requested services are likely to be more effective than other treatment options.  The current medical evidence supports the requested lumbar medial branch radiofrequency in this patients case.  Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation.  The authors concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting.  This patient is a good candidate for this procedure as she reported reduction in her pain and increased mobility following lumbar medial branch blocks.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male has requested Rituximab (Rituxan) injections for treatment of his multiple sclerosis.  Findings:  Two physician reviewers found that the patient has refractory multiple sclerosis, and has been resistant to multiple first line therapies, including: copaxone, interferon, tysabri, gilenya, IVIG and solumedrol. Despite these therapies, the patients symptoms and MRI findings have demonstrated a progression in his disease. Given the patients disease progression, the patients provider recommended a trial of Rituximab (Rituxan). Although Rituximab is not a first line therapy for multiple sclerosis, there is very good literature supporting its use for this condition. Rituximab has been found to be effective in the treatment of multiple sclerosis, as an add-on therapy (Naismith, et al.). In a phase I clinical trial, patients were followed for a total of 72 weeks and received two courses of Rituximab six months apart. The authors reported no serious adverse events with the use of this medication (Bar-Or, et al.).  The use of a second-line therapy, such as Rituximab, is reasonable and appropriate in this case, as the patient has not responded adequately to the first-line therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested authorization and coverage for a high frequency chest wall oscillation air pulse generator system for treatment of the enrollees bronchiectasis without acute exacerbation.  Findings:  Two physician reviewers found that the patient has a history of bronchiectasis, asthma, gastroesophageal reflux disease (GERD), thick sputum production, and frequent episodes of bronchitis (4 or more times per year) treated with antibiotics and corticosteroids. The patient has been using the high frequency chest wall oscillation (HFCWO) air pulse generator system (Vest) for over two years with reduced bronchitis exacerbations. The provider has requested authorization for the HFCWO Vest airway clearance system which the Health Plan has denied as investigational. The peer-reviewed medical literature includes some data supporting the effectiveness of the requested device in patients with non-cystic fibrosis bronchiectasis. Specifically, the literature suggests that the Vest HFCWO helps to move sputum out of bronchiectatic airways when other methods fail. The Centers for Medicare and Medicaid Services (CMS) generalized the indications for the HFCWO air pulse generator system systems for bronchiectasis caused either by cystic fibrosis, or other causes in November of 2003. CMS requires a patient with severe disease to have failed conventional treatments including chest physical therapy and postural drainage. The Vest should continue to move sputum out of the patients lower airways, and prevent infection, hospitalization, recurrent bronchitis, and reduce drug resistant organisms. Therefore, the Vest airway clearance system is likely to be more beneficial than repeated attempts at conservative therapy in managing this patients non-cystic fibrosis bronchiectasis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested Minimally Invasive 5 Box Maze for treatment of his atrial fibrillation.  Findings:  Two physician reviewers found that the patient has a history of very symptomatic paroxysmal atrial fibrillation that has been refractory to anti-arrhythmic medications and three prior percutaneous ablation procedures.  In this clinical setting, the requested Minimally Invasive 5 Box Maze is likely to be more efficacious than other treatment alternatives.  This patient has continued symptomatic atrial fibrillation that has been refractory to medication and percutaneous catheter ablation.  As noted by Sirak and colleagues, the requested procedure performed minimally invasively through a thoracoscope has been shown to have favorable preliminary efficacy and safety data compared to historical controls of the standard surgical Maze procedure.  There is sufficient evidence in the scientific literature demonstrating the long-term safety and efficacy of the requested Minimally Invasive 5 Box Maze in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested authorization and coverage for Innovative Neurotronics WalkAide External Functional Neuromuscular Stimulator. Findings:  Two physician reviewers found that the patient has right-sided myelopathy due to central nervous system demyelination. There are significant disruptions to walking ability and walking potential. The inability to dorsiflex during ambulation has limited the ability to perform normal activities without fatigue due to inefficient gait pattern as result of foot drop. A request for a WalkAide device was placed by the provider. For the treatment of multiple sclerosis, the current standard of treatment includes medications to improve or modify the disease state, as well as improve symptomatology including fatigue or gait through use of assistive devices, as well as prescribed physical therapy. The condition of foot drop as caused by peripheral perineal weakness is a significant weakness in the muscles of the ankle which control dorsiflexion. Weakness of this type causes the foot to drop in an unsupported manner when the leg is lifted by the hip and when walking, with a tendency to catch or drag the toes which may present risk for fall. The therapy for this foot drop will depend on etiology, with the principle and standard of treatment being an ankle foot orthotic (AFO) brace. This is a plastic type brace which functions in a capacity to splint the ankle to keep the foot in a neutral position to avoid tripping. In review of the medical literature, there are peer-reviewed publications evaluating the use of neuromuscular electrical stimulation in certain conditions. However, there are no large, randomized, double-blind, controlled studies demonstrating the efficacy or superiority to other current standard treatment in MS. The WalkAide and similar devices are designed to offer patients with foot drop increased mobility and functional independence. The WalkAide functional electrical stimulator is not standard of care of treatment for multiple sclerosis related to gait. All told, the WalkAide is currently not supported by adequate clinical evidence for use in patients with foot drop secondary to multiple sclerosis.