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

A 36-year-old male enrollee has requested total disc arthroplasty (CPT code 22856) artificial disc replacement for treatment of his neck pain. Findings:  Three physician reviewers found that further investigations in the form of large, prospective, randomized trials are needed to determine the long-term benefits of artificial cervical disc replacement. Although there are well-controlled, prospective studies showing comparable short-term results of cervical spine arthroplasty and anterior decompression and fusion, there are insufficient long-term randomized controlled trials demonstrating the safety and efficacy of the requested procedure.  All told, the superior efficacy of total disc arthroplasty (CPT code 22856) artificial disc replacement has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested occipital nerve stimulation for treatment of his occipital neuralgia. Findings:  Three physician reviewers found that this patients records do not provide enough data to establish that a thorough work-up has been completed. In addition, any lesions should be ruled out by MRI or CT scan before placing an ONS to rule out any correctable lesion or facet arthrosis. At this time the denial should be upheld due to lack of documented failure or exclusion of other therapies and its use would be investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections for treatment of her migraine headache. Findings:  The physician reviewer found that this patient has been diagnosed with migraine, with medication overuse. There is no evidence that she has tried standard preventives in the past, or that detox from daily analgesics has been tried. Nor is there evidence that acute migraine abortive agents such as triptans have been used. Phase 3 studies of Botox for treatment of individuals with chronic migraine have shown clinical and statistical benefit in reduction of headache days in comparison to placebo, with average Botox dose of 165 units. Although Botox has been shown to be beneficial for headache preventive management for chronic migraine, the submitted evidence does not demonstrate that this patient has chronic migraine. Therefore, Botox is not medically necessary for this patients headache management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested a referral to a vascular surgeon for vascular surgery for treatment of the enrollees leg pain. Findings:  The physician reviewer found that sclerotherapy for the treatment of spider veins is not medically necessary. It is possible to have some symptoms in the area of spider veins, but it is generally accepted that spider veins are not the underlying cause of the pain. Although this patient has leg pain, there is no evidence in the submitted medical records of larger varicosities that would be amenable to surgical intervention. As such, the requested referral for vascular surgery is not necessary from a medical standpoint. Furthermore, the request for vascular surgery is not reconstructive in nature as this patients condition does not represent an abnormal structure of the body. Millions of individuals are affected by spider veins, and while they can be unsightly, they do not rise to the level that they are considered an abnormal structure of the body. All told, a referral to a vascular surgeon for vascular surgery is not reconstructive in nature and is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity.   Findings:  Two physician reviewers found that the patient meets generally accepted criteria for bariatric surgery. Laparoscopic sleeve gastrectomy is not investigational and is an appropriate primary treatment of morbid obesity. The laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested  speech and language therapy for treatment of the enrollee's autism.  Findings:  The physician reviewer found that patients need to engage in imitation and play to improve social and language development. Therefore, consistent with the medical literature and available scientific data, this patient should receive speech and language therapy to maximize his ability to function and communicate. As such, the requested service is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested Genotropin for treatment of the enrollees Prader-Willi syndrome. Findings:  The physician reviewer found that this patient has Prader-Willi syndrome. Although her height is currently within normal limits, she is likely to have at least some degree of impaired growth hormone secretion. This contributes to abnormal body composition and energy expenditure and abnormal carbohydrate and lipid metabolism. Based on the physicians letter of appeal, there is evidence of panhypopituitarism. Thus, growth hormone therapy is medically indicated for this patient, even if she has not yet demonstrated fall-off in growth. Growth hormone treatment for children with Prader-Willi syndrome has been shown to improve linear growth, promote growth of lean body mass, decrease fat mass, and improve cardiovascular risk factors.  Complications of growth hormone therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, growth hormone therapy is considered to be generally safe in this population.  All told, Genotropin is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old male enrollee has requested a brain PET scan for evaluation of his memory loss. Findings:  The physician reviewer found that the relevant scientific evidence includes a few small studies that favorably compared the accuracy of PET to clinical evaluation for differentiating fronto-temporal dementia from Alzheimer's disease. In view of the limited therapeutic options, however, the clinical value of this technique is unproven. Per the American Academy of Neurology guidelines: `PET scanning appears to have promise for use as an adjunct to clinical diagnosis, but further prospective studies with PET are needed to establish the value that it brings over and above a competent clinical diagnosis.` Given the lack of compelling evidence of added clinical benefit in this setting, the medical necessity of PET scan for evaluation of memory loss and/or possible Lewy Body dementia is not established.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an urgent medical condition requiring immediate medical services. Urgently needed services are defined as services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. This case does not meet the prudent layperson criteria for urgent care. The urgent care notes document only one complaint reported by the patient, dry throat following an upper respiratory infection. The records do not document any severe symptoms that would indicate to a prudent layperson that his health or bodily functions were at risk of serious deterioration. At the time of presentation, the patient had throat discomfort which is common and is not a condition for which most laypersons seek urgent care. The patient did not present with symptoms concerning for H1N1 and no documentation of fears about H1N1 were noted in the urgent care records. All told, the evidence provided does not demonstrate that the patient was experiencing symptoms such that a prudent layperson in his situation would believe he was at risk of serious deterioration if he did not seek urgent treatment. As such, this patients condition did not require urgent care at the time the services at issue were provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested acute inpatient detoxification for treatment of his substance use disorder.  Findings:  The physician reviewer found that there were no noted co-morbid substance use disorders at admission in this case. He did not present as a complicated withdrawal and was noted to be sleeping on two occasions during evening rounds and did not require withdrawal prophylaxis. The patients vital signs at detoxification admission reflected an elevated pulse and blood pressure. Applying the American Society of Addiction Medicine (ASAM) criteria, this patient presented with a potential for alcohol withdrawal as his clinical institute withdrawal assessment for alcohol (CIWA-Ar) score was greater than 10 and he had tachycardic pulse rate. However, the patient was not noted to have actually experienced any withdrawal symptoms that could not have been adequately managed on an outpatient basis. Overall, detoxification in an inpatient setting was not medically necessary for this patient, and proper outpatient treatment could have been a reasonable alternative for care. In addition, inpatient rehabilitation could have also been supplanted by an outpatient rehabilitation program for alcohol dependence as no reported past inpatient or outpatient rehabilitation programs were recorded. Aversion therapy does not support evidence-based practice. As such, the medical necessity for the detoxification services and inpatient alcohol rehabilitation was not satisfied for the time period in review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested general anesthesia provided during a colonoscopy for evaluation of her extensive pelvic adhesive disease. Findings:  The physician reviewer found that this patient had risk factors and medical conditions which included a history of pelvic adhesions secondary to endometriosis, and a history of invasive rectal trauma which required the use of deep sedation during the procedure. The documentation indicates the medical necessity for the anesthesia care provided during the colonoscopy. All told, general anesthesia provided during the colonoscopy was medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested genetic testing for evaluation of her breast cancer. Findings:  Two physician reviewers found that from the patients correspondence, it appears that she was interested in knowing whether she was a carrier for breast cancer susceptibility genes such as BRCA1 or BRCA2.  There is a brief notation in the patients clinic progress sheet of her mothers cancer. There is no note from a genetics counselor or from a physician who discussed the MammaPrint test. MammaPrint testing, one of the first gene expression array-based prognosticators, classifies tumors as low-risk or high-risk for breast cancer recurrence. It requires unfixed, frozen tissue for DNA microarray analysis of the 70-gene set. The test result, a binary score (low-risk and high-risk), is then derived through an algorithm based upon gene expression. The MammaPrint is not the appropriate test to look for BRCA mutations. Nor was there any other indication for MammaPrint testing is this particular scenario. All told, the genetic testing performed on the said date was not likely to be superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested mental health outpatient treatment 5 times per week from the said date forward for treatment of her anorexia nervosa, major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that although the patient was clearly in need of ongoing treatment, the therapist failed to provide adequate details to establish the treatment was the least intensive service available likely to be safe and effective for management of her condition. As indicated by the APA guidelines for eating disorders, treatment should include appropriate monitoring of the patients weight, vital signs, and labs however these were not available in the records provided for review. Further, this patients documentation did not identify a history of past hospitalizations or provide details of the patients reported suicidality. In addition, the treatment plan is confusing as the current reported global assessment of functioning (GAF) score was lower than the highest reported GAF score during the preceding year. Without significant progress noted between the dates in question, (which were the only outpatient treatment reports submitted), it is likely this patient could have been adequately treated on a less frequent basis. In fact, it appears the patient has progressed in treatment such that the frequency of visits has decreased. Overall, the multiple visits per week were not medically necessary to closely monitor this patient for suicidality or for compromises in her physiological status related to her eating disorder. For these reasons, the medical necessity for 5 psychotherapy visits per week for management of this patients condition has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee has requested emergency services (a magnetic resonance imaging of the left knee) for the treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case meets the prudent layperson criteria for emergent care. Severe swelling and extreme pain in a newly traumatized knee joint constitute valid criteria for a prudent layperson to seek immediate medical attention. In addition, the treating orthopedic surgeon agreed that this problem was emergent due to his findings of pain, swelling, and instability of his left knee and he recommended an MRI of the injured knee to be done as soon as possible. Since the following Monday was the earliest possible date to perform the MRI, it was reasonable the imaging was done on that date. The provider documented the necessity of the MRI was to to rule out any ligament damage or torn cartilage, as this would determine his appropriate care and treatment options.  Thus, the MRI performed was emergent in nature such that a prudent layperson would have followed the advice of his provider and undergone the MRI at issue for evaluation of his traumatic injury for proper diagnosis and treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested radiofrequency ablation (RFA) for treatment of her Barretts esophagus (with low-grade dysplasia). Findings:  Two physician reviewers found that the use of RFA in this setting is not consistent with the standard of care in the community practice of gastroenterology. The relevant literature does not support the continued use of radiofrequency ablation in this setting.  While the literature suggests some utility for RFA in the treatment of Barretts esophagus, further studies are considered necessary in order to establish the effectiveness of this treatment in reducing cancer risk and in defining optimal management strategies versus surveillance. Fleischer and colleagues found that currently there is no treatment for dysplastic or non-dysplastic Barretts esophagus that achieves a complete response in all patients, eliminates all risk of developing cancer, results in zero adverse events or eliminates the need for surveillance. Thus, RFA has not been shown to have significant clinical advantage as compared to other options in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested growth hormone therapy, Nordiflex 1.5mg daily injections for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the submitted medical records do not document this patients birth weight, growth curves charts and clinical lab workup data. As such, the information provided does not demonstrate an improvement in growth velocity as a result of GH therapy. Nor do the records document the patients failure to catch-up in growth by two years of age; thus, the diagnosis of small for gestational age cannot be validated based on the information provided. In addition, there is no definitive scientific literature which supports combination therapy for short stature and pubertal suppression. Therefore, there is inadequate clinical and scientific evidence demonstrating that the proposed therapy is likely to result in an improved outcome in this particular setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested urgent care 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 emergent or urgent 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.  Urgently needed out-of-network services are those obtained due to an unforeseen illness or injury while travelling outside ones services area when it would be unreasonable to delay services until a patient can return to her service area. This patient reported a three week history of back pain and dysuria. She developed urinary frequency two days prior to her urgent care visit. The patient denied fever, chills, or other acute symptoms. She had not sustained any recent trauma. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent or urgent basis. There was sufficient opportunity to contact her primary care provider.  The patients symptoms on the date of service at issue did not meet prudent layperson criteria for emergent or urgent care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergent or urgent care to jeopardize her health in these circumstances.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, eight-month-old female enrollee has requested speech and language therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that extensive review of the literature including meta-analysis by Law and colleagues demonstrates the positive effect of speech and language therapy interventions for children with expressive phonological and vocabulary difficulty. Appropriate receptive language skills and symbolic play are associated with resolution of delays. As noted by Feldman and Messick, intervention in the form of speech and language therapy attempts to create an optimal language learning environment which capitalizes on the importance of environmental stimulation in the process of learning language. The authors recommend speech therapy for patients with a delay of greater than 25% and found that approximately 50% of patients who are delayed at 2-years, catch up to their peers by 3-years of age with appropriate treatment. The discussion concluded that patients who participate in speech-language treatment show improvement when compared to patients who did not receive therapy.  Based on the records provided, this patient has a greater than 50% identified delay in expressive speech. Given this patients continued deficits in expressive and receptive language, future services are indicated. All told, the requested speech and language therapy is medically necessary for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested participation in the UCLA Early Childhood partial hospitalization program (PHP) for treatment of the enrollees autism.  Findings:  The physician reviewer found that given the severe functional impairment, aggression and tantrums, this young patient requires the structure, monitoring and medical/psychological interventions available in a PHP. Applying the guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP), it is likely that this patient with the delineated serious behavioral issues would experience escalation at a level of care lower than PHP. Moreover, the Child and Adolescent Level of Care Utilization System (CALOCUS) recommendations and community standards suggest treatment at the least restrictive level of care possible. For this patient, whose aggressive behaviors have markedly decreased since beginning treatment at the current facility, the PHP level of care is the least restrictive level of services at which he can be safely and effectively treated. Since the records show improvement, yet continued safety concerns with aggressive behavior and prolonged tantrums, the PHP services at issue have been demonstrated to be medically appropriate.