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

A 52-year-old female has requested bilateral MRI of the breast for evaluation purposes.  Findings:  Three physician reviewers found that the patient has a family history of breast cancer.  Per the submitted documentation, her sister had breast cancer.  The patient presented last year with a palpable lump in the left breast.  Left breast ultrasound showed two areas of concern in the left breast at the 12 oclock and 1 oclock positions.  A left breast ultrasound performed six months later was benign.  The following year, a screening mammogram was negative.  The patients provider has recommended a bilateral breast MRI due to the patients family history and dense breast tissue.  The submitted documentation does not demonstrate that the requested bilateral breast MRI is likely to be superior over other available methods of evaluating this patient.  If evaluation is needed based upon the palpable abnormality in the left breast, a biopsy is the preferred method of evaluating this patient.  Per the current medical evidence, the requested diagnostic procedure is not likely to be of benefit and involves a high degree of false positive results.  This patient does not have at least two first-degree relatives with breast cancer, and there is no genetically-proven predisposition to the disease.  Therefore, bilateral breast MRI is not likely to be more efficacious than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his Aspergers syndrome.  Findings:  The physician reviewer found that ABA therapy has been widely used in the therapeutic intervention in autistic children. Studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (greater than 20 hours per week). In addition, studies have also been conducted looking at intensive ABA therapy versus standardized care. Comparing patients that received ABA therapy versus those who received standardized therapy, there is a statistical improvement in cognitive, language, and adaptive behavior skills in patients who have received ABA treatment. ABA therapy is superior to special education or standardized care in improving the outcome in patients with autism. On average, the children who received the behavioral treatment gained 17 IQ-points, 13 points in language comprehension, 23 points in expressive language and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, 1 point in language comprehension, 2 points in expressive language and zero points in adaptive behaviors in one study (Eikeseth, et al). Given the scientific data demonstrating that ABA is an accepted and appropriate modality for treatment of patients with autism spectrum disorder, ABA therapy is medically indicated and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for Venofer infusion for treatment of her anemia.  Findings:  The physician reviewer found that it is common after gastric bypass surgery for a patient to develop a number of mineral, vitamin, and micronutrient deficiencies. In particular, iron deficiency is due to the low contact time of food with stomach acid, decreased intake, and bypass of the segments of the intestine responsible for iron absorption, the distal duodenum and jejunum. Patients who are unable to meet their needs orally require IV iron. Therefore, the requested Venofer infusion has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female has requested a sinus endoscopy with balloon dilatation for treatment of her chronic sinusitis.  Findings:  Two physician reviewers found that the patient has chronic maxillary and frontal pain. She has been treated with nasal steroids and antibiotics. In the peer-reviewed medical literature, Levine and Rabago concluded that although randomized controlled trials comparing balloon sinuplasty with conventional functional endoscopic sinus surgery have not been conducted, existing prospective and retrospective assessments suggest that balloon sinuplasty is a viable option for sinus intervention, either alone or in combination with conventional surgical treatment. While no randomized clinical trials comparing balloon sinuplasty to functional endoscopic sinus surgery have been performed, the procedure is considered equivalent by many experts in the treatment of patients with mild disease of the frontal and maxillary sinuses (Stewart and Vaughan). For these reasons, balloon sinuplasty should be approved in this patient as she has failed standard medical therapy and she has mild disease for which the requested procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 21-year-old male has requested reimbursement for lab testing provided while staying at a recovery center. Findings:  The physician reviewer found that the patient was hospitalized for hypothermia and bradycardia related to malnutrition and secondary to alcohol abuse.  He was treated for approximately two days but then left the hospital against medical advice (AMA), flew to Florida (where his parents live), and checked into a recovery center.  His vital signs were grossly abnormal with a heart rate of 44, respiratory rate of 10, and temperature of 95.2F. His blood pressure was low normal at 96/64.  He was treated for five days for malnutrition related to his alcoholism, many laboratory tests were performed, and he was discharged. The patient was released from the recovery center because the providers at the facility felt he required a higher level of care. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention during the time frame under review. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This patient was critically ill at the time of his admittance to the recovery center.  He needed emergency care and he needed to be hospitalized for that care.  Despite the fact that the patient left the hospital and sought treatment at a non-acute care facility, he did have grossly abnormal vital signs, and a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention.  The patients symptoms during the time frame under review met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for Comprehensive Colaris and Concurrent PMS 2 Sequencing Test for evaluation of his family history of colorectal cancer. Findings:  Two physician reviewers found that Lynch syndrome is a genetic susceptibility to the development of a variety of different cancer types that occurs in certain families.  Lynch syndrome is detected by the requested testing.  The current medical guidelines support the requested testing for individuals without personal cancer if they have two or more first-degree or second-degree relatives with a Lynch related cancer, such as colon cancer. In this clinical setting, the requested Comprehensive Colaris and Concurrent PMS 2 Sequencing Test is likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for duodenal switch bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is evidence indicating that the duodenal switch operation leads to superior outcomes in individuals with a body mass index greater than 50.  Given the patients body mass index of 52.30 when she was initially evaluated, the regain of weight after the medically supervised weight loss program, and the most recent body mass index of 49.79, she will likely achieve superior outcomes from the duodenal switch.  All told, the requested duodenal switch bariatric surgery is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old female enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that applied behavior analysis (ABA) is an empirically proven treatment intervention for children, adolescents and adults with autistic disorder. Granpeesheh, et al. stated that, ABA has also been demonstrated to be effective in addressing particular challenging behaviors and skill deficits in older children and adolescents. Accordingly, based on the clinical presentation and literature review, a course of the requested therapy was medically necessary for treatment of the patients medical condition. As such, there is insufficient evidence that continued therapy beyond a three-month treatment course is medically necessary. Therefore, based on the documentation provided, three months of ABA treatment, was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested speech therapy services, once per week, for one hour for treatment of her speech delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she has significant receptive and expressive language delay, and this is impacting her ability to communicate effectively and function socially.  Based on the literature, speech therapy services, once per week, for one hour, are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation therapy provided from over an approximate 5-week timeframe for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has major depressive disorder.  In a letter, the provider noted that the patient had only a partial response to a prior course of electroconvulsive therapy nine years prior.  Per the provider, the patient failed treatment with multiple medications, including Wellbutrin, Lexapro, Zoloft, Abilify, Lamictal, Geodon, Seroquel, Ativan, Ambien, and Pristiq.  Her symptoms include anxiety, poor sleep, poor concentration, low energy, fatigue, anhedonia, interpersonal withdrawal, and suicidal ideation.  The patient has requested reimbursement for transcranial magnetic stimulation provided during the dates in question.  In this patients case, the services at issue were not likely to have been more efficacious than other treatment options.  Per the submitted documentation, the patient experienced minimal benefit from transcranial magnetic stimulation.  The patients Zung score changed very little throughout the sessions that she received.  Although the patient experienced some improvement, this was not lasting.  Additionally, the improvement was accompanied by reinstituting weekly psychotherapy and adding Lamictal to her regimen.  Thus, it is not clear that this improvement was a result of the transcranial magnetic stimulation.   The submitted medical records do not demonstrate that the patient had exhausted available standard therapies prior to undergoing transcranial magnetic stimulation.  All told, transcranial magnetic stimulation provided during the timeframe in question was not likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested surgery to repair a fracture of the distal aspect of the nasal bone for treatment of her nasal fracture. Findings:  The physician reviewer found that there is no middle vault collapse or other defect that would be expected to cause nasal airway obstruction.  There is no obvious source of nasal airway obstruction and there is no deformity or step off visible from the nasal bone fracture.  Septal deviation is common in the general population.  Many people have a deviated septum with various degrees of severity and no nasal airway obstruction.  Of note, the mere presence of a scar such as that on the nasal bridge of this patient does not make its removal medically necessary.  In the absence of documentation of unstable scar prone to skin breakdown, impaired function, or symptoms (such as pain or itching), the removal of such a scar would be considered cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism spectrum disorders with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, Brosnan and Healy have indicated that ABA therapy is highly effective in reducing or eliminating aggressive behavior across a range of ages and degrees of development. Another meta-analysis reports that long-term comprehensive ABA intervention leads to positive effects, in terms of intellectual function, language development, acquisition of social skills, and acquisition of focusing skills (Virues-Ortega). The request for ABA therapy is medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male  has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for patients with autism (Foxx). In a study comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than did the other group (Eikeseth, et al.). Howard and colleagues reported similar results. Behavioral approaches are considered to be first line treatment for autistic spectrum disorders, along with speech and language therapy and many consider the advances made in the treatment of children with autism spectrum disorders to be attributable to applied behavior analysis therapy (Matson, et al.). All told, ABA therapy has been practiced and studied for decades, and studies show positive results from consistent implementation of this method. ABA therapy is a standard modality for the treatment of children with autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested for residential treatment center (RTC) services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that applying the Milliman guidelines for admission and treatment at the RTC level of care, the patient must manifest symptoms and behaviors which represent deterioration from their usual status and include either self-injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24-hour structured setting. This patient meets these criteria. Her mental health deteriorated throughout her previous state as a college student and attempted suicide. In the medical literature, Kaplan and Sadock state that, impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. By this definition, the patient is in the high-risk group for self-harm.  Consistent with these facts and the Milliman guidelines, this patient meets the medical necessity criteria for RTC.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for speech therapy for treatment of her status post hemorrhagic stroke. Findings:  The physician reviewer found that aphasia is a common complication following stroke and affecting about one-third of those who experience a stroke (Brady, et al.). Speech therapy in the early aftermath following stroke, which is complicated by aphasia, is generally considered an appropriate intervention (Bernheisel, et al.), but clear evidence of efficacy of the various interventions that are typically provided is still lacking (Langhorne, et al.).the available peer-reviewed medical literature has not established that long-term formal speech therapy is clinically effective. Long-term speech therapy in the setting of chronic complications after stroke, such as cognitive impairments and aphasia, is not proven to be of clinical benefit.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) angiogram of the coronary arteries for evaluation of the enrollees chest tightness and irregular heartbeat.  Findings:  Two physician reviewers found that the patient has hypercholesterolemia and sought care from a cardiologist due to persistent and typical chest pain. He was evaluated in two years prior with a stress echocardiogram (ECHO), which was normal without evidence of myocardial ischemia. Due to persistent symptoms of angina, and to avoid an invasive coronary angiogram, a CT coronary angiogram was ordered to rule out obstructive coronary artery disease. The Health Plan ruled his coronary computed tomography angiogram (CTA) as investigational.  Coronary computed tomography (CTA) is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner (Hendel, et al). No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of CTA. In addition, coronary CTA has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography, and percutaneous coronary angioplasty. Coronary CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information (Mark, et al). The American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Society of Cardiovascular Computed Tomography (SCCT) guidelines recommend the use of coronary CTA in patients with chest pain and intermediate Framingham risk. This is due to the fact that coronary CTA is non-invasive and without complications associated with invasive coronary angiography. CTA also provides equal if not better information on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology. This all translates into a robust technique which contains multiple important levels of clinical information in a safe, accurate and non-invasive manner. The guidelines for coronary CTA state that for the indication of a chest pain syndrome, with the explicit intent to rule out coronary artery anomalies, a score of 9 was assigned, suggesting this as an appropriate indication. In this patient, it is import to rule out congenital coronary anomalies as the cause of his persistent and recurrent chest pain. Per the ACC/AHA/SCCT guidelines, this is best accomplished with a coronary CTA. As such, the use of a coronary CTA angiogram in this case is medically appropriate and within the standard of care. Thus, the requested coronary CTA is likely to be more beneficial for evaluation of the patients suspected medical condition than any standard therapy (invasive coronary angiography).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested authorization and coverage for Mohs micrographic surgery for treatment of the enrollee, who has a history of skin cancer. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Mohs micrographic surgery is not medically indicated at this time, given that the lesion in question has not been evaluated and is not a biopsy-proven skin cancer.  Once a diagnosis is made by a dermatologist, appropriate treatment may or may not include surgical intervention.  Given her history of skin cancer, the patient requires routine evaluation by a dermatologist.  However, appropriate services are available in-network.  All told, the requested Mohs micrographic surgery is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for readmission to acute hospitalization for treatment of her non-small cell cancer of the lung, with metastases to the brain, bone, and spinal meninges. Findings:  The physician reviewer found that the medical records indicate that the patient is receiving no intravenous pain medications or any other essential intravenous therapies.  The documentation fails to demonstrate the medical necessity of the requested services.