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

A 59-year-old male enrollee has requested implantation of the X-Stop interspinous device for treatment of his spinal stenosis. Findings:  Two physician reviewers found that the X-Stop procedure is intended to address neural foraminal stenosis of moderate degree. The literature supports the more traditional posterior laminotomy in patients with severe spinal stenosis, which is not present in this patient. The rationale for the X-Stop device is that neural foraminal stenosis and intervertebral disc pressures will be influenced by the device. The anatomical studies published to date document an increase in the cross sectional area of the neural foramen and a decrease in interdiscal pressures, but these anatomical changes do not continue over time, and there is a reversion to the preoperative dimensions of the neural foramen and the intervertebral disc pressures. Pain generators are present within the annuli of the intervertebral disc and within the facet joints themselves. Additionally, inflammatory processes within the posterior ganglia and spinal nerve root structures are recognized as likely pain generators. The literature of the outcome of the X-Stop procedure published to date relies heavily on patient scored subjective scoring, including the Oswestry Disability Index and the Brigham Low Back Pain Questionnaire. There are issues of patient selection bias in the prospective studies reported to date, and the placebo effect has not been adequately addressed. The control groups receiving conservative management are poorly defined, particularly in reference to specificity in the conservative treatment protocols. There is evidence that increased dimensions of neural foramina and decreased interdiscal pressures initially present are lost over time. Longer term studies with improved criteria to assess patient and provider selection bias and more accurate definition of conservative protocols serving as controls are needed before the efficacy of the X-Stop procedure can be reliably determined.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested CPT codes 76102, 70250, 77077, and 92520 for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that the patient has been diagnosed with obstructive sleep apnea and was being worked up for a mandibular repositioning device. The provider indicated that the patient did not have any history of temporomandibular disorder. The CPT codes in dispute, 76102, 70250, 77077, and 92520, are not accepted as part of a standard work up for a patient being fitted with a mandibular repositioning device. The need for this level of imaging is not supported within the scientific literature under these circumstances. The records indicate the patient had an adequate work up without the CPT codes at issue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested intravitreal injection of Avastin for the treatment of her diabetic macular edema. Findings:  Two physician reviewers found that the scientific literature reveals adequate evidence supporting the efficacy of anti-VEGF medications in the treatment of diabetic macular edema and proliferative diabetic retinopathy. A study by Kook, et al. concluded that even in cases with chronic diffuse ischemic diabetic macular edema, a long-term decrease of central retinal thickness can be observed following repeated intravitreal injections of bevacizumab [Avastin]. In these patients, mean decrease in retinal thickness is aligned with a gain in mean VA [visual acuity]. Further, Centers for Medicare and Medicaid Service (CMS) criteria includes both macular edema and proliferative diabetic retinopathy as appropriate indications for treatment with Avastin. Given this patients diagnoses, intravitreal injection of Avastin is likely to be more effective for her condition than alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy services two hours per day, five days per week to include therapeutic services for the use of a non-speech generating device, including programming and modification for the treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy techniques can be successful in inducing the autistic child to speak and the crucial role of the speech therapist is outlined in the monograph by the American Speech-Language-Hearing Association Ad Hoc Committee on Autism Spectrum Disorders (Goldstein). Turner and colleagues conducted a controlled study of autistic children who did or did not receive speech in early childhood, and concluded that by the age of nine, the speech therapy group was far superior in language compared with the control group. The controlled study by Goorhuis-Brouwer and Knijff reports that children with significant cognitive impairment will benefit from speech therapy. Thus, the literature strongly supports the medical necessity of speech therapy in the autistic child. However, there is no evidence demonstrating that daily speech therapy is any more effective than therapy provided at a frequency of three times per week.  The frequency of therapy authorized by the Health Plan is medically appropriate in this setting. The need for daily speech therapy (for a total of 10 hours per week) is not established as it is not likely to yield greater results than less frequent therapy. Furthermore, with regard to the request for therapeutic services for the use of a non-speech generating device (or augmentative and alternative communication device), there is a paucity of literature in support of such devices. Currently, there is a lack of evidence demonstrating the efficacy of this technology for patients with autism. In addition, the clinical findings in this case do not support the benefit of a non-speech generating device for this patient at this time. The patient is not currently functioning at a level that will allow him to benefit from use of the proposed device. Thus, the medical necessity for therapeutic services for the use of a non-speech generating device has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10 year old female enrollee has requested speech therapy for the treatment of the enrollees auditory processing disorder. Findings:  The physician reviewer found that the American Speech-Language-Hearing Association (ASHA) broadly defines auditory as the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Auditory processing disorder is described as a deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors. In order to properly assess young patients, ASHA emphasizes that evaluation must be individualized with testing based on complaints and symptoms. A wide variety of tests can be utilized to provide a thorough assessment, including auditory discrimination, auditory temporal processing, and patterning. Interpretation of these tests should be performed by a specialist trained in the complexities of central auditory processing disorders. It is recommended that intervention should be implemented as soon as possible following the diagnosis, to exploit the plasticity of the CNS, maximize successful therapeutic outcomes, and minimize residual functional deficits. The medical literature also suggests that the 7% of children with auditory processing disorders typically present with difficulties understanding what they hear, listening through background noise, following oral instructions, and understanding rapid or degraded speech. Bamiou and colleagues reported that, Auditory processing disorders may have detrimental consequences on a childs life, if undiagnosed and untreated. As noted in the case under review, this patient has significant deficits in auditory processing that have already and will continue to affect her participation in academic and social interactions if left untreated.
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 according to California regulations, urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plans service area. The Health Plan defines urgent needed care as any otherwise covered medical service that a reasonable person with average knowledge of health and medicine would seek for treatment of an injury, unexpected illness or complication of an existing condition, including pregnancy to prevent serious deterioration of his or her health, but which does not qualify as Emergency Care. This patient reports that she experienced a flare-up of her rheumatoid arthritis (RA) while outside her Health Plans service area. The notes reviewed from her visit do not support a sudden flare of her symptoms. An acute flare is characterized by the rapid buildup of symptoms over a period of a few days. The providers examination notes indicate minimal swelling with good hand grasp and good strength. Blood tests obtained on that date show a normal hemogram and a normal ESR. Further, the patient had been receiving ongoing treatments for her symptoms prior to leaving her service area. Based on the submitted documentation, there is insufficient data to support a finding that the patient was experiencing a sudden worsening of her arthritis symptoms necessitating urgent care. While intravenous antibiotics may be helpful in controlling symptoms of RA, there is currently no emergent or urgent indication for their use. This patient had been undergoing treatment for her condition and was familiar with the antibiotic regimens. All told, there is no evidence that a reasonable person in these circumstances would believe that her health would seriously deteriorate if she delayed treatment until she returned to the Plans service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for continued acute inpatient psychiatric treatment for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patients ability to engage in treatment has also been limited by his tendency to withdraw and express conflict with his providers. Given these dimensions, transition to treatment in a residential setting with 24-hour monitoring is indicated following discharge from his current acute level of care. This finding is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines. Treatment at a level of care that does not include 24-monitoring has been attempted without success, and at this juncture, is likely lead to further deterioration. Therefore, the requested discharge to residential level of care is also clinically reasonable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested an MRI, including CPT code 73220 for evaluation of her left arm injury. Findings:  The physician reviewer found that this patient has a diagnosis of left ulnar neuropathy. With this diagnosis, there is concern of entrapment of the ulnar nerve. MRI is an accepted imaging study for the evaluation of the ulnar nerve. MRI can determine if the ulnar nerve is inflamed, entrapped by a bone spur or surrounded by scar tissue from prior trauma.  The American College of Radiology guidelines advocate for MRI of the elbow to evaluate for ulnar neuropathy.  Vucic and colleagues noted that MRI of the ulnar nerve should be used in patients with clinical features of ulnar neuropathy.  Andreisek and colleagues stated that MRI may help establish the cause of the condition and provide information crucial for conservative management or surgical planning for patients with a diagnosis of peripheral neuropathy. Hochman and Zilberfarb noted that imaging can have an important role in defining the site and etiology of nerve compression. Most entrapment abnormalities of the ulnar nerve are located within the elbow, although abnormalities within the forearm and wrist can also lead to ulnar neuropathy.  MRI studies can also be used for surgical planning.  MRI was medically indicated for this patients evaluation and treatment planning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested laparoscopic Roux-en-Y gastric bypass for treatment of his obesity. Findings:  The physician reviewer found that given the patients BMI and comorbid conditions, the only viable option of controlling his obesity is surgical intervention. Non-surgical methods are unlikely to benefit this patient. Furthermore, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese (see studies by Adams, et al. and Bray). The requested surgery is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for the anterior retroperitoneal approach to lumbar spine L5-S1, radicle discectomy L5-S1, anterior interbody fusion with PEEK interbody spacer, bone morphogenic protein and screw stabilization surgery for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation does not establish that the patient met clinical indications for the fusion surgery. In a review of the medical literature pertaining to the treatment of intractable low back pain without stenosis or spondylolisthesis, an intensive course of physical therapy rather than fusion is appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested for a referral to an infectious disease specialist for treatment of her stiff neck, fatigue, headaches and back pain. Findings:  The physician reviewer found that clinical evidence demonstrates that the patient has been assessed by a number of physicians. These have included a rheumatologist, several neurologists, family practice providers, a maxillofacial surgeon and a physiatrist. The patient has had a variety of symptoms that do not suggest a specific diagnosis. There is no evidence that there is an infectious etiology to her complaints.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested for a stand-up magnetic resonance imaging scan and electrodiagnostic studies including nerve conduction study with electromyography for evaluation of his neurological pain and extremity pain and numbness.  Findings:  The physician reviewer found that no evidence has been provided that the patient has experienced any significant changes in his symptomatology since the previous NCV and EMG testing. As such, there is no evidence from which to conclude that repeat NCV with EMG is likely to result in clinically useful information that will alter the management of this patients condition. Thus, I have determined that the requested repeat electrodiagnostic testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for a cervical MRI, MRI of the shoulder, and refills of the medication Vicodin for treatment of her neck and shoulder pain. Findings:  The physician reviewer found that the usefulness of repeated magnetic resonance imaging (MRI) studies is limited to particular situations. One indication for repeat MRI is significant changes in clinical findings. Additionally, repeat MRI may be indicated before a proposed surgery to evaluate the anatomical status of the involved region (see Benz and colleagues). Further, in the case of a patient suffering from multiple injuries in the same physical region with a prolonged time period in between the injuries, an MRI may be indicated to reassess the status of the structures involved. In the absence of factors such as these, there is little evidence of the value of repeated studies (see Mays and colleagues). The medical records in this case document that this patient received an adequate evaluation at each of her provider visits, and there is no evidence of the presence of any examination findings supporting the need for additional MRI studies at this time to evaluate her cervical spine or right shoulder.In this patients case, the submitted clinical evidence suggests possible dependence on Vicodin, and the patient has been referred to a chemical dependency rehabilitation program. There is no indication in the patients record to support the continuation of her narcotic prescription (Vicodin).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for a virtual colonoscopy for evaluation of her given her strong family history of colon cancer. Findings:  The physician reviewer found that the American College of Gastroenterology guidelines for colorectal cancer (CRC) screening, as discussed by Dominic and colleagues, generally suggests a colonoscopy every 10 years beginning at age 50. The authors indicate this frequency of preventative testing is appropriate in patients with a single first-degree relative with CRC or advanced adenoma diagnosed before age 60. For patients with two first-degree relatives with CRC or advanced adenoma diagnosed at a young age, the guidelines recommend a repeat colonoscopy every 5 years beginning at age 40 years, or 10 years younger than the youngest relatives age at diagnosis. Considering that this patient has two first-degree relatives with a history of CRC, she should be followed up with a colonoscopy every five years.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for a referral to an otolaryngologist for treatment of her jaw pain. Findings:  The physician reviewer found that there is no evidence demonstrating that a referral to an otolaryngologist is clinically indicated for evaluation and management of this patients jaw pain/TMJ disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested for intravesical Botox injections for treatment of her neurogenic bladder and bowel.  Findings:  The physician reviewer found that the use of the InterStim device was the first significant advance for patients in this subset seen in many years. While the device does help a significant number of patients, some who have failed to achieve relief of symptoms with the InterStim device, appear to respond to the use of intravesical injections of Botox. The scientific literature demonstrates that some patients with urinary incontinence do receive benefit from Botox.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for adult psychiatric acute inpatient services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient had no active suicidal ideation, no obvious delusional thoughts, and a moderately depressed mood.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for antigen therapy for treatment of her medical condition.   Findings:  Three physician reviewers found that the American Medical Association Council on Scientific Affairs notes that some patients present to physicians with symptoms that cannot be attributed to any known condition, disorder, or disease. Further, they may have no physical findings or laboratory abnormalities to support a standard diagnosis. Physicians who practice clinical ecology associate these symptoms with repeated exposure of susceptible individuals to very low levels of substances that exist in the environment or are ingested as food or liquids. After these substances have accumulated to a threshold concentration in the body, they are purported to produce immune dysfunction and result in a generalized clinical disorder, multiple chemical sensitivity syndrome. The American Academy of Allergy, Asthma and Immunology states, There is no clear evidence that the diseases and symptoms listed are related to allergy, sensitivity, toxicity, or any other type of reaction from food, water, chemicals, pollutants, or microorganisms (see Resiman).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for the use of robotic assistance during myomectomy for treatment of her uterine fibroids.  Findings:  Three physician reviewers found that Laparoscopic myomectomy is a treatment option for some women with symptomatic fibroids as it minimizes the size of the abdominal incision and oftentimes results in a shorter post-operative recovery. However, currently there are no peer-reviewed randomized controlled studies comparing the addition of robotic assistance to laparoscopic myomectomy. Further studies, including randomized clinical trials, are needed to better determine clinical outcomes as the proposed procedure is still considered experimental and investigational.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headache, there is ample medical literature supporting its use for this condition. Additionally, she has previously had marked benefit on a trial of Botox. As this patient has already been given adequate trials of traditional therapies, treatment with a different agent such as Botox is clinically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old female enrollee has requested for minimally invasive parathyroidectomy surgery for treatment of her  hyperparathyroidism. Findings:  The physician reviewer found that a surgeon performing a selective parathyroidectomy may only have to explore the left side of the patients neck, thereby avoiding unnecessary potential complications. This approach offers clear advantages for this high-risk patient. Thus, in order to decrease the potential for morbidity in this patients case, minimally invasive parathyroidectomy surgery is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested for a computed tomography scan of the chest and lungs for evaluation of his pulmonary nodule and weight loss.  Findings:  The physician reviewer found that MacMahon and colleagues discussed the well established role of radiographic studies in the evaluation of pulmonary nodules as set forth by the Fleischner Society. Vanderschueren and colleagues suggest that, Simple, non-invasive screening tests, embarking from thorough history-taking and clinical examination, are advocated first. The authors suggest that additional testing should be directed towards areas of concern raised by this initial evaluation. Thus, a provider should perform a thorough history and physical, and order appropriate laboratory studies including basic chemistry panels and blood counts, prior to considering radiographic evaluation for involuntary weight loss. The records fail to discuss whether the patient experienced any further symptoms or what basic evaluations were performed other than a series of tumor markers and hormone level testing