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

A 44-year-old male has requested Xarelto (rivaroxaban) for treatment of his left ventricular noncompaction cardiomyopathy.  Findings:  The physician reviewer found that left ventricular noncompaction cardiomyopathy (LVNC) is a rare cardiac disorder characterized by a thin, compact, epicardial layer of the myocardium with prominent, deep intertrabecular spaces.  Recent advances in echocardiographic recognition and use of specialized cardiac MRI have resulted in increased awareness of this rare disorder.  Clinical complications of LVNC are variable and range from asymptomatic patients to patients with complications of heart failure, cardiac arrhythmias, and thromboembolic events.  Clinical series have reported thromboembolic complications in 21-38% of patients, including cerebrovascular accidents, transient ischemic attacks, pulmonary embolism, and mesenteric infarctions.  The treatment of LVNC is directed at management of heart failure, treatment and/or prophylaxis for cardiac arrhythmias, and attempt to prevent thromboembolic complications.  Treatment guidelines generally recommend long-term prophylaxis with anticoagulants.Multiple ongoing studies of Xarelto (rivaroxaban) are in progress for assessment of its efficacy in acute coronary syndromes, prevention of stroke in patients with atrial fibrillation, and prevention of venous thromboembolism in hospitalized patients.  This patient has an MRI-based diagnosis of noncompaction left ventricular cardiomyopathy.  His medical records indicate that he is relatively asymptomatic and has no history of cardiac arrhythmias, heart failure, or thromboembolic events.  Current standard cardiovascular practice in the management of this disorder would include oral anticoagulation for prevention of thromboembolic complications.  There is a lack of clinical data supporting the use of Xarelto in this clinical setting.  Alternative management with warfarin anticoagulation would be standard practice at this time.  All told, Xarelto is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee has requested a Dexcom continuous glucose monitoring system (CGMS) and the sensors for treatment of his type I diabetes.  Findings:  The physician reviewer found that there is substantial support in the peer reviewed medical literature for the use of continuous glucose monitoring in the treatment of type 1 diabetes. The current American Diabetes Association (ADA) and American Association of Clinical Endocrinology (AACE) guidelines recommend the use of CGMS for patients with brittle diabetes mellitus type 1 and hypoglycemia unawareness. The use of CGMS was associated with improved glycemic control in adults over 25 years old with type 1 diabetes (Juvenile Diabetes Research Foundation) and with reduced time spent in hypoglycemia (Battelino, et al.). Although CGMS is an evolving technology, the available data in the peer reviewed medical literature suggests that in patients who are motivated to wear it most of the time, it may be particularly useful in those with hypoglycemia unawareness and/or frequent episodes of hypoglycemia. This patient is on the insulin pump, has wide glucose fluctuations, hypoglycemia unawareness, and is very motivated to use CGMS for self-management of his diabetes. The requested Dexcom CGMS will help this patient and his provider to determine his insulin pump settings with more precision and it will help prevent dangerous blood glucose fluctuations and hypoglycemic events. Therefore the requested Dexcom CGMS is medically necessary and appropriate for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested coverage for past and future transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient's provider noted that the patient has not benefited from multiple prior medications, including Cymbalta, Ambien, Lexapro, Elavil, Prozac, Effexor, Remeron, Zoloft, trazodone, Celexa, Paxil, Wellbutrin, Pristiq, and Abilify.  Per the provider, the patient has received cognitive therapy and psychotherapy.  Her symptoms include poor sleep, depressed mood, anxiety, feelings of hopelessness and helplessness, anhedonia, cognitive impairment, fatigue, irritability, and diminished work performance.  In this patients case, the services at issue were and are likely to be more beneficial than other treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  In this clinical setting, although electroconvulsive therapy may be beneficial, the side effects include memory loss.  Grunhaus and colleagues noted that repetitive transcranial magnetic stimulation and electroconvulsive therapy reached similar results for patients with non-psychotic major depressive disorder.   This patient has failed treatment with multiple medications.  Therefore, the superior efficacy of transcranial magnetic stimulation provided, and the superior effectiveness of continued transcranial magnetic stimulation have been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees stuttering.  Findings:  The physician reviewer found that this patient has struggled with intermittent dysfluency issues since three years of age.  Most recently, this has affected her school participation and social interactions.  Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma.  Up to 80% of children who experience developmental dysfluency or mild pathologic dysfluency recover spontaneously.  However, a certain number of children deteriorate, developing severe dysfluency.  For this latter group, if therapy is started early, the prognosis is favorable.  While this patient does not demonstrate severe dysfluency at this time, her condition is affecting her social interactions and participation in public activities.  It is important to address this disorder now with speech therapy in order to improve the patients communication skills and prevent future difficulties.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested authorization and coverage for lumbar fusion surgery at the L5-S1 level for treatment of the enrollees low back pain. Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain. In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. Thus, the patient does not meet the above mentioned indications for spinal fusion. Further, the American Pain Society has also developed evidence-based recommendations on the use of interventional surgeries for low back pain of any duration, which states that surgical benefits are often only moderate and appear to decrease over time (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, as well as the lack of evidence that this patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year old female enrollee has requested an electric motorized wheelchair for treatment of her diabetic polyneuropathy.   Findings:  The physician reviewer found that the records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device. The records do not substantiate any significant neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to a degree that would preclude her from accomplishing her mobility related activities of daily living in the home using a manual wheelchair. Specifically, the physiatrist noted good strength in the upper limbs and the physical therapist noted functional range of motion and strength in the upper limbs. If necessary, a manual wheelchair could be adapted for simultaneous propulsion using the lower limbs. In addition, this patient has multiple chronic health conditions that would benefit from increased physical activity and exercise. Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for patients with mobility impairments (Keyser, et al; Valent, et al). Overall, an electric motorized wheelchair is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female has requested Botox injections for treatment of her migraine headaches.   Findings:  Three physician reviewers found that the patient is being treated by an ear, nose and throat (ENT) provider for sinus symptoms and migraines. Per the submitted documentation, she has had nasal symptoms for several years. The provider notes indicate she has used sumatriptan, and that she is diagnosed with cluster/migraine headaches. The patient noted on the application that she has blinding headaches. She has previously undergone treatment with Botox 25-50 unit injections from her ENT provider. This patient has been diagnosed with migraines, but the records provided do not document headache characteristics, baseline frequency or other features that are consistent with a diagnosis of chronic migraines. Additionally, a comprehensive neurological evaluation was not included in the provided documentation. The patient has been treated with low dose Botox, however, the results and efficacy of this treatment are not documented in her medical records. Botox has been found to be beneficial for the prevention of chronic migraines, but has not been shown to be beneficial for the treatment of episodic migraines. The documentation provided does not support a diagnosis of chronic migraines. Also, the previous doses of Botox used to treat this patient have been found to be suboptimal in the treatment of migraines. Therefore, the requested treatment is not 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 55-year-old female has requested a panniculectomy for treatment of her lipodystrophy.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with a severely enlarged overhanging pannus, which is an abnormal state of the abdomen. In addition, the patient is being treated for obesity which can be classified as a disease. The records indicate the requested surgery is being performed to both improve function and create a normal appearance to the extent possible. The patient is noted to have chronic back pain treated with multiple analgesics. Based on the photographs, one would expect the patient to have a significant functional deficit related to a severely enlarged pannus. She is noted to have chronic back pain as well as limitations related to further weight loss and exercise. This physical limitation should be improved with a panniculectomy. A panniculectomy would also help to create a more normal appearance. As stated by the American Society of Plastic Surgeons (ASPS) position statement, [w]hen surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. However, this patients records document signs and symptoms of functional abnormalities. This patient has chronic back pain which is expected to place physical limitations on her ability to exercise. Further, Manahan and Shermak stated that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity for which a panniculectomy can be used to treat these symptoms. Consistent with this support, a functional abnormality has been defined and the requested panniculectomy should be authorized as a medically necessary reconstructive surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested general anesthesia in a hospital or surgery center setting for treatment of the enrollees dental caries requiring pulpectomy.  Findings:  The physician reviewer found that coverage for general anesthesia in a hospital or surgery center setting is medically necessary for the patients dependent dental services. The patient has severe disease requiring extensive dental surgery. The patient is a one-year-old without fully developed oropharyngeal reflexes to protect the airway. General anesthesia provides a safe and effective setting for the dental surgery. General anesthesia also provides a controlled setting in which the patients airway is protected from excessive secretions and aspiration which can potentially put the patient at risk for respiratory distress. Dial and colleagues performed a retrospective review on sedation of 301 pediatric patients undergoing various procedures. The authors tested the hypothesis that the need to attain immobility during pediatric sedation for procedures determines the depth of sedation, which cannot always be predicted. They reported that pediatric sedation results in four categories of immobility. Complete immobility during painful and invasive procedures is associated with a higher incidence of adverse events. The depth of sedation required to achieve immobility varies from patient to patient. Thus, granting a limited sedation authority (i.e. conscious sedation only) to providers is of limited practical value. In this patients case, conscious sedation in a non-surgical setting for a dental procedure that requires stability and immobility is not ideal or safe in a one-year-old patient. Cote and colleagues performed a critical incident analysis to determine the factors that contribute to adverse sedation events in children undergoing procedures. The authors identified several features associated with adverse sedation events and poor outcome. Specifically, adverse outcomes and inadequate resuscitation were more often associated with a non-hospital based facility setting. Inadequate physiologic monitoring was another major factor contributing to poor outcome in all venues of non-hospital based settings. Consistent with these findings, the requested authorization and coverage for general anesthesia in a hospital or surgery center 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 54-year-old female has requested an epidural lysis for treatment of her L3-4 arachnoiditis.  Findings:  Three physician reviewers found that the patient has a history of decompressive laminectomy from L3 to S1 and posterior lumbar fusion. The patient reported right hip and low back pain starting a year ago. She reported symptoms of radiating pain to the right lower extremity, down to her foot. Past therapies were noted to include: Motrin, soma injections, massage therapy, ice, surgery, Vicodin and Neurontin. The patients physical examination was positive for tenderness of the lumbar sacral junction and right sacroiliac joint junction, gait with right sided limp and reduced twisting ability with reported pain. A MRI of the patients lumbar spine evidenced thickening and tethering of the right-sided nerve roots at the L3-4 levels, which was noted to be compatible with arachnoiditis. The patient underwent an epidural lysis on 4/13/12 with noted pain relief. The provider has recommended a second epidural lysis procedure to target the patients residual low back and buttock pain. Percutaneous adhesiolysis is a technique whereby scarring or fibrosis is removed or modified using not only mechanical instrumentation, but chemical injections as well and is generally used postoperatively for continued back and leg pain.  Epidural scarring can develop after surgery, infection, bleeding, and leakage of nuclear material.  Use of a wire bound steerable catheter is used to direct medication, generally saline, local anesthetic, and commonly hypertonic saline. Helm and colleagues reviewed several studies involving individuals with spinal stenosis and post lumbar surgery syndrome and found that there was a fair amount of evidence supporting use of epidural lysis in the reduction of back and/or leg pain. Evidence based guidelines in the management of chronic spinal pain found that there is strong evidence supporting the efficacy of epidural lysis in the treatment of chronic low back and lower extremity pain in post surgery syndrome (Boswell, et al.). A review by Epter, et al. identified percutaneous adhesiolysis as being clearly superior to fluoroscopically directed epidural steroid injections, especially in those patients with chronic, refractory low back and lower extremity pain. Thus, the peer reviewed medical literature and the documentation submitted for review in this case, support the use of epidural lysis for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested for revisional bariatric surgery consultation and surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient has no documented recent dietary or behavioral evaluation specifically regarding bariatric revisional surgery.  Per the records, there were no overt complications of the prior procedure mandating removal.  Given the increased risk of complications and morbidity, a thorough multidisciplinary evaluation documenting understanding of these risks, as well as an evaluation indicating likelihood of compliance, should be documented.  The current medical evidence does not support the requested services in this patients case.  All told, the requested revisional bariatric surgery consultation and surgery are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old female has requested coverage for past air ambulance transport services.  Findings:  The physician reviewer found that the patient is a gravida 4, para 0, Ab 3 female who was 32 and 2/7-weeks pregnant when her membranes ruptured and she began having episodic uterine contractions.  She presented to the Emergency Department (ED) and was admitted for observation and fetal monitoring.  The fetus heart rate did not become abnormal.  She was consulted on and physical examination revealed that the patient was 80% effaced and 1-cm dilated.  Laboratory tests confirmed that the vaginal fluid leak was amniotic fluid.  She was also noted to have a culture-proven group B strep urinary tract infection (UTI).  She was treated with penicillin for her UTI, Decadron to prevent lung disease associated with pre-term delivery, and terbutaline to inhibit additional contractions.  The treating physician consulted the perinatologist at a medical center, and the transfer was accepted.  The provider was concerned that ground transportation would take too long, with an estimated transport time of 1 hour and 10-minutes, and opted to send his patient via helicopter air ambulance transport, with a transport time of 20 minutes.  The transfer was accomplished without complications.  At the request of the provider at the receiving hospital, the patient was given magnesium sulfate IV during transport to further ameliorate uterine contractions. At 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.Premature rupture of membranes is concerning for imminent delivery and the possibility of risk to the fetus life. A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. The choice of transport from the emergency facility to the hospital was made by the physicians at those two facilities.  A layperson would not be expected to have the medical knowledge necessary to assess the pros and cons of ground versus air transport and would reasonably be expected to rely on the advice of the doctors involved in her care, which in this case was to utilize air transport. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency air transport to jeopardize her health.