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

A 43-year-old female has requested ventral hernia repair, reconstructive abdominoplasty, and abdominal panniculectomy for treatment of her pannus and intertrigo dermatitis.  Findings:  The physician reviewer found that the reviewed records do not justify the medical necessity of the requested ventral hernia repair as it is unclear that she actually has such a hernia. The ultrasound did not view the area where the ventral hernia is reported to be.  Although the patients surgeon has reported a hernia, the documentation does not report the size of the fascial defect or exactly where it was located along the vertical scar. Abdominoplasty is a procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.  Thus, the medical necessity of the requested abdominoplasty has not been demonstrated in this patients case.  Panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions.  The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary. Given the absence of documentation of a skin condition related to the pannus that is refractory to medical treatment, the submitted records do not support the medical necessity of the requested abdominal panniculectomy.In the absence of an infraumbilical hernia, the records do not document any condition which constitutes an abnormal structure of the body or a functional impairment. Thus, the requested reconstructive abdominoplasty and abdominal panniculectomy are not reconstructive in nature.  All told, the requested ventral hernia repair is not medically necessary for the treatment of this patient.  The requested reconstructive abdominoplasty and abdominal panniculectomy are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male has requested coverage for past chiropractic care provided for treatment of his cervicalgia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The records do not include an initial examination.  The treatment notes lack documentation regarding reassessment of the patients condition at each visit.  Additionally, there is a lack of information regarding response to treatment, home education, or alternative available treatments.  The records do not adequately document that a subluxation exists, and the notes do not clearly describe the type of chiropractic adjustment provided at each visit.  All told, chiropractic care provided was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male has requested anal fissure surgery for treatment of his anal fissure.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  There is no indication that topical therapy has been exhausted for the treatment of this patients anal fissure.  The records indicate that sigmoidoscopy only revealed external hemorrhoids.  The clinical notes do not show that surgical treatment is the recommended treatment in this clinical setting.  The current medical evidence does not support the requested procedure in this case.  All told, the requested anal fissure surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested coverage for past inpatient mental health level of care services provided for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this was a chronically ill and labile patient who has a long history of a painful condition as well as PTSD and major depression that were complicated by borderline personality disorder. She presented as a significant risk for decompensation and self-harm had she been discharged prematurely. Her treatment plan was changed regularly, her aftercare planning was timely, and she was discharged to her spouses custody following improvement from the Ketamine therapy. All told, the inpatient mental health services provided were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female has requested coverage for acute inpatient psychiatric treatment provided for treatment of her pain disorder with psychological factors and medical conditions.  Findings:  The physician reviewer found that based on review of the available records, acute inpatient psychiatric treatment provided on the dates at issue was medically necessary for treatment of this patients medical issues. This patient has a complex presentation and history that requires treatment of multiple chronic medical problems, all of which are inter-related and must be treated together. The medical record indicates that this patient was labile and not in control of her own behavior for more than a few hours per day. Whenever she perceived any type of stress or was not able to have her own way, she began to decompensate. The complex interplay among her problems could not be handled in an outpatient setting. She also needed the supervision of a large staff with careful coordination of her care. She was intolerant of dealing with any stress. She required continued observation over a period of weeks in order to clarify her complex situation and develop a treatment plan that had some chance of succeeding in helping her improve her functioning. All told, the acute inpatient psychiatric services provided to this patient on the dates at issue is supported as medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male has requested a left knee/patella osteochondral allograft procedure for treatment of his osteochondritis dissecans of the patella.  Findings:  Two physician reviewers found that per the medical records, the patients condition has not responded to conservative treatment.  Additionally, the submitted documentation noted prior open bone grafting and fixation in an attempt to heal the lesion of the patella.  The provider reported that the patient has symptomatic knee pain with any weight-bearing activity.  In this patients case, the requested services are likely to be superior over other available treatment options.  There is limited support in the medical literature for osteochondral allograft of the patella, although this is due to the rarity of this condition.  There are limited treatment options in this clinical setting.  These treatment alternatives include patellectomy and arthroplasty.  This patient is too young for arthroplasty, and patellectomy should remain as a salvage procedure if other treatments fail.  In this case, the requested left knee/patella osteochondral allograft procedure is likely to be of greater benefit than the other available treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female has requested radiofrequency neurolysis for treatment of her pain.  Findings:  Two physician reviewers found that the submitted documentation indicates that prior radiofrequency ablation resulted in one year of significant relief.  Per the medical records, the Health Plan has indicated that results of a short-term nerve block are needed prior to approving the requested services.  Specifically, the Health Plan noted that the short-term nerve block needs to reduce the patients pain by at least half.  This patient has chronic low back pain with no radiation into the lower extremities and without any neurological dysfunction.  Prior radiofrequency ablation provided one year of significant relief.  The current medical evidence supports the requested services in this patients case.  Radiofrequency neurotomy has been demonstrated to be an effective modality in managing chronic lumbar facet joint pain.  The average relief with a single radiofrequency neurotomy is approximately six months.  In this patients case, there is no history of any additional injury, and it has been have shown that radiofrequency can be effective even in patients without diagnostic blocks.  Further, it is not necessary to perform diagnostic blocks prior to each radiofrequency neurotomy as pain recurs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested coverage for a hospital bed utilized for one month for treatment of her post-surgical recovery.  Findings:  The physician reviewer found that abdominal wall strength and function is significantly compromised in the early aftermath following TRAM flap surgery, particularly in the setting of bilateral TRAM flap surgeries (Atisha, et al.). This can affect activities such as standing up straight and changing positions. Difficulties in basic mobility may be seen for days to several weeks or longer after surgery (Spector, et al.). By eight weeks postoperatively, however, there is typically a return to near baseline functional status (Dell, et al.). In the present case, the patient had difficulty in mobility after her bilateral TRAM flap surgeries. She was unable to get up her stairs to her regular bed. There are no indications in the records, however, that the patients needs could not have been met with a standard non-electric bed placed on her ground floor, set up with bed wedge(s) and possibly simple temporary side bed rails to help with transfers into and out of bed. The records do not establish that the patient had mobility impairments that necessitated a semi-electric hospital bed at home during her convalescence following her bilateral mastectomies and TRAM flap surgeries. In the absence of such evidence, the medical necessity of a hospital bed has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested magnetic resonance imaging (MRI) of the left breast for evaluation of the extent of free silicone in the left breast.   Findings:  Two physician reviewers found that the patient presents with no noted high risk of breast malignancy. She had bilateral silicone augmentation implants with subsequent removal and saline implant replacement four years ago. Free silicone was noted in the medial aspect of the left breast on recent mammogram. There is no clinical finding to suggest malignancy. The provider has requested a bilateral breast magnetic resonance imaging (MRI) to provide a baseline of the degree of free silicone in each breast in this patient. This patient was found at implant revision to have free silicone in the breast parenchyma from previous silicone augmentation implants. Such free silicone makes mammography difficult even under ideal circumstances. Further, the free silicone gel may produce physical findings over time. Overall, MRI is the most sensitive means with which to identify free silicone and with MRI as a baseline subsequent imaging over time will be useful to separate free silicone versus lesions. Ultrasound and mammography are not particularly useful in the detection of free silicone gel within the breast. Over time, the free silicone may coalesce and present as a palpable mass making a differential diagnosis difficult. At this time, there is no clinical indication for biopsy. Consistent with these findings, the requested MRI of the breasts would be more beneficial for this particular patient than any other available exam and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male has requested radiofrequency ablation of the esophagus for treatment of his Barretts esophagus.  Findings:  Two physician reviewers found that the patient presents with a 30-year history of gastroesophageal reflux disease.  The medical records noted that the patient was found to have Barretts esophagus on esophagogastroduodenoscopy.  A recent  pathology report noted intestinal metaplasia with no dysplasia.  The submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case.  Per the current standard of care, if the Barretts esophagus has any form of dysplasia, then radiofrequency ablation may be a reasonable option.  In the setting of dysplasia, surveillance is not recommended and active therapy, including radiofrequency ablation, may be indicated.  In this patients case, there was no evidence of dysplasia.  Based upon the medical records, active surveillance is appropriate in this setting.  All told, the requested radiofrequency ablation of the esophagus is not likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female has requested a CT needle guided core lymph node biopsy with Versed and propofol, bone/marrow biopsy/aspiration (with these two biopsies under one anesthesia session), blood count, metabolic panel and pathology services for treatment of non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Non-Hodgkins lymphoma is separated into categories of low-grade lymphomas, intermediate-grade lymphomas, and high-grade lymphomas.  This patient originally presented with a low-grade lymphoma that subsequently transformed to a high-grade lymphoma.  Per the submitted records, it appears the stem cell transplant may have eradicated the high-grade component, leaving her with the low-grade component.  She now appears to have progressive lymphoma, and this is likely due to the low-grade component.  However, it is important to confirm this and fully stage the disease in order to plan future treatment or management.  In order to do so, the provider must re-biopsy the enlarging node, check various chemistries, and ascertain whether the bone marrow is involved.  Thus, the requested services are critical for this patients ongoing care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female has requested endovenous chemical ablation, left leg, using CPT code 37799 x 2 units (two dates of service), and endovenous chemical ablation, right leg, using CPT code 37799 x 1 (one date of service), in addition to sclerotherapy, right leg, using CPT code 36471 for treatment of her varicose veins.   Findings:  Two physician reviewers found that the patient has a long standing history of bilateral lower extremity varicose veins who presents complaining of bilateral leg pain and swelling severe enough to require over the counter analgesic medication. She is status post left short saphenous ligation and stripping about 15 years ago. There is documentation of palpable pedal pulses bilaterally. On duplex there is no evidence of deep vein thrombosis (DVT) or superficial thrombosis. There is evidence of reflux in the right greater saphenous vein (GSV) below the knee and in the right lateral accessory vein. There are also numerous incompetent perforators bilaterally. The provider has recommended treatment consisting of endovenous chemical, ablation, left leg, using CPT code 37799 x 2 units (two dates of service), and endovenous chemical ablation, right leg, using CPT code 37799 x 1 (one date of service), in addition to sclerotherapy, right leg, using CPT code 36471.  This patients records include documentation of attempts at treatment for significant symptoms including use of medical grade compression stockings. There is documentation of palpable pedal pulses and the absence of DVT. There is documentation of reflux in the veins to be treated. Consistent with the peer-reviewed medical literature, injection of a sclerosing chemical into the larger refluxing veins is reasonable and appropriate in this patients case. The distal GSV is not an ideal site for surgical stripping due to nerve proximity. As such, the requested endovenous chemical ablation is likely to be more beneficial to this patient than standard alternatives. The provider makes a distinction between the large, deeper veins and the small reticular superficial veins. Although the documentation does not support the necessity of sclerotherapy of the small superficial veins, the sclerotherapy code would be appropriate for injection of sclerosant into the larger veins. Therefore, sclerotherapy of the larger veins bilaterally is likely to be more beneficial than standard therapies for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male has requested Enbrel 50mg subcutaneous injection, twice weekly for three months, followed by Enbrel 50mg once weekly for treatment of his moderate to severe chronic plaque psoriasis.  Findings:  Three physician reviewers found that the patient has chronic plaque psoriasis affecting approximately 20% of scalp and skin and has failed standard topical and systemic therapies. Considering contraindications to systemic cytostatic and immunosuppressors, his provider has prescribed treatment with etanercept (Enbrel).  Psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the US population and 4.8% of people worldwide. Approximately 30-45% of those affected first experience symptoms during childhood or adolescence (Marji, et al). Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of biologic therapies for the treatment of moderate-to-severe psoriasis has been a major clinical and research focus (Patel, et al). Enbrel is effective and well tolerated in children and adolescents with moderate-to-severe plaque psoriasis (Beikert, et al; Papoutsaki, et al). This patient has widespread plaque psoriasis that requires systemic treatment. However, the medications traditionally used in adults such as methotrexate and cyclosporine are contraindicated for use in children and adolescents. These facts, taken together with the good safety and efficacy profiles of Enbrel in children and adolescents, indicate that use of this medication is likely to provide this patient with an improved health outcome beyond that expected with standard alternative therapies.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested coverage for past urgent care services provided.  Findings:  The physician reviewer found that the patient presented to an urgent care facility complaining of pain in her lower abdomen, burning pain with urination, and visible blood in her urine. Her symptoms had begun the previous day. Her vital signs were normal. The patient rated her pain at 8 out of 10 on the pain scale. Upon evaluation, the patients history did not include fever, flank pain, nausea, vomiting or diarrhea; however, a previous history of kidney disease was noted. Physical examination revealed suprapubic pain to palpation. Urinalysis was positive for leukocyte esterase and blood, findings most compatible with acute hemorrhagic cystitis - a urinary tract infection (UTI). The patient was diagnosed with a UTI with dysuria and given prescriptions for ciprofloxacin to treat the infection and phenazopyridine to treat the pain. She was discharged from the urgent care facility with instructions to follow-up with her primary care provider in two to three days as needed.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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.Review of the submitted documentation demonstrates the patient had severe pain (8/10) associated with symptoms most likely representing an infection of the urinary tract. As noted above, the presence of severe pain is considered an appropriate indication for seeking immediate medical attention. Additionally, the patient had a history of pre-existing kidney disease which could have been subject to worsening in the presence of an untreated urinary tract infection. All told, a prudent layperson in this situation would have thought that immediate medical attention was necessary to prevent serious deterioration of health or complication of an existing medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested additional chiropractic services for treatment of her back and shoulder pain.  Findings:  The physician reviewer found that the proposed treatment is not medically necessary for this patients medical condition given the lack of proven benefit of chiropractic manipulation on clinical course or outcomes in the setting of chronic neck, shoulder, or back pain (Ernst; Johnston, et al). In the medical literature, Ernst concluded, that the notion that chiropractic or massage are effective interventions for pain control has not been demonstrated convincingly through rigorous clinical trials. In 2008, Bronfort and colleagues did not report significant, sustained benefit to spinal manipulation and mobilization over other conservative management. More recent high-grade studies establishing the clinical efficacy of these interventions have not been published. Overall, there is insufficient data to establish that this intervention delays or prevents the need for clinically appropriate surgical interventions. All told, no significant marginal benefit is expected with the proposed treatment over an independent exercise program balanced with judicious rest, as well as self-applied palliative modalities. Although the patient remains symptomatic, the proposed chiropractic therapy is not reasonably expected to provide significant clinical benefit and is not medically necessary.