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

The parent of a 5-year-11-month-old female has requested individual speech therapy, at a frequency of 1 session per week for 60 minutes per session for treatment of her autism.  Findings:  The physician reviewer found that the medical literature supports speech therapy in the autistic population. The report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Although the patients clinical presentation and the available data in the peer-reviewed medical literature demonstrate that speech therapy is medically necessary in this patient with autism, the underlying concern is whether 60 minutes per week of individual speech therapy is medically indicated over 30 minutes per week in this patient. While the medical literature demonstrates that the total hours of speech therapy received over the entire course of the patients treatment is significant, there is no literature supporting that speech therapy received in increments of 60 minutes per week is more effective than speech therapy received in increments of 30 minutes per week. It has not been established that a weekly 60-minute session results in better clinical outcomes in this patient population compared to a weekly 30-minute session. Rather, it is the overall duration of therapy (i.e., the total length of time the individual receives therapy) that is likely to affect outcomes in this setting. Thus, there is insufficient evidence to support the conclusion that 60 minutes per week of speech therapy is medically necessary over the proposed 30 minutes per week of speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested reimbursement for mobile cardiac outpatient telemetry (MCOT) for evaluation of the enrollees cardiac condition.  Findings:  The physician reviewer found that based on the records provided, the patient had symptoms of palpitations in the setting of normal ventricular function and no provokable ischemia noted on a stress echocardiography. In this circumstance, if additional monitoring for a cardiac dysrhythmia were thought to be medically necessary then non-real time (off-line) monitoring devices such as extended or serial Holter monitoring or event monitoring would be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24 to 48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.  Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) are effective at recording symptomatic dysrhythmias during less frequent symptoms.  In less common cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. There is no documentation to indicate the patient was not able to effectively manage these standard monitoring devices. Current expert consensus guidelines endorsed by several national organizations also consider off-line Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of dysrhythmias. Continuous mobile cardiac outpatient telemetry services were not medically necessary in this case, since off-line analysis of a patient activated device, auto-triggered device or continuous Holter monitor would have been sufficient to identify dysrhythmias without jeopardizing patient safety. The use of mobile outpatient cardiac telemetry in this setting is not consistent with the standards of accepted medical practice. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques and was not medically necessary in this case. Thus, the Health Plans denial was appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested reimbursement for urgent care services.  Findings:  The physician reviewer found that the patient presented to the urgent care center for evaluation of pain in his right shin that he had been experiencing for one week. The patient noted that he had been playing club rugby recently and doing a lot of running. However, he did not note any specific injury to the right lower leg, he denied numbness or weakness, and no pain level was documented although it was noted that the patient was in no acute distress.  He had been applying ice packs directly to the shin. The physical examination revealed a first degree burn of the skin of the anterior tibial area but no underlying bone pain with actively standing on his heel and toes.  Bilateral pes planus (flat feet) was noted.  No x-rays were performed.  He was diagnosed with shin splints in the right lower leg and bilateral pes planus.  He was discharged from the Urgent Care Center with instructions to use Advil for pain, to refrain from running, and to follow up with a podiatrist. The patient states that he was subsequently diagnosed with a right tibia fracture by another provider. The patient has requested reimbursement for the urgent care services which the Health Plan has denied.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines urgently needed services as a those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area.Review of the submitted documentation reveals that although the patients level of pain was not documented in the medical records provided, the records note that the patient was in no acute distress. There was no specific injury to cause one to think that a bone had been fractured, and the patient was bearing weight without difficulty. In addition, the patient indicated that he had been obtaining temporary relief from Motrin. A prudent layperson would not have thought that urgent medical attention was necessary to prevent serious deterioration of health, injury or complication of an existing condition. Treatment could have been delayed until the patient returned to the plan's service area or a provider was found in the new service area. Thus, the patients symptoms on the date in question did not meet prudent layperson criteria for urgent care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested coverage for past adult substance abuse subacute/residential treatment center rehabilitation services for treatment of his polysubstance dependence and major depressive disorder. Findings:  The physician reviewer found that this patient presented with prominent addictive influence with anxiety and affective symptomatologies as well.  The American Psychiatric Association (APA) Clinical Practice Guideline on substance use stated [r]esidential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this particular case, the medical documentation provided fails to demonstrate the need for comprehensive treatment encompassing all elements of the bio-psycho-social model in a 24-hour supervised setting. Based upon the documentation provided, the patient posed no imminent danger to self or others, expressed motivation for care, possessed family support, and had not pursued less restrictive interventions, such as community programming, intensive outpatient or partial hospitalization, any of which would have been medically appropriate interventions in this setting. Accordingly, the services at issue were not medically necessary for treatment of the patients medical condition. The patient could have been appropriately treated in a less intensive level of care including community programming, intensive outpatient or partial hospitalization.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for lumbar artificial disc replacement surgery with the Pro Disc artificial disc for treatment of her lumbar radiculopathy.  Findings:  Three physician reviewers found that the artificial disc replacement at issue in this case is not likely to be more beneficial for treatment of the patients low back pain and radiculopathy than any available standard therapy. The ProDisc-L total disc replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The main conclusions of the study at 24 months noted that the overall incidence of adverse events occurring in the ProDisc-L group, the number of device-related adverse events, and the overall success rate of the ProDisc-L group was no worse than that of the control group, using FDAs criteria for overall success. The results of this trial were published in 2007, but there were issues with the reporting outcomes (Zigler, et al). Given the unknown long-term safety and efficacy of the device, in its approval, the FDA requested a post-approval study to obtain a total of five year follow-up data from all patients in the clinical study. Given the overall lack of long-term (greater than two years) safety and efficacy data, the requested surgery is not likely to be more beneficial for treatment of the patients low back pain and radiculopathy than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for removal of excess skin from the buttocks, hips, and arms for treatment of her excess skin. Findings:  The physician reviewer found that 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.  Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions.  A buttock lift is an abdominoplasty or panniculectomy that is extended circumferentially around the back of the body.  The submitted medical records do not support the existence of a skin condition in the buttock area or severe enough excess skin hampering function that would justify the medical necessity of a buttock lift.  Although the records support the existence of upper inner thigh skin rolls, they do not support the existence of a skin condition in this area or severe enough excess skin hampering function that would justify the medical necessity of a thigh lift. All told, the requested removal of excess skin from the buttocks and hips are not medically necessary and do not meet the criteria for reconstructive surgery.  The requested removal of excessive skin from the arms meets the criteria for reconstructive surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for breast reduction surgery for treatment of her back pain and breast pain. Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, etc. To further delineate the group of patients who are likely to benefit from breast reduction surgery, a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. This also makes intuitive sense because if the surgeon removes a small amount of tissue (e.g., less than 75 gm) it is highly unlikely the surgery would have any effect on back pain. As the amount removed is increased, the procedure changes from a cosmetic procedure to a medically necessary procedure. The aforementioned scale accounts for this by relating the amount removed to body surface area (size of the person) rather than just weight or height. In this case, the removal of 900 gm from each breast meets these criteria. In sum, this patient is an appropriate candidate for medically necessary breast reduction surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested lesion removal surgery for treatment of her nasal scarring and obstruction.   Findings:  The physician reviewer found that based on review of the available records and photographs, the patient has a scar of the right nose. The scar was caused by previous surgical treatment of the area. Due to a history of bleeding, one could not rule out that this was a skin malignancy. However, there is no documentation that there is a functional deficit with the existing scar. It appears to have matured. There can be functional problems associated with hypertrophic scars (Yang, et al). The existing scar is no longer hypertrophic or immature based on analysis of the photographs. Overall, the patients documentation demonstrates a normal appearance consisting of a well-matured scar that is poorly discernible. All told, the requested surgery is not expected to significantly improve this patients appearance.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the review of the documentation, a prudent layperson would have sought immediate medical attention due to the pain, discomfort and uncontrolled urinary bleeding that this patient was experiencing. Her symptoms of dysuria, urinary frequency, urinary hesitancy, and gross hematuria were consistent with a urinary tract infection, cystitis, pyelonephritis, renal lithiasis, and other disorders which could result in serious impairment of the renal system, dysfunction of the urinary system, and could possibly place the patients health in serious jeopardy. A prudent layperson with this patients symptoms would reasonably expect that the absence of immediate medical attention could result in a serious health risk.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested reimbursement for urgent care services.   Findings:  The physician reviewer found that the patient presented for urgent care due to a history of productive cough, headache, runny nose, scratchy throat and phlegm for four days.  She complained of having felt feverish.  Her brother was also ill for a period of time. The patients symptoms were unresponsive to over the counter medications. Her vital signs were normal. A letter from the patient and her parent indicated that the patients primary care physician did not have an appointment available for several weeks. Physical examination on the date in question was significant for erythema of the pharynx. The patient was diagnosed with an acute respiratory infection and was discharged on antibiotics and an antitussive medication. The patient has requested reimbursement for the urgent care services provided on the date in question, which the Health Plan has denied on the basis that the services not required on an emergent basis. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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 that the patient was experiencing a constellation of symptoms at the time she presented which were consistent with a potential threat of serious deterioration of her health. Based upon the patients presentation, the differential diagnosis included meningitis, pneumonia, acute bronchitis, acute epiglottitis, acute pharyngitis, and other infectious disorders. Thus, the patients symptoms met prudent layperson criteria for emergent care, especially given reports that the patient would not be able to see her primary care physician in the near future. A prudent layperson in the patients circumstances would reasonably expect the absence of immediate medical attention to jeopardize their health.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested artificial disc replacement at the C5-6 level and spinal fusion at the C6-7 level for treatment of her cervical neuralgia and stenosis.  Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for several years, there is currently insufficient data in the available peer-reviewed medical literature which adequately assesses the long-term performance of total disc replacement procedures. There is no evidence demonstrating that disc replacement reliably, reproducibly and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion and few adjacent segment degenerative problems. Although artificial disc replacement procedures have shown promise, they have also been associated with a high rate of re-operations and there is limited long-term follow-up data available. In this patients case, she has central canal stenosis at the C5-6 and foraminal stenosis on the left-hand side at the C6-7 level, for which the standard treatment would be a two level anterior cervical discectomy and fusion. Artificial disc replacement has not been shown to be superior to discectomy and fusion and has not been studied in patients with adjacent level disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested for a standing frame; Buffalo Stander with Head Support,  for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the standing position is vital in humans to maintain vasovagal sympathetic/parasympathetic responsiveness to prevent hypotension and to maintain varying cardiac tone for circulation. It is unlikely that this could be proven in immobile children, due to the inability to research this very limited pool. However, a study by Goemaere and colleagues found that standing in immobile paraplegics does prevent loss of bone mass. Additionally, Kunkel and Scremin have found psychological benefits of standing for bed-ridden patients.  This patient is fitted with ankle foot orthotics (AFOs) to aid in the prevention of ankle foot contractures. Gibson and colleagues noted that the use of standing frames in non-mobile children significantly improved ankle contractures.  While the feasibility of scientific studies of standing frames in this patient population is limited, it is generally accepted within the rehabilitation medical community that the standing position in immobile children will improve cardiac tone, help prevent vasovagal syncope, reduce loss of bone density, and improve pulmonary toilet. All told, the patient is an appropriate candidate for the requested Buffalo Stander with Head Support and its use in this setting is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested a hydrogen breath test for evaluation of his ulcerative colitis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested hydrogen breath test.  Lactose intolerance results in symptoms often attributable to inflammatory bowel disease.  However, as noted by Brannon and colleagues, many patients who believe they are lactose intolerant are not lactose malabsorbers.  As noted by Eadala and colleagues, there is an increased prevalence of lactose intolerance in the irritable bowel disease population.  In this patients case, his treating providers have not recommended a hydrogen breath test.  The current medical evidence does not support the requested testing in this patients case.  All told, a hydrogen breath test is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that based on review of the records, medical necessity has not been established for the requested bariatric surgery procedure. As noted in the medical literature by Smith and colleagues, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. This patients records do not document any of these conditions.  Accordingly, the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services provided over a two-week period for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this 26-year-old patient was admitted to residential treatment for management of anorexia nervosa. She was generally non-compliant with feeding and routine on the unit, and persistently displayed poor judgment in deliberately harming herself with food restriction. Her admission to the residential program terminated after an intentional overdose. Consistent with the American Psychiatric Association (APA) treatment guidelines, this overdose provides evidence that the patient could not have been managed safely in a lower level of care. Her admission to a center for residential treatment was appropriate to treat the patients condition. The records indicate that management of this patients condition could not have been provided safely on an outpatient basis or less restrictive setting and was consistent with standards of good medical practice. As such, the services provided were medically necessary for treatment of the patients medical condition.