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

A 39-year-old female enrollee has requested a voice amplifier device for treatment of her dysphonia after thyroidectomy and vocal cord paralysis. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of the requested device.  Per the submitted documentation, there was a significant improvement in the patients voice following the injection.  The medical records note less difficulty projecting her voice following this injection.  There is no documentation of speech therapy.  Additionally, the medical records do not show that this patient has severe expressive speech impairment.  All told, the requested voice amplifier device is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Lyrica for treatment of her transverse myelitis of the cervicothoracic cord from C4-T4 in the setting of Lupus.  Findings:  The physician reviewer found that the literature including Tuchman, et al., and Moore et al., clearly show the efficacy of Lyrica from sound biochemical basic pathways and inhibition of calcium channels in peripherally, (i.e. diabetes, or post-herpetic neuralgia) and centrally mediated (i.e. post-stroke, transverse myelitis, or multiple sclerosis) syndromes. The cortical perception of pain in the primary somatosensory cortex and thalamus transmit neuropathically mediated pain signals the same no matter the pathophysiological cause. Therefore, the neuropathic pain guidelines support Lyrica as a first-line agent for this condition. Given that this patient experienced superior pain relief from a moderate dose of Lyrica (300 mg per day), when compared with a high dose of Neurontin (2700 mg per day), it is clinically appropriate for Lyrica to be approved as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested inpatient psychiatric services for treatment of his depression.  Findings:  The physician reviewer found that the patient presented with significant medical problems which compounded the issue of which conditions in fact contributed to his altered mental state. Furthermore, he had a reported head injury prior to the admission. The patient was not consistently alert and was not described as cognitively clear until the date in question. Consistent with the American Psychiatric Association (APA) practice guidelines for the treatment of patients with bipolar disorder, this patients condition clearly merited the level of care provided during the period at issue. His medical condition was not stabilized consistently until his discharge date. Thus, the inpatient psychiatric services provided from the dates in question were medically indicated and necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Provigil for treatment of his severe obstructive sleep apnea.  Findings:  The physician reviewer found that according to the scientific data, Provigil is clinically indicated for treatment of patients with obstructive sleep apnia (OSA) who experience daytime sleepiness, such as this patient. Further, this patients provider noted that the patient was consulted regarding possible use of Caffeine, however it was decided that Caffeine would exacerbate his ulcer, so its use was contraindicated. Given that Provigil is an accepted medication for treatment of residual hypersomnia secondary to OSA, its use is medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested left anterior lumbar interbody fusion at L5-S1 for treatment of his degenerative disc disease of the lumbosacral spine.  Findings:  The physician reviewer found that this patients records do not document that conservative measures have been exhausted. Given the absence of attempts at conservative therapies and lack of clinical findings indicative of fusion, the requested surgery has not been demonstrated to be medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested continued speech therapy for treatment of her fruste ataxia.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not establish the medical necessity of continued speech therapy.  Physician notes were not submitted for review.  Thus, although therapy notes indicate a diagnosis of fruste ataxia, the actual diagnosis was not documented.  The medical literature endorses speech therapy for specific diagnoses including recovery post stroke or post brain injury.  All told, the requested speech therapy is not medically indicated for this patient.  There is insufficient support for continued speech therapy at this time based upon the provided records.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-month-old male enrollee has requested physical therapy for treatment of the enrollee, who has Down syndrome.  Findings:  The physician reviewer found that while the evidence demonstrates that standard of care recommends physical therapy for children with developmental delays associated with Down syndrome, the variability of developmental delays is wide.  As noted by Ranweiler, children with Down syndrome show varying degrees of developmental delays, and physical therapy is important for optimizing motor development. The physical therapy consultation provided used standardized testing to demonstrate developmental delay.  In addition, the provider documented specific developmental delays.  The primary physician documented that the patient was demonstrating developmental delays and had gross motor deficits.  All told, physical therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  24 additional occupational therapy (OT) visits for treatment of the enrollees medical condition status post dislocated elbow with fracture.  Findings:  The physician reviewer found that this patient continues to have pain and a loss of elbow range of motion despite treatment with occupational therapy. She has a complication of heterotopic ossification which prolongs the recovery from this type of injury (Ellerin, et al.). There is little evidence in the medical literature that provides conclusive evidence that one treatment modality is superior to another in this clinical setting. However, given the documented gains the patient with previous therapy and the fact that she continues to have pain and loss of range of motion, the requested additional occupational therapy sessions have been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested cold therapy device for treatment of his status post shoulder surgery. Findings:  The physician reviewer found that although cryotherapy has long been utilized in orthopedic surgery for pain relief, there has been a wide variation in its use, with a lack of evidence for improved clinical outcomes. The literature is conflicting regarding the value of cryotherapy after surgery (Nyland and Nolan). Evidence of decreased subacromial and glenohumeral temperature is lacking, even when some analgesic effect is noted. No increased effectiveness in reducing intra-articular temperature has been seen in the use of a device as compared to ice (Warren and colleagues).  All told, there is a lack of evidence supporting the medical necessary for the use of a cold therapy device for the treatment of this patient.  The cold therapy device at issue was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested laparoscopic banding bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has failed dietary efforts in the past, including supervised attempts with her primary care physician.  She has also tried phentermine.  The patient has clinically severe obesity that has failed conservative efforts. She has completed a thorough multidisciplinary evaluation that did not reveal any metabolic, dietary, behavioral or medical barriers to surgery.  This patient meets the National Institutes of Health Consensus Guidelines for bariatric surgery.  In this patients case, the requested laparoscopic banding bariatric surgery is medically indicated for her treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested a sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that this patient can benefit from weight loss surgery. The sleeve gastrectomy has been performed as a part of the duodenal switch operation for many years.  There is sufficient data demonstrating the benefits of the sleeve gastrectomy.  The advantage of the sleeve gastrectomy over the Lap-Band is that the sleeve gastrectomy does not involve the placement of a foreign object and does not require constant monitoring and adjustment.  In this patients case, the requested sleeve gastrectomy is likely to be the most efficacious treatment alternative.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested emergency services for treatment of his reported fever and cough that started the prior day. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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.  The patient had a fever, sore throat, cough and congestion symptoms for one day prior and had no chronic medical conditions.  The patient was in no acute distress according to the Emergency Room records.   Vital signs and pulse oximetry were all normal on arrival, except for a temperature of 103.2 and a slightly increased pulse. The patient did not have any concerning signs such as lethargy, vomiting, chest pain, seizure activity or decreased responsiveness. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health in these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested average volume assured pressure support (AVAPS) treatment and related accessories for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that although the records provided for review support a diagnosis of OSA, there is insufficient documentation to confirm a diagnosis of obesity hypoventilation. As there are no carbon dioxide (CO2) levels available for review, it is difficult to ascertain whether use of the AVAPS resulted in improvement of the patients CO2 levels. Given that the provider recommended the treatment at issue, it may be that the patients CO2 levels have in fact improved with use of AVAPS, thus making its use more reasonable. If documentation was provided showing improved CO2 levels, it may be recommended based upon that data. At this time, the equipment at issue remains investigational or experimental in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested rhinophyma surgery for treatment of his rosacea and rhinophyma. Findings:  The physician reviewer found that this patients condition constitutes an abnormal structure of the body, as consistent with the California Reconstruction Statute. Rhinophyma is a condition of the nose where there is sebaceous gland hyperplasia causing the nose to become bulbous and lobulated. It is also characterized by fibrosis, follicular plugging and teleangiectasis. It is categorized as a glandular form of acne rosacea. The actual cause is unknown but can be considered an overgrowth of tissue, thus acting like a tumor. Some providers, as reported by Thorne and colleagues, indicate that it may also be considered a disease. The authors state that, Understanding the disease and controlling the underlying process with an optimal dermatologic regimen are critical. This patients records demonstrate that he has undergone different topical regimens without success. Thus, the patient has already been treated by dermatologic means. Overall, it appears the primary goal of the procedure is to address non-cosmetic issues. Moreover, an appropriate procedure would have an excisional nature that allows for pathologic analysis. As such, the requested surgery should be determined to be reconstructive in nature and is therefore medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollee, who has Down syndrome. Findings:  Three physician reviewers found that children with global developmental delay, such as those with Down syndrome, are at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information. It is important to aggressively and thoroughly address these deficits to prevent further impact on growth and development. This patient has made progress with speech therapy. Aggressive work in oral motor strength and control as well as tongue positioning will also lay the groundwork for improvement in his ability to communicate. In this patients case, the requested therapy is likely to be the most efficacious treatment alternative for his condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a panniculectomy for treatment of her hernia repair.   Findings:  The physician reviewer found that the condition of a recurrent hernia would be an abnormal occurrence associated with previous surgery. The abdominal pannus can be considered a collection of skin and subcutaneous tissue beyond that normally expected in that region. The umbilical hernia could be considered caused by a developmental abnormality, while the incisional hernia would be directly related to previous surgery for a possible infection. The surgery at issue, specifically the panniculectomy, may have been expected to improve function by reducing the incidence of recurrent hernia or by allowing improved exposure of the hernia repair. However, the documentation does not support this conclusion in this case. The photographs provided do not demonstrate that functional improvement was reasonably expected by removal. There is some indication from the plastic surgeon that removing the abdominal pannus is necessary, but there is no documentation from the general surgeon to support this as the goal of the procedure. There is no preoperative assessment, medical history, physical examination, current weight status, or history of weight loss provided for review. Also absent are relevant factors including the patients weight over this course, previous attempts to reduce her weight and pannus, and detail of the cause and chronological occurrence of the hernias. Further, there is insufficient data indicating the surgery was being performed in an attempt to create as normal an appearance as possible. The photographs do not allow for this consideration and there is no history and physical examination available to clarify the providers rationale for the procedure. Overall, there is minimal evidence to support a finding of the abdominoplasty as reconstructive nature in this instance. In the medical literature, Shermak concluded that there can be a functional and aesthetic improvement from the combination of abdominoplasty and hernia repair. Also, Reid and Dumanian indicate a functional reasoning behind panniculectomy and hernia repair being combined. In this case, however without sufficient evidence to support the functional need for the surgery at issue, it cannot be determined to be reconstructive or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested emergent psychiatric care followed by acute inpatient level of care for treatment of her medical condition. Findings:  The physician reviewer found that the services rendered during the initial treatment period were not required at the emergent level of care and the services rendered during the second treatment period were not medically necessary at the acute inpatient level of care. American Psychiatric Association (APA) practice guidelines indicate that patients should be managed in the least restrictive setting that is likely to be safe and effective. Based on the documentation provided, the patients condition had stabilized by initial treatment date and she was no longer experiencing a psychiatric emergency. The submitted records include no evidence of acute risk to self or others as of that date and no indication of a need for restraints, seclusion or intra-muscular medications. Additionally, the patient was cooperative with treatment. Thus, the patient did not require treatment at an emergent level of care during her initial treatment period. Furthermore, as of the start date of the second treatment period, the continued need for containment and skilled observation and procedures on a 24-hour basis is not established in the medical record documentation provided. There was no evidence of risk of harm to self or others and the patient was cooperating with treatment. The patient did not require the intensity of service that is associated with acute inpatient services during the second treatment period. During this period, the patient was appropriate for treatment in a partial hospitalization program (PHP), which is the clinically indicated level of care in this setting. Per APA guidelines, partial hospitalization is appropriate for patients who do not require 24-hour protected, controlled or monitored environment and for whom there is evidence of capacity for reliable attendance at the PHP and compliance with a medication regime. As of the start date of the second treatment period, the patient was no longer at acute risk of harm to self or others and was cooperative with treatment. Thus, a PHP level of care would have been appropriate during this treatment period.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her resistant depression.  Findings:  Three physician reviewers found that this patient has struggled with severe anorexia nervosa, received extended inpatient hospitalizations. Her medication trials have included anti-depressants, mood stabilizers, and antipsychotic regimens. In addition, she has received 3 different courses of electroconvulsive therapy (ECT) with the last treatment about 6 years ago. She has also engaged in individual and couples therapy sessions. All services have reportedly provided less than optimal responses, at times significant side-effects, with overall limited benefits. Throughout these treatment trials, she has continued to work although this has been impaired some more recently due to cognitive changes. The peer reviewed reports that discuss findings of repetitive TMS for depressive disorders is gaining momentum, as is the number of patients receiving this modality of care. According to the literature available on TMS as treatment for depression, there are varying reports on the efficacy, especially long-term, and potential side-effect profile issues along with uncertainty in patient selection. Gross and colleagues provided an updated meta-analysis of studies related to this TMS. The authors concluded that although results are suggestive that TMS has significant anti-depressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous, but continued trials are required to advance this treatment from the experimental phase into standard therapy. Similarly, Gershon and colleagues reported on the positive responses of repetitive TMS as an anti-depressant treatment, but cautioned of the outstanding need for verification and standardization of best practices and patient selection. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Overall, this treatment modality may be beneficial, but has not been demonstrated as superior to current standard treatments for depressive disorders. Thus, verification of ongoing and comparative efficacy and tolerability trials of repetitive TMS as standard care still remains in the investigational stage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested chemotherapy with carboplatin and gemcitabine for treatment of her triple-negative breast cancer.  Findings:  Two physician reviewers found that triple-negative breast cancer (TNBR) is a newly defined subcategory of breast cancer which is especially responsive to platinum-based chemotherapy. Laessig and colleagues concluded that, Combination chemotherapy with gemcitabine and carboplatin is an effective and generally well-tolerated treatment option for intensively pretreated patients with metastatic breast cancer. In this young patient with no significant response to neoadjuvant chemotherapy, it would be medically reasonable to treat her with a platinum based chemotherapy combination of carboplatin and gemcitabine based on the relevant peer reviewed clinical literature demonstrating its efficacy and safety in this subset of patients. According to the scientific data, this systemic chemotherapy regimen is more likely to provide her with a superior health outcome than any standard treatment and should not be categorized as investigational in this setting