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

A 33-year-old male enrollee has requested authorization and coverage for a cervical artificial disc replacement procedure (CPT code 22856) at the C5-6 level for treatment of the enrollees C5-6 disc herniation. Findings:  Three physician reviewers found that the patient has a history of neck pain and left shoulder pain. He has experienced some numbness and weakness in his left hand. He has been evaluated by neurological surgeons and physical examinations revealed negative Spurlings tests, no motor, sensory, nor reflex deficits and normal reflexes. His imaging studies have demonstrated anterolisthesis at C3-4 and disc osteophyte complexes at C4-5 and C5-6 with more significant stenosis at the C5-6 level on the left. The patients provider has discussed surgical options with the patient, including anterior decompression and fusion at the C5-6 level and artificial disc replacement at the C5-6 level. The patient has requested authorization for a cervical artificial disc replacement procedure at the C5-6 level. There is no data available in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of the artificial disc replacement procedures utilizing the ProDisc C. Although there are a number of published reports which indicate artificial disc replacement with the ProDisc C is promising, these studies are small in scale and of short duration. A study by the Food and Drug Administration (FDA) to determine the long-term safety and efficacy of the ProDisc C is still ongoing and results have not been published. Therefore, there is inadequate evidence demonstrating that the requested procedure is likely to result in a better clinical outcome for this patient as compared to standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested NeuroStar transcranial magnetic stimulation therapy for treatment of her bipolar disorder.  Findings:  Two physician reviewers found that along with bipolar disorder, the medical records also noted obsessive-compulsive disorder and alcohol dependence.  Per the submitted documentation, the patients symptom complex includes depressed mood, anxiety, obsessions to cut, fatigue, hopelessness, anhedonia, and hypersomnia.  She has received electroconvulsive therapy, but experienced only a partial response and significant memory loss.  The patient is currently in psychotherapy.  Her prior medications have included Prozac, Luvox, Zoloft, Cymbalta, Pristiq, Wellbutrin XL, risperidone, Lamictal, stimulants, Abilify, lithium, Trileptal, Effexor XR, Seroquel, Lexapro, Depakote, and Buspar.  Psychopharmacotherapy has been hindered by poor efficacy, lack of sustained effect, and tolerability issues.  The patient has requested coverage for NeuroStar transcranial magnetic stimulation therapy (CPT codes 90867 and 90868).  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. In this patients case, the requested services are not likely to be more efficacious than other treatment alternatives.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, this recommendation does not extend to the treatment of bipolar disorder.  Although some preliminary support exists in the medical literature regarding the use of transcranial magnetic stimulation therapy for patients with bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  Thus, the current medical evidence has not established the superior efficacy of the requested NeuroStar transcranial magnetic stimulation therapy in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.   Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Several articles are cited from the literature that shows that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups. This patient has been treated with multiple available standard therapies without improvement in symptoms. Consistent with this clinical support, the requested TMS therapy is likely to be beneficial than other standard therapies available to this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her back pain.   Findings:  The physician reviewer found that based on review of the available records, the patient presents with low back pain. However, there are no documented signs or symptoms of concern, such as neurological deficit, infection, cancer or radicular pain that would necessitate an MRI of the lumbar spine. Physical therapy has been ordered but the patient has not reportedly attended the program. Consistent with the American College of Radiology (ACR) criteria, this patients medical condition is not an indication for the requested MRI of the lumbar spine.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 55-year-old male has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department with a chief complaint of flu-like symptoms for a duration of three days, which consisted of generalized body aches, intermittent headache, a mild cough and nasal congestion. The day prior to his emergency room visit, the patient reported that he had a fever up to 100.3 degrees. The records indicate the patient endorsed his pain level as 4 on a scale of 10. It was also noted in the records that the patient had just returned from a trip to India and was concerned that he may have contracted a disease while traveling  abroad. The provider ordered lab tests and a chest x-ray. The lab tests revealed that the patient had influenza-B and the chest x-ray was negative for pneumonia. The patient was treated with ibuprofen 600mg orally in the emergency room and was discharged to home with a prescription for Tamiflu.  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.The patient did not have a high fever, severe pain or a severe cough. Therefore, 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 or her health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested vagal nerve stimulator implantation for treatment of her epilepsy.  Findings:  The physician reviewer found that this patient has a history of refractory seizure disorder, as well as possible non-epileptic seizures.  Per the submitted medical records, electroencephalography has given indication of localization of specific seizure source.  The patient has had continued high seizure frequency despite concurrent use of three anticonvulsants, with reported fatigue, which may be a medication side effect.  The current medical literature shows that vagal nerve stimulation can be beneficial in reducing seizure frequency in patients with partial onset seizures who have failed adequate control with medications.  Vagal nerve stimulation is medically appropriate for the management of medically-refractory seizures.  All told, the requested vagal nerve stimulator implantation is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested reimbursement for intensive outpatient program (IOP) for one month and continued authorization for IOP services from a specific date and onward for treatment of the enrollees multiple mental health conditions. Findings:  The physician reviewer found that The patient had not consolidated the treatment gains necessary to succeed in less restrictive setting by the first date of the IOP.  Indeed, the patient was unable to negotiate stressors that led to an acute hospitalization. But, prior to that, the patient was enduring persistent problems related to her acute crisis that prompted IOP placement.  Further, she was having difficulty managing boundaries and was relying on self-defeating coping strategies, such as drinking, to alleviate her intrapsychic discord.  Finally, she was residing in a chaotic environment that was not conducive to recovery.  Thus, the IOP services provided were medically necessary for the treatment of the patients medical condition.  Continued authorization for IOP services, provided from the date in question and onward, were not and are not medically necessary for the treatment of the patients condition.  Psychiatrically, the patients medication regimen does not exceed a level of complexity appropriate for routine outpatient care and there are no unresolved medical issues which might support placement at the IOP level of care.  In reviewing the therapy notes, the patient was consolidating the concepts of mindfulness and cognitive behavioral therapy, while developing proficiency in an array of coping skills such as guided imagery, experiential relaxation, deep breathing, counting and praying.  She received positive feedback from her group cohort and although she continues to need work on core issues, there is no evidence provided in the record that IOP services are medically necessary for the patient to achieve these goals. Therefore, as of the date in question, services were not and are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Dexilant 60mg for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that based on review of the available records, there is no documentation that the patient has acid related symptoms. Further, based on the patients presentation, she may have non-acid reflux, which would be consistent with her history of failing numerous anti-secretory therapies. In addition, Dexilant is a long-acting version of lansoprazole, and there is no documented physiologic reason noted why the patient would be expected to respond to this medication as opposed to generic lansoprazole. For these reasons, the requested medication has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male has requested a pediatric otolaryngologist (ENT) specialist to perform his tonsillectomy and adenoidectomy.  Findings:  The physician reviewer found that Baugh and colleagues evaluated various findings in their clinical practice guideline based on the available peer-reviewed medical literature. As discussed, providers should recommend watchful waiting for recurrent throat infections if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past two years, or fewer than three episodes per year in the past three years. Further, the guidelines suggest that providers may recommend a tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year, or at least five episodes per year for the past two years with documentation for each episode of sore throat and one or more of the following: temperature greater than 38.3C; cervical adenopathy; tonsillar exudate; or positive test for group A beta hemolytic streptococcus (GABHS). Although this patient has been documented to have episodes of recurrent tonsillitis, there was only mention of four episodes within the past year without any mention of other subjective signs including fever, cervical adenopathy or tonsillar exudate or positive test for GABHS. Consequently, the patient does not meet the guidelines in the consensus statement. It is well established that pediatric sleep disordered breathing improves in the majority of cases after tonsillectomy and adenoidectomy surgery. Currently, children with symptoms of sleep disordered breathing are recommended to undergo polysomnography as a means of determining their clinical status. In this specific case, the parents reported abnormal sleep patterns but there was no mention of a polysomnogram. The documentation provided suggests that the patient was seen by two different participating in-plan otolaryngologists. The initial provider reported that he did not believe that the patient was a candidate for surgery at the initial visit and that the second provider suggested further monitoring and possible consideration of surgery. The patients tonsil size was described by both providers as about 2+-3+, but no crowding of the posterior oral cavity was seen. Subsequently, a non-plan provider recommended consideration of tonsillectomy and adenoidectomy for improvement of the patients condition. However, the Health Plan indicated there are competent plan board certified otolaryngologists who routinely perform tonsillectomy and adenoidectomy in uncomplicated pediatric patients. Reviewing the medical status of the patient in this case, there is no documentation of any complicated health issues that would require the services of a fellowship trained pediatric otolaryngologist. Tonsillectomy and adenoidectomy is a routine surgical intervention performed by most otolaryngologists. As this patient presents no other potential health related symptoms, routine tonsillectomy and adenoidectomy can be safely and adequately performed by the plan providers trained for this procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested psychotherapy twice a week with a PhD psychologist, monthly psychiatric appointment with Comprehensive Neurobehavioral Specialists (CNS) and applied behavioral analysis (ABA) therapy for treatment of her mental health conditions. Findings:  The physician reviewer found that applied behavior analysis (ABA) is an empirically proven treatment intervention for children, adolescents and adults afflicted with autistic spectrum disorders.  However, the documentation provided does not substantiate a diagnosis of Aspergers disorder.  Determination of this condition involves input from multiple disciplines and structured interviews. It is uncommon practice to make this diagnosis after a single visit and the evaluating physician acknowledged no past history of the diagnosis and conceded that it is difficult to tease apart which of her symptoms are from Aspergers versus ADHD versus sleep disorder versus depression.  Diagnostic uncertainty aside, there was no conclusive, well-delineated functionally impairing symptomatologies from Aspergers disorder that would support targeted treatment goals of ABA. ABA therapy is not medically necessary for treatment of the patients medical condition.  Psychotherapy and monthly medication management with a psychiatrist as part of a multi-dimensional and comprehensive evidence-based treatment plan are appropriate, safe and consistent with good medical practice in the United States.  Thus, psychotherapy twice a week with a PhD psychologist and monthly psychiatric appointments are medically necessary for treatment of the enrollees medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old female has requested Xolair injectable therapy, every month for 6 months, for treatment of her urticaria of the idiopathic type.  Findings:  Two physician reviewers found that  the patient has severe chronic urticaria.  Per the submitted documentation, she is currently on high doses of several antihistamines, and she continues to have debilitating hives.  Her provider noted that the patient has experienced significant weight change, behavior change, and sleep difficulties due to her exposure to high doses of prednisone.  The provider has recommended Xolair injectable therapy, every month for 6 months.  In this patients case, Xolair injectable therapy, every month for 6 months, is likely to be more efficacious than other treatment alternatives.  She has severe urticaria despite daily, high doses of several antihistamines.  Numerous studies have demonstrated the efficacy of Xolair therapy for the treatment of patients with chronic urticaria.  The current medical evidence supports Xolair injectable therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male has requested past and future coverage for partial hospitalization program (PHP) services provided for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that in this case, the patients symptoms failed to meet published guideline criteria for partial hospitalization program (PHP) level of care services for the dates at issue. Specifically, the patient does seem to have insight into the severity of his drug and alcohol problem and has the ability to develop coping skills to deal with this problem.  During the time frame at issue the patient was on medication that was helping him control his cravings for alcohol. Additionally, he did not have any intervening medical or psychiatric event that was serious enough to interrupt his rehabilitation. Although he does have MDD and PTSD, these are being treated, and the patients treating psychiatrist lists his MDD as being in partial remission.  Thus, the patient failed to meet established mental health care guideline criteria for PHP services beginning on the date at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for removal of sling mesh for treatment of her diagnosed with chronic interstitial cystitis and dysuria frequency syndrome. Findings:  The physician reviewer found that the current medical literature has not demonstrated that surgical excision of residual mesh has a significant impact in this clinical setting.  The complex nature of this patients pelvic pain cannot fully be categorized, as her symptoms have included cystitis and vulvar pain.  In this patients case, additional surgical intervention is not supported by the current medical evidence.  All told, the requested removal of sling mesh is not medically indicated for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for azelastine (Optivar) 0.05% ophthalmic solution, Alrex 0.2%, Azelex 20% cream, Lunesta 3mg, and epinastine 0.05% for treatment of his HIV positive. Findings:  The physician reviewer found that the patient has seasonal allergic rhinitis.  The medical records notes that the patient tried fluticasone for approximately 6 to 8 months, with no improvement.  In this clinical setting, azelastine (Optivar) 0.05% ophthalmic solution is medically indicated. The patient was noted to have failed treatment with Patanol, Astelin, and Elestat. In this patients case, Alrex 0.2% is medically necessary.  The provider submitted a prior authorization request for Azelex 20% cream for the treatment of acne rosacea.  The provider noted that there was no available formulary alternative for the treatment of this patient.  Additionally, the provider noted that the patient had already been tried on a multiple medications, which were not of benefit.  Therefore, the clinical documentation supports the medical necessity of Azelex 20% cream in this case.  The documentation fails to demonstrate the medical necessity of Lunesta 3mg and epinastine 0.05%.  The medical records do not provide support for the medical necessity of Lunesta 3mg, and there is indication that the patient has been offered another medication for sleep.  Additionally, there is a lack of documentation supporting epinastine 0.05% in this patients case.  All told, azelastine (Optivar) 0.05% ophthalmic, Alrex 0.2% and Azelex 20% cream are medically necessary.  Lunesta 3mg and epinastine 0.05% are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for bariatric surgery consultation, bariatric surgery, and aquatic/pool therapy (pre, post or in lieu of bariatric surgery) for treatment of her morbid obesity. Findings:  The physician reviewer found that the current medical evidence does not support the requested bariatric surgery in this patients case. The medical necessity of the requested aquatic/pool therapy has not been established. Medical clearance in support of aquatic therapy was not provided.  In general, there is no consensus regarding the use of aqua exercise for cardiac patients, as some studies show increased cardiac work.  At this time, further published data is needed to document the improved outcomes of aquatic therapy in this clinical setting.  All told, the requested bariatric surgery consultation, bariatric surgery, and aquatic/pool therapy (pre, post or in lieu of bariatric surgery) are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male has requested non-formulary Olux foam for treatment of his chronic dermatitis and inflammation of the hands.  Findings:  The physician reviewer found that hand dermatitis is often well-treated using topical steroid preparations (Bolognia, et al.; and Sehgal, et al.).  He has tried one other class I topical steroid, Lidex, in the past without improvement, but there is no documentation of the patient having been treated with clobetasol ointment, cream, solution, or gel. All of these medications are generic equivalents with the active ingredient found in Olux. The patients health plan indicates that coverage for non-formulary branded medications may be considered if the generic formulations are ineffective.  Given that the generic formulations of clobetasol have not been trialed, the request for coverage of Olux foam should be denied.