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

A 63-year-old male enrollee has requested total ankle arthroplasty for the treatment of his end stage arthritis of the right ankle. Findings:  Two physician reviewers found that total ankle arthroplasty is approved by the FDA for the treatment of arthritis. Review of the scientific literature demonstrates that the results of total ankle arthroplasty with respect to pain relief are equivalent to the results of ankle fusion, with lower incidence of side effects. Ankle fusion often leads to the development of arthritis in surrounding joints, such as the talonavicular joint and the subtalar joint. This patient's treating physician has already noted that the patient has pain and restricted motion in the subtalar joint and radiographic evidence of early arthritis within the subtalar joint. Ankle fusion is likely to exacerbate the patient's painful subtalar arthrosis and hasten its progression. Total ankle arthroplasty is more likely to provide the patient with a better functional outcome by virtue of the fact that the incidence of the subtalar arthrosis with total ankle arthroplasty is much less than the incidence of subtalar arthrosis with ankle fusion.  Thus, total ankle arthroplasty represents a superior treatment modality for patients such as this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested azithromycin 250mg, twice per day for the treatment of his Lyme disease. Findings:  The physician reviewer found that the submitted information reveals no clinical or laboratory evidence of any infection. The patient has been treated with several times the recommended duration of antibiotics for Lyme disease. There is no evidence that he has Babesia or Ehrlichia infection based on the results of the single serologies provided. Furthermore, although azithromycin is appropriate therapy for Babesia, the recommended therapy is a maximum of 11 tablets.  Thus, azithromycin 250mg, twice per day, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested twice weekly outpatient mental health services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted documentation does not demonstrate any imminent safety issue, active psychotic thought process or any new symptom or complication that requires intensive outpatient treatment. This patients symptoms and impairment do not support the need for twice weekly outpatient mental health services. Per the patients letter, she had two or more sessions per week for approximately 18 months. The submitted evidence does not demonstrate that this has translated into significant improvement in the patients symptoms, behaviors or functional impairment. Furthermore, the psychiatric literature indicates a combination of pharmacotherapy and psychotherapy is appropriate in this setting. The submitted documentation does not demonstrate that adequate attempts at pharmacotherapy have been tried and failed. All told, the medical necessity of twice weekly outpatient mental health services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 60-year-old male enrollee has requested continued skilled nursing facility (SNF) care/rehabilitation services for the treatment of the enrollees multiple medical problems. Findings:  The physician reviewer found that upon admission to Covina Rehabilitation Center, the patient required and received skilled level of care services. His medical conditions were stable, but he required skilled therapies to maximize improvement to his previous level of function. He was not considered a candidate for further treatment (chemotherapy) for his colon cancer condition. He had significant baseline deficits from his mental retardation that were compounded by his psychosis. According to the medical records provided, the patient often did not participate in therapies. The records indicate that therapies were re-initiated and stopped again two days later. During the period at issue, the patient was medically stable, tolerating his oral medication regimen and an oral diet. He had no active wound care issues. There was no documentation indicating he required skilled nursing on a daily basis for medical management issues. By the period at issue, the needs of the patient could have been met at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested chiropractic services for the treatment of her back pain. Findings:  The physician reviewer found that the submitted records do not establish the medical necessity of chiropractic services for this patient. Specifically, the records do not include complete examinations and re-examinations in light of the complaints indicated by the patient. Further, there is no documentation of functional gains or specifics provided as to the objective restoration of lost function or the degree of range of motion improvements. The records also do not include follow up in subsequent visits of positive orthopedic and motion analysis as indicated on exam sheets. While the patient complains of pain in the areas of the shoulder, neck, hip and tailbone, there is no evidence of a complete neuromusculoskeletal or postural analyses. Nor is there documentation of review at subsequent visits of the patients chief complaint. The submitted records omit provocative and palliative complaints, identification of pain, tenderness, and quality and intensity of pain at each visit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested Revlimid for treatment of the enrollees relapsed high-risk stage IV neuroblastoma. Findings:  Three physician reviewers found that the efficacy of the combination of Celebrex and Revlimid for the treatment of advanced neuroblastoma has not been proven in clinical trials. Available medical studies and reports do not show that the regimen is likely to result in an improved outcome in this setting. Revlimid is myelosuppressive and does not show well-documented benefit in neuroblastoma. As such, there is inadequate scientific evidence supporting the efficacy of Revlimid in this setting to support its use in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested acute psychiatric inpatient care for treatment of her behavioral health problems. Findings:  The physician reviewer found that it appears that a majority of the patients symptoms have been secondary to opiate withdrawal as opposed to her diagnosis of bipolar disorder. As noted by Schatzberg and Nemeroff, this reaction is typical for patients undergoing opiate detoxification. The submitted records suggest that the patients worsened mood and morale is due to her opiate detoxification than underlying psychiatric pathology.Further, there is no documentation of the patient having any plans to harm herself and there were no self-injurious behaviors noted. She was not documented to be a danger to others, nor was she noted to be grossly disorganized, gravely disabled, delusional or psychotic. Her cognitive status is documented to be alert and oriented per the group therapy notes during the period under review. According to generally accepted guidelines, disturbances in the above are considered a minimum requirement for continued acute inpatient psychiatric stay. Additionally, the therapy group progress notes indicate the patients focus was on her substance abuse issues and not those issues related to the improvement of her bipolar disorder. In conclusion, the patient does not meet the medical necessity criteria for continued inpatient psychiatric hospitalization from the date of service in question forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested adult psychiatric electroconvulsive therapy for treatment of her bipolar disorder. Findings:  The physician reviewer found that ECT is a well-documented safe and effective treatment for bipolar disorder and major depression. This patient has been refractory to many first and second-line treatments, and therefore ECT is a reasonable treatment option. While it can result in cognitive side effects, these have been minimal in this patients case and the associated risk is outweighed by the patients low level of function prior to ECT. American Psychiatric Association Practice Guidelines note that ECT may be considered for patients with severe or treatment-resistant mania, or if ECT is preferred by the patient. In addition, there is evidence to support the use of maintenance/continuation ECT in patients with bipolar disorder (see Schatzberg). Although this patient is not currently on an anti-depressant, she is on a mood stabilizer (Abilify). The absence of an anti-depressant from the patients regimen does not preclude continued ECT as she has a diagnosis of bipolar I disorder and the ECT treatments she has been receiving have likely had anti-depressant properties. For major depressive disorder, the standard of care is to continue anti-depressant medication as long as the risk of relapse is high. Although this standard has also been applied clinically to patients with bipolar depression, the scientific evidence does not support this practice (see Mallah). Furthermore, in the study by Mallah, 33 patients who received anti-depressants for an episode of depression and were followed prospectively over 12 months showed no benefit to continuing anti-depressants, and their time in remission did not differ from that of patients who discontinued anti-depressants. Given the patients many failures of anti-depressant medications, her treating psychiatrist determined that she likely had bipolar disorder and not major depression.  Due to the above factors including the patients poor response to adequate trials of psychiatric medication in the past, her success with ECT, the severe and chronic nature of her illness, and her worsening symptoms and worsening daily functioning without maintenance ECT, ECT was and is medically necessary for this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested Orthovisc injections for the treatment of his osteoarthritis. Findings:  The physician reviewer found that patients with osteoarthritis of the knee obtain moderate benefit from treatment with viscosupplementation. That stated, not all patients receive the same relief with the therapy; as this patients records demonstrate, he only received mild relief of his symptoms after treatment. For patients who obtain measurable positive pain relief with prior injections it may be medically justifiable to authorize future treatments after a reasonable waiting period. However, based on the records provided this patient has not met these criteria. Furthermore, the concept that viscosupplementation is likely to have a better effect after the microfracture procedure warrants further study, but has not yet been medically proven. There is even less support for the proposed therapy in patients such as this patient who failed to obtain moderate benefit with prior treatment.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested emergency services for the treatment of his medical condition. 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. This patient had been suffering symptoms of phlegm in his throat and difficulty swallowing only when in the supine position. His symptoms had been present for weeks, and he had a known diagnosis of gastroesophageal reflux disease as well as an esophageal stricture. The patient was in no distress, and denied any pain or difficulty breathing. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patients provider recommended residential level of care due to significant depression, anxiety and decompensation in functioning. There is no documentation indicating that the patient has had any prior inpatient hospitalization or prior suicide attempt or gesture. Additionally, there is no history of aggression or violence. The submitted records include no documented history of any delusion, thought disorder or perceptual abnormalities. The patient does not have a history of drug use, self-mutilation or legal problems. Additionally, there is no history suggestive of any imminent risk of harm to self or others. There was no suicidal ideation, homicidal ideation, psychotic thought process or aggressive behavior upon presentation or at any time during his admission. All told, residential treatment was not and is not medically necessary for this patient. There is no documentation of psychotic symptoms or behaviors. Additionally, there is no documentation of impaired reality testing or aggressive, out of control behavior. Although the patient had been in therapy, there is no evidence of a history of intensive outpatient treatment. While the patient does have chronic, emotional problems, his outpatient treatment, including medication management and psychotherapeutic intervention, could have been further maximized. The intensity, frequency and degree of impairment documented do not support the necessity for psychiatric residential treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested Cialis 20mg, 30 tablets per month for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that this patient has erectile dysfunction. Erectile dysfunction is felt to be multifactorial in origin, and the medical records do not conclude a reason for his symptoms of erectile dysfunction. The references demonstrate that Cialis is very effective in improving erectile dysfunction. However, the medication has not been shown to be more effective in treating the medical condition when taken on a daily dosing schedule. The medical literature does not support a medical need to take the medication on a daily basis. Coverage for 6 tablets of Cialis 20mg per month as authorized by the Health Plan is within the standard of care and medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested skilled rehabilitation for the treatment of her medical condition. Findings:  The physician reviewer found that the medical records demonstrates that while in the skilled nursing facility the patient was alert and oriented, continent, had a foley catheter, medically stable, and did not require parenteral medications or skin care. She was receiving bladder training and daily physical therapy. Initially she was non-ambulatory due to her non-weight bearing status, but was eventually cleared for toe-touch weight bearing status and was able to ambulate with a front-wheeled-walker with moderate assistance. Her transfer status was stand-by-assistance. Her ambulatory status eventually progressed to contact-guard assistance and her bed mobility increased to an independent level. However, her weight bearing status was changed back to non-weight bearing due to concern about the healing of her fracture. The patient received occupational therapy and she gained steady progress in that area with most of her difficulty being in donning her socks. All told, this patient required skilled rehabilitation and was making progress with her mobility training, activities of daily living training, and bladder training throughout this period. However, due to her weight-bearing status being changed back to non-weight bearing, further significant progress was not expected with her activities of daily living or her mobility training. In addition, her bladder training had ceased. In summary, the patient had achieved her maximum potential with her activities of daily living and mobility given her new weight-bearing status with further significant progress not being expected.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested use of a continuous passive motion machine for the treatment of her knee, status post right knee anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the medical literature contains extensive research on use of a CPM device following knee surgery. Studies have primarily focused on patients who underwent total knee arthroplasty. As noted by Brosseau and colleagues, there is no conclusive evidence demonstrating the benefit of CPM following total knee arthroplasty. A more recently published trial conducted by Bruun-Olsen and colleagues also suggested that there is no significant benefit of CPM use following total knee arthroplasty. Additionally, with respect to arthroscopic ACL repair, there are no reliable scientific data that supports the use of CPM when compared to standard treatment consisting of physical therapy alone. An early study by Noyes and colleagues concluded that no significant short- or long-term functional advantages were observed in patients treated with CPM versus those who did not receive such therapy. Further, Richmond and colleagues found no clear dose-effect for CPM following arthroscopic ACL repair. In a small trial published in 1989, Anderson and Lipscomb reported that the optimal rehabilitation post-ACL repair included electrical muscle stimulation and immobilization in flexion with early limited range of motion. The CPM group in this study did not do as well as the group that was immobilized in flexion and underwent early limited range of motion. In a small trial published in 1997, Gaspar and colleagues noted some improvements in a CPM group versus a non-CPM group at the time of hospital discharge following ACL repair, but no significant difference in outcomes at 6-month follow up. A more recent trial by Friemert and colleagues concluded that patients with active motion had better outcomes than patients treated with CPM with respect to joint position following ACL repair. Overall, the literature does not demonstrate a significant benefit from CPM following ACL repair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested the medication Xifaxan (1/2 tablet three times daily for ten days for the treatment of the enrollees small intestinal bacterial overgrowth (SIBO). Findings:  The physician reviewer found that all of the alternative antibiotics recommended by the Health Plan are absorbed through the gastrointestinal (GI) tract. Neomycin has been considered a non-absorbable antibiotic by some, but oral administration can be associated with malabsorption and nephrotoxicity so it is not a preferred antibiotic and contains a black box warning from the Food and Drug Administration.  Furthermore, neomycin is not approved for children less than 18 years of age. The other antibiotics that were recommended by the Health Plan have systemic effects and therefore were not considered suitable for the patient by her prescribing physician. Of the absorbable antibiotics, tetracyclines are generally not used in young children because of concerns over bone and dental health. Fluoroquinolones and ciprofloxacin for example, negatively affect growing cartilage in young children.  Norfloxacin is used mainly for the treatment of urinary tract infections and prostatitis and is not approved for patients less than 18 years of age. Metronidazole also has considerable safety issues. In the United States, Xifaxan is the only non-absorbable antibiotic with a low-complication profile that is available for the treatment of SIBO. There are studies that show it is an effective agent for the treatment of SIBO. Although the FDA approves Xifaxan for children 12 years and older, this patient, at 11 years of age was within months of that age at the time the medication was prescribed and thus its use in this setting was medically reasonable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a bone density scan (DEXA scan) for an evaluation of her bone density. Findings:  The physician reviewer found that the clinical indications for bone mineral density testing are well-documented in the literature. The published guidelines for bone mineral density testing recommend testing for all women over age 65. Additionally, this testing is recommended for postmenopausal women 60 to 65 years of age with one risk factor. These risk factors include fracture after age 45, hip fracture in a parent, tobacco abuse, bone mass index less than 22 and extended glucocorticosteroid use greater than three months. The guidelines also recommend bone mineral density testing in postmenopausal women of any age with non-traumatic fracture, incidental finding of osteopenia on x-ray, glucocorticoid use, hypogonadism or hyperparathyroidism. This patient does not meet any of these criteria.  All told, the requested bone density scan (DEXA scan) is not medically indicated for the evaluation of the patients medical condition.