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

The parent of a five-year-old male enrollee has requested occupational therapy one time per week (using codes 92526 x 1, 97530 x 2 for a total of 92526 x 12 and 97530 x 24) for treatment of the enrollees feeding disorder.  Findings:  The physician reviewer found that this patient demonstrated severe dietary self-imposed restrictions.  Essentially, he was limiting himself to chicken nuggets as his major caloric intake. His dietary preferences had a psychogenic etiology. However, the etiology of the patients food aversion is not clear from the records.  The study by Mannella and Trabulsi discusses childhood limited food selection as a harbinger of a poor adult choice of diet and the authors stress that increasing fruit and vegetable consumption early in life may lead to an adequate life-long intake of fruits and vegetables, which will be beneficial for weight control and prevention of cardiac dysfunction later in life.  Food desensitization, such as introduced by the occupational therapist, is an important component of eliminating selective feeding by a child (Tamura, et al.). Additionally, parenting and the social environment are important factors in the development of eating behaviors (Gahagan). Thus, it is important for an outside influence to alter this patients eating behaviors. The patients long range health is being jeopardized by his poor dietary habits. Therefore, the recommended occupational therapy is medically necessary and appropriate.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 71-year-old male has requested coverage for past hospital services provided him for seventeen days. The Health Plan has denied this request indicating that the enrollee was stable for transfer to a contracted hospital.  Findings:  The physician reviewer found that at issue in this case is whether the patient was stable for transfer at any point during the seventeen-day period under review. The patient developed an acute stroke as a procedural complication followed by acute chest discomfort, so transfer during this time period would not have been medically safe. However, by the second day of the time period at issue the patient was determined not to have an acute myocardial infarction and his neurologic symptoms had not progressed. No recurrent chest discomfort was reported and only mild asymptomatic sinus bradycardia was present. On this day, the patients medical conditions had stabilized enough to make transfer to a participating hospital safe.  Thus, the care provided for the final fifteen days of hospitalization was correctly categorized as post-stabilization care for which the provider did not seek authorization by the Plan before providing.  Hospital transfers after observing a patient for 24-hours in the setting of unstable angina, as well as hospital transfers after stroke, are safe and occur routinely as patients can be transported for appropriate care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested authorization and coverage for weekly individual psychotherapy services.  Findings:  The physician reviewer found that based on review of the available records, the medical documentation does not support the medical necessity for weekly psychotherapy. A letter from the patients provider describes recommendation for weekly psychotherapy, noting the ongoing challenges related to her brothers psychiatric illness, as well as diagnoses of adjustment disorder with mixed anxiety and depression. Progress notes from same provider indicate the therapist mentioned going from weekly to every other week. Progress notes from a later date notes the patient enjoyed a social event with her friends. The providers notes approximately a month later describe the patient as bouncy; the note references the patient helping with birthday parties over the summer. The patients child psychiatrists notes dated three months later indicates good compliance with medications, no side effects, and no positive findings under risk assessment. Several notes from treating psychiatrist indicate the patient has good social skills, has friends, and is involved in age appropriate activities. The patients GAF scores provided by her psychiatrist have ranged from 60-71. Overall, the medical documentation does not provide a contraindication for decreasing therapy sessions to every other week as discussed by the therapist. As indicated by the American Psychiatric Association (APA), treatment reduction should be gradual. Similarly, the American Association of Child and Adolescent Psychiatry (AACAP) practice parameters on systems of care note the value of utilizing natural community supports and resources as part of a comprehensive treatment plan. The current peer reviewed literature also indicates cognitive behavioral therapy (CBT) is one of the most effective evidence-based treatments for childhood anxiety. Consistent with these findings, the patient should receive individual sessions at the frequency of twice per month with an updated treatment plan, assessment, and documentation of response to treatment. Therefore, a portion of the requested therapy has been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested authorization and coverage for Provigil, 200 mg oral tablet for treatment of the enrollees multiple sclerosis.  Findings:  The physician reviewer found that Provigil is widely used in the treatment of patients with fatigue secondary to MS. In the treatment of fatigue, most MS specialists concur that this medication has a role in treatment of some MS patients. There have been multiple studies that have confirmed a clinical benefit in some patients. Use of Provigil for the treatment of MS related fatigue is a reasonable alternative to manage this patients fatigue associated with MS. For these reasons, the requested Provigil is clinically indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested authorization and coverage for a left lower extremity WalkAide.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device in this patients case.  In general, post-stroke foot drop is managed with either a plastic molded ankle foot orthosis or a double-metal upright ankle foot orthosis depending on various clinical factors.  However, some post-stroke patients may have significantly improved gait mechanics with the use of a functional electrical stimulation unit, such as the WalkAide.  This can only be determined through a detailed assessment of a patients gait mechanics with the use of an appropriately prescribed ankle foot orthosis versus a functional electrical stimulation unit.  This evaluation is typically done by a licensed physical therapist.  In this case, such a comparison analysis does not appear to have been done.  The records do not include a detailed assessment of the patients gait with the use of an appropriately prescribed ankle foot orthosis, nor do they include documentation of significantly improved gait mechanics with use of the WalkAide when compared with a standard ankle foot orthosis.  All told, the requested left lower extremity WalkAide is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female has requested coverage for past and future chiropractic treatment services for treatment of her intermittent neck and back pain.  Findings:  The physician reviewer found that current treatment guidelines state that the treating provider is expected to keep and maintain adequate case records clearly showing the patient care and clinical analysis from visit to visit. The following information is required within each subsequent visit: review of chief complaint; changes in the patients condition since the last visit; assessment of the patient since last visit; percentage of improvement, posture and gait analysis; pain scale; palliative and provocative assessment; range of motion; motor, sensory, and deep tendon reflexes (when warranted); systems review (especially if positive findings were documented with the last visit), including orthopedic and neurological evaluations of the area of the spine involving the diagnosis; evaluation of treatment effectiveness; and the treatment provided at time of visit. The records fail to support the patients care as medically necessary beyond a specific date at issue. Due to the lack of documentation provided, medical necessity has not been demonstrated for the treatment period beyond the date at issue. Thus, the initial examination and treatment provided was medically necessary and appropriate, however, the treatment provided subsequently and onward is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A 27-year-old male has requested Cymbalta 60mg, two capsules per day for treatment of his joint pain.  Findings:  The physician reviewer found that Cymbalta (Duloxetine) is medically necessary treatment for the patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peerreview medical literature as a safe and effective treatment for combined disorders of chronic joint pain and depression.A study by Citrome, et al. examined the use of Duloxetine for the treatment of osteoarthritic pain. The authors reported that Duloxetine received FDA approval in 2010 for the indication of chronic musculoskeletal pain, including osteoarthritis. The authors concluded that the new data supports the application of Duloxetine for the treatment of chronic musculoskeletal pain. Skljareviski and colleagues performed a randomized double blind placebo controlled study to assess the efficacy and safety of Duloxetine in patients with chronic low back pain. The authors found that Duloxetine treated patients reported greater reduction in pain than  the placebo-controlled group and concluded that the data demonstrates the efficacy and safety of Duloxetine in the treatment of chronic low back pain. The authors also reported that Duloxetine received approval for treatment of chronic low back pain in 2010. In sum, the requested medication is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested integrated pain management for treatment of her Crohns disease and pain disorder.  Findings:  The physician reviewer found that Currie and colleagues published a study describing outcome evaluations of a pain management program adapted to the needs of patients diagnosed with concurrent pain and substance abuse disorders. The authors concluded that patients with concurrent chronic pain and recovering substance abuse were responsive to an integrated treatment model of pain management and relapse prevention. The patient in this case is more likely to benefit from an integrated pain management program if she works toward abstinence from cannabis. Chelminski and colleagues performed a clinical trial to evaluate the effectiveness of a multi-disciplinary pain management program for opioid-treated patients with psychiatric co-morbidity and disability. The authors concluded that a primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to follow-up. The patient has multiple medical problems, including psychiatric disorders. Consistent with these findings, the requested integrated pain management program is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested  stereotactic body radiation therapy (SBRT) for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the patient presented to his provider with an elevated prostate specific antigen (PSA) of 7.4. The patient was found to have Gleason score 3+3 adenocarcinoma stage T1c prostate cancer without evidence of perineural invasion. Currently, large scale and long-term clinical trials comparing SBRT with or without CyberKnife to standard treatments are not available. The National Comprehensive Cancer Network (NCCN) guidelines state that further studies are needed prior to recommending SBRT as standard therapy for patients with localized prostate cancer. Further, there are no clinical studies demonstrating superior efficacy or safety over the current standard treatments for prostate cancer. Given the lack of reliable scientific data showing improved health outcomes with SBRT over standard alternatives, including surveillance, the requested therapy is not likely to be more beneficial for treatment of this patients prostate cancer than any available modality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a reduction mammoplasty for treatment of her status post breast augmentation.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The reviewed records support the existence of an extracapsular ruptured silicone implant on the right and capsular contracture on the left.  The records do not support the existence of macromastia or any macromastia related symptoms given the absence of shoulder bra strap grooving in the photographs.  The requested mammoplasty is not likely to relieve the patients symptoms.  The patients breasts will not constitute an abnormal structure of the body following breast implant removal and capsulectomy.  All told, the requested reduction mammoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the patient presented to the Emergency Department (ED) in the morning of the date in question with a chief complaint of awakening with congestion in his right ear.  The pain level was documented by the triage nurse to be 5 out of 10 or moderate pain.  The treating physician noted that the patient was non-toxic and afebrile and that the right tympanic membrane is red and dull.  No treatment was rendered in the ED.  The diagnosis was right otitis media and the patient was prescribed azithromycin (an antibiotic) and Vicodin (an opioid pain medication).  He was discharged from the ED with follow-up instructions to see his primary care physician if he did not improve within three days.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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 was noted to be non-toxic looking and afebrile in the ED. In this case, the patients pain level was documented by the triage nurse to be only moderate, which is a determinative factor.  Given the absence of a severe level of pain as well as any other acute symptoms such as fever or significant swelling, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention in an emergency room. 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Botox injections for treatment of the enrollees migraines.  Findings:  Two physician reviewers found that the patient has been diagnosed with migraine, status migrainosus, chronic migraine, medication overuse, and myofascial pain. Her baseline headache frequency is not stated. Her attacks are reported to last four days. She has been treated with triptans and opiates. She has been receiving Botox treatment for approximately two years. The providers clinical notes indicate that Botox has been effective in managing the patients pain. With it, her attacks are infrequent, and headaches are reported to be better responsive to abortive medications. The Health Plan has denied the patients request for coverage for Botox, stating that Botox is experimental and investigational for muscle pain. The medical records document a diagnosis of chronic migraine. The specific terms of numbers of headache days is not documented. Muscle pain is common in patients with migraine, with 60 to 80% of migraine patients reporting neck and shoulder pain. The presence of muscle pain in migraine patients does not indicate a diagnosis of a non-migraine source of pain. Botox has been demonstrated to be effective for the treatment of chronic migraine, with the standard treatment patterns including areas within the neck and shoulder that can be sensitive and sore in migraine patients. The literature documents that Botox is effective for the management of chronic migraine. Neck pain, often diagnosed as cervicogenic headache, is frequently a component of migraine, as documented in the literature. This patients treatments have been consistent with the FDA approved treatment paradigm, and her benefit has been documented in the chart. Thus, it appears she is being treated for chronic migraine for which Botox is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for laser treatment for treatment of the enrollees growth on his scrotum.  Findings:  The physician reviewer found that angiokeratoma of the scrotum, also known as angiokeratoma of Fordyce, is a common benign cutaneous lesion of capillaries, resulting in small marks of red to blue color with a horny overgrowth. These vascular lesions may be single and discrete or arranged in clusters. New lesions are red, soft and compressible, while the older lesions may be firm and non-compressible, often keratotic. The lesions of angiokeratoma may be asymptomatic, while in some cases there may be itching. Associated fungal eczema of scrotum/groin may lead to trauma and chronic irritation causing changes in the vessel wall in susceptible individuals. Histologically, this vascular disorder occurs in the papillary dermis and characterized by dermal vascular ectasia with overlying hyperkeratosis of the epidermis (Pahwa, et al). Although angiokeratomas of Fordyce usually do not need to be treated, they can be treated because of cosmetic concerns or bleeding that causes anxiety to the patient. It can be challenging to treat when lesions occur in large numbers. Treatments include surgery or locally destructive treatment modalities. Surgical excision or locally destructive methods such as electrocoagulation or cryotherapy may be used. Excision is not practical if there are many lesions, and electrocoagulation and cryotherapy may not be suitable for diffuse patterns. These modalities can cause hypopigmentation, hyperpigmentation, and atrophic scarring. Several vascular lasers have been used successfully to treat angiokeratoma of Fordyce with minimal side effects. In addition, ablative lasers such as carbon dioxide and erbium-doped yttrium aluminum garnet lasers have been used to remove the hyperkeratotic epidermis before treatment with a vascular laser (Civas, et al). Based on review of the available records, the patients angiokeratomas represent a cosmetic problem. There are no documented complications such as frequent bleeding. Therefore, treatment does not appear to be medically necessary at this point in time. Because angiokeratomas are not tumors, these do not qualify for reconstructive surgery. Consistent with these findings, the requested services are not reconstructive in nature or medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment level of care from a specific date and forward for treatment of the enrollees bulimia nervosa. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) and the American Psychiatric Association (APA) clinical practice guidelines recommend residential treatment for patients 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. Based on review of the available records, residential placement was recommended by the patients providers who know the patient has not yet integrated the sustained learned behaviors or consolidated the treatment gains necessary to break the negative schemas, pathological symptom complex and self-defeating coping strategies which keep her from succeeding in the community. Further, the patient had previously failed treatment in a less restrictive setting and poses an imminent risk that her complex psychosocial stressors will produce enough distress to undermine treatment in a lower level of care. As such, discharge from residential level of care would place the patient at risk for acute hospitalization. Accordingly, residential treatment services were and are medically necessary for treatment of the patients medical conditions and should be covered from the date in question and forward.