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

A 41-year-old female enrollee has requested bilateral breast reduction for treatment of her symptomatic mammary hypertrophy.  Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) has guidelines for determination. The ASPS state that, based on the results of level I and II evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Based on the patients complaints of upper back, neck and shoulder pain, and shoulder grooving, photographs documenting severe macromastia and shoulder grooving as well as her examination detail satisfies these guidelines established by ASPS. Her breast macromastia had impacted her quality of life and she has chronic back and neck pain and shoulder grooving that has failed non-operative management.  Her photographs support these findings as well. Based on this, her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. Further, the patient has an abnormal appearance as seen in the photographs and breast reduction is well-known to establish a relatively normal appearance. Her entire clinical picture is one of a functional problem, but her appearance would be significantly improved as well. The planned procedure is for improving function related to significant pain of the back, neck and shoulders as a direct result of the well-documented macromastia. Consistent with these findings, the requested surgery is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested bariatric surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, although this patients records support a diagnosis of clinically severe obesity with a BMI of at least 35 with history of sleep apnea, the medical necessity for bariatric surgery is not supported at this time. The patients records do not include documentation of previous dietary efforts. In addition, there is no documentation of any multidisciplinary evaluation that would include medical clearance, dietary evaluation and behavioral evaluation as part of standard nationally accepted criteria such as the National Institutes of Health (NIH) consensus guidelines. Therefore, the requested surgery is not medically necessary for treatment of this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested minimally invasive lumbar decompression (MILD) for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence has not established the long-term safety and efficacy of the requested services.  Chopko and Caraway reported on 78 patients who had undergone the MILD procedure.  Six-week follow-up was obtained on 75 patients. Although outcomes were generally favorable, this follow-up period is too short to draw conclusions from this study.  Lingreen and Grider reported on 42 patients who experienced some relief of symptoms immediately after the procedure, but the period of follow-up was limited to the perioperative period.  Mekhail and colleagues reported on 58 patients who underwent the MILD procedure.  One-year data showed significant reduction of pain as measured by the visual analog scale.  However, this was not a controlled or randomized trial comparing MILD to other procedures, such as standard laminectomy.  Also, the one-year follow-up period is not long enough to determine the efficacy of this procedure.  All told, the requested MILD procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested a power wheelchair for treatment of her cerebral palsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records forwarded for review indicate that the patient has fair to good strength in her limbs.  She is ambulatory in the home environment, but she has sustained falls.  The patients residence does not have wheelchair-accessible ingress/egress.  Her needs with respect to mobility-related activities of daily living in the home could be resolved with an assistive device such as a cane, walker or manual wheelchair.  A power mobility device is not medically necessary for this patient given that her mobility deficits in the home can be addressed by other means.  Ongoing exercise through ambulation aided with an appropriate assistive device would be expected to provide significant health benefits use over power wheelchair use.  All told, the requested power wheelchair is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested transforaminal selective nerve root block (SNRB) right L5 (CPT code 64483) for treatment of her complex regional pain syndrome of the lower limb.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested transforaminal (SNRB) right L5. It appears SNRB of the right L5 nerve root has been proposed to confirm that the pain sensation is being transmitted by the L5 nerve root; if so, a radiofrequency procedure will then be performed to modulate the L5 nerve roots ability to transmit pain signals. There is a lack of documentation within the current medical literature of the prognostic value of selective nerve root block (SNRB) followed by radiofrequency ablation of the dorsal root ganglion in complex regional pain syndrome. Its place in the treatment algorithm for this clinical condition does not yet rise to meet generally accepted standards of care. Further studies are needed in order to establish the prognostic benefit of SNRB in this clinical setting. Moreover, there is a lack of evidence to support the therapeutic use of SNRB in this case, as the submitted clinical documentation does not provide confirmatory evidence of radiculopathy based on clinical exam, MRI or CT imaging of the lumbar spine, or electrodiagnostic studies. In conclusion, the medical necessity of SNRB for treatment of this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested continued care at an inpatient hospitalization level of care facility for treatment of his depression and anorexia.  Findings:  The physician reviewer found that in this patients case, discharge on the date in question would have been premature as he continues to have insomnia, social isolation and depression with suicidal ideation and plan. His providers are concerned regarding his pattern of weight gain and the success of the re-feeding stage. As of the most recent note, the patient remained plagued by a prominent affective disorder, with questionable cognitive impairment and multiple risk factors for suicide, and had not demonstrated the consolidation of treatment that would allow for success in a less restrictive setting. Thus, he requires continued specialty care and 24-hour supervision to cement the therapeutic skills necessary for success. Consistent with these findings, the services at issue were and are medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis.  Findings:  Three physician reviewers found that the requested Orthovisc injections are not likely to be of greater benefit than other treatment options in this clinical setting.  This patient has right knee osteoarthritis.  Her prior treatment has included two series of viscosupplementation therapy.  Per the current medical literature, more than two series of injections have not been proven efficacious.  In sum, there is a lack of support for the requested services for the treatment of this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that the medical documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support Norco in the clinical setting.  Baron and McDonald reported that chronic use of high-dose opiates may contribute to pain sensitization via opioid-induced hyperalgesia.  Chronic opiates may also cause adverse outcomes, as noted by Ballantyne and Mao.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested continued partial hospital program (PHP) level of care services for treatment of her bulimia nervosa. Findings:  The physician reviewer found the patient has been receiving comprehensive services. She has made clinical progress in some areas including improved family dynamics as evidenced by the positive therapy session and the ability to take a short hiatus from the program. However, the patient has continued to struggle with emotional dysregulation, anxiety, impulsivity and eating disordered behavior despite psychotherapy and modification to her psychotropic medication regimen. Overall, the patient remains symptomatic with significant impairment due to her psychiatric condition and has not consolidated the treatment gains necessary to succeed in a less restrictive setting. Although efforts should be geared to mobilize this patient to an intensive outpatient program (IOP), discharging her from PHP at this time would most likely result in relapse requiring re-admission to PHP or a higher level of care. Thus, continued partial hospitalization is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested total left knee replacement for treatment of her left knee pain. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The American Academy of Orthopaedic Surgeons recommend patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low impact aerobic exercises, neuromuscular education and physical activity. In this patients case the there is a lack of documentation indicating that physical therapy has been tried and failed. The documentation submitted also indicates that this patient has a lumbosacral condition with abnormal nerve root morphology suggesting that there may be an overlapping radicular component to her knee pain. In sum, further attempts with conservative treatments are required before the medical necessity of total joint replacement is established. As such, the requested procedure is not considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her status post silicone breast implant placement.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this patients case.  There is a lack of physical findings or documented clinical suspicion suggesting rupture.  The Health Plan has offered evaluation with mammogram and ultrasound, which is the appropriate first-line of accepted imaging in this clinical setting.  There is a lack of support for the requested breast MRI in this case.  If evaluation with mammogram and ultrasound are non-diagnostic or equivocal, then further evaluation with breast MRI may be considered.  However, absent evaluation with these accepted first-line imaging modalities, the medical necessity of the requested breast MRI cannot be established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested intensive outpatient program mental health treatment for his polysubstance abuse.   Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity for the services at issue. This patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. Throughout his treatment he was frequently withdrawn, even blunted. To decrease services in such a scenario is inconsistent with accepted medical practice. In the absence of intensive outpatient programming, the patient will likely relapse and endure undue morbidity and may require treatment at a higher level of care and/or face a poor clinical outcome. This patient requires a period of sustained sobriety along with improved insight, optimization of his psychosocial support system and enhanced coping strategies to impart meaningful change and foster independent, successful and drug-free living. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were and are medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested continued transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  TMS therapy carries less risk when compared to electroconvulsive therapy.  Additionally, TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this particular case, the patient received TMS during an acute depressive episode and achieved a significant clinical response, if not remission.  However, the utility of TMS in long-term and/or maintenance treatment for major depressive disorder has not been established by the scientific community.  Thus, there is a lack of support for TMS therapy from the said date forward in this clinical setting.  The application of TMS as maintenance, preventative or long-term therapy for major depressive disorder is not supported by the current medical evidence.  All told, TMS therapy during this time frame was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 19-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of his behavioral health condition. Findings:  The physician reviewer found that acute psychiatric hospitalization was initially indicated for this young man with a history of violent behavior and emotional dysregulation. Due to the patients unpredictable aggressiveness at home, he was placed on an involuntary hold. During the hospitalization, the patient was not witnessed to be violent by staff.  Per the physician transfer of care note on the specified date, the patients boundary mismanagement and social inappropriateness were responsive to verbal de-escalation and redirection. Although the patient demonstrated social oddities consistent with the diagnosis, he had a linear flow of thought with unimpaired cognition. Although there was no evidence of grave disability, inability to provide basic self-care, or imminent threat to self, during a family meeting it was reported that the patient remained violent and threatening outside of staffs awareness, effectively raising the concern for on-going threat to others and underscoring the importance of a coordinated discharge to a group home. In reading the social work note, it is inferred that appropriate facilities were available for discharge.Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the medical necessity of inpatient psychiatric hospital services to the present and onward has been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested balloon sinuplasty of bilateral maxillary sinuses for treatment of her chronic sinusitis.  Findings:  Two physician reviewers found that the underlying principles of the technique of balloon sinuplasty of bilateral maxillary, which is the strategy of modifying and/or opening the pathways to facilitate presumably impaired sinus mucous drainage has been articulated and supported in the medical literature. The means of visualization and instrumentation has evolved over the years, but the concept and goals of many of the operations have not. Current imaging and visualization techniques using a balloon instead of a metal dilator, allow this more focused approach to the underlying strategy to be resumed. In this case, the absence of radiologic evidence of a (architecturally) blocked sinus opening only means that functionally, the patient had blockage. Thus, the procedure at issue provided the exact combination of probable success without exposing the patient to inappropriate risk. Therefore, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested 5 hours per week of direct care (code H2019), 4 hours per week of supervision (code H0032) and 8 hours per month of parent consultation (code H0032) of applied behavioral analysis (ABA) services for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Kelley et al). Granpeesheh and colleagues note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey et al). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Grey et al). The goals for older children are frequently to identify and remediate particular deficits.Treatments based on operant principles of learning have been noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey et al). The behaviors in this patient to address include maladaptive behaviors of communication and noncompliance, and increasing functional life skills. Improvement has been noted with the patients current ABA plan. Continued ABA therapy including parent consultation/training is medically necessary to effectuate further gains. The proposed frequency of 5 hours per week of direct care (code H2019), 4 hours per week of supervision (code H0032) and 8 hours per month of parent consultation is medically reasonable and appropriate based upon this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested morphine for treatment of her chronic pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has reported divergence by self-injecting morphine. It is noted that the patient violated her pain contract. The patients morphine was prescribed as a tablet and her provider indicated that morphine as an injectable was not an appropriate manner of taking the medication. The patient recently had an abscess to her right shoulder due to her injection techniques. Given the patients divergence from her pain medicine contract, the Health Plans recommendation that she follow-up with the Chronic Pain Department and the Chemical Dependency Recovery Program for a treatment plan that includes non-opiate medications and modalities is medically reasonable and appropriate. As such, the requested morphine is not considered medically necessary.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested emergency dental services. Findings:  The physician reviewer found that 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. In this patients case, she presented with severe dental pain.  Given the diagnosis of irreversible pulpitis of several maxillary teeth, it is reasonable to assume that a prudent layperson would have sought immediate medical attention.  The patients severe pain would have likely affected her oral intake and left untreated would have placed the patient at risk for a significant risk for infection given the diagnosis of irreversible pulpitis. The patients symptoms during the dates of service at issue met prudent layperson criteria for emergency care. The services provided during this period were required to stabilize the patients condition and alleviate her severe pain which rose to the level of an emergency medical condition. The patients condition did not stabilize such that she no longer required emergency care until after the date of discharge.  A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize her health in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  There is adequate support in the peer-reviewed literature for transcranial magnetic stimulation in this clinical setting.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies used to combat depression.  Considering the medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, transcranial magnetic stimulation is an appropriate treatment.  All told, TMS therapy is medically indicated for the treatment of this patient.