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

A 60-year-old female enrollee has requested x-rays of the soft tissue, sinus x-rays and computer muscle testing for an evaluation of her chronic headaches accompanied by atypical facial pain, temporomandibular joint sounds on opening and closing of the jaw, dizziness and bilateral cervicalgia. Findings:  The physician reviewer found that the current, well-accepted, universally performed test to identify the presence or absence of temporomandibular disorders or one of its subcategories is a comprehensive evaluation of the patients history and clinical examination. This is considered the gold standard by some. There are many other tests and diagnostic studies that are employed in the treatment of temporomandibular disorders, such as surface/needle EMG, thermography, sonography and mandibular kinesiology (jaw tracking). However, the evidence for the use of these modalities in the differential diagnosis and monitoring of temporomandibular disorders and orofacial pain is not supported in the literature. At present, the well-accepted standard for the diagnosis of temporomandibular joint disorders and orofacial pain is patient history and clinical examination, and, when indicated, select temporomandibular joint imaging. It is also accepted that obtaining temporomandibular joint radiographs to determine whether condyles translate during jaw opening is unnecessary, as that information can be obtained by physical examination. X-rays of the soft tissue, sinus x-rays and computer muscle testing were not medically indicated or appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee has requested orthognathic surgery for the treatment of his mandibular underdevelopment. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patient has a maxillofacial skeletal malformation which has resulted in mandibular hyperplasia with a significant overjet. The patient has a functional deficit in that he has difficulty with mastication. Given the degree of his mandibular hyperplasia, orthognathic surgery is indicated and will result in improved mastication and swallowing and improved musculoskeletal, dento-osseous and soft tissue relationships.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested rituximab infusions for the treatment of her autoimmune disease. Findings:  Two physician reviewers found that this patient has a history of limited Wegeners Granulomatosis (WG) characterized by subglottic stenosis. She has been treated with corticosteroids for three years and has also been treated with methotrexate, which she reportedly failed. Cyclophosphamide is considered the standard therapy for induction of remission in WG. However, it is well known to cause infertility, with the incidence of ovarian failure rising significantly in women in their upper 20s. Because of concern over possible loss of fertility, this iparous patient does not want to take cyclophosphamide. The treating rheumatologist ordered rituximab, but the patients Health Plan denied this treatment on the grounds that it is investigational for this patients condition.The goal of treatment in WG is induction of remission followed by maintenance therapy. A common treatment regimen is corticosteroids and cyclophosphamide for induction followed by maintenance with an agent less toxic than cyclophosphamide, such as methotrexate or azathioprine. In this patient, however, cyclophosphamide is relatively contraindicated because of the fertility issue. It has been documented that she failed treatment with methotrexate. Several uncontrolled studies have shown a beneficial effect of rituximab in refractory, limited WG and in refractory antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis. Rituximab is a rational therapy since depletion of B cells by this drug would be expected to reduce the titer of antineutrophil cytoplasmic antibodies. A number of case reports have documented clinical improvement in refractory WG after treatment with rituximab (see Tamura and colleagues).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested bariatric Lap Band surgery for the treatment of her obesity. Findings:  The physician reviewer found that Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for treatment of morbid obesity. Considering this patients BMI and co-morbid conditions, she is an appropriate candidate for weight loss surgery. Furthermore, the medical literature has consistently shown the Lap Band is efficacious and is associated with less morbidity than the Roux-en-Y gastric bypass or the duodenal switch procedure. The Lap Band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested inpatient residential treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient had been consuming an enormous amount of nitrous oxide, alongside a substantial amount of alcohol at the time of her admission to residential treatment. In addition, a diagnosis of PTSD had been made and the patient presented as depressed and clearly unable to desist from drug and alcohol use. There is notation within the submitted medical records of her still very much craving return to use of nitrous oxide. Given the very serious consequences of continued nitrous oxide abuse, as noted in the aforementioned references, this patient required the level of supervision afforded by a residential level of care. The patient should continue at this level of care through the planned discharge date.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Provigil for the treatment of her multiple sclerosis. Findings:  Three physician reviewers found that fatigue is a very common complaint associated with multiple sclerosis. Apart from life changes, rest, and aerobic therapy, there are very few pharmacological interventions that have shown benefit. Amantadine has been used with statistically significant but rather mild success. Two studies have been published in the medical literature suggesting the beneficial effects of Provigil in treating MS-induced fatigue. Provigil is a unique wake-promoting agent that is chemically distinct from traditional stimulants. Zifko and colleagues presented an open-label study showing that Provigil significantly improves fatigue and sleepiness and is well-tolerated by patients with MS. Rammohan and colleagues concluded in a two-center phase II study that 200 mg/day of Provigil significantly improves fatigues and is well-tolerated in patients with MS.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a referral with a foot specialist for the treatment of her nerve problem. Findings:  The physician reviewer found that it appears medically necessary for the patient to have a consultation with a foot specialist (i.e., a podiatrist) to treat her foot pain/neuroma. This patient has had foot pain for three months. The foot pain has not responded to 10 days of non-steroidal anti-inflammatory drugs (NSAIDs). Neuromas are physically enlarged nerves and rarely respond to any conservative care and it may be necessary for a podiatrist to institute local steroid injections or fabricate orthotics with a neuroma pad. In addition, a podiatrist may more accurately assess the efficacy of the treatment and transition into surgical treatment if necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Reclast for the treatment of her osteopenia. Findings:  The physician reviewer found that none of this patients fracture risk assessment tool (FRAX) scores reach levels requiring treatment with Reclast or any bisphosphonate treatment. Her T-score is not more than -2.5 standard deviations below the mean. She has not documented history of fracture. By definition, the patient does not have an osteoporotic condition requiring treatment. In a patient with this clinical presentation, the risks of Reclast outweigh the benefits.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested photochemotherapy with UVA for the treatment of her morphea. Findings:  Three physician reviewers found that this patient has progressive localized scleroderma. She has been treated with first-line topical therapies for several months. She has had progression of her original plaques as well as multiple new lesions, despite these treatments. The patient has had an adequate trial of prolonged topical therapy. Continued use of topical steroids will most likely just produce atrophy of the skin overlying the plaques, without improving the underlying sclerosis. Because of the progression and extent of involvement of her disease, it is reasonable to consider other therapies. There are several studies that demonstrate the beneficial effects of photochemotherapy with UVA in the treatment of localized scleroderma. Kroft and colleagues noted that treatment with UVA can shorten the active disease period of localized scleroderma and prevent further disease progression. The requested services are supported by many studies in the medical literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested a custom anterior cruciate ligament (ACL) brace for the treatment of the enrollees torn cartilage. Findings:  The physician reviewer found that the use of a custom anterior cruciate sparing knee orthotic or brace as recommended by the treating surgeon appears medically reasonable for this patient following surgical reconstruction. Allograft has been demonstrated to have delayed healing potentials and a properly fitted anterior cruciate sparing brace is likely to be protective during this period of time. This young patient is identified in the clinical record as an aggressive sports participant. She will remain vulnerable to recurrent injury but her prognosis improves with use of a custom brace.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested adult mental health partial treatment eating disorder services for the treatment of her eating disorder. Findings:  The physician reviewer found that the submitted clinical evidence indicates that the patient has had a long-standing eating disorder with associated anxiety and depression. The patient was appropriate for partial hospital/day treatment level of care at the time of her admission to the program. However, on the basis of the treatment records, she had made clear and apparent improvement. The physician notes indicate stable weight, no overt eating disorder behavior, no clear indication of a significantly disordered mood, thinking or behavior, and no particular medical problems. Although the patient indicates that she was experiencing anxiety, the latter was not a prominent issue in the physician notes. There was no reason to expect that the patient would regress if discharged. Any relatively minor laboratory abnormalities could be followed on an outpatient basis. It would have been medically prudent and appropriate to treat the patient at a lesser level of care. Therefore, the services provided were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested abdominal surgery for previous umbilical hernia repair with mesh plug to be removed and replaced with a tension free mesh patch and simultaneous repair of surrounding tissues and/or nerves for the treatment of his abdominal and groin pain. Findings:  The physician reviewer found that this patient appears to have incurred a significantly disabling complication after a second periumbilical hernia repair with mesh, under tension. There is data suggesting that foreign body mesh causes a significant fibrotic reaction with contracture in the body at the local area of implantation. It is likely that this eventually resulted in the patients increasing right-sided inguinal discomfort (see Parviz, 2004). This patient now appears to have exhausted all attempts to obtain relief. At this point, explantation of the mesh plug with placement of a flat, completely tension-free mesh repair is medically necessary. Furthermore, with regard to the request to repair the injured nerves, the proper surgical repair would be a triple neurectomy (see Parviz, 2003) which is also medically indicated and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested cefotaxime (Claforan) for the treatment of her Lyme disease. Findings:  Three physician reviewers found that the laboratory testing submitted does not support a diagnosis of Lyme disease in this case. Furthermore, the patient has already received the maximum recommended duration of parenteral therapy for any type or form of Lyme disease. Moreover, long-term antibiotic treatment is associated with known risks and has not been shown to be effective to treat the symptomatology with which the patient presents.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient spent approximately three months in the wilderness program and immediately thereafter was admitted to the residential program at issue. When she left the wilderness program, she was not afforded an opportunity for treatment at a lesser level of care. Thus, she could not have been considered refractory to a lesser level of treatment because such care had not been provided. Her course in the residential facility showed some variation in behavior, but at no time did she become suicidal, homicidal, or psychotic. Her interactions with peers and staff were occasionally problematic but were not of such severity as to require residential care. At no time during her admission did her clinical state necessitate the need for care at a residential level. Residential treatment was not medically necessary because the patient could have been safely and effectively treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a continuous glucose monitor system (CGMS) and the related supplies for the treatment of her type I diabetes. Findings:  The physician reviewer found that this patient suffers from hypoglycemia unawareness, which is clearly documented in the submitted records. She has needed emergency medical services to attend to severe cases of hypoglycemia that lead to coma and seizures. Therefore, the CGMS and related supplies are medically necessary for this patient with brittle, long-standing diabetes mellitus type 1 complicated by frequent hypoglycemic events. The device will alert the patient when a severe glucose excursion occurs during the unattended gaps, which may be asymptomatic and not detected by her standard handheld monitor. The CGMS will prevent the patient from progressing into a life threatening condition such as hypoglycemic coma or diabetes ketoacidosis. She has been unable to bring her HbA1c to any control for fear of hypoglycemia. In the long-term, with CGMS, the patient will likely be able to better control her diabetes mellitus, and prevent diabetic related complications, as documented by the Diabetes Control and Complications Trial Research Group trial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested one-on-one speech therapy and apraxia testing for the treatment of the enrollees apraxia. Findings:  Three physician reviewers found that the submitted evidence demonstrates that the patient has significant speech delay and demonstrates autistic characteristics. The American Speech-Language Clinical Hearing Association indicates that children in this setting benefit from assessment and intervention services provided by speech-language therapists. Greatest efficacy results from early intervention, intensive instruction and individualized objectives. Given that this patient is at least two standard deviations behind in speech, one-on-one speech therapy and apraxia testing are medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer.  Findings:  The physician reviewer found that Avastin does show activity in metastatic disease especially when combined with paclitaxel as reported by Miller and colleagues. These findings are also reported by Chan and colleagues and lend support for the treating oncologists proposed regimen. Abraxane is an alternate formulation of paclitaxel as noted by Ibrahim and colleagues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested Lyrica for the treatment of his limb pain and cervical stenosis. Findings:  The physician reviewer found that this patient has been diagnosed with neuropathic pain resulting from cervical spinal stenosis and has experienced pain relief with the use of Lyrica. Neither fluoxetine nor cyclobenzaprine have showed any efficacy against neuropathic pain and therefore are not indicated for management of this patients symptomatology. Although a tricyclic antidepressant could be used, the side effect profile of Lyrica is much better than any of these medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested subacute residential level of care for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted medical documentation does not support medical necessity for residential level of care. There is no documentation of disruptive behavior, self harm behavior, destructive behavior or severe impairment in social functioning. The physician/nursing notes indicate no psychotic symptoms. The patients thoughts were organized, his affect was mood-congruent and euthymic, and the provider noted no problems with impulse control. Consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) treatment guidelines and the Child and Adolescent Level of Care Utilization System (CALOCUS), the need for residential level treatment is not supported by the medical records provided and a less restrictive level of care was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested bilateral breast implants for the treatment of her breast asymmetry. Findings:  The physician reviewer found that although symmetry is the surgical objective of breast reduction surgery, perfect symmetry of nipples, areolae, and breasts cannot be achieved. Furthermore, the two sides of the human body are not the same and can never be made the same. A patient with preoperative asymmetry prior to surgery will most likely have asymmetry after surgery, even though the surgeon strives to decrease the degree of asymmetry at surgery. No surgeon can guarantee or predict final breast size after breast reduction surgery any more than they can after breast augmentation. The error in the preoperative estimate versus final result can be as high as between 1 and 2 cup sizes. In this patients case, the end result, though not perfect, was within the realm of acceptability for this surgery. Reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease to improve function and/or create a more normal appearance. The patients breast asymmetry would not be considered abnormal and this degree of asymmetry is present in a significant portion of the non-operated public. The patients current condition is normal in that the dog ear and asymmetry are not visibly affected by disease or infection, and the asymmetry is not so great so as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the proposed procedure, the initial surgery was performed to treat a functional problem, namely neck and back pain. Those problems apparently have resolved. No current functional problems relating to the patients breast asymmetry have been documented. Thus, the proposed surgery is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested Supartz injections for the treatment of his bilateral patellofemoral pain. Findings:  The physician reviewer found that the records indicate that viscosupplementation has been used by this patient in the past with good results. Viscosupplementation is FDA approved for treatment of mild to moderate osteoarthritis. While the Health Plan is correct in that the patient is requesting an off-label use of viscosupplementation, these injections have been successful in the past for this particular patient. Given the documented benefits and low risk associated with this therapy, additional Supartz injections are medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Lyrica for the treatment of her lumbar radiculopathy. Findings:  The physician reviewer found that this patient has a persistent neuropathic pain (PHN) syndrome, with neuropathy versus radiculopathy. PHN and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain, due to their relatively high prevalence and thus ease of study. Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes, such as radiculopathy. A literature review documents the broadly useful profile of Lyrica for neuropathic pain, even beyond the FDA indication. This patient has tried and failed standard treatments for neuropathic pain. She has, however, had successful treatment with Lyrica with improved pain and good tolerance. Lyrica is more likely than standard alternatives to benefit this patients neuropathic pain, and is medically necessary for management of her condition.