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 additional speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this patient initially presented with expressive and receptive language delay and verbal apraxia. Verbal apraxia, or apraxia of speech, is an impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders that affect the brain, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. While this patient has significantly improved with prior therapeutic interventions, such that verbal apraxia is no longer considered to be a concern, he continues to have difficulties with expressive and receptive language and articulation skills. Speech therapy is therefore medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 75-year-old female enrollee has requested speech therapy (cognitive therapy) for the treatment of the enrollee, who is status post stroke. Findings:  Three physician reviewers found that the use of speech therapy to assist with cognitive problems related to stroke is well-established and accepted. The evaluation of the patient was comprehensive and established problems with memory that were associated with communication processing. The resultant therapy, including the use of compensatory mechanisms, produced an improvement in the patients function. The submitted clinical evidence documents the gains achieved by the patient with speech therapy. She has not yet plateaued and is likely to derive further benefit from continued therapy. No other modality is likely to be more efficacious in this setting than the disputed therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested a Flexitouch System (multi-chamber programmable lymphedema pump) for the treatment of her lymphedema. Findings:  The physician reviewer found that genital and truncal swelling in patients with lymphedema are often associated with standard pumps which treat only the limb and apply static pressures. The provider indicated that he specifically prescribed a Flexitouch System for this patient because the patient had failed treatment with a standard pump and the Flexitouch System has the ability to treat her right lower extremity and truncal/genital lymphedema. Although the published medical literature regarding treatment of lymphedema in a situation such as this is limited, the rationale for use of the Flexitouch System in this particular case is well-supported by the patients provider.  The patient has clearly failed treatment with a standard lymphedema pump. The continued use of a standard pump is contraindicated for this patient as the device was ineffective and resulted in clinical problems of very notable concern. The patient has had documented improvement with the use of the Flexitouch System as evidenced by decreased swelling in her lower extremity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested an eating disorder partial hospital program for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient has an eating disorder characterized by binging, restrictive patterns, purging, excessive exercise and intrusive thinking about her body and eating. She carries diagnoses of co-occurring diagnoses (PTSD, severe depression and marijuana dependence) and her psychiatric symptoms include panic attacks as well as suicidal ideation with a history of attempts in the past. Her acceptance of treatment seems adequate (with frequent statements about her trying to pursue healthier choices) although throughout the documentation she continues to manifest symptoms of her eating disorder (with episodes of excessive exercise, restrictive and binging eating patterns and preoccupation with her body). The psychiatrist also states that the patient was eating meals outside of the program in an effort to catch up to the controlled meals she received in the partial hospitalization program (PHP). When this information is measured against published standards regarding in what environment treatment for an eating disorder should occur, the patient meets the criteria for a PHP level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested treatment for obsessive compulsive disorder and treatment for alcohol abuse for the treatment of his dual diagnosis. Findings:  The physician reviewer found that this patient has clearly experienced significant impairment from his obsessions and compulsions, which are documented as extreme and severe. This patients troubles stem from alcohol dependence as well as his OCD, and the two appear to be interconnected. Mancebo and colleagues concluded that 27% of the 323 patients with documented OCD met the lifetime criteria for a substance use disorder (SUD). Of those who reported an SUD, 70% were found to have a diagnosis of OCD at least 1 year prior to SUD onset. In addition, patients with onset of OCD at a younger age have been associated with increased risk of alcohol use disorders. From the descriptions of the patients presentation throughout treatment and the continuation of care required to assist him with daily functioning, it was medically appropriate for him to receive partial hospitalization program services for both OCD and alcohol dependence.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested a neuropsychological evaluation for an evaluation of her memory loss. Findings:  The physician reviewer found that the requested neuropsychological evaluation is medically necessary for this patient in order to properly investigate causes for her memory loss which may include: the extent of her hypoxia during the seizures that she experienced after the birth of her child; structural brain issues caused by those seizures; the epilepsy disease itself; and the effect of medications that she is taking. Neuropsychological testing is part of the standard neurological assessment for patients with epilepsy of this level of severity. The patients memory loss may be caused by a variety of factors. These factors need to be clarified in order to guide her treatment course and improve her quality of life.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a colonoscopy for an evaluation of the enrollee, who has a personal history of colon polyps. Findings:  The physician reviewer found that this patient does not have rectal bleeding and is otherwise asymptomatic. Per the American College of Gastroenterology (ACG) guidelines for colorectal cancer screening and other references, more frequent screening is indicated for patients with two first degree relatives with a history of colorectal cancer or advanced adenomas. While the patient reports a family history of colorectal cancer, the submitted medical records do not document this history. Therefore, the Health Plans denial should be upheld at this time. If objective documentation is provided which demonstrates a family history of colorectal cancer/advanced adenomas in the patients father and brother, or that her fathers colorectal cancer was diagnosed at age 60 or younger, then a screening colonoscopy would be indicated for this patient every five years per ACG guidelines and the requested diagnostic procedure should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested sleeve gastrectomy for the treatment of her morbid obesity. Findings:  The physician reviewer found that the laparoscopic vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of morbid obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of morbid or super morbid obesity in the well selected patient such as this patient. As with any weight loss surgical procedure, the patient should undergo appropriate pre-surgical workup including psychological evaluation, dietary evaluation and documentation of normal TSH level prior to the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Hyalgan injections for the treatment of his advanced degenerative arthritis. Findings:  The physician reviewer found that the use of viscosupplementation in the treatment of osteoarthritis of the knee has been shown to be effective and safe, as noted by Brzusek and Petron. A series of three to five injections constitutes one treatment, depending on the particular medication utilized. In the case of Hyalgan, five injections are usual. Repeated courses of treatment may be of value if there was a good response to the initial course and a period of time, usually six months, has passed. There does not appear to be a problem with repeated courses of therapy, other than a slight increase of local adverse events. Hyalgan may also have a beneficial effect on the articular cartilage structure, as noted by Amiel and colleagues. This patient has undergone one course of treatment, with good result. Recurrent problems have been documented, and he has a history of NSAID use with evidence of intolerance. A repeated course of Hyalgan was recommended five months after the initial course. Thus, the criteria for a repeated series of Hyalgan injections are documented. Hyalgan injections were and are indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested speech therapy for the treatment of his medical condition. Findings:  The physician reviewer found that the patient was over two years post injury. He continued to have profound cognitive deficits across all domains despite a prolonged course of supervised cognitive linguistic therapy (speech therapy). Although he did show some improvement in pre-functional gains, it was unlikely that additional speech therapy would result in significant functional gains in a reasonable and/or predictable period of time. In fact, significant gains were not achieved as the patients therapist notes that functional communication remains moderately to severely disordered. Available literature supporting the efficacy of cognitive rehabilitation for traumatic brain injury is limited. Standard clinical practice two years post injury would involve transition to a home program and participation in computer-based therapeutic activities. As such, speech therapy services during the period at issue were not medically indicated. Nor is additional speech therapy currently indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Cialis (for 16 20 mg tablets/month) for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction after a radical prostatectomy (performed with or without robotic-assisted laparoscopic techniques) is not uncommon. The treatment of this problem is being investigated in many centers. The role of the early use of phosphodiesterase inhibitors (such as Cialis) is still not proven. The dosage, frequency of dosing and duration of dosing are still being investigated. The need for a mechanical device, in addition to use of this class of drug is also being investigated. The Health Plan did allow six months of every other day dosing of a phosphodiesterase inhibitor post-surgery, but after six months the allowance of six tablets of Cialis (20 mg) per month is appropriate in this clinical situation and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested nuclear imaging studies for an evaluation of his chest pain. Findings:  The physician reviewer found that this patient has some cardiac risk, including advanced age and hyperlipidemia. He also has symptoms highly suggestive of coronary ischemia and findings of provokable ischemia on routine treadmill testing, as evidenced by both reproducible chest discomfort and ischemic ECG changes. In this circumstance, the post-test likelihood of significant obstructive coronary disease is very high, such that additional noninvasive nuclear stress testing is not medically indicated. The patients routine treadmill exercise test results were not equivocal or borderline to warrant additional noninvasive diagnostic testing. Current guidelines that are endorsed by several national organizations consider nuclear stress testing appropriate in the setting of a recent stress test only if results are equivocal or borderline. In this circumstance, the diagnosis is secured such that appropriate treatment should include aggressive risk factor reduction according to secondary prevention guidelines and consideration of invasive coronary angiography if revascularization is thought to be medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested intensive outpatient therapy for the treatment of her eating disorder and depression. Findings:  The physician reviewer found that this patient has a long history of body image issues as well as a history positive for binging and purging. She has been amenorrheic. Her amenorrhea, obsessions about her body, and a tendency to alternately binge, restrict and purge have persisted. She is also obsessed with exercise, and has a history of laxative abuse as well as self-induced vomiting. She has been alternately underweight and normal weight. She has had symptoms of depression, which commonly arises in patients with eating disorders. She has a history of self injurious behaviors, including cutting. Treatment of this patients eating disorder through intensive outpatient therapy was appropriate and consistent with the standards of clinical practice for management of patients with similar symptoms.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 60-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. Review of the submitted clinical evidence demonstrates that this patient complained of swelling and pain in the neck as well as in his left ear. No diagnostic testing was performed although these symptoms could reasonably have engendered a cardiac work-up to include an electrocardiogram, chest x-ray, complete blood count, chemistry panel, and Troponin levels. The treating provider did not quantify the severity of the patients neck pain or order diagnostic tests. As such, the patients diagnosis of superior vena cava syndrome was not discovered at that time. However, this does not negate the fact that the patient had a bona fide emergency at the time of his presentation to the ED. Superior vena cava syndrome commonly occurs with lung cancer. A tumor in the chest or swollen lymph nodes can press on the superior vena cava, blocking the blood flow, and thus cause symptoms that would lead a prudent layperson to seek immediate medical attention. All told, the patient had an emergency medical condition and needed to be seen in the ED. The patients final diagnoses are life-threatening medical problems and a prudent layperson would have reasonably believed his life to be in peril without immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B. Findings:  The physician reviewer found that This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009. Most primary care physicians are not familiar with the guidelines for the treatment of hepatitis B. The expertise and experience of gastroenterologists and hepatologists are needed for monitoring patients with hepatitis B. These specialists are familiar with antiviral therapy for hepatitis B, including the efficacy, resistance profile and stopping rules. These specialists also have the required expertise for monitoring for viral breakthrough and surveillance for hepatocellular carcinoma. Follow-up care with the patients gastroenterologist is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested acute inpatient hospitalization for the treatment of his bipolar affective disorder and mental and behavioral disorder due to alcohol use. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient continued to require an acute inpatient level of care during the period at issue. The patients providers described the patient as a potentially vulnerable patient whose clinical course was complicated by his comorbid bipolar illness. The patient seemed motivated for treatment. A significant new stressor during the dates of services at issue was his relatives diagnosis of recurrent breast cancer. Such a stressor further supports the medical necessity of continued acute inpatient hospitalization, especially considering the patients history of recidivism, serious comorbid condition and lack of psychosocial support. Additionally, he was just beginning to stabilize on his medications. Thus, acute inpatient hospitalization provided during the period at issue was medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested urgent care services for the treatment of the enrollee's 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. Review of the submitted clinical evidence demonstrates that this patients pain was acute in nature as it had reportedly started earlier that same day. The patients vital signs were normal and no elevated temperature was recorded. In consideration of the patients age, there are several common causes of knee pain in patients without a history of trauma, none of which are likely to require emergent or urgent treatment. In the absence of any additional symptoms, including fever or intense pain on slight movement, infection was also unlikely. Given this patients history and the physical findings on examination, although the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to his health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested rhinoplasty for the treatment of the enrollees nasal obstruction/deformity secondary to post-traumatic nasal deformity with nasal bone fracture. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates a structural abnormality in the patients nose. This structural abnormality was the result of trauma. The proposed procedure is being performed to improve the function of breathing. The procedure will offer more than a minimal improvement in the appearance by straightening the septum and correcting the collapsed lateral nasal wall (middle nasal vault). As such, the proposed rhinoplasty meets the requirements of reconstructive surgery as defined by California law. The requested procedure is also medically necessary in this case. Proper correction of the twisted nose with a significant caudal septal deviation, collapsed middle vault, and fractured nasal pyramid (bones) requires an open structure rhinoplasty approach. The patients breathing problems cannot be corrected with a septoplasty alone since the collapsed upper lateral cartilage must also be corrected using spreader grafts. In addition, osteotomy and straightening of the collapsed nasal bones must be carried out. Finally, in order to prevent the need for another operation in a few years, the significant deviation of the caudal septum has to be corrected by cutting the cartilage and re-positioning it into the columella and securing it to the lower lateral cartilage and the nasal floor. This can only be accomplished using an open rhinoplasty approach.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested scar excision/revision for the treatment of her keloid. Findings:  The physician reviewer found that the submitted documentation does not support the presence of an abnormal structure of the body in the patient caused by congenital defects, developmental abnormalities, infection, trauma, tumor or disease. The submitted medical record documentation does not demonstrate that the excess tissue is so great so as to be considered abnormal. The keloid would have to be quite large to be considered an abnormal structure. Thus, the California statute regarding reconstructive surgery does not apply. With regard to general concepts of medical necessity, the presence of a keloid scar in and of itself does not make its removal medically necessary. It must be established that the procedure is necessary to improve functional impairment or relieve symptoms caused by the keloid. In the absence of objective, medical chart documentation of impaired function, such as blockage of the ear canal or impaired range of motion, and/or symptoms, such as pain, itching or infection, the proposed removal of the patients keloid scar is not necessary from a medical standpoint.