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

A 44-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.   Findings:  Three physician reviewers found that the indications for breast MRI have been clearly defined by the American Cancer Society. These indications include a patient with a defined high risk of developing breast cancer, someone newly diagnosed with breast cancer, to evaluate extent of disease, assessment of disease after treatment, as well as several other specific indications. Although this patient has a family history of breast cancer, she does not meet the defined criteria for a breast MRI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested  for Vyvanse for treatment of the enrollees attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that Vyvanse is approved by the Food and Drug Administration (FDA) for treatment of ADHD. While d-amphetamine has been used for many years for this indication, Vyvanse is converted into active d-amphetamine throughout the day, having a continuous therapeutic effect. Clinically, long-acting medications are preferred as they prevent multiple dosing and side effects are lessened due to a more continuous and even dispersion.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for Avastin and Abraxane combination therapy for treatment of his metastatic melanoma.   Findings:  Two physician reviewers found that there is essentially no standard therapy for metastatic melanoma. As such, national guidelines often recommend clinical trials in this setting; however, for various reasons most patients are not eligible for participation in such trials. With regard to systemic therapy in this setting, a phase II study of the combination of Avastin/Abraxane has been reported with very promising results (see Rao and colleagues). In addition, Abraxane is a reformulation of paclitaxel, and has in general been found to be more effective and less toxic than native paclitaxel. Paclitaxel is included in national guidelines for melanoma. However, most importantly, this patient has been treated with this combination in the past and has had an excellent response. This is the single best predictor that this regimen is likely to be efficacious for this patient in the future.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for cardiac-gaited cerebral spinal fluid (CSF) flow study performed via magnetic resonance angiography (MRA) and magnetic resonance imaging (MRI) of the brain, cervical spine and lumbar spine for evaluation of the enrollees Chiari 1 malformation.  Findings:  The physician reviewer found that the scientific data comparing the CSF flow patterns in patients who are symptomatic for Chiari 1 malformation with those who are asymptomatic for tonsilar ectopia, is extremely limited. Hofkes and colleagues studied 17 patients with tonsils extending more than 5 mm below the foramen magnum and classified patients as symptomatic for Chiari 1 malformation or asymptomatic for tonsilar ectopia. The CSF flow images of the two groups were read independently in blinded fashion by four neuroradiologists. Of 17 patients, 9 were classified by the neurosurgeon as symptomatic Chiari 1 malformation and 8 as asymptomatic tonsilar ectopia. While the readers detected an abnormal CSF flow pattern significantly more often in patients with symptomatic Chiari 1 malformation than in patients with asymptomatic tonsilar ectopia, the utility of the test is questionable given the low sensitivity and specificity. In addition, the authors cautioned that the non-quantitative nature of the test also limits its current utility.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested the X-Stop interspinous distraction device for treatment of his lumbar spinal stenosis. Findings:  Three physician reviewers found that the Food and Drug Administration (FDA) indicates that X-Stop should not be used with significant instability, and this patients records mention Grade I or Grade II spondylolisthesis, which is suspicious for instability. In addition, X-Stop is not appropriate when a neurogenic bowel or bladder is present. This patients recent urinary retention may be a manifestation of that condition. Moreover, the use of X-Stop remains investigational because it is still being researched in patients to determine the long-term (greater than two years) efficacy and safety. To that end, the FDA has required a five-year study to determine the long-term safety and effectiveness of the device, which is still ongoing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested  for a custom knee brace for treatment of her right knee patellofemoral syndrome.  Findings:  The physician reviewer found that custom knee braces are most effective when there is ACL instability present. This patients records indicate the ACL is intact and there is no evidence of instability. The patient had a posterolateral corner repair and partial meniscectomy. Based on the type and degree of this patients complaints, it is unlikely that a custom brace will result in a superior result in terms of symptom improvement. A standard device with medial and lateral hinges is medically appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for a custom knee brace for treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that there is a lack of support in the peer-reviewed medical literature for the efficacy of bracing after anterior cruciate ligament reconstruction. As noted by Wright and Fetzer, there is a lack of evidence demonstrating that pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. No long-term differences in clinical outcome were identified in patients who wore postoperative braces as compared to those who did not. There have been some reports of decreased pain with brace use in the early postoperative period, but no differences in function or laxity at follow-up, as noted by Brandsson and colleagues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested intensive outpatient program (IOP) treatment four days per week for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient has a multiple symptoms and complaints that appear to emanate from his prior place of work and the stress level he encountered during that employment. The record does not demonstrate that adequate attempts at outpatient therapy have occurred. In addition, the patient has been diagnosed with co-morbid chemical dependence, which untreated, is a contraindication to the requested IOP treatment. Further, the patient continues to take Tramadol and Ativan. Given the patients use of these medications, it does not appear that medical management has been optimized. All told, the submitted clinical evidence does not support the necessity of an IOP level of care for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested for continued residential treatment facility services  for treatment of the enrollees anorexia nervosa. Findings:  The physician reviewer found that it appeared that she was not stable while on an outpatient basis and was referred to the more restrictive and supervised setting of a residential treatment center.  This patient has weekly, if not, daily power struggles with the staff of the residential treatment center. This behavior makes her progress in treatment very slow. There is minimal documentation that she has severe body image distortion issues. The patient has continued to have orthostatic vital signs throughout her stay. She has had abnormal electrolytes and has been suspected of purging by her physician, although she denies these allegations.  Per the American Psychiatric Association guidelines, continued residential treatment facility services from 5/14/10 were medically appropriate.  As of 5/17/10, the patient was at 79% of ideal body weight. She continued to have almost daily orthostatic vitals. Motivation appears to be poor. She is documented on several occasions to have thrown food on the floor. The patient has also been unwilling to make dietary modifications as recommended by the nutritionist. She has struggled with depression and anxiety throughout her treatment. Her psychiatric medication has only been initiated in the past several weeks. The patient has continued episodes of meal avoidance.  She was observed several times by staff running in place, dancing and standing in order to burn calories, despite these activities being against the residential treatment center policy.    Treatment for any condition should be tailored to the individual and based upon the patients progress and ability to be treated at the least restrictive setting, especially for children. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested for Lunesta for treatment of his insomnia. Findings:  The physician reviewer found that the medical studies do not support the contention that Lunesta is less safe and effective than benzodiazepines (which this patient has tried and failed) in the elderly patient population. It is true that all hypnotics can potentially cause undesirable side-effects (as do many other medications), but with proper dosage, indication and follow-up care these effects can be monitored if they occur.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an electric scooter for treatment of her mobility difficulties. Findings:  The physician reviewer found that scooters/power operated vehicles are considered medically necessary when the individual requires the device in order to safely perform activities of daily living in the home setting, as noted by Dicianno and Tovey. In addition, an individual must demonstrate both a willingness and capacity to safely operate the requested scooter in the home environment. In the case under review, the patient has not provided documentation that supports her need for a scooter to perform her activities of daily living or her capacity to safely operate such a vehicle. Although no formal evaluation of her functional mobility has been provided, the notes available for review indicate that she is capable of ambulating with the use of a cane. An electric scooter is not necessary for the patients ambulation within the home.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year and ten-month-old female enrollee has requested for a speech evaluation and speech therapy for treatment of the enrollees expressive language impairment. Findings:  The physician reviewer found that documentation does not support the need of a speech evaluation and speech therapy for this patients isolated expressive language delay. The relevant medical literature does not contain convincing evidence to support the medical necessity of speech evaluation/therapy in a patient such as this patient. This patients physician has repeatedly documented that the patient has good motor skills, great comprehension and bilingual exposure. There is no evidence demonstrating the presence of any deficits other than an isolated expressive language delay which is likely to resolve at the patient matures.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for participation in the requested phase 1-2 clinical trial for Hana Biosciences Marqibo for treatment of her choroidal melanoma with liver and lung metastases.  Findings:  Two physician reviewers found that the rare form of melanoma found in this case is a very uncommon, highly aggressive malignancy for which no standard therapy exists. This patient has been offered the opportunity to participate is a clinical trial specifically for patients with uveal melanoma. As addressed by Houghton and colleagues, in their discussion of the National Comprehensive Cancer Network (NCCN) practice guidelines for melanoma, participation in a clinical trial would be the highest recommendation for this patient and most likely to prolong her survival.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for an increase in Viagra 100mg from 6 to 20 tablets per month for treatment his erectile dysfunction. Findings:  The physician reviewer found that the use of Viagra has been offered for the treatment of erectile dysfunction. Per the medical literature, this medication has a risk of side effects and/or adverse reactions. The medication is titrated so the lowest dosage needed is recommended for the treatment of erectile dysfunction. The number of pills taken per month is not a medical issue, as the medication does not treat the underlying condition or prevent progression.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for photochemotherapy for treatment of her granuloma annulare. Findings:  Two physician reviewers found that photochemotherapy is a well-established and commonly employed first-line option for this patients condition. There is a lack of high-quality data demonstrating that other therapies are likely to result in a superior outcome in this setting as compared to photochemotherapy. Furthermore, photochemotherapy has a more favorable safety profile than other options. As such, photochemotherapy is a more appropriate treatment option for this patient than the standard alternatives available.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for sclerotherapy for treatment of his varicose veins. Findings:  Three physician reviewers found that sclerotherapy is not indicated in this clinical situation. Removal of superficial veins in the face of reflux of larger veins is not standard of care, as the smaller veins may recur. The available medical literature does not support the requested sclerotherapy in this patients case. Tisi and colleagues performed a literature review of the use of sclerotherapy for varicose veins. The authors concluded that the evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins. The use of sclerotherapy as primary therapy for superficial veins in the setting of large saphenous veins remains of unproven long-term efficacy at the present time.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that there were no symptoms that indicated a severe infection. Her migraine began the morning of her emergency room visit. The patient had a history of migraines. A migraine can be a particularly painful condition, and the patient did report nausea and photophobia. Migraine patients can occasionally experience acute episodes of severe pain that require emergency care for relief.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female has requested a Lap-band procedure for treatment of her obesity. Findings:  Two physician reviewers found that according to well-accepted criteria for weight loss surgery, patients with a BMI between 35 and 40 must have significant co-morbidities in order to be considered appropriate candidates for weight loss surgery. This patient has a BMI of 35. The patient also has a history of diabetes mellitus which is considered a significant weight related co-morbid condition. This patient was an appropriate candidate for weight loss surgery. The Lap-band procedure is a well-accepted weight loss method. It is accepted by the American Society of Bariatric Surgeons and the Society of American Gastrointestinal Endoscopic Surgeons as a suitable weight loss procedure in this patient population.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested continuing emergency services for 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 parents circumstances would believe their child 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 documentation indicates the patient was advised to seek post-exposure prophylaxis (PEP) for environmental exposure to bats by the visiting states health department. Rabies is an infection contracted by mammals and spread through contact with an infected animals saliva via bite wounds, open cuts in the skin, or mucus membranes. Once symptoms commence, the disease is almost uniformly fatal. The most important reservoir for rabies in the Unites States are bats. Of the 21 cases of human rabies in the United States between 1996 and 2006, 19 were contracted from bats. However, only half of those patients reported being bitten. Therefore, transmission of rabies from bats has occurred with seemingly unimportant (not-biting) exposure. Accordingly, the Centers for Disease Control (CDC) recommends PEP, when a bat is found indoors with someone who might be unaware that a bite or direct contact had occurred (such as someone sleeping, an unattended child, or a mentally disabled person.) (Marx and colleagues). In this patients case, the PEP protocol was appropriately initiated. In all cases, once the decision has been made for immunoprophylaxis, the entire vaccine series must be completed and hence the patient was advised to return to the emergency department for follow-up service.  The vaccine is generally not carried in any physicians office, but stocked only in the emergency department. As such, a parent in these circumstances would reasonably believe his or her child was at serious risk of harm without the emergency department services on the dates in questions.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient reported a cough for three weeks in duration. The cough was bothersome and prevented her from sleeping at times, but the medical record documents that the patient denied vomiting, chest pain, or shortness of breath. There is no evidence that the patient experienced a sudden worsening of her symptoms.She was in no distress and had normal lung sounds. A nebulizer was administered for symptomatic relief only.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was evaluated in the Emergency Department for right elbow pain that commenced two weeks prior. The pain was located at the medial aspect of the elbow and worsened with range of motion. The patient was diagnosed with tendinitis. At issue in this case is whether a prudent layperson would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient reported that she had experienced the onset of pain two weeks prior to her Emergency department visit. She had not sustained any recent injury. No systemic symptoms were reported. The patient denied any symptoms of a serious health problem, such as redness, fever, swelling or skin changes. Although she had some pain, she had full range of motion without sensory or vascular deficits. The submitted medical record documentation does not demonstrate that the patient was experiencing symptoms that would cause a prudent layperson to believe her health was at serious risk without immediate medical attention. She had not sustained an acute injury and had been experiencing symptoms for two weeks. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis. The patients symptoms on the date of service in question did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.  Further, the submitted clinical evidence does not document the presence of severe pain upon presentation to the Emergency Department.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested the combination treatment of bone replacement graft and guided tissue regeneration for the treatment of her medical condition. Findings:  The physician reviewer found that bone graft replacement on tooth numbers 25 and 30 was medically necessary, but guided tissue regeneration was not medically necessary. This is because the evidence submitted in this case does not support the medically necessity of both the bone grafting and guided tissue membrane placement. Although the medical literature does indicate that in certain situations both materials can work synergistically to improve the result of bone regeneration and reduce pocket depth where bone loss is marked, in this particular case the submitted documentation does not demonstrate that such a condition existed. Based on the information provided, using both procedures, was unnecessary because the bone loss and pocket depths did not appear extensive enough to require each. The pocket depths indicate that the patient, at most, had Class II/(early) Class III periodontal disease. In this situation, the patients bone loss would most likely have been minimal, or there possibly was an isolated vertical defect that might have benefited from bone grafting. There is no evidence that there was sufficient missing structure from the walls of bone supporting the teeth to require the additional use of guided tissue regeneration membrane.