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

A 58-year-old female has requested approval for gastric bypass surgery for treatment of her obstructive sleep apnea, hypertension, and gastroesophageal reflux disease.   Findings:  The physician reviewer found that based on review of the available records, the patient meets all of the standard nationally accepted criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. This patient is an adult over 18 years of age with a BMI of 36 with documentation of sleep apnea, and hypertension. This patient therefore meets the definition of clinically severe obesity. In addition, she has failed dietary efforts in the past and completed thorough dietary and behavioral evaluations that did not reveal any obvious dietary, medical or behavioral barriers to surgery. Consistent with these findings, the requested surgery, gastric bypass surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his medical condition.  Findings:  The physician reviewer found that  review of the submitted documentation demonstrates that the patient has had three evaluations along with a developmental history that support a diagnosis of autism spectrum disorder. The behaviors in this patient that need to be addressed include maladaptive behaviors of communication, nonfunctional rituals, complying with requests, as well as social and language skills. As the above cited literature demonstrates, applied behavioral analysis (ABA) has been shown to be effective in treating maladaptive behaviors associated with autism spectrum disorder. As such, ABA therapy is medically necessary for this patient with autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female has requested sunitinib (Sutent) 25 mg capsule for treatment of her malignant neoplasm of the pons.  Findings:  The physician reviewer found that this young patient was treated with standard options, but her condition has progressed. The National Cancer Institute (NCI) recommends enrollment in an appropriate clinical trial. This was attempted but this patient was not eligible. At this time, the patients oncologist has recommended treatment with Sutent, where he would closely follow an ongoing COG clinical protocol. Despite the rarity of the condition, one phase I trial of Sutent was tested against diverse pediatric solid tumors and eight of the patients evaluated had glioma. Sutent was not tolerated in those patients who had received prior anthracyclines. Overall, there was no efficacy data from this study (DuBois, et al). In a follow-up to this study, Dubois and colleagues showed stable disease in two patients with high grade glioma. The clinical trials do demonstrate Sutent to be safe. All told, use of Sutent in this patients case is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested  removal of a mole (skin tag) under her eye.  Findings:  The physician reviewer found that based on review of the available records, the patient has a mole that is symptomatic and possibly enlarging. The diagnosis that needs to be considered is one of malignancy.  The American Society of Plastic Surgeons recommendations state that, Removal of a skin lesion(s) is considered reconstructive surgery and medically necessary when one of the following diagnoses or conditions are present. Two of those conditions include symptoms of pain or itching, which is present for this patient. In addition, McGuire and colleagues, the differential diagnosis of lentigo maligna includes some benign lesions. This patient is documented to have a nevus. Thus, based on these considerations, removal is medically necessary. Further, a mole or skin lesion that is symptomatic or changing should be considered abnormal. The diagnosis is in question based on the symptoms and examination. Thus, a tumor/malignancy has to be considered. To this end, the goal of the surgery would be to affect overall function. Diagnosing a possible malignancy would be reconstructive and medically indicated as well. Overall, the surgery would help to correct the symptoms of pruritus and tenderness that the mole has created. Moreover, the requested services are likely to result in a more than minimal improvement considering the estimated size of the lesion. Therefore, the requested removal of moles (skin tag) under the eye is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male has requested approval for physical movement therapy (electrical muscle treatment) for treatment of his medical condition status post stroke.   Findings:  Three physician reviewers found that the patient is status post right middle cerebral artery cerebrovascular accident (CVA) a little over one year ago secondary to a traumatic carotid artery dissection with residual left-sided spastic hemiparesis. The patients upper extremity has dense spastic plegia and lower extremity strength is antigravity. A physical movement therapy device (PMTD) by Flexiciser has been prescribed as a home therapeutic device to improve the patients functional mobility and activities of daily living (ADLs).  Although there is some preliminary evidence suggesting that passive motion exercise may result in improved cardiovascular fitness, there is a lack of scientific evidence supporting its efficacy to promote motor or functional recovery following stroke (Wee). As noted by Lum and colleagues, Robotic devices for movement therapy are moving closer to becoming commercially available tools for aiding in stroke rehabilitation. However, the clinical value of stroke therapy systems are still being studied and any improvement in patient outcomes has not been established. Therefore, based on the current medical literature, it is unlikely that the requested device is likely to be more beneficial for the patients condition than standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male has requested a comprehensive pediatric multidisciplinary assessment for treatment of his autistic disorder and mood disorder, not otherwise specified.   Findings:  The physician reviewer found that this patient has an extensive history of severe behavioral problems including verbalization of a desire to kill, suicide ideation, tantrums, and obsessive/compulsive actions. Intellectually, the patient is probably of superior intelligence and has above average fine motor skills. Based upon the documentation provided, the patient has already seen a child psychiatrist, a child neurologist, multiple educators and psychologists. A comprehensive pediatric multidisciplinary assessment would not be of significant clinical value at this time. The patients neurological exam has been normal, he is of superior intelligence, and has above average motor skills. His neurological tests include a normal video-monitoring electroencephalogram so further neurodiagnostic studies are likely to be of limited yield.  The paper by Rapin cited above, points out that a child neurologist should be judicious in evaluating developmental and behavioral issues and defer to child psychiatrists when the individuals problems are psychiatric in nature. In this case, the clinical utility of a comprehensive pediatric multidisciplinary assessment has not been established. As such, the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested coverage for Xolair injections for treatment of the enrollees severe asthma, chronic pulmonary fibrosis, and respiratory insufficiency.  Findings:  Two physician reviewers found that the patient has a history of asthma, pulmonary fibrosis, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) with exacerbations. The patients provider has requested Xolair to treat asthma in this patient. The providers documentation for a routine office visit notes that the patient is complaining of persistent cough with white, thick mucus and wheezing with some shortness of breath. The shortness of breath has reportedly been better on prednisone. At the time of the visit, the patient was taking Xolair 225 mg every two weeks, prednisone 20 mg per day, Ventolin, Daliresp, Spiriva, Advair, and Singulair. The patient has an IgE level of 307 and her forced expiratory volume in one second (FEV1) on spirometry was 90% of the predicted. A respiratory profile panel revealed allergies to alder tree, birch white tree, cedar mountain juniper, dog hair, elm tree, oak tree, olive Tree, and Ragweed Pollen. A letter from the provider states that her FEV1 is 90% of predicted. The patient has requested authorization and coverage for Xolair injections, which the Health Plan has denied as investigational.  Xolair is FDA approved for patients who have moderate to severe persistent asthma, a skin test or in vivo reactivity to perennial aeroallergens, symptoms that are not controlled on inhaled long acting corticosteroids and long acting beta agonists, FEV1 of less than 80% predicted, and serum IgE level greater than 30 IU/ml. Based on the providers office note and his letter, the patient does not have moderate or severe persistent asthma or an FEV1 of less than 80% of predicted. Therefore, use of Xolair in this patient is not 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

A 41-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.   Findings:  The physician reviewer found that the records indicate that this patients depression is treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the medical literature, Schutter reported that TMS had a moderate effect of TMS on treatment resistant depression. In addition, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Further, Avery and colleagues provide evidence that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines endorse TMS for treatment of depression in the acute phase of therapy. Thus, although relatively new, TMS is an effective treatment, has been granted a category I CPT code by the American Medical Association (AMA) and is FDA approved for the treatment of patients with treatment resistant major depressive disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male has requested approval for ABA therapy beginning at the date at issue, and forward, for treatment of his autism.   Findings:  The physician reviewer found that ABA therapy has a 40-year, scientifically documented history of substantially improving motor, verbal, and interactive social skills in autistic children. Myers, et al. states, The effectiveness of ABA-based interventions in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intervention programs in university and community settings.  Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Additionally, in regard to older children and even adults, Myers et al. reports, published research evaluating comprehensive educational programs for older children and adolescents with ASDs is lacking. However, there is empirical support for the use of certain educational strategies, particularly those that are based on ABA, across all age groups to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. As autism is a lifetime diagnosis, with an uncertain prognosis, the duration of therapy remains uncertain and must be determined on an individual basis. This 12-year-old patient has demonstrated measurable social and communication improvements while receiving ABA therapy. Two years ago, he was only able to perform at a one to two-year level; however the following year, he was performing at a three to five-year level. While progress has been slow, this patient has clearly demonstrated improvement during ABA treatment. An individualized educational plan dated last year noted good progress in communication, ability to follow instruction, expressive language, and social skills. Accordingly, it is medically necessary that the patient receive ABA therapy for 10 hours per week with 16 hours of monthly supervision.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female has requested a positron emission tomography (PET) scan for evaluation of her stage 3 pancreatic cancer.   Findings:  Two physician reviewers found that the patient also reportedly has multiple sites of metastatic disease. She has been followed with imaging including positron emission tomography (PET) and computed tomography (CT) to evaluate her treatment status. The patients provider has recommended a PET/CT to assess need for treatment modification. The National Comprehensive Cancer Network (NCCN) guidelines reference an increased sensitivity for metastatic disease using PET versus CT or magnetic resonance imaging (MRI) alone. At the same time, the guidelines do not make a strong recommendation for using PET as a surveillance tool. Given the patients previous imaging and need for confirmation of disease status, the requested PET/CT has more sensitivity than conventional imaging and thus is likely to be more beneficial in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested approval for osteochondral allograft surgery for treatment of her kneecap cartilage loss and subchondral bone involvement.   Findings:  Two physician reviewers found that the patient has a history of a chondral injury to her left patella. An MRI of her left knee showed advanced chondromalacia patellae with cartilage irregularity on both sides of the joint. The patient underwent a left arthroscopic chondroplasty of her patella. A 1 mm x 2 mm lesion was found on her medial facet. The provider recommended that the patient have an osteochondral allograft surgery to her left knee as she had failed all standard therapies. In his appeal letter, the provider indicated that the kneecap supports very large weight bearing loads in normal life and it is the thickest cartilage in the body for this reason. He noted that biomechanics and other studies show that the kneecap supports up to six times body weights with bending, walking or climbing stairs. The provider noted that because of the patients young age, it would be inappropriate to recommend she undergo a total knee replacement.  There is a paucity of scientific data supporting the clinical effectiveness and superiority of osteochondral allograft for patellar defects at this time. Allograft is approved for use for weight bearing surfaces of a limited degree with respect to the femoral condyle, but not the patellofemoral joint. Therefore, there is inadequate evidence that the proposed osteochondral allograft surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male has requested approval for Xifaxan for treatment of his Crohns disease.   Findings:  The physician reviewer found that the role of antibiotics in the management of Crohns disease remains controversial (Guslandi, et al). Early observational data suggested that metronidazole and ciprofloxacin may be beneficial for Crohns colitis. These agents are generally not helpful in Crohns ileitis or ulcerative colitis. In addition, there is concern that the patients gastrointestinal tract will become colonized with resistant organisms (Kothary, et al). All told, the requested Xifaxan therapy cannot be recommended for long-term IBD management and therefore is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male has requested IVIG therapy for treatment of his painful weakness of the arms.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy.  This patient has had progressive painful upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The medical records indicate that the patient has had findings that may be due to a variant of chronic inflammatory demyelinating polyneuropathy.  As IVIG therapy has been shown to be appropriate for chronic inflammatory demyelinating polyneuropathy, and this patient has had findings which may be due to this or a similar autoimmune disease, the requested IVIG therapy is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested approval for a PET scan for evaluation of her Hodgkins disease.   Findings:  Two physician reviewers found that the patient was diagnosed with Hodgkins disease twenty-three years ago.  She was treated with chemotherapy.  Three years ago, a PET/CT scan showed no hypermetabolic activity.  Four months ago, the medical records noted weight loss, fatigue, and a slightly elevated IgM.  The current National Comprehensive Cancer Network guidelines do not advocate the use of PET scanning as a routine monitoring tool.  However, the current medical evidence supports the diagnostic procedure at issue in this clinical setting.  This patient presented with systemic complaints, including weight loss and fatigue.  Additionally, the medical records noted an elevated IgM.  In this patients case, further imaging evaluation is indicated.  The requested PET scan is likely to be superior over other available imaging modalities for the detection of possible recurrence.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a then three-year-old female has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient was brought to the emergency department with complaints of cough and congestion for several days and acute onset of right ear pain one hour prior to arrival. Vital signs in the emergency department included temperature 99.2 degrees, respiratory rate 32, heart rate 108, and oxygen saturation of 100%. Upon examination, the provider noted evidence of otitis media, right with dull, red, thickened, bulging tympanic membrane; left tympanic membrane was normal. The patient was diagnosed with acute upper respiratory infection and otitis media and was treated with antibiotics.  At issue in this case is whether a prudent layperson would have sought immediate medical attention for the patient on 3/31/12. 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.Upon review of the submitted documentation, a prudent layperson would have sought immediate medical attention on the date of service in question. While the submitted emergency department records do not document the patients pain level, the patients parent reports the patient experienced acute onset of severe ear pain an hour prior to presentation, which prompted the family to seek emergency room services. As the above cited statute indicates, the presence of severe pain is an appropriate indication for seeking immediate medical attention. In this case, the patients acute symptoms of severe ear pain were of sufficient severity that absence of immediate medical attention could reasonably be expected to result in continued severe pain and possible impairment of bodily functions (hearing). As such, the patient met prudent layperson criteria for emergency services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male has requested twelve hours per month of applied behavioral analysis (ABA) supervision services for treatment of his autism.   Findings:  The physician reviewer found that the patients provider and parent are seeking authorization for twelve hours of ABA supervision per month as opposed to the six hours per month authorized by the health plan. ABA therapy is one of the few documented treatments that have been proven to have some efficacy in decreasing the behavioral problems and increasing communication in children with ASD. The above cited evidence demonstrates that ABA therapy is effective in improving communication and socialization in children with ASD. However, none of these extensive reports state the recommended division in total hours between direct interventional therapy and supervision. A review of the scientific evidence did not reveal compelling evidence related to the application of hours between therapy and supervision. A small study by Hayward found that the number of hours spent in clinical intervention and intensive parental managed intensive supervision did not make a significant difference. Rather, it was the total hours of combined treatment that determined efficacy. All told, there is inadequate evidence that twelve hours per month of ABA supervision is medically necessary compared to six hours per month of supervision.In the case of this patient, he has received twelve hours of ABA supervision for nearly the past year which should have afforded sufficient opportunity to educate the family on the required parental contribution to the program. At this point in time, the need for supervision is limited to providing progress reports and suggestions to the patients parents as to the necessary interactions with the patient. Six hours of supervision per month is sufficient for achieving this goal.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male has requested approval for brachytherapy services for treatment of his adenocarcinoma of the prostate.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of brachytherapy in this patients case.  There are several single institution and multi-institution studies which support using high-dose rate or low-dose rate brachytherapy as monotherapy, in which intermediate-risk patients are included in the cohort or represent the entire study cohort.  Brachytherapy is an established treatment for prostate cancer.  For the indication of intermediate-risk prostate cancer, brachytherapy as monotherapy is not an advisable treatment for all patients, although select patients with disease confined to the prostate and other favorable features could be considered appropriate candidates.  The current medical evidence supports the requested services in this patients case.