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

A 44-year-old male enrollee has requested in home physician services for evaluation of his symptoms of feeling sick, dehydrated, and weak.  Findings:  The physician reviewer found that 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. The treating physician did not document a need for immediate laboratory tests or recommend any other emergent testing. There is nothing in the documentation provided to suggest that this patients symptoms represented an acute, severe, change in his condition that a prudent layperson would believe would jeopardize his health without immediate care. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested spinal fusion surgery (L4-L5 and L5-S1) for treatment of his low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. The patient has chronic low back pain and he has had residual symptoms/signs from his more recent laminectomy/discectomy. His most recent MRI does not show a recurrent disc herniation but does show the expected post-operative scar/granulation tissue. According to Bambakidis and colleagues indications for surgical fusion include instability, spondylolisthesis at the indicated segment, scoliosis, infection, tumor, fracture and spinal stenosis (Bambakidis et al). In this patients case, he does not have any of the accepted criteria listed above. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested proton beam radiotherapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that the providers letter states that proton therapy is safe and effective and that there is accumulating evidence that it is a superior means to deliver high dose radiation. Although proton therapy for prostate cancer is an accepted treatment approach, other treatment approaches including IMRT and image guided radation therapy (IGRT) are also highly effective and well tolerated. Further, there is a paucity of compelling data to suggest that proton therapy is superior to or more beneficial than these standard alternatives. As a result, the generally accepted standard is to only offer proton beam therapy as part of a clinical trial. Thus, the requested proton beam radiotherapy is not 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 53-year-old female enrollee has requested Bioness L300 (functional electrical stimulation walking device) for treatment of her multiple sclerosis with foot drop. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. Functional electrical stimulation devices may be useful in the treatment of significant foot drop due to upper motor neuron disorders of the brain and spinal cord including stroke, spinal cord injury, and multiple sclerosis. In this case, the patient has multiple sclerosis with right foot drop. The patient was evaluated and an 8-week gait training therapy program was planned. However, the documentation submitted for review indicates that the patient did not attend the follow-up physical therapy appointments. Therefore, it would be reasonable to consider a trial of the Bioness if after an adequate trial of physical therapy has been completed. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested equipment has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested FM system (hearing device) for treatment of the enrollee, who has been diagnosed with dysfunction of the corpus callosum. Findings:  The physician reviewer found that the submitted records demonstrate the medical necessity of the requested device in this patients case.  The records indicate hearing that there is history of diagnosis of central auditory processing disorder (APD).  Per the current literature, FM technology refers to a type of wireless system that helps people better understand speech in noisy situations.  FM systems commonly work together with a patients hearing aids, although systems are also available for those with otherwise normal hearing.  The current literature supports the use of an FM auditory amplification system, even in patients with measured normal hearing, in the context of APD.  All told, the requested FM system (hearing device) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested calprotectin fecal laboratory testing for evaluation of his Crohns disease. Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective than other tools of evaluation.  Per the medical records, this patients symptoms of Crohns disease were under control at the time of testing, and Humira had been initiated.  There is a lack of support for the testing at issue in this clinical setting.  The use of calprotectin fecal laboratory testing would not have been expected to be of benefit in this patients case.  Therefore, calprotectin fecal laboratory testing was not likely to have been of greater benefit than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested surgical procedures (left hip multiple epiphysis drilling of the femoral head for decompression, left hip harvesting of bone graft for bone marrow cells, and left hip injection of autologous bone marrow cells) and associated hospital stay for treatment of the enrollees left hip avascular necrosis. Findings:  Three physician reviewers found the services at issue were likely to be more efficacious than other treatment options.  The procedure performed in this case was a decompression and bone grafting procedure.  Decompression was performed through drilling, which is a very common technique.  Bone grafting was performed by injection of harvested marrow cells.  This technique avoids the functional difficulties of harvesting the patients fibula as one alternative and avoids implanting foreign tissue.  There is sufficient support for the services at issue in this patients case.  Therefore, surgical procedures (left hip multiple epiphysis drilling of the femoral head for decompression, left hip harvesting of bone graft for bone marrow cells, and left hip injection of autologous bone marrow cells) and associated hospital stay were likely to have been of greater benefit than other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested substance abuse intensive outpatient program (IOP) services for treatment of his substance abuse.  Findings:  The physician reviewer found the medical records describe the patient as distant, guarded, preoccupied, and complaining that he is too busy with his current activities. During this period of time, there is no revision of the treatment plan to alter his course. Applying the American Society of Addiction Medicine (ASAM) criteria for IOP level of care, the patient was not in acute withdrawal and did not pose a danger to self or others. In addition, he did not have any biomedical or psychiatric comorbid conditions, he was able to care for himself, and showed adequate coping skills. Although he had not been attending 12 step meetings, he did attend group and individual sessions and his family was supportive. Thus, he did not meet the criteria for IOP level of care services and could have safely been treated at a lower level of care such as an office based or 12 step community setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a magnetic resonance imaging of the breast for evaluation of her medical condition. Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. The patient was diagnosed with Hodgkin lymphoma, mixed cellularity type. A metastatic work-up was negative and the patient was treated with chemotherapy and radiation. There is a lack of peer-reviewed literature that supports a breast MRI for this patient with normal mammogram and normal breast ultrasound. Also, the medical records fail to indicate that this patient has a lifetime risk of breast cancer that is 20-25% or greater. The patient has no suspicious breast lesions on mammography, ultrasound or physical exam. Thus, the request for MRI of the breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested laparoscopic Roux-en-Y gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patient meets generally accepted criteria for bariatric surgery. She presents with a BMI that exceeds 35 as well as co-morbid medical conditions related to her obesity including gastroesophageal reflux disease, hypertension, hyperlipidemia, joint pain, and stress urinary incontinence. She has failed multiple medically-managed weight loss attempts. In addition, she failed a surgical attempt at weight loss with a laparoscopic adjustable gastric band placed more than five years ago. Laparoscopic adjustable gastric band surgery has been demonstrated in recent years to be associated with a very high weight loss failure rate (Victorzon, et al.). For this reason, there has been a dramatic decline in the use of laparoscopic adjustable gastric banding as a primary treatment of obesity (Nguyen, et al.). Repeat bariatric surgery should be considered for patients who fail to achieve or maintain clinically significant weight loss following laparoscopic adjustable gastric banding if the patient meets generally accepted criteria for bariatric surgery. Roux-en-Y gastric bypass after failed laparoscopic gastric banding surgery has been demonstrated to be safe and is associated with clinically significant weight loss (Robert, et al.; Elnahas, et al.; and Perathoner, et al.). Based upon the submitted clinical documentation as well as the relevant peer-reviewed scientific evidence, the requested laparoscopic Roux-en-Y gastric bypass is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested inpatient psychiatric hospitalization services for treatment of his schizophrenia.  Findings:  The physician reviewer found during the course of the hospitalization from the specified time period, the patient is described as having improved quite a bit while becoming stabilized on Abilify. Further, the patient indicated that he liked the way Abilify made him feel. The patient was cooperative with his care and taking his medications. The progress notes indicate that while he remains gravely disabled, the patient is not a danger to self or others. Thus, the patient did not require the intensity and 24-hour supervision provided at the inpatient psychiatric hospital setting. Consistent with American Psychiatric Association (APA) treatment guidelines, the patient could have been discharged to a structured living environment where he could have received assistance with his activities of daily living, and any further changes to his medications could have been provided on an outpatient basis. Thus, the inpatient psychiatric hospitalization services were not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested emergency services for evaluation of her abdominal pain, nausea and vomiting.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date and time in question. In this case, the patient presented with abdominal pain, vomiting, and diarrhea. She had already been evaluated at another emergency department for these same symptoms and had been discharged from the other facility after receiving medical treatment. There is nothing in the record to suggest that the patient had experienced any sudden or acute worsening of her symptoms in the prior amount of time that would lead a prudent layperson to believe their health to be in imminent danger. This patients pain was chronic, not acute. There was no sudden deterioration in her physical condition to justify a second emergency visit on that date. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested brain imaging, positron emission tomography (PET) (78608) for evaluation of his medical condition. Findings:  Two physician reviewers found that there is sufficient medical literature supporting the use of a PET scan in this clinical setting. This patient has a variety of symptoms that are relatively mild and do not yet meet criteria of dementia, but suggest the possibility of early frontotemporal dementia (FTD). PET scan has been well documented to be helpful in making the diagnosis of FTD and differentiating it from Alzheimers. This patient has underlying obsessive-compulsive disorder (OCD) tendencies, high anxiety and life stress issues and given the unclear diagnosis after standard testing and two neurologic opinions, the requested brain imaging PET scan is likely to be more beneficial in determining a diagnosis and developing an appropriate care plan than other standard testing. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested PET scan is likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested acute inpatient detoxification services for treatment of her chemical dependency. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Although the patient had a rather unremarkable physical examination at the time of the admission, she described a history of alcohol use which included blackouts and withdrawal symptoms.  Her concomitant benzodiazepine use elevated her risk for a poor outcome.  The patient was at risk for a complicated withdrawal syndrome, so inpatient treatment was initially medically necessary.  While hospitalized, the primary detoxification modality was a benzodiazepine taper, which is standard of care. Per the medical records, the patient did have hallucinations on a specified date. She was sent to the medical emergency department to rule out the potentially fatal diagnosis of delirium tremens.  She returned to the detox unit and thereafter, there was no mention of concerning signs and symptoms of alcohol withdrawal.  Therefore, inpatient detoxification services were medically indicated.  However, the records fail to demonstrate the medical necessity of inpatient detoxification services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested gastric bypass surgery for treatment of her morbid obesity status post vertical band gastroplasty. Findings:  The physician reviewer found that this patient meets all of the National Institutes of Health (NIH) criteria for bariatric surgery. She is status post vertical banded gastroplasty which was developed as an early bariatric procedure. The patient is having complications of GERD, dysphagia from the fixed band and remains morbidly obese. She meets all consensus guidelines for primary treatment and would benefit from revision of the vertical banded gastroplasty to gastric bypass to definitively treat the GERD, morbid obesity, and the complications of the vertical banded gastroplasty such as esophagitis from ongoing GERD. For these reasons, the requested gastric bypass surgery is supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male enrollee has requested applied behavioral analysis and ABA supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with applied behavioral analysis (ABA) therapy in children. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in autistic children. In this case, the patient is a 4-year-old male diagnosed as autistic by age 2 with his assessments indicating significant cognitive delay. The documentation submitted for review also indicates that the patient has made definitive improvement in multiple maladaptive behaviors in an 8-month interval while receiving 33 hours of individual ABA therapy per week. Based on the patients rate of improvement and current level of functioning, 30 hours of ABA therapy per week is medically appropriate and necessary. The patients initial intervention was at a very favorable young age. The patient showed a moderate degree of improvement while receiving 33 hours of ABA therapy per week. He is now nearly 8 months older and the medical literature supports a reduction of ABA hours to be replaced by school attendance and group social activities as the patient ages. As to the supervision, 2 hours per month is medically appropriate and necessary in this clinical setting as his parents have been receiving parental guidance and this intervention can be tapered down to 2 hours per month. As such, a portion of the requested therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested continued residential treatment services provided for treatment of his behavioral health condition. Findings:  The physician reviewer found the documentation submitted for review indicates that in the month specified, the patient had his antipsychotic medication increased. He was making progress with his exposure/response prevention therapy, but was not symptom-free and he feared the recrudescence of florid symptomatologies. The patient had not consolidated the treatment gains necessary to succeed in community-based programming. On a specified date, the psychiatrist commented that the patient would regress in a less restrictive setting. Thus, it is reasonable to expect that the services in dispute would improve the patients condition and prevent a more serious health condition or the need for a higher level of care. Additionally, during the residential stay the patient received active treatment consistent with current practice guidelines and relevant peer-reviewed literature. Considering these variables, and both the clinical presentation and longitudinal history, residential treatment was safe, appropriate and consistent with good medical practice. Thus, the services at issue were medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 14-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patient has a concerning history of drug use, anxiety and mood symptoms with recurrent suicidality, coupled with limited coping skills and poor psychological mindedness. The patient also lacks an internal locus of control, healthy sense of self and the ability to self-soothe. These limitations are compromising her developmental task of identity formation. Per the medical records, the patient has failed outpatient treatment and required multiple acute care services. Currently, she remains symptomatic with anxiety, poor impulse control, and urges to use drugs. Her family dynamics and home situation remain volatile. She is described as active in therapy, recently beginning trauma focused therapy, but the patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. The patients affective dysregulation, anxiety, urge to use, psychosocial stressors, family support system and developmental factors unique to her case would likely undermine efforts at a lower level of care at this time. Consistent with these findings, the residential treatment to this patient is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested Onfi (clobazam) for treatment of his epilepsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is a lack of controlled, randomized studies with flexible dose regimens conducted in children with rolandic epilepsy.  Tegretol has been a mainstay of treatment in this condition, and the records do not demonstrate that this has been tried in this patients case.  There is an absence of information about the patients response to Onfi, with a lack of documentation regarding the frequency of seizures and associated seizure related disability.  All told, Onfi is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested inpatient chemical dependency treatment services for treatment of her alcohol abuse. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Per the American Psychiatric Association (APA) Clinical Practice Guideline on substance use, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this particular case, the patient has failed community programming and treatment in a less restrictive clinical setting.  Her alcohol consumption has been dominating all functional domains and her current social setting is unable to support her sobriety.  Considering the patients presentation, difficulty with outpatient detoxification and history of alcohol consumption, she is at risk for significant morbidity from alcohol withdrawal and treatment non-adherence outside a 24-hour supervised setting.  Thus, the submitted medical records support the medical necessity of an inpatient chemical dependency treatment program.