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

A 61-year-old male enrollee has requested for continued skilled nursing facility (SNF) services (with physical therapy and occupational therapy) for treatment of his medical condition. Findings:  The physician reviewer found that the patient was progressing well towards the stated goals. He was actively participating in regularly scheduled therapy sessions, and it is likely that he will continue to achieve measurable gains at a reasonable and predictable pace. His baseline function was MI, and the stated long-term goals of achieving a similar level of function were and are appropriate. This patients medical and clinical situation is complex, and rehabilitation services continue to be reasonable and necessary and best rendered in a skilled inpatient setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for a positron emission tomography (PET) with computed tomography (CT) scan every 2 months for evaluation of her inflammatory breast cancer.  Findings:  The physician reviewer found that the utilization of PET/CT meets criteria as defined by the Centers for Medicare and Medicaid Services (CMS), which is the generally accepted standard of care in this setting. Specifically, PET is covered for restaging after completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or metastasis, or to determine the extent of a known recurrence. In general, restaging applies to testing after a course of treatment is completed. CMS further recommends PET/CT scanning when it is expected that conventional studies will be insufficient for the clinical management of the patient and PET/CT could potentially obviate the need for the standard imaging. This patients records document that CT alone was insufficient in that it was not sensitive enough to detect the liver metastases subsequently visible on PET/CT. In addition, the PET/CT findings were confirmed with a liver biopsy that demonstrated metastatic disease. Thus, it remains likely that conventional CT would continue to be inadequate for restaging purposes, while PET/CT would be more instructive to guide this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for Oxycontin 80 mg for treatment of her bilateral sciatica and spondylosis.  Findings:  The physician reviewer found that the medical literature reports that high-dose opioids may also cause adverse outcomes including those noted by Baron and McDonald in their 2006 study. The authors concluded that high-dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Further, Ballantyne and Mao reported on studies demonstrating that prolonged use of high-dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The authors noted the goal of practice guidelines is to protect patients from the adverse effects of opioid therapy, and presently, Oxycontin 80 mg, twice daily is the maximum recommended dosage. This patient reported a 5 of 10 VAS pain level with her current medication regimen, including Oxycontin 80 mg, 3 times per day. Consistent with the scientific data, the requested dosage of Oxycontin is not indicated given that she continues to carry a significant level of pain, and has not demonstrated any increase in function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested intensive outpatient treatment (IOP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the data reviewed are incompatible with both the American Psychiatric Association and American Society of Addiction Medicine (ASAM) guidelines for this level of care. Per the peer-to-peer review documentation submitted by the Health Plan, the patient was motivated for treatment and compliant with the program. He was apparently working on issues of self esteem. There is no evidence of serious medical concerns and no evidence of potential serious risk to self or others related to his substance abuse. His parents were supportive of recovery. Thus, there was no indication for continued IOP services. APA guidelines indicate that patients should be treated in the least intensive setting which will be safe and effective. The information submitted fails to establish that an IOP setting was the least intensive viable setting for treatment in this case. Additionally, there was no indication of an intensification of symptoms, that the patient lacked sober social supports, or that he was resistant to treatment. As such, the submitted documentation does not establish that dimensions 4-6 of the ASAM placement criteria were met during the time period at issue.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested transcranial magnetic stimulation (TMS)for treatment of his major depression, recurrent. Findings:  Two physician reviewers found that there are no medical records available for review in this case.  There is also no mention as to whether the patient has tried any type of psychotherapy.  He has several psychiatric diagnoses listed in the records provided.  His medication trials have caused intolerable side effects.  The patient feels his psychiatric symptoms were not improved during the above medication trials. However, his psychiatrist noted that the patient did have some relief of his depression. It is difficult to tell if the trauma that caused his post-traumatic stress disorder may be causing many of his depressive symptoms.  It is also very likely that his medical problems and fibromyalgia may be causing or worsening his mood symptoms.  There is a lack of TMS studies that include patients that have as many comorbid conditions as this patient.  TMS has been shown to be effective in depression.  However, there is a lack of evidence indicating that it would benefit a patient with his history.  A vast majority of the studies done on TMS have excluded patients such as him due to the length of his depression alone. There are variable results available in the literature regarding TMS. This patient does not fit into the category of the vast majority of patients who have been successfully treated so far with TMS(Schutter).  Issues around duration of treatment effectiveness, type of stimulation, and use of this modality as a monotherapy versus an adjunct remain ill-defined. Further, medication-resistant patients often show small to moderate improvement and are more often vulnerable to relapse(Schutter). The fact that he and his psychiatrist disagree as to whether past medications were actually helpful to him indicates that he may be medication-resistant, even to numerous medications.  Therefore, there is little hard evidence that in his situation TMS would be more beneficial than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested prolotherapy for treatment of his back and buttock pain. Findings:  Three physician reviewers found that prolotherapy describes a variety of treatment approaches using repeated injections of irritant solutions to strengthen ligaments and reduce some types of chronic pain (Dagenais and colleagues). Generally, a concentrated dextrose solution is injected into a ligament or tendon where it attaches to the bone. These injections are intended to cause a localized inflammation with the increased local blood flow thought to carry in nutrients and stimulate the presumably damaged tissue to repair itself. Kim and colleagues reported that there is no high-grade evidence in the published peer reviewed medical literature that establishes the efficacy of prolotherapy on health, pain or functional outcomes in the setting of musculoskeletal complaints, including chronic low back pain. Some anecdotal reports and low quality studies offer suggested response, but a marginal improvement in outcomes greater than placebo therapy has not been established for this intervention. Further, Dagenais and colleagues noted adverse effects related to prolotherapy in their 2006 study. Thus, prolotherapy is an unproven treatment for any condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a laparoscopic vertical sleeve gastrectomy for treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient has morbid obesity, has failed reasonable weight loss attempts and does not have any obvious metabolic, medical, dietary or behavioral barriers to surgery. The patient meets generally accepted criteria for bariatric surgery. The vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for severe 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 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 co-morbidities including sleep apnea compared to other restrictive procedures, with relatively low major complication rates. All told, there is adequate evidence supporting the benefit of laparoscopic vertical sleeve gastrectomy in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for laparoscopic supracervical hysterectomy with or without removal of ovaries for treatment of her pelvic pain, uterine fibroids, dysfunctional uterine bleeding and dysmenorrhea. Findings:  The physician reviewer found that the records do not indicate when her endometrium was noted to be benign, since there were no specific records of such an evaluation.  Such an evaluation is medically necessary before consideration of hysterectomy.  As noted by the American College of Obstetrics and Gynecology, all women older than 40 years who present with suspected anovulatory uterine bleeding should be evaluated with endometrial assessment after pregnancy has been excluded.  They also note that adult women of reproductive age with menorrhagia, metrorrhagia or amenorrhea require evaluation for a specific cause. The laboratory assessment of these women should include a pregnancy test, a fasting serum prolactin level and determination of levels of thyroid stimulating hormone.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.  Findings:  The physician reviewer found that the literature supports the effectiveness of manual therapy and spinal manipulative therapy for the management of chronic neck pain (Hurwitz, et al.). In addition, Wolsko and colleagues concluded that chiropractic techniques are commonly applied for the treatment of neck pain, and have been rated very helpful by patients. Moreover, Bronfort and colleagues reported positive outcomes with spinal manipulative therapy and mobilization for the management of low back pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested for real-time cardiac monitoring for evaluation of his palpitations. Findings:  Three physician reviewers found that the documentation does not include a report of a standard Holter monitoring study.  No record was submitted of any attempted pharmacological treatment.  In this patients case, a standard 48-72 hour Holter monitor would have been appropriate to detect the arrhythmia. In this clinical situation, remote monitoring was premature.  More standard diagnostic approaches should have been employed prior to remote monitoring. In this patients case, the superior efficacy of real-time cardiac monitoring over more standard approaches has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for left hip femoral acetabular surgery for treatment of herr labral tear and hip impingement syndrome.  Findings:  Two physician reviewers found that hip impingement is a fairly recently recognized pathologic process, and femoro-acetabular impingement syndrome (FAIS) is being considered as an early cause of osteoarthritis. The condition occurs primarily in younger patients and is not usually due to trauma. The medical literature describes two different types of impingements: Cam type and Pincer type. Larson and Giveans reported on arthroscopic treatment of femoro-acetabular impingement on 100 hips treated with labral debridement or repair. There was a 6% incidence of heterotopic bone formation, and 3% of the patients underwent total hip arthroplasty at a later stage. The authors questioned the alteration of the natural progression of FAIS to osteoarthritis, and sustained pain relief as a result of arthroscopic surgery. Philippon and colleagues recommend arthroscopic management of femoro-acetabular impingement and osteoplasty techniques to be performed only in high performance athletes and high demand patients. Further, Espinosa and colleagues examined labral re-fixation after FAIS as it affects clinical and radiographic results. The authors retrospectively reviewed 52 patients in 60 hips with FAIS and found that only 28% of the resection group had excellent results, compared to 80% of the re-attachment group. Overall, the authors concluded that long-term follow-up remains necessary to prove the success rate, safety and long-term (greater than two-years) outcome of the procedure.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances 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 had been experiencing back pain for two weeks in duration. She states that she had new onset of numbness in her legs, which along with her pain caused her to seek emergency services. However, the emergency department records do not indicate the numbness was a new symptom. The records note numb pain with duration noted as weeks. In addition, no acute neurological symptoms such as weakness, paralysis, or bowel or bladder dysfunction are documented in the records provided. Further, the patients pain level was noted as 6 and 7 in the submitted records, which indicates moderate but not severe pain. Thus, this patients symptoms did not meet the prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health or cause serious impairment or dysfunction.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested for canaloplasty for treatment of her glaucoma. Findings:  Two physician reviewers found that clinical evidence reveals that in this circumstance, further intervention is needed to preserve the patients vision. Canaloplasty is a relatively new procedure that has been shown to result in good outcomes when performed by experienced surgeons. The medical literature supports the efficacy of this procedure.  For example, a study by Lewis and colleagues was performed to evaluate the safety and efficacy of circumferential viscodilation and tensioning of the inner wall of Schlemm's canal (also known as canaloplasty), a new surgical procedure for the treatment of open-angle glaucoma (OAG). Evaluation was performed at baseline and 1 day, 1 week, and 1, 3, 6, and 12 months. The authors concluded that canaloplasty was a safe and effective surgical procedure to reduce IOP in adult patients with OAG.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for magnetic resonance imaging (MRI) scan of the hips and spine for evaluation of her medical condition. Findings:  The physician reviewer found that there is no clinical concern of spinal infection or metastatic disease. There is also no clinical concern of avascular necrosis of the hips. An MRI of the spine is medically indicated when there is clinical evidence of a disc herniation, spinal stenosis, spinal infection or metastatic disease. However, this patient does not have a clinical presentation to support MRI of the spine. An MRI of the hip is utilized to evaluate for suspected avascular necrosis. However, this patient does not have a clinical presentation to support MRI of the hips. In regards to the patients concern of osteoporosis, DEXA studies are one of the accepted imaging studies for the evaluation of osteoporosis. MRI studies are not utilized in the evaluation of bone density. This patient had a recent normal DEXA study, which was not suggestive of a diagnosis of osteoporosis. All told, there is insufficient medical evidence to support an MRI of the spine and hips for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his prostate cancer. Findings:  Three physician reviewers found that the use of stereotactic radiosurgery for the treatment of prostate cancer is relatively new, and thus follow-up is relatively short. The American Society for Therapeutic Radiology and Oncology has addressed the role of stereotactic radiosurgery for low-risk prostate cancer. They note that stereotactic radiosurgery regimens currently under investigation have only extremely short follow-up times and small numbers of patients. They also state that data at this time are inadequate to demonstrate either significant efficacy or toxicity rates. They note that further clinical trials addressing the uncertainties in the clinical implementation of this new approach to prostate cancer treatment should be conducted. At this time, the superior efficacy of stereotactic radiosurgery over alternative treatment options has not been demonstrated in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested Botox injections (on a 10-week frequency) for treatment of her migraine headaches.  Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine or chronic headaches, there is adequate literature citing its use for these conditions.  For this particular patient, she has failed multiple first-line preventative therapies for migraine headache. Furthermore, she has already experienced a documented beneficial effect from treatment with Botox. Based on the literature, the patients failed response to conventional medical therapy, and the documented relief of her symptoms secondary to treatment with Botox, its continued use is medically appropriate. The literature suggest re-treatment approximately every 3 months, thus, that frequency is likely adequate as this patient reported relief lasting about 10 weeks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for Voltaren 1% gel for treatment of her joint pain. Findings:  The physician reviewer found that diclofenac (Voltaren) can have significant adverse effects including but not limited to gastritis, gastric and duodenal ulcers, hepatotoxicity, and cardiac toxicity including myocardial infarction. Oral diclofenac, a nonselective NSAID, may have greater cardiovascular toxicity than other nonselective NSAIDs according to recent reports. The formulation of diclofenac as a topical gel was intended to decrease the risk of systemic adverse effects while providing pain relief for osteoarthritis of the knee. Diclofenac gel has been shown to be efficacious in relieving pain associated with osteoarthritis of the knee. A randomized trial of diclofenac gel in symptomatic osteoarthritis of the knee showed significant improvements in pain control and physical function after a three-month treatment period, as noted by Barthel and colleagues. The medical literature does not provide support for the limitation of this formulation to individuals with an intrinsic swallowing difficulty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested for tomotherapy  for treatment of his prostate cancer. Findings:  The physician reviewer found that tomotherapy is an integrated machine that offers one form of image-guided intensity modulated radiation therapy (IMRT). There are many different platforms that offer image-guided IMRT, and no one platform has been demonstrated to be superior. Image-guidance may be performed with or without fiducials, regardless of whether tomotherapy is used. Fiducial placement involves a procedure similar to a biopsy. It is a well-established form of image-guidance, as demonstrated by Hsu and colleagues. If a patient can tolerate a biopsy without difficulties, fiducial placement should not be problematic. Ultrasound-based image guidance is an alternative form of image guidance that does not require any procedures. Tomotherapy does not involve the performance of an MRI prior to treatment, but rather a megavoltage cone-beam computed tomography (CT). Megavoltage cone-beam CT has poorer soft tissue resolution as compared to kilovoltage units present on many modern linear accelerators; both can perform image guidance without fiducials, but fiducials are often preferred even with cone-beam CT.