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

The parent of a one-year-old female enrollee has requested cranial osteopathy treatments for treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that while therapy for this patients head shape is medically necessary, there is insufficient support in the literature for cranial osteopathy as a valid treatment option.  Positional plagiocephaly is a broad term used to encompass a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning.  Based upon current guidelines, for infants less than three months of age, aggressive repositioning of the infant off the flattened occiput is recommended with neck exercises. Among infants between three to five months of age, orthotic cranioplasty may be indicated, and for children 5 to 18 months of age, orthotic cranioplasty is required.  This patient has an abnormal head shape for which treatment is medically necessary. However, the paucity of literature supporting cranial osteopathy precludes supporting it as a medically viable therapy. The standard of care at this time is use of orthotic cranioplasty.  All told, cranial osteopathy treatments are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested Lexapro, 10mg tablets for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that a review of the relevant scientific data suggests that Lexapro has been prescribed with significant improvement in adolescent patients and is approved by the Food and Drug Administration (FDA) for treatment of adolescent patients with this diagnosis. A randomized controlled study published by Emslie and colleagues in 2009 studied young patients with major depressive disorder who were treated with Lexapro and found Lexapro to be efficacious and well tolerated. Additionally, Lexapro is the second selective serotonin reuptake inhibitor (SSRI) approved by the FDA for use in treating adolescents with MDD, with the first being Prozac (Yang and Scott). To switch this patient to another medication given her positive response to Lexapro would place the patient at risk for an exacerbation of her illness and is clinically unreasonable. Moreover, alternative medications such as Paxil and Effexor are not FDA approved specifically for adolescent depression and could generate adverse side effects, especially when taken in conjunction with her cardiac medication. For these reasons, the requested Lexapro, 10 mg daily has been demonstrated to be medically necessary for treatment of this patients condition and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested 3 Lyme disease tests including ELISA, Western Blot and PCR and a consultation with an infectious disease specialist for evaluation of the enrollees facial and neck pain with numbness and paresthesias.  Findings:  The physician reviewer found that the patient has expressed concerns that he may have Lyme disease as an explanation for his symptoms of neck pain and spasms. These symptoms would be very unusual for Lyme disease. In fact, this patient has no recollection of a tick bite and has had no symptoms such as a rash or joint complaints that would support this diagnosis. In addition, two providers have suggested the patients symptoms change when his attention is diverted and that stress is a likely etiology for his complaints. Moreover, the patient has had a normal neurological assessment by several providers including a neurologist. The testing for Lyme disease was done correctly in this case. An ELISA screening test was done with negative results. According to the Centers for Disease Control (CDC), there is no need for additional testing when a screening test is negative. As noted by the CDC, The first step uses an ELISA or IFA test. These tests are designed to be very sensitive, meaning that almost everyone with Lyme disease, and some people who dont have Lyme disease, will test positive. The CDC indicates that if the ELISA or IFA is negative, it is highly unlikely the patient has Lyme disease, and no further testing is therefore indicated. As such, there is no need for an infectious diseases consultation or additional Lyme disease testing based on this patients symptoms, normal neurological examination, and negative Lyme ELISA test. For these reasons, the requested diagnostic testing and consultation services are not medically necessary for evaluation of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested tinnitus retraining therapy (TRT), including applicable durable medical equipment for treatment of his tinnitus.  Findings:  Two physician reviewers found that there was no history of excessive noise exposure.  Information pertaining to other therapies was not provided.  Physical examination was unremarkable, and MRI of the brain was normal.  The tinnitus was determined to be of uncertain etiology, and tinnitus retraining therapy was recommended.  Studies to date are inconclusive regarding the benefit of tinnitus retraining therapy for the treatment of tinnitus.  Further studies are needed at this time. Over half of their patients could not tolerate the tinnitus control instrument or obtained a poor result from the tinnitus retraining trial (Hatanaka and colleagues). At this time, there is a lack of scientific evidence establishing the superior efficacy of the requested tinnitus retraining therapy in this clinical scenario. I have determined that the requested therapy 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

The parent of a 16-year-old female enrollee has requested Dexcom Continuous Glucose Monitor System for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that this patient has unexplained frequent hypoglycemic episodes and is at risk for a severe, life-threatening hypoglycemic event. She also has widely fluctuating glucose levels and poor glycemic control, despite intensive diabetes management with frequent blood glucose monitoring, attention to diet, and use of an insulin pump. Use of a continuous glucose monitor will help prevent severe hypoglycemia and will improve overall glycemic control.  The medical evidence supports the requested equipment in this clinical scenario.  In this patients case, the requested Dexcom Continuous Glucose Monitor System is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested a right knee arthroscopy for treatment of his right knee meniscal degeneration.   Findings:  The physician reviewer found that , the presence of meniscal injury on MRI is not an indication for meniscal surgery unless there is also a correlation with clinical findings, such as effusion, joint line tenderness, and a positive McMurray test (McGinty and colleagues). In addition, Miller and Cole reported that some tears become asymptomatic with conservative care, including activity modification, anti-inflammatory medications, and exercise. It should be noted that not every meniscal lesion is a cause of clinical complaints and vice versa. Lim and colleagues found that a significant number of patients with meniscal injury who are treated with conservative care improve in functional level sufficiently to avoid surgery. In this case, the patients MRI describes the tear as small, probably degenerative, and in the posterior peripheral area of the medial meniscus. The provider documented a lack of persistent effusion although the patient reported medial line tenderness. There is no documentation of severe or acute problems, such as locking or giving way, which might suggest the need for intervention on a more urgent basis. The only conservative treatment described in the records is activity modification. Given that the records do not demonstrate other measures such as anti-inflammatory medications and supervised therapy, this patient has not exhausted all available treatment modalities that may effectively improve his function without surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested Vyvanse, 80mg per day for treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the medical records provided by the treating physician note that that the patient has a short temper and is distracted at work.  Anxiety is also noted. The medical notes indicate that the patient has been on Lexapro for several years.  There is no documentation regarding Vyvanse or the need for the 80mg per day dose.  The recommended maximum dose of Vyvanse is 70mg per day. Both safety and efficacy have been studied within this dose range (Brown and colleagues and Weisler and colleagues).  Based upon the submitted documentation, the medical necessity of Vyvanse, 80mg per day, has not been established. All told, Vyvanse, 80mg per day, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Dexilant/Kapidex for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that given that this patient has failed treatment with several medications and at varied dosages, Dexilant/Kapidex is an appropriate next step for treatment of her reflux. In this patients case, Dexilant/Kapidex is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested additional physical therapy treatments for treatment of her low back pain and difficulty walking.  Findings:  The physician reviewer found that based on the functional gains observed in physical therapy during the course of treatment, new long-term goals were established and additional therapy sessions were requested. The patient has demonstrated an excellent response to the therapy program and had progressed from a non-ambulatory status to ambulatory with use of an assistive device. It is reasonable to expect that the patient has the potential to progress further. Additional gait training without an assistive device and on uneven surfaces was planned. The patient has not plateaued functionally and has the potential to make further significant gains.  Thus, the requested additional physical therapy treatments are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Amitiza 24 mcg, twice per day for treatment of her chronic constipation.  Findings:  The physician reviewer found that the records submitted for review substantiate that this patient meets the Rome III criteria for the diagnosis of chronic constipation with symptoms persisting throughout her lifetime. The records suggest her chronic constipation has worsened and her provider has prescribed Amitiza 24 mcg twice a day to treat her chronic constipation. According to the medical literature, chronic constipation is the most common gastrointestinal complication of long-standing diabetes. Because of her diabetes, she likely has slow transit constipation. Recently, Wald published results indicating that fiber therapy (i.e. Metamucil, Citrucel, calcium polypcarbophil) will likely worsen constipation in patients with this type of condition. In addition, saline laxatives may place this patient at risk of phosphate nephropathy and renal failure due to her diabetes and a phosphate laxative is contraindicated since patients with long-standing diabetes likely have underlying kidney disease. Similarly, the recommendation that mineral oil be used to treat constipation is not standard practice. The potential complications of chronic mineral oil use include anal stenosis and, if aspirated into the lungs, lipoid pneumonia which is a potentially life-threatening condition especially in a patient with long-standing diabetes. Mineral oil is easily aspirated when ingested because it is less dense than water. Since Amitiza is appropriate given this patients co-morbid condition, the requested Amitiza 24 mcg twice daily has been established as medically necessary for management of her condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Valtrex/valacyclovir (4 grams per day) for treatment of her herpes simplex virus.  Findings:  The physician reviewer found that Valtrex is the standard treatment for the treatment of herpes, and in this case, the dosing is at issue.  However, a range of different dose regiments is not unusual for the use of antiviral medications. The recommended Valtrex dosage and length of treatment depends on several factors, such as patient age, concurrent medications, renal status, and the actual indication for use. Although uncommon, it is also documented that patients can have refractory herpes simplex virus disease, and can have resistance to traditional treatment dosing.  Treatment in these patients with refractory disease is limited. In this patients case, she has responded to valacyclovir, 4 grams per day.  All told, the requested Valtrex/valacyclovir, 4 grams per day, is likely to be the most efficacious treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested ultrasonographic measurements of carotid intimal medial thickness (CIMT) for evaluation of his hypertension and risk for heart disease. Findings:  Three physician reviewers found that the American Society of Echocardiography (ASE) has published guidance for the performance of CIMT. In this particular case, none of the indications supported by the ASE for this diagnostic procedure are present. The decision to initiate therapy for dyslipidemia had already been made as the patient was either taking or advised to start taking medications prior to the CIMT study. The notes do not indicate that the prescribing provider used the information from the CIMT to alter decision making regarding the patients pharmacologic therapy. In the absence of more complete data regarding this patients risk, the study at issue was not likely to have altered this patients treatment strategy and therefore is investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested Celebrex for treatment of his low back pain.  Findings:  The physician reviewer found that this patient has severe Crohns disease.  Non-selective COX inhibitors can cause significant risks in Crohns patients, such as risk of flare up, gastrointestinal bleeding, and delayed healing or remission times.  In this case, the primary physician and surgeon have provided adequate support for the use of Celebrex in this clinical scenario.  The medical literature has shown much lower relative risk and odds ratios for upper and lower gastrointestinal effects overall, and decreased risk for patients with Crohns disease using Celebrex and other COX-2 specific inhibitors. All told, Celebrex is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested physical therapy for treatment of her status post fracture of shaft of tibia.  Findings:  The physician reviewer found that the submitted documentation indicates that the patient partially achieved goals, but a home exercise program was recommended in preparation for additional skilled rehabilitation. The medical notes indicate that the patient had plateaued functionally and had achieved her pre-fracture level of function. Further gains were not expected. In order for skilled physical therapy to be considered medically necessary, it should be reasonably expected that significant functional gains will be achieved. This patient has received training in a home exercise program. All told, the requested physical therapy is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Botox for treatment of her intractable migraines. Findings:  Three physician reviewers found that Botox injections for episodic, chronic, tension type headaches may provide substantial improvements in symptoms for some patients who are refractory to pharmacotherapy. Despite this contention, the current scientific data does not demonstrate statistically significant outcomes between Botox treatment groups and placebo. The references confirm that Botox treatment of migraine headaches remains in the experimental stage and is not FDA approved for this indication. In addition, it is not preventative of migraine headache and has not been established through well designed clinical trials to be more effective than standard treatments that are proven, first-line therapies. As the records do not support a diagnosis of spasmodic torticollis, the patients migraine headaches may well be managed with conventional, proven alternative treatment modalities. For these reasons, the requested Botox treatment remains investigational and experimental for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested Opana ER 20 mg tablets, 3 times per day for treatment of her cervical spondylosis. Findings:  The physician reviewer found that in the medical literature, Opana is a well documented long acting Mu agonist with potent binding affinity at central receptors with less availability in the periphery causing decreased pruritis. The recommendations indicate that it should only be dosed twice daily due to the extended half life. As reported by Matsumoto in his study, this is also one of the benefits of the medication. The opioid rotation idea is consistent with the standard of care and can vastly lower the doses needed based on receptor subtype and distribution throughout the CNS and spinal column. Thus, for this patient, the approved dosage should be Opana ER 30 mg, twice per day, as the medical necessity of this medication has been established in this case, but the guidelines have not approved the requested dosage.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested emergency services for treatment of the enrollee's complaints of fever, dry cough and sore throat. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient 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 developed a fever, cough, and sore throat. His father states in his appeal letter that he was concerned about H1N1 given the media attention surrounding that illness. It is documented in the record that the patient had not been vaccinated for influenza. Although this patient did not fit into any high risk category for influenza, it was reasonable for the parent to seek medical attention. However, this patient did not exhibit any acute symptoms of serious illness such as vomiting, trouble breathing, or irritability. He was over the age of five and had no underlying medical illness.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested inpatient, sub-acute psychiatric residential treatment for treatment of his bipolar disorder.  Findings:  The physician reviewer found that this patient had been having mood symptoms over six months prior to the self-referral to this program. There were no precipitating events or issues. He had no acute symptoms and no relapse in either illness. The contention that the inpatient intervention was to be preventive of a relapse is not supported in the clinical records.  This patient could have been managed at a lesser level of care, such as a partial hospitalization program.  The submitted documentation does not establish the medical necessity of the services at issue. All told, inpatient, sub-acute psychiatric residential treatment provided from the dates in question was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees delayed speech/language development.   Findings:  The physician reviewer found that there is no medical documentation provided that describes a disease, injury or congenital deformity as the cause of this patients receptive and expressive language delay. Based upon the current medical literature, a meta-analysis of treatment of language delay show some benefit in treatment. However, without an underlying medical cause, speech therapy would not typically be considered medically necessary. Expressive and receptive language delays are not uncommon in young children; in the absence of an identifiable medical condition, such delays are generally appropriately addressed through the educational system. All told, the records provided for review do not establish the medical necessity of speech therapy services for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 74-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine while under general anesthesia or sedation for evaluation of her hip, back and leg pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient is 74-years of age and takes multiple medications. She has been referred for Open MRI where the claustrophobia issue will not be encountered. Given that the open MRI is a viable option that is likely to produce equivalent results, her request for general anesthesia for the conventional MRI is not reasonable. General anesthesia in MRI is reserved for only those patients when there is no alternative due to difficulty in controlling the patient due to the increased risk associated with anesthesia. There have been reported fatalities in similar clinical situations. Since there is an alternative for this patient without the attendant risk, the request for general anesthesia during MRI should be denied as it is not medically necessary for evaluation of her condition.