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

A 47-year-old male enrollee has requested use of an interferential neuromuscular stimulator (electrical pulse delivery) for treatment of his chronic back pain. Findings:  Two physician reviewers found that the clinical practice guidelines have not supported the use of electrical stimulation for lumbago. The American College of Environmental Medicine (ACOEM) guidelines state that interferential therapy is not recommended in the setting of chronic low back pain. This view is consistent with the Philadelphia Panel review that reported a lack of evidence demonstrating efficacy of interferential therapy for management of low back pain. Given the status of the scientific data and the standards of modern evidence-based medical practice, the device is of unproven clinical efficacy and therefore remains investigational.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested cognitive skills development therapy for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  Three physician reviewers found that cognitive skills therapy was not and is not likely to be more beneficial for the treatment of attention deficit/hyperactivity disorder than standard therapy.  In the report by Antshel and Barkley, limited efficacy for cognitive therapy was noted.  The American Academy of Child and Adolescent Psychiatry practice parameters note that formal skills training for children with attention deficit/hyperactivity disorder has not been shown to be effective.  All told, cognitive skills development therapy was not and is not likely to be the most beneficial treatment alternative.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that there is a paucity of data supporting the use of TMS in patients in depression with serious co-morbidity, as in this case. Specifically, TMS is not indicated for treatment of PTSD, alcohol dependence, GAD, or borderline personality disorder. With regard to TMS being a potential treatment of major depressive disorder, Gelenberg reports that the American Psychiatric Association (APA) practice guidelines do not establish TMS as more efficacious than other available therapies. In addition, a recent randomized controlled trial published in 2007 suggests that electroconvulsive therapy (ECT) is more efficacious in treating major depression. Furthermore, Martin and colleagues concluded that there are insufficient randomized, controlled studies with outcomes supporting the efficacy of TMS to warrant its use at this time. Thus, TMS should be classified as investigational as the current research does not establish its superiority over other treatments in terms of efficacy. Consistent with these data, evidence-based, proven treatments are more likely to be effective for ameliorating this patients depression than TMS therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested urgent care services for treatment of her medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing a medical condition requiring urgent medical services. Urgently needed services are defined as services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. This case does not meet the prudent layperson criteria for urgent care. The patients complaints of nasal congestion, cough, and chills and symptoms of nasal discharge with facial pain and pressure are common and would not cause a reasonable layperson to seek immediate treatment at an urgent care facility. There was no documentation of extreme pain, inability to eat or drink, or other alarming symptoms. Furthermore, there was no documentation in the urgent care notes of the patient concerns regarding the H1N1 virus. There is no indication in the treatment records of any complaints, signs or symptoms that would cause a prudent layperson to believe he or she was at risk of serious deterioration without urgent medical attention. In summary, this patients condition did not constitute an urgent care situation. A prudent layperson in this situation would reasonably assume that treatment could be safely rendered at a later time by a primary care provider without any risk to the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a panniculectomy, bilateral thigh lift, bilateral hip lift and bilateral buttock lift for treatment of the enrollee, who is status post bariatric surgery. Findings:  The physician reviewer found that in regards to the panniculectomy, although the pannus hangs over the symphysis, there is insufficient documentation of a skin condition under the pannus and its failure to respond to non-surgical treatment. There is also insufficient documentation of a skin condition that would warrant breast surgery. With respect to the bilateral thigh lift, there is no evidence of any skin condition that would warrant this in the photographs. With respect to the bilateral hip lift and bilateral buttock lift, although this would address buttock rhytids, such improvement would only be cosmetic, as almost all of these are superior to the sitting area and are not sufficiently deep enough folds to cause a functional problem. All told, the proposed procedures are not necessary for treatment of this patients condition from a medical standpoint. Furthermore, the submitted evidence does not establish that the patient has a condition that constitutes an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While the patient has excess skin, this condition is not so excessive as to be considered an abnormal structure of the body. As such, the proposed surgery does not meet the expanded concept of medically necessary reconstructive surgery defined in California law.  In this patients case, the requested panniculectomy, bilateral thigh lift, bilateral hip lift and bilateral buttock lift are not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Namenda for treatment of her chronic migraines.  Findings:  Three physician reviewers found that Namenda has not been approved by the Food and Drug Administration (FDA) for the use of migraine headache. Thus, its use in this case would be off-label. Namenda is indicated and FDA approved for the treatment of neuronal degeneration and Alzheimers disease. A review of the relevant scientific data confirms that Namenda is not supported in the clinical studies as safe and effective for treatment of migraine headache. The publications referenced above suggest that Namenda has been researched as a treatment for chronic tension-type headaches, but the retrospective and observational studies have methodological flaws that prevent their findings from establishing Namenda as a proven treatment modality for this indication. This patients condition is likely exacerbated by her coincidental status post surgical fusion at C5-6 with myofascial neck pain and right shoulder pain. There is insufficient documentation in her records of failure or intolerance to standard treatments that have been the subject of randomized, controlled, blinded trials, and are FDA approved for the treatment of migraine headache. Thus, the use of Namenda for this patients condition would be investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old female enrollee has requested up to 2 hours per week of speech therapy and up to 10 hours per week of occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that there is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autism spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, and behavioral therapy. Fundamental to the diagnosis of ASD are deficits in speech and language. Most young patients with ASD benefit from therapies designed to improve their ability to communicate and engage in social interactions (Volkmar and colleagues). The authors found that, Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Of import is that the deficits in the use of language can serve as major impediments to successful social adaptation and acceptance. Overall, the authors suggest that, The sooner and more aggressively these deficits are targeted, the better chance the child has for developing adequate skills to function in the community. As this patient exhibits significant deficits in expressive language, receptive language, and pragmatics, the requested speech therapy is medically necessary and appropriate for management of her deficits. Therefore, up to two hours per week of speech therapy is clinically indicated to address her delays and should be authorized.With regard to the requested occupational therapy (OT), Roley and colleagues noted that OT focuses on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information and regulating the response to incoming information. These goals address many of the deficits discussed by Case-Smith and Arbesman who noted that, Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. With regard to the necessity of therapy, the authors found that Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. For these reasons, OT is well-suited to affect positive change in children with ASD. This patient exhibits significant deficits in self help skills, fine motor skills, motor planning, and the processing of sensory information. The requested OT for up to 10 hours per week is therefore medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested applied behavioral analysis (floor time) therapy for up to 20 hours per week for treatment of the enrollees autism. Findings:  Three physician reviewers found that the data suggests that long-term, comprehensive ABA intervention leads to positive effects in terms of intellectual functioning, language development, acquisition of daily living skills and social functioning in children with autism. As such, ABA therapy is an accepted form of therapy and should be approved for the 20 hours a week as recommended for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a partial vulvectomy for treatment of her labial hypertrophy. Findings:  The physician reviewer found that there are many factors that can lead to labia hypertrophy including congenital, developmental, trauma, and infection. The patient states that this is a developmental occurrence and not from other factors. However, there is insufficient documentation of a work-up to establish that her labia hypertrophy is not the result of another condition. Thus, although the requested surgery is stated to improve pain and may try to create normal appearance, there is insufficient documentation to support these goals. There are no records demonstrating failure or intolerance to conservative measures to improve or to treat the patients pain. Overall, this patient may have functional concerns from her hypertrophic labia minora. However, given that the requested surgery is traditionally considered a largely aesthetic procedure, the treating providers must adequately describe the problem, functional concerns, non-surgical failures and work-up for other causes in order for surgical intervention to be medically reasonable in this instance. The procedure would be expected to improve the appearance, but lacking adequately defined functional improvement and justification for the procedure, the records do not satisfy the requested surgery as being reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested child/adolescent psychiatric residential treatment for treatment of the enrollees major depressive disorder, recurrent, moderate, attention deficit/hyperactivity disorder, cocaine dependency and parent-child relational problem. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity for residential level of service during the time period at issue.  The submitted documentation indicates patient improvement following residential treatment at the prior facility. Specifically, information from the prior residential treatment facility indicates that the patient did not demonstrate dangerousness to herself or others, and her self-harm and restrictive eating behavior had been well-managed. Psychiatric evaluation on admission indicates that the patients mood was mildly depressed, with congruent affect. Insight was fair, and motivation was described as good. The medical records noted that thought content was without suicidal or homicidal ideation, and no psychotic symptoms were described.  As of the admission date, the patient was a candidate for intensive integrated services at a less restrictive level of care, such as partial hospitalization or day treatment. All told, child/adolescent psychiatric residential treatment provided during the time period at issue was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested  residential treatment services for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that this patient was referred to residential treatment with diagnoses of major depressive disorder, generalized anxiety disorder and parent-child conflict. She has a long psychiatric history that has included outpatient therapy, multiple medication trials and partial hospitalization services.  The treating physician indicated that the patient has been under his care from the said dates in question.  He noted that the patient has treatment-resistant depression and anxiety with repeat episodes of decompensation over the past 24 months.  Severe functional impairment was noted, and this included an inability to attend school.  The patient had difficulty with activities of daily living and was isolating. She also has a history of past suicide attempt and self-injury.  In this patients case, residential treatment services from the dates in question forward were and are medically indicated.  This patient has failed attempts at lower levels of care, she has serious functional impairment secondary to depression and anxiety, and there is an ongoing risk for self-harm.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Euflexxa injections for treatment of her osteoarthritis of the knees.  Findings:  The physician reviewer found that lussier and colleagues report that Hyaluronan viscosupplementation therapy has been an accepted treatment for the treatment of osteoarthritis of the knee for many years. However, Dagenais noted that the efficacy is greater in patients with mild to moderate degeneration, while Wang found the therapy even less effective in patients with advanced disease. Although there have been some reports of benefits from repeated series of injections (Waddell, et al.), there have been reports of increased frequency of problems including local reactions (Leopold, et al.). As such, Cole and Malek reported that there remains a need for controlled, blinded, prospective studies to evaluate the benefits and risks of repeated injections. In the absence of data demonstrating the positive health outcomes in this patient subset, there is inadequate evidence to establish the medical necessity of repeated courses of viscosupplementation for management of this patients osteoarthritis. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has significant deficits in the language areas of semantics and morphology, as well as difficulty formulating thoughts and expressing herself with her own vocabulary. This combination of auditory processing deficits and delay in semantics and morphology is adversely affecting her participation in academic and social interactions. Moreover, these issues are negatively impacting her expressive and receptive language skills. For these reasons, speech therapy is medically necessary and appropriate for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested neck surgery for treatment of her degenerative disc disease. Findings:  The physician reviewer found that in this patients case, there is evidence of disease at multiple levels on x-ray, MRI, and CT scan, and there is a lack of evidence of localization of the level of origin of the symptoms. The electroneurodiagnostic studies performed were not specific, and no other investigation is documented. There is also a lack of documentation of conservative measures other than chiropractic, acupuncture, and epidural steroid injections. Physical therapy is mentioned, but not described as to modality or results. There is no documentation of the use of nonsteroidal medications, or the reasons for not using them.  Based upon the submitted documentation, the medical necessity of the requested neck surgery has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 75-year-old male enrollee has requested continued physical therapy, at a frequency of once per week for eight weeks for treatment of his cervical radiculitis. Findings:  The physician reviewer found that this patient has multilevel cervical spondylosis with nerve root compression. He has responded well to conservative management with physical therapy but remains symptomatic. Manual therapy is considered an effective treatment for patients with neck pain. His treating physician has recommended a limited course of additional physical therapy to address his residual pain and impairments. The physical therapy notes have identified specific impairments, defined a specific treatment plan, and established reasonable therapeutic goals. The patient continues to require skilled physical therapy and is not at the point where an independent home exercise program alone would allow for a similar outcome.  All told, continued physical therapy, at a frequency of once per week for eight weeks, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that the patients diagnosis at admission was eating disorder, not otherwise specified. Laboratory testing on the dates in question were reported to be within normal limits.  There was no history of binging or purging, and exercise was reported to be four times per week. There was no history of use of diet pills or laxatives. There were no major comorbidity issues.  The patient rated her depression 4 out of 10 and noted a positive response to mood stabilizers. She was also described as motivated for treatment.  In this case, the patient does not meet American Psychiatric Association guidelines for residential level of care. Consistent with American Psychiatric Association treatment guidelines, the patient was a candidate for intensive outpatient services, such as full day partial hospitalization.  All told, residential treatment services from the said dates forward were not and are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Rituxan, 1000 mg for treatment of her relapsing remitting multiple sclerosis. Findings:  Two physician reviewers found that the medical literature reveals that MS is frequently treated with immune suppression when progressing despite immune modulation treatment. Rituxan has been subject to small studies for treatment of MS and it has been beneficial. This patient has a reported diagnosis of MS, however prior treatment trials and responses are not noted. Without data showing that the patient has tried and failed standard medications, Rituxan cannot be shown to be more effective than standard treatments and is investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested growth hormone therapy (Saizen, 8.8mg, 1.5 cartridge) for treatment of the enrollees growth failure in the setting of an abnormal pituitary MRI.  Findings:  The physician reviewer found that although this patients height is more than two standard deviations below normal for age and sex, his adult predicted height based on one bone age assessment and height measurement falls within normal range for an adult male.  Although the provider argues that this patients growth velocity is abnormally low, the low growth velocity of 3.2 cm per year is based only on two measurements that are 3 12 months apart, and the duration of time between these two measurements is not long enough to declare the growth velocity to be abnormally low.  Pre-treatment growth velocity for at least a one-year time period should be documented prior to consideration of growth hormone therapy, particularly during the peripubertal period, when some children may normally have a slump in linear growth.The finding of a flattened pituitary gland on MRI does not, in and of itself, argue for growth hormone deficiency, particularly when biochemical testing shows normal results, there is no evidence of any other pituitary deficiencies, and there is no clear documentation of abnormal linear growth velocity over at least one year of time.  The fact that the patient experienced acceleration in growth after treatment with growth hormone therapy does not prove that he is growth hormone deficient. Without documentation of pre-treatment pubertal stage, it is possible that sex steroid secretion has contributed to the boost in his growth velocity coincident with administration of growth hormone therapy. Additionally, augmentation of growth may occur with growth hormone therapy even in children without bona fide growth hormone deficiency.  All told, the medical necessity of the requested growth hormone therapy has not been established by the submitted documentation.