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

A 47-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scans every nine weeks. The Health Plan has denied this request indicating that the requested diagnostic imaging is considered investigational for evaluation of the enrollees stage IV lung cancer. Findings:  Two physician reviewers found that the patient was diagnosed with stage IV non-small cell lung cancer (NSCLC) 5 years ago. There was tissue confirmation, and the patient had brain metastases. She has been treated with chemotherapy, and is currently on a regimen of pemetrexed administered every three weeks.  According to the patients physician, the patient is in complete remission, with no evidence of recurrent disease. Multiple recent PET scans have been reported as not showing evidence of tumor.  An MRI of the brain dated reported brain lesions that were felt to be less conspicuous. The issue in this appeal is whether PET scans at intervals of every nine weeks are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based on the kinetics of tumor development, obtaining frequent follow-up imaging studies is often not diagnostically or clinically useful. For example, in the case of this patient, she reportedly has no signs of tumor in her chest/abdomen/pelvis. In order to obtain useful information on a follow-up study, there must be sufficient time for the tumor to present itself. A further issue is that detecting a tumor earlier, before it becomes clinically apparent, often does not necessarily alter the course of disease. The National Comprehensive Cancer Network (NCCN) has developed guidelines for when to best obtain follow-up studies for surveillance. Their current recommendation for NSCLC Stages I-IV for patients with no evidence of clinical/radiographic disease (NED) is to obtain a history and physical and chest CT +/- contrast every 6 to 12 months for 2 years and then a history and physical and a non-contrast-enhanced chest CT annually. Specifically, PET is not indicated for routine follow-up. (NCCN Guidelines). Alberts indicates that in lung cancer patients following curative intent therapy, the use of blood tests, PET scanning, sputum cytology, tumor markers, and fluorescence bronchoscopy is not currently recommended for surveillance. In sum, the peer-reviewed medical literature does not demonstrate that the use of frequent PET scans is recommended in the surveillance of NSCLC.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested Orthovisc injections for treatment of his bilateral knee osteoarthritis.  Findings:  The physician reviewer found that when possible, it is oftentimes best to temporize and postpone total joint replacement because of routine operative risks and the known cumulative effects of wear debris from metal and methylacrylate bearing surfaces. A younger patient will be exposed to longer duration of particulate exposure and will have an increased risk of localized bone resorption and prosthetic subsidence, as well as both abrasive and contact wear of the components. Despite the advantages of delaying total joint replacement in this patient, the efficacy of hyaluronan injection preparations is poorly supported in the medical literature and patients undergoing these treatment protocols are vulnerable to a powerful placebo effect. In the study cited above by Jorgensen and colleagues, a double-blind placebo controlled administration of intra-articular Hyaluronate demonstrated no efficacy in patients studied at 3, 6, 9 and 12 months after injection when compared to physiological saline. Repeated injections are not without potential complications including aseptic inflammatory response and possible septic arthrosis. Given the lack of clinical data supporting the utility of viscosupplementation therapy for this patient, the medical necessity of the requested Orthovisc injections has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested a trial of spinal cord stimulator for treatment of his low back pain.   Findings:  Two physician reviewers found that the patient has refractory pain that is unlikely to benefit from a very large and risky surgical procedure.  The surgical notes detail a history of tried and failed interventional and medical therapy.   The patients providers agree he is a reasonable candidate for trial stimulation.  The trial of spinal cord stimulator will allow for extended assessment with minimal risk.  The use of spinal cord stimulation in this patient has the potential to restore function, decrease medication use, and avoid a large surgical procedure with uncertain outcome.  In this patients case, there is sufficient evidence supporting the requested trial of spinal cord stimulator.  Therefore, the requested services are likely to be of greater benefit than other treatment options in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested an upper gastrointestinal (GI) endoscopy, or esophagogastroduodenoscopy (EGD) for evaluation of her epigastric abdominal pain.  Findings:  The physician reviewer found that this patients records suggest that there is a low to moderate suspicion for celiac disease. In general, the first step in management includes assessing for celiac antibodies such as IgA tissue transglutamase antibodies. To that end, an EGD would not be indicated as a first diagnostic step. However, in this patient with upper GI tract symptoms and occult blood in the stool, performing an EGD is clinically indicated and supported in the medical literature. Rockey and colleagues concluded that, In a group of patients with positive fecal occult-blood tests who were referred for further evaluation, from which those with iron-deficiency anemia and active bleeding had been excluded, upper gastrointestinal lesions were identified more frequently than colonic lesions. As this patient has been ruled out for anemia and had a positive fecal occult blood test, the requested EGD diagnostic procedure should be approved as medically necessary for further evaluation of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested embolization of the ovarian vein and internal iliac veins for treatment of her pelvic congestion syndrome.  Findings:  Three physician reviewers found that pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. Development of an evidence-based approach to managing this condition has been limited by the absence of definitive diagnostic criteria. There are no definitive diagnostic criteria for PCS. In general, the diagnosis is based on a combination of characteristic symptoms, tenderness on physical examination, and documentation of pelvic vein dilatation or incompetence, after exclusion of other causes for these nonspecific findings. The documentation provided does not demonstrate that the patient has been fully evaluated or given alternative therapy prior to the recommendation of embolization therapy.. This patient may have PCS and may benefit from embolization therapy, however it is not clear that she has been fully evaluated per the records available for review, nor is there clear evidence that other therapies have been tried. Embolization has only been shown to be of benefit in selected cases and there is an inherent risk of the loss of ovarian function with this procedure. In sum, without clear evidence of a diagnostic work up and failed attempts at conservative therapies, this procedure is not likely to be more beneficial for treatment of this patients medical condition than any other standard treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested methylcobalamin 0.25mg/ml (injectable) for treatment of his autistic disorder. Findings:  The physician reviewer found that the use of vitamin B12 is not considered a standard modality for the treatment of autism. The relevant scientific literature includes a French report which notes that vitamins B12 and B6 have been studied in autistic children with debatable results in a paucity of double blind studies (Hjeiej, et al.).  The available literature demonstrates that the use of vitamin B12 to modify abnormal behavior in autistic children has had mixed results, but generally is not associated with improvement. Further data is needed to establish that vitamin B12 is effective in modifying behavior abnormalities in patients with autism. Therefore, the requested medication is not medically necessary for treatment of this patients autism.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested authorization and coverage for a spinal disc add-on (arthroplasty) of L5-S1 and fusion of L4-L5 surgical procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees L5-S1 and L4-5 degenerative disc disease and lumbar radiculopathy.  Findings:  Three physician reviewers found that this patient has chronic low back pain. There is no evidence of any localizing features to her pain and the records do not demonstrate that either L4-5 or L5-S1 have been determined to be her pain generators. Additionally, there is no evidence provided that the patient has any instability, spondylolisthesis, infection or scoliosis, which are accepted criteria for lumbar fusion (Milliman Care Guidelines; Bambakidis, et al.). The use of an artificial disc is considered experimental/investigational, as there is a lack of large, scientific studies establishing its long term safety and efficacy. Additionally, the Food and Drug Administration (FDA) has required a five, seven and ten year study regarding the long term safety and efficacy of total disc replacement, which is still ongoing. In sum, the available peer reviewed medical literature and the medical records provided do not demonstrate that the requested lumbar fusion and artificial disc replacement procedure is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested artificial disc replacement surgery for treatment of her lumbar stenosis, spondylolisthesis, and radiculopathy.  Findings:  Three physician reviewers found that this patient presents with chronic low back pain. She has right lower extremity pain and numbness but no symptoms of a defined radiculopathy or sciatica. She has an abnormal MRI at L5-S1, but this has not been shown to be her pain generator. She has no evidence of instability, spondylolysis, infection, or fracture at L5-S1. In addition, L4-5 has not been shown to be abnormal or to have degeneration. She has undergone a discogram which was normal at L3-4 and with concordant pain L4-5. The provider indicates that the discogram was attempted at L5-S1 but not performed as the patient had severe pain. On the basis of the L4-5 finding and the severe pain with the attempt at L5-S1, the hybrid procedure artificial disc replacement at L4-5 and 360 fusion at L5-S1 is proposed. Valid discography requires three levels of injection, pressure measurements, post discogram computed tomography (CT) results with Modic/Dallas 4 of 5 findings. In the medical literature, Chou cautioned that discography should not be performed in patients with chronic non-radicular low back pain as a tool for diagnosing discogenic low back pain. Further, the procedure should not be performed by the surgeon. Resnick and colleagues noted that discography should not be used as a stand alone procedure prior to surgery. This patients records do not demonstrate that these criteria have been met. With regard to patient selection, Zigler and colleagues reported that a patient is a candidate for artificial disc replacement who has an anatomically abnormal disc which is clearly the pain generator in the face of normal adjacent levels. Since this patient has a normal L4-5 disc, abnormal L5-S1 and is about to undergo fusion, she is not a candidate for artificial disc replacement. All told, the requested surgical intervention is not likely to be more beneficial for treatment of the patients medical condition than conventional alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male has requested  increased speech therapy for treatment of his autism. Findings:  The physician reviewer found that Myers and Johnson, et al. is frequently cited in the autistic literature as a definitive source of the evaluation and treatment of autistic children, and it is useful to quote from it in formulating a decision as to whether speech therapy is necessary in this case. According to the authors, [p]eople with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. The study by Turner, et al. is a controlled study comparing autistic children who did and did not receive speech therapy.  Those that did receive therapy had far greater communication skills than those that did not receive speech therapy. The report of the Speech-Language and Hearing Association, states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. All told, it is medically necessary that this patient continue to receive speech therapy is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested for physical therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that Effgen and McEwen advocate in favor of the positive effects of PT for patients with delays greater than 33%. The authors recommend PT for continued improvement in gross-motor skills acquisition, prevention of secondary disability, and to improve fine motor control and overall muscle strength. In addition, Strubhar and colleagues found that the long-term benefits of PT help to minimize impairments in motor coordination and learning (Strubhar, et al).  The requested PT services have been established as medically necessary in the management of her hypotonia and related gross motor delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of two-year-eleven-month-old female enrollee has requested speech therapy, occupational therapy, and physical therapy services for treatment of the enrollees developmental disabilities. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by same-aged peers (Shevell, et al.). Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Physical and occupational therapies are standard modalities for children with significant delays in gross and fine motor skills and cognitive functioning. The main goal of treatment is to enhance the level of functioning. This patient has delays in speech and gross motor skills with fine motor and cognitive delays. Appropriate services including speech, physical and occupational therapies are medically necessary and promote adaptive skill development and independence (Wolraich, et al.)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech and occupational therapy services for treatment of his autistic disorder. Findings:  The physician reviewer found that occupational therapy studies have shown benefits that prevent deterioration or a reversal of function and result in a significant improvement in activities of daily living (Case-Smith & Arbesman; and Shoener). In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. The medical community has also determined that occupational and speech therapies are medically necessary as evidenced by the American Academy of Neurology guidelines for autism which state that the immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Individuals with mild autism should also receive adequate assessments and appropriate diagnoses and therapies.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old female has requested reimbursement for emergency room services. The Health Plan has denied this request indicating that the enrollee's condition was not an emergent medical condition.  Findings:  The physician reviewer found that the patient presented to the emergency room (ER) with a chief complaint of tearing associated with swelling and pain in the region of the medial canthus of the right eye, present for one year, but worse since the prior day. She had been seen for this problem multiple times by her primary care provider. In the ER, her vital signs were unremarkable, and the emergency physician noted that she was in no apparent distress. No specific pain score was entered into the record by that physician.  Slight swelling was noted at the medial canthus and along the right side of the nose with tenderness to palpation.  There was no overlying skin erythema or increased warmth.  There was no exudative drainage expressed from the medial canthus area. The physician diagnosed the patient with dacryocystitis and recommended warm compresses. The patient was given a prescription for Norco for pain. She was referred back to her primary care physician for referral to otolaryngology or ophthalmology.At issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted evidence indicates that the patient presented to the emergency room with complaints associated with a problem that had been occurring for a year.  At the time of her presentation to the ER, the patient was in no apparent distress. The examining physician noted only slight soft tissue swelling, with no evidence of infection.  A reasonable and prudent layperson with slight soft tissue swelling associated with a condition that had been present for a year would not believe that she was experiencing an emergency medical condition. The evidence provided does not support the patients contentions that she was in extreme pain, had severe swelling and had experienced significant worsening of her condition since being seen by her primary care physician earlier that day. As such, the patients condition did not meet prudent layperson criteria for emergency services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested  speech therapy services and continued speech therapy services at a frequency of one time per week (one hour each session) for treatment of his delays in receptive, expressive and social language skills.  Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator.  There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language.  As noted by Volkmar, most children with autism spectrum disorder will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Children on the autistic spectrum have deficits in speech and language, as well as social communication. Therapists with experience working with children with autism spectrum disorder, handling the myriad of communication challenges that face these children, are most appropriate. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. All told, the submitted documentation demonstrates the medical necessity of speech therapy services provided during the said time frame. Additionally, continued speech therapy services at a frequency of one time per week (one hour each session) are medically necessary for the treatment of this patient.