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

A 45-year-old female enrollee has requested laparoscopic adjustable gastric band (lap band) surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested lap band surgery in this case. This patient meets generally accepted criteria for medical necessity of bariatric surgery at this time including the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with serious co-morbid conditions. Thus, the patient meets the standard definition of clinically severe obesity at this time. The patient has failed prior dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery at this time. All told, the medical necessity of the requested procedure has been established.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested emergency services for treatment of his perineal discomfort.  Findings:  The physician reviewer found that the submitted documentation indicates the patient had perineal swelling of significant size. However, the medical records do not mention the severity of pain and there is no documented evidence of systemic symptoms associated with the infection. While perineal swelling of this size would be cause for some concern by a layperson, there is no documented evidence of the abscess rapidly enlarging, any systemic symptoms, or severe pain. The problem had been going on for several days and the patients arrival time at the Emergency Department was only four to five hours prior to the time a primary care providers office would have opened and could have been contacted. As such, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested follow-up visits with a reproductive endocrinologist for treatment of her polycystic ovarian syndrome and infertility.  Findings:  The physician reviewer found that based on review of the available records, the requested services are medically necessary for treatment of this patients medical condition. The patient has a documented history of infertility since her initial visit with her provider in 2011. She currently has been infertile for five years. A semen analysis in 2011 was abnormal revealing a male factor, and the patient has ovulatory factor with a diagnosis of PCOS with oligo-ovulation. The medical records suggest that infertility services are recommended for the patient. Infertility evaluation services, which include the evaluation of this couple for male and female infertility, are within the standard of care. Therefore, the requested services are medically necessary for management of this patients medical condition and should be approved.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested services on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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.Review of the submitted clinical information indicates the patient presented to the Emergency Department with a headache that was not associated with fever or a focal neurologic deficit. The patients pain level was documented as moderate (6 on a scale of 1 to 10).  There is no medical record documentation confirming the presence of severe pain. Nor is there evidence of the presence of signs or symptoms that would cause a prudent layperson to believe his or her health was in serious jeopardy. All told, a prudent layperson would not have reasonably believed this to be an emergency medical condition and would not have sought immediate medical attention in an Emergency Department.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested Xyrem for treatment of her insomnia. Findings:  The physician reviewer found that the patient has a chronic pain syndrome with refractory insomnia. According to the manufacturer prescribing information, Xyrem has been approved by the U.S. Food and Drug Administration (FDA) to reduce daytime sleepiness and cataplexy in patients with narcolepsy. Xyrem has not been approved by the FDA for the treatment of insomnia. At this time, there is a lack of peer-reviewed evidence supporting the use of Xyrem for the treatment of chronic insomnia. In the absence of scientific data demonstrating the safety and efficacy of Xyrem for individuals with insomnia, the medical necessity of Xyrem for this patient is not established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a SPECT scan (CPT code 78607) for her migraine headaches and history of hyperbaric therapy. Findings:  Three physician reviewers found that the available peer-reviewed medical literature, there is a paucity of data supporting the clinical utility of SPECT imaging in this setting. Specifically, there is no indication for a brain SPECT scan in patients with migraine headaches or those who have received hyperbaric oxygen therapy. All told, the use of the SPECT scan in this patients case was not likely to have provided additional useful information for assessing her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested  an abdominoplasty for treatment of her ventral and umbilical hernias.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Abdominoplasty involves the removal of skin and fat from the pubis to the umbilicus or above.  Unlike a hernia, diastasis is a benign condition with no long-term sequelae because the intestines and omentum cannot escape from the intra-abdominal space via the diastasis.  Additionally, it is not necessary to perform abdominoplasty at the same time as hernia surgery.  There is no decreased scarring in performing all of the procedures at one time versus in separate times.  In this patients case, the excess abdominal skin does not constitute an abnormal structure of the body, and the requested abdominoplasty would not be performed to improve function.  All told, the requested abdominoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy (40 hours per week of ABA therapy and up to 20 hours per month of program supervision, progress monitoring and data analysis) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. Applied behavior analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also note improvement of function in older children with autism spectrum disorders using intense ABA interventions (Grey, et al). The goals for older children often are to identify and remediate particular deficits. Older individuals with autism may need intensive and comprehensive treatment particularly if they present with dangerous behaviors (BACB 2012). The evidence suggests treatment intensity can play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes. Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. They noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week (Granpeesheh, et al.). For individuals over 3 years of age, 30-40 hours per week of ABA behavioral therapy is recommended (BACB 2012). Furthermore, a specific tiered services delivery of ABA therapy with carefully trained and well-supervised behavioral techniques is common practice in ABA treatments (BACB 2012). This patient presents with significant maladaptive behaviors including self-injurious and aggressive behaviors, poor adaptive skills, and stereotypic and perserverative behaviors and therefore ABA therapy is medically necessary. In conclusion, it is medically necessary that this patient receive 40 hours per week of ABA therapy and up to 20 hours per month of program supervision, progress monitoring and data analysis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a coronary calcium scan for evaluation of the enrollees history of chest pain.  Findings:  Two physician reviewers found that per the current medical evidence, the requested services are likely to be of greater benefit than other methods of evaluating this patient.  This patient has an intermediate risk profile for coronary artery disease.  She has a history of chest pain.  However, initial non-invasive testing did not confirm flow-limiting coronary artery disease.  Current guidelines support coronary artery calcium scanning for intermediate risk patients.  There is an additional benefit for coronary calcium scoring for persistently symptomatic patients.  The results of the coronary calcium scan can be used to guide treatment planning.  A coronary calcium scan is a non-invasive and appropriate method to further investigate this patients persistent chest symptoms and assess long-term risk.  Thus, the requested services are likely to be more efficacious than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested authorization and coverage for gastric bypass surgery for treatment of her morbid obesity and thrombophlebitis.  Findings:  The physician reviewer found that the medical necessity of the requested surgery is has not been demonstrated in the records provided for review. This patient has not completed an updated multidisciplinary evaluation, including dietary and behavioral evaluations. In addition, there is no documentation of compliance with follow-up since her surgery in 2000. In the absence of any overt complication of the gastric bypass documented on EGD or UGI that would be improved by a revisional procedure, the medical necessity of the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested physical therapy, three hours daily, Monday to Friday, for eight weeks for treatment of his status post gunshot wound. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The patient sustained a traumatic injury affecting the right-sided sacral nerve roots.  He has, in effect, a motor incomplete sacral spinal cord injury.  The majority of patients sustaining this type of injury regain functional ambulation at the community level.  Formal therapy and frequent physical activity play an important role in this process and in the general health and outcomes following this type of injury.  However, there is no medical necessity of formal therapy services at three hours per day, five days per week, on an outpatient basis in this case.  The patient has undergone inpatient rehabilitation and has been ambulating household distances independently with a walker.  He was independent with a home exercise program as of the time of discharge from inpatient rehabilitation.  There are no documented exercises that he cannot do independently or that could not be substituted with independent exercises.  No significant marginal improvement in clinical course or functional outcomes would be expected with the requested frequency and duration of therapies over a less intense schedule.  All told, physical therapy, three hours daily, Monday to Friday, for eight weeks, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested extreme lateral interbody fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested surgery in this patients case.  Per the submitted documentation, this patient does not have any significant radiculopathy or significant neurological deficits on clinical examination.  The records submitted for review do not document exhaustion of conservative care.  The peer-reviewed literature does not support the requested surgery absent radicular symptoms and absent documentation of exhaustion of conservative care.  In this patients case, there is lack of documentation of instability or significant stenosis.  The current medical evidence does not support the requested surgery in this clinical setting.  All told, the requested extreme lateral interbody fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested subcutaneous hormone replacement therapy (CPT 11980) for treatment of her status post hysterectomy with bilateral salpingo-oophorectomy. Findings:  Three physician reviewers found that in this patients case, the medication and issue was not and is not likely to be superior over other treatment modalities.  There is a lack of support in the current medical literature for subcutaneous hormone replacement therapy.  Per the medical literature, there is a lack of evidence demonstrating that bioidentical hormones are superior to conventional hormones.  Compounded hormones confer additional risks, as there is a lack of efficacy and safety data.  Compounded hormones have variable purity and potency.  Therefore, conventional hormone preparations are preferred over compounded therapy for the treatment of menopausal symptoms.  Thus, subcutaneous hormone replacement therapy was not and is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested  circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that circumcision is a treatment for phimosis in patients who fail the aforementioned management and is likely to be successful in refractory cases (Robinson, et al.). In cases in which the steroid treatment fails, a follow-up visit with the provider and attempt at repeat treatment is standard of care. A circumcision would only be indicated for true failure of steroid therapy. In this case, the clinical documentation does not demonstrate the patient had undergone sufficient treatment attempts with steroid therapy to establish the failure of such therapy. All told, the circumcision performed was not medically necessary to treat the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested emergency services for treatment of his broken right clavicle.  Findings:  The physician reviewer found that based upon the evidence provided, a prudent layperson would not have sought immediate surgical intervention in this situation. The patient was promptly seen and appropriate immediate medical attention took place following the injury, i.e., x-ray examination to accurately diagnosis the patients condition, pain medication and adjustment in pain medication and the use of a sling. There was no evidence to lead a prudent layperson to believe that immediate surgery or surgery as early as the date indicated was necessary to address a serious medical threat. For the reasons set forth above, the patients symptoms did not meet prudent layperson criteria for emergency care on the date indicated. A prudent layperson in the patients circumstances would not reasonably expect the absence of immediate surgical intervention to jeopardize his or her health.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A parent of a six-year-old male enrollee has requested  emergency services for treatment of the enrollees right earache, cough and nasal congestion.  Findings:  The physician reviewer found that the submitted documentation indicates the patient had an acute ear infection. According to the emergency department records, the patients pain was moderate in nature (6 on a scale of 1 to 10). There is no documentation of other presenting symptoms that could have reasonably been expected to result in any serious jeopardy to the patients health or bodily functions. All told, the patients symptoms were not of sufficient severity on the date in question to cause a prudent layperson to reasonably believe that immediate medical evaluation in an emergency department was required.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested occupational therapy for feeding twice a week for 16 weeks (32 visits) for treatment of the enrollees feeding disorder due to chromosomal abnormality. Findings:  The physician reviewer found that based upon the records provided, the patient has failed to alter her dislike for most foods despite two four-month courses of weekly occupational therapy. Manckam and colleagues report that successful results in cases involving severely developmentally delayed children requires a structured approach involving multiple disciplines, including a gastroenterologists assessment, which based upon the documentation provided, it does not appear this patient has received. In summary, this patient is achieving adequate nutrition, despite her limited food choices. There is no evidence she had undergone a complete gastroenterological assessment which could be helpful in pinpointing problems and could result in an improvement in her selection of foods. Her past occupational therapy has failed to result in measurable improvement and there is no indication that additional occupational therapy at this time is likely to result in improvement of the patients diet. As such, the medical necessity of occupational therapy for feeding has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Ampyra 10mg for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medications.  This patient has been diagnosed with secondary progressive multiple sclerosis.  Per the medical records, he has progressive gait difficulty.  The current medical evidence supports the requested medication in this clinical setting.  Ampyra (dalfampridine) has been shown to improve walking speed and may improve lower extremity strength.  Improvement in function of demyelinated axons can improve gait and other function in this setting.  The documentation indicates that the patient previously responded to Ampyra.  All told, Ampyra 10mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested neck surgery, brand name medications Percocet and Norco, and Carisoprodol and Diazepam 10 mg for treatment of his neck pain.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient would not benefit from the continued use of Percocet, Norco, Carisoprodol, and Diazepam given the lack of any significant relief to warrant continued use, in addition to the presence of significant risk factors. In the medical literature, Savage and colleagues noted that, effective management of pain in patients with a co-occurring addictive disorder requires a comprehensive approach that recognizes the biological, pharmacological, social, and psychiatric aspect of substance misuse and addiction, as well as practical means to manage risk, treat pain effectively, and ensure patients safety. With regard to Carisoprodol, the FDA recommends its use for no longer than two to three weeks in order to avoid the risk of dependence, withdrawal, and abuse. The documentation suggests the patient has a history of non-compliance with medication use and inconsistent urine drug screens. The patient has previously stated he cannot take generic medications due to thyroid disease and side effects; however, the submitted medical records do not provide confirmatory evidence of this. Additionally, there are other more appropriate therapies available to provide short-term pain relief. All told, the medical necessity for continued use of brand name medications Percocet and Norco, as well as Carisoprodol, and Diazepam, is not demonstrated in the records provided for review. Regarding the request for neck surgery, this patient does have objective findings to substantiate complaints of pain, including cervical pathology warranting surgical intervention. An article by Haldeman and colleagues concluded that it is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared with non-operative measures. However, relatively rapid and substantial relief of pain and impairment in the short term (6-12 weeks after surgery) after surgical treatment appears to have been reliably achieved. This patient is noted to have evidence of myelopathy at C2-3. As such, anterior cervical discectomy and fusion (ACDF) at C2-3 may be beneficial. However, the patient is considered a poor surgical candidate at this time in the absence of a primary care provider in place for medication management. The Health Plans recommendation of participation in a chemical dependency evaluation is medically reasonable and appropriate. This should occur within a chronic pain management program. The patient should be re-evaluated in three months to determine if he is an appropriate candidate for surgical intervention at that time.