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

A 72-year-old female enrollee has requested magnetic resonance imaging (MRI) of the shoulder for evaluation of her shoulder pain.  Findings:  The physician reviewer found that based on review of the available records, this patient has chronic shoulder pain which inhibits normal activities including sleep due to pain. The records indicate that physical therapy has not been accomplished. Radiographs of the shoulder have been described as showing classic evidence of chronic rotator cuff tear including cephalad migration of the humeral head. In addition, there is evidence of calcific peritendinitis. In this clinical circumstance, MRI is the procedure of choice to determine if all of the rotator cuff tendons are torn and the degree of degenerative joint disease present. Although the patient has not been treated with physical therapy or standard conservative management, the described radiographic abnormalities are classic for significant, chronic rotator cuff tears. Therefore, MRI is medically necessary for evaluation of this patients shoulder pain prior to further treatment, including physical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested the compound medication Mustargen for treatment of her diagnoses with mycosis fungoides stage IB. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has requested coverage for topical nitrogen mustard (Mustargen) for treatment of mycosis fungoides, which is a rare form of cutaneous T-cell lymphoma.  She responded well in the past to this established and proven therapy for mycosis fungoides.  Skin-directed therapy with Mustargen has been shown to be safe and effective for early stage disease.  All told, the compound medication Mustargen is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested psychiatric services for treatment of the enrollees polysubstance abuse and bipolar disorder.  Findings:  The physician reviewer found that the records do not support the medical necessity of acute inpatient treatment during the said timeframe. The patient did not show any agitation, irritability, or behavioral problems. In addition, the records indicate the patient was compliant with treatment recommendations, took medications, and had no side effects. There is inadequate documentation demonstrating the need for 24-hour nursing or medical care. Therefore, the patient did not meet continued stay criteria for inpatient level of care beginning the date in question and could have been treated at a less intensive level of care. Consistent with these findings, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested an external cardioverter defibrillator (LifeVest) for treatment of his history of severe ischemic cardiomyopathy. Findings:  Three physician reviewers found that survival in ischemic cardiomyopathy is greatly diminished in patients with cardiomyopathy with ejection fractions of less than 35% and mild or moderate congestive heart failure. This is due to the risk of serious arrhythmias including ventricular tachycardia and ventricular fibrillations. Clinical trials have shown a survival benefit for patients with low ejection fraction treated with ICDs compared with patients treated without such devices. Following a myocardial infarction, the initial impairment in left ventricular function may sufficiently improve such that a device is no longer needed. For this reason, a 40 day waiting period is indicated prior to implanting an ICD. While the risk of serious arrhythmias is highest following a myocardial infarction, ICD or WCD has not been shown to improve survival during this period. All told, the device at issue was not likely to have been more beneficial than standard therapies including medical management for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested continued skilled nursing care for treatment of the enrollees cutis-marmorata telangiectatica congenita.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  This patient has multiple medical problems affecting his health and well-being.  While the parent has some skills needed to help care for this patient, continued skilled nursing care is medically appropriate.  This patient requires constant vigilance because of the risk of hydrocephalus and brainstem compression, aggressive respiratory care because of the risk of aspiration pneumonia, careful feeding because of the risk of aspiration, and prompt recognition and treatment of breakthrough seizures.  Such interventions require the clinical judgment, experience, and expertise of skilled nursing personnel, and cannot be provided at a lower level of care.  All told, the requested continued skilled nursing care is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested a consultation with a rheumatologist for evaluation of her medical condition.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service. First, ANA testing is not sufficient to establish or refute the diagnosis of lupus or other autoimmune diseases (Peng and Craft). The laboratory method by which the ANA result was obtained is not specified in the medical records. The standard for antinuclear antibody testing is the fluorescent ANA test. However, many laboratories currently use an enzyme-linked immunosorbent assay (ELISA) which is less sensitive than the fluorescent test (Meroni and Schur). The result of a negative ELISA does not rule out the diagnosis of lupus. Second, the patient is complaining of pain, dry eyes, and numbness of the hands and the records show that she was diagnosed with lupus and fibromyalgia in the past. For the reasons provided above, the requested consultation with a rheumatologist is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested Verifi prenatal laboratory testing (CPT code 84999) for evaluation of her  pregnancy.  Findings:  Two physician reviewers found that current methods of fetal genetic testing involve obtaining samples of amniotic fluid, placenta, or fetal blood. The invasive techniques required for obtaining fetal samples place the fetus at risk of injury. Noninvasive prenatal testing that uses cell free fetal DNA from the plasma of pregnant women, including the Verifi prenatal test, offer potential as a screening tool for fetal aneuploidy. The American College of Obstetricians and Gynecologists (ACOG) recommend testing for aneuploidy either by screening or invasive prenatal diagnosis regardless of maternal age. Cell free fetal DNA is one option that can be used as a preliminary screening test in women at increased risk of aneuploidy, including patients who are ages 35 and older. Since the Verifi prenatal test is a type of non-invasive cell free fetal DNA test, and the patient was over 35 years of age, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested reduction of inferior turbinates by coblation (CPT code 30140) submucous resection inferior turbinate, partial or complete, any method for treatment of her moderate obstructive sleep apnea. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  The peer-reviewed medical literature suggests subjective improvement of symptoms of sleep disorder, but there is a lack of evidence of any objective demonstration of improvement of outcomes. Sundaram and colleagues reference evidence of outcomes of surgery, but there is a lack of peer-reviewed articles that demonstrate substantial improvement of the apnea/hypopnea index. Although the clinical evidence and peer-reviewed literature listed show some improvement of nasal symptoms, there remains a lack of documentation showing that the radiofrequency ablation of hypertrophied inferior turbinates improves sleep patterns.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested OxyContin 80mg. for treatment of his sickle cell anemia.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, most patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the effects of opioid-induced hyperalgesia. High dose opiates may also cause adverse outcomes and therefore the patients requested authorization and coverage for OxyContin 80mg twice per day is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. Consistent with these findings, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested bilateral maxillary balloon sinuplasty for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other available treatment options.  This patient had chronic sinusitis with acute exacerbations.  The medical records noted bilateral maxillary sinus disease after maximal medical therapy.  Balloon sinuplasty is an established procedure in this clinical setting, and there is adequate medical evidence supporting the services at issue in this patients case.  Thus, bilateral maxillary balloon sinuplasty performed on the said date was likely to have been of greater benefit than other available treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested a WalkAide functional electrical stimulator (FES) for treatment of her multiple sclerosis.   Findings:  Two physician reviewers found that FES devices have become more common use for patients with foot drop due to upper motor neuron lesions. The devices are prescribed for patients with multiple sclerosis. The peer-reviewed medical literature supports gait improvements beyond gains made with an AFO. This patient has had a trial with the FES WalkAide device and there is documented improvement as well as the patients subjective report of improvement. The patient has tried standard therapies including anti-spasticity agents with Baclofen and AFO. Further, the patient is not a candidate for treatment with Ampyra due to a higher risk of seizure as noted on an electroencephalogram (EEG). Given the patients improvement with WalkAide, the requested device is more likely to be beneficial for treatment of her medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested laparoscopic duodenal switch for treatment of her severe obesity.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery in this case. According to the American Society for Metabolic & Bariatric Surgery (ASMBS), the duodenal switch is considered a standard primary treatment for morbid obesity and clinically severe obesity. This patient is morbidly obese with a BMI that is greater than 40 and has already been approved for weight loss surgery. This patient meets generally accepted criteria for medical necessity of bariatric surgery at this time. Based on standards within the field and published medical literature, this patient should be a candidate for any primary treatment which would include DS. All told, the medical necessity of the requested laparoscopic duodenal switch procedure has been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old male 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 enrollees circumstances would have sought immediate medical attention on the date of service at issue. 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.  In this patients case, he has been diagnosed with multiple sclerosis and has been treated on a routine schedule with medication.  These treatments have been prescribed on a once monthly basis.  Per the current medical evidence, it is important that the patient remain on the scheduled monthly dosage of the medication at issue in order to prevent an exacerbation.  A prudent layperson with multiple sclerosis would stay on schedule with this medication, even while traveling.  The patients symptoms on the date of service at issue met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his health in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested sexual reassignment surgery: free flap phalloplasty for treatment of his gender dysphoria.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Free flap phalloplasty is the preferred method for female-to-male genitalia reconstruction. This procedure is preferred to the pedicled groin flap. Neither of these techniques are single stage procedures. Multiple procedures are common for both, but there are usually fewer procedures required when using the free flap compared to the pedicled groin flap. The free flap procedure is better vascularized, has fewer complications and has better outcomes compared to the pedicled groin flap. Moreover, the free flap procedure meets all of the criteria sought by the patient. The free flap does not contain muscle and generally does not affect forearm or hand strength. Urinary problems are common long-term for both procedures and urology involvement and follow up is necessary. A penile prosthesis is necessary for intercourse in any free flap surgery except for the fibula free flap. The anterior lateral thigh flap and latissimus musculocutaneous flaps are less preferred than the free flap because they are usually much thicker tissues and are too large. All told, the requested free flap surgery is a well-accepted procedure and is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested intensive speech therapy for treatment of the enrollees aphasia status post stroke.  Findings:  The physician reviewer found that ongoing speech therapy for chronic aphasia is effective in well selected patients (Moss and Nicholas). However, the duration and intensity of the therapy necessary to achieve outcomes has not been established (Meinzer, et al). It is unclear whether intensive speech therapy achieves sustainable goals or promotes a brief increase that is not sustained without continued practice from the patient (Moss and Nicholas). This patient has a stable speech pattern that shows little change from the year indicated. The records indicate that she showed very moderate progress when attending the intensive speech program at the specified facility and did not reach her goals. The Health Plan has offered outpatient therapy and made a number of recommendations to the patient. Her speech has stabilized and there is no evidence in the literature the specific activities and intensive therapies at the independent facility are superior to the range of services available within the Health Plan. Therefore, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested residential eating disorder for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that the patient remains at high-risk in the absence of an effective course of intensive treatment prior to step-down transitioning to community-based programming. She has failed less restrictive treatment settings in this course of illness and her complex psychosocial stressors will more than likely produce enough distress to undermine treatment in a lower level of care at this time.  This patient requires the structure and 24-hour supervision afforded by residential placement to cement the therapeutic skills necessary for success, and premature discharge places the patient at risk for morbidity and acute hospitalization. Accordingly, residential treatment services were and are medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested 30 sessions of aquatic therapy for treatment of his spinal cord injury.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested therapy. This patient has progressed well with physical and occupational therapy and is independent at wheelchair level. While the patient was working on standing in physical therapy, this is not a functional task at this time. Aquatic therapy is not a standard of care modality in this setting and is not considered medically necessary for this pathology. There is no documented medical indication for aqua therapy at this time. All told, it is not medically necessary that the patient receive the requested 30 sessions of aquatic therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old enrollee has requested bilateral mastectomy with chest reconstruction for the enrollees transgender reassignment. Findings:  The physician reviewer found that review of the submitted documentation indicates the patient has a body mass index (BMI) of approximately 35. Obesity with a BMI of 35 slightly increases the risk of surgical complications. An individual with a BMI of 35 may be at higher risk for surgical and wound healing problems. However, a BMI of 35 is not a contraindication to proceeding with the requested surgery. The patient is an appropriate candidate for bilateral mastectomy with chest reconstruction from a medical standpoint. Psychological clearance for the proposed surgery should be obtained before the procedure is performed.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested botulinum toxin A (Botox) injections for treatment of her cervical dystonia.  Findings:  Three physician reviewers found that this patients medical records support that the patient has cervical dystonia, and has been well managed for years with Botox therapy. Cervical dystonia is characterized by involuntary movements, spasms, pain, and altered mobility. Botox is beneficial for these symptoms, and is considered first-line therapy in the literature. In addition, the FDA states that Botox is indicated for treatment of cervical dystonia in adult patients, to reduce the severity of abnormal head position and neck pain. Botox is therefore likely to continue to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested Molecular Pathology Procedure Level 5 testing (CPT code 81404) for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that review of the submitted documentation and medical literature demonstrates that the procedure requested is likely to be more beneficial for evaluation of the patients medical condition than standard therapies. This patients diagnosis remains unclear. Obtaining the correct diagnosis allows for the proper counseling, estimate on prognosis, and most importantly, it guides treatment strategies. Mitochondrial and lipid storage diseases are treated very differently and have varying clinical courses. The patient has already received an appropriate work-up (muscle biopsy) without a clear determination of the disease process. Although genetic testing is not necessary in all cases, it would be appropriate in this particular case.  The literature above outlines cases of rhabdomyolysis and describes its association with select diseases and genetic influences. For the reasons set forth above, the requested diagnostic procedure is likely to be more beneficial for this patient than any available standard therapies.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested urgent care services.  Findings:  The physician reviewer found that this patient had a recurrence of a chronic respiratory problem for which he had treatment available to him at home in the form of amoxicillin.  He had already started himself on that therapy, and based on the clinical documentation his primary reason for presenting to the urgent care was to obtain a refill for amoxicillin. The patient indicated he still had a few pills left at the time he presented to the urgent care center. He was not febrile, was not short of breath, did not have chest pain, and had a normal physical exam including normal oxygen saturation on room air.  A prudent layperson in this situation would not have thought that immediate medical treatment was necessary to prevent serious deterioration of health, injury or complication of an existing condition.