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

A 64-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma with exacerbation.  Findings:  Two physician reviewers found that this patient has severe asthma and has been treated with first-line therapies without substantial benefit. The records indicate the patient continues to have exacerbations requiring steroid therapy. For these reasons, this patient is an appropriate candidate for bronchial thermoplasty, which has been proven to be effective in patients with severe persistent asthma in reducing exacerbations, the need for steroids, and hospitalizations. All told, the requested procedure is likely to provide superior benefit when compared with standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Concerta 36mg, twice daily for treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold standard psychopharmacologic intervention for attention deficit/hyperactivity disorder.  Accordingly, Concerta 72mg daily may be an appropriate dose for the treatment of uncomplicated attention deficit/hyperactivity disorder.  However, it is not medically necessary in this patients case due to diagnostic uncertainty and evidence of misuse.  Per the submitted records, this patient has a history of unilateral dose escalation, losing his medication, and early refill requests.  Diagnostically, this patient has a history of treatment with antipsychotic medication, suggestive of a co-occurring formal thought disorder or other serious mental disorder.  The patient was noted to be psychotic, and the medication was stopped.  Continued stimulant treatment with this diagnostic uncertainty and unclear clinical status would be inconsistent with good medical practice.  All told, Concerta 36mg, twice daily, is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of his hepatocellular carcinoma.  Findings:  The physician reviewer found that although the provider noted concern over use of conventional IBD immune modifying drugs in treating this patients medical condition, there is inadequate support for treatment with IVIG for Crohns disease at this time. There are a few case reports and case series evaluating IVIG in this clinical setting. However, as concluded by Rogosnitzky and colleagues, encouraging findings provide a rationale for the initiation of larger randomised controlled trials of IVIG in CD with the aim of providing further treatment options for this difficult-to-manage condition. All told, IVIG is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested lumbar artificial disc replacement surgery for treatment of his low back pain. Findings: Three physician reviewers found that this patient has chronic low back pain. He has not had any localizing features to his pain. His pain generator has not been identified. He has undergone an L4-S1 fusion which is a contraindication to use of ProDisc-L. Moreover, there is a paucity of well designed clinical trials in the peer-reviewed medical literature demonstrating the long-term safety and effectiveness of this procedure. Therefore, the FDA has required a Post Approval Study to determine the long-term safety and effectiveness of ProDisc-L. This study has neither been reported nor concluded. Finally, the American Academy of Orthopedic Surgeons has noted that nuclear replacement and motion sparing technology are too new to have demonstrated long-term data regarding their efficacy (Madigan, et al). Given the lack of scientific data showing the long-term benefits and side effects of artificial disc replacement, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a lumbar laminectomy for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has chronic lumbar spine pain.  The submitted records do not include objective evidence of six weeks of non-operative therapy for this patient, as physical therapy notes and interventional injection notes were not provided for review.  There is lack of documentation of significant neurological findings on clinical examinations.  The current medical evidence does not support the requested services in this clinical setting.  The submitted records do not demonstrate significant neurological deficits, and there is a lack of documentation of conservative care.  All told, the requested lumbar laminectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested continued speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patients speech is delayed at the 24-month level and speech therapy services are indicated. However, the patient also needs to undergo a complete speech and language evaluation. Speech therapy is recommended for patients with delays greater than 25% (Volmar and Weisner). Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.  Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested brand name Seroquel for treatment of his diagnosed major depressive disorder. Findings:  The physician reviewer found that testing ensures that generic products perform the same as the respective brand name products.  In general, there is a possibility that a generic medication may result in differences in clinical outcome.  However, in this case, the patients reports of clinical deterioration center on sleep, irritability, and pain.  Seroquel is not indicated for these symptoms.  Further, reasonable evidence-based alternatives to the brand name medication have not yet been exhausted.  Such interventions include increasing the dose of the generic quetiapine since the bioavailability may be less compared to the brand, and targeting the irritability by either increasing the relatively low-dose serotonergic enhancing medication or converting to a serotonin-norepinephrine reuptake inhibitor, as these medicines can treat mood, anxiety, and pain.  All told, the requested brand name Seroquel is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollees stuttering disorder. Findings:  The physician reviewer found that despite years of community and school based speech therapy the patient continues to stutter. The patients speech therapist reported a 70% speech dsyfluency and the child psychiatrist assessed the patient as a stutterer. Intensive speech therapy is necessary to prevent stuttering from becoming a lifelong disability. Based on an extensive survey of children in North Carolina, spontaneous remission from stuttering is the exception not the rule, and that the chance of recovery from stuttering diminishes with age (Kalinowski, et al). Without intensive speech therapy this nearly 12 year-old patient has little chance of improvement from stuttering. The patients Tourettes syndrome, associated tics and ADHD compound his poor potential for spontaneous improvement. Yanuss and colleagues provide an overview of the current therapies that are effective in helping children improve their speech fluency and diminish the negative effects of the disorder; the authors conclude, speech-language pathologists can help children increase their fluency while simultaneously minimizing the adverse impact of their speaking difficulties and helping them improve their overall communication. Furthermore, Onslow and OBrien emphasizes that intensive and early speech therapy intervention is necessary before stuttering becomes intractable. Stuttering in an adult can cause profound psychological, social, educational, and occupational problems (Onslow and OBrien). A meta-analysis of the reviewed literature reported that children who receive speech therapy are 7.7 times more likely to have resolution of their stuttering than non-treated children (Onslow and OBrien). The lack of obvious structural abnormality does not negate the fact that this patients stuttering has its origins in the structural failure of the neurological development of speech. It is medically necessary that this patient receive individual speech therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested sodium fluoride (NaF-18) PET bone scan (CPT 78815) for evaluation of his prostate cancer.  Findings:  Three physician reviewers found that following a radical prostatectomy for prostate cancer, it is appropriate to obtain sequential prostate-specific antigen levels every six to twelve months for five years.  In cases of progressive increases in prostate-specific antigen levels, further evaluation with radionuclide bone scans, MRI, or other imaging modality may be appropriate.  Conventional bone scans are generally sufficient for the evaluation of this patient population.  However, sodium fluoride (NaF-18) PET bone scans are appropriate as a second-line scanning technique.  There is adequate support in the current medical literature for the requested diagnostic procedure in this patients case.  Per the submitted medical records, there have been questionable findings on prior imaging.  The requested sodium fluoride (NaF-18) PET bone scan is likely to be superior over other available options for the evaluation of this patient.  The requested diagnostic procedure will allow for appropriate treatment planning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested mastopexy, bilateral removal, and insertion of breast implants for treatment of her ptosis and grade III capsular contracture.   Findings:  The physician reviewer found that by contrast, implant replacement and mastopexy are not medically necessary. The patients functional deficit is related to an implant complication. Removal of the implants should correct this problem. Replacing the implants is not medically necessary from a functional standpoint. In addition, the photographs provided for review suggest that the requested mastopexy has no functional significance. Brief mention of intertrigo was noted, but there is no supporting documentation of symptoms or attempts at treatment in the patients records. Thus, the requested mastopexy is not medically necessary. Further, there is no evidence the requested implant replacement and mastopexy are reconstructive in nature, as the patients condition resulted from augmentation mammaplasty rather than congenital defect, developmental abnormality, trauma, infection, tumor, or disease. As such, the proposed implant replacement and mastopexy do not meet criteria for reconstructive surgery as defined by California law. All told, the requested bilateral implant removal is supported as medically necessary and should be authorized, while the insertion of bilateral implants and bilateral mastopexy is not reconstructive in nature or medically necessary for treatment of this patients medical condition
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  The physician reviewer found that this patient has a history of a chronic, recurrent affective illness. Currently, he is experiencing an acute major depressive episode that is causing significant functional impairment. He has pursued other standard therapies used to treat depression but remains symptomatic. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested PediaSure with fiber and benecalorie for treatment of the enrollees cerebral palsy and spastic quadriplegia.  Findings:  The physician reviewer found that based on review of the available records, the requested PediaSure with fiber and benecalorie are medically necessary as enteral therapy. This patient is dependent upon fortified PediaSure with fiber for his nutritional needs. Because of his neurodevelopmental deficits, he is not able to tolerate anything but small amounts of pureed foods. PediaSure was originally developed for children who were unable to maintain intake of nutrients adequate to meet their needs for growth and development by other means. According to the initial safety and efficacy studies, PediaSure is both safe and efficacious in the maintenance of nutritional status and the promotion of growth in chronically disabled children who require specialized nutritional support. PediaSure, supplemented with benecalorie, provides the nutrients that this patient needs in a way that he can tolerate. The requested PediaSure with fiber and benecalorie is therefore medically necessary for this patient because it is his primary source of nutrition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested deep brain stimulation for treatment of his medical condition status post intracranial hemorrhage and cognitive deficits.  Findings:  Three physician reviewers found that there is no indication for deep brain stimulation in this case. The risks of this procedure outweigh any expected benefit. The use of DBS is currently being evaluated and there are insufficient controlled studies demonstrating its benefit or safety for patients such as the one documented in this case. Most of the studies demonstrated considerable improvements with the interventions, but their low strength of evidence limits the validity of these findings (Oliveira, L. and Fregni). Based on the lack of scientific evidence demonstrating the equivalence or superiority of DBS compared to standard therapies in treatment of this patients medical condition, the requested therapy is not likely to provide additional benefits.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 45-year-old male enrollee has requested continued acute rehabilitation services for treatment of the enrollees medical condition status post intracranial hemorrhage and cognitive deficits.  Findings:  The physician reviewer found that the patient had a stroke last year and was severely impaired. The severity of stroke is a powerful predictor of stroke outcome (Massucci, et al). Stroke outcome at three months is unchanged based on the intensity of rehabilitation (Grenthe Olsson and Sunnerhagen). On the said date, the inter-disciplinary team conference noted no change in functional status and communication skills. He changed 5% in transfer and positioning but remained 85% dependent. He improved to 75% assistance with placing aftershave. These are minimal changes after three months of acute rehabilitation. After these changes there were no further gains. At this time, post-stroke no significant change in functional status can be expected from a reasonable medical perspective for continued stay in an acute rehabilitation hospital. Thus, the requested acute inpatient skilled services are not medically necessary to maintain or restore functional status.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested inpatient hospital care for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this patients case, she was adherent with her mood stabilizing and antipsychotic medications.  She was switched from oral to intramuscular Haldol on the said date.  Neither the physician notes nor the nursing notes document that the patient posed an imminent risk to self or others.  The medical records do not establish the need for continued inpatient services as the said date.  All told, inpatient hospital care from the date in question forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested 10 tablets of oxycodone (OxyContin) 80mg per day (800mg total per day).  for treatment of his pain.  Findings:  The physician reviewer found that the current medical evidence fails to demonstrate the medical necessity of the requested medication quantity in this patients case.  This patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy.  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, the majority of 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 theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, 10 tablets of oxycodone (OxyContin) 80mg per day (800mg total per day) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Panniculectomy involves the removal of the lower abdominal skin without the muscle tightening or supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty.  Per the submitted photographs, this patients pannus skin fold has resulted in a disruption of skin integrity.  The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a plastic surgery consultation for treatment of his blepharitis.  Findings:  The physician reviewer found that based on review of the available records, this patient complains of chronic blepharitis and blepharochalasis. He reports that two ophthalmologists have been unable to diagnose his condition, but the case summary notes indicate that his most recent ophthalmology examination was in 2010. Ophthalmology notes from prior visits are not provided for review. Blepharoplasty is not an appropriate treatment for blepharitis and is not an appropriate treatment for a patient who has unexplained eye swelling and who has not yet had a comprehensive ophthalmologic examination. While a plastic surgeon can remove excess eyelid skin, a plastic surgeon is not trained in the evaluation and medical treatment of unexplained eyelid swelling. Without a diagnosis, blepharoplasty is contraindicated, and a plastic surgeon is not the appropriate specialist for referral to diagnose eyelid swelling. Therefore, the requested referral to a plastic surgeon for evaluation is not medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Botox injections for treatment of his torticollis secondary to spastic dystonia, dysphagia, and muscle spasm.  Findings:  The physician reviewer found that cervical dystonia is identified when there is uncontrolled muscle spasm, often associated with tremor, altered posture, altered mobility, and pain. Torticollis is a fixed or dynamic tilt, rotation or flexion of the head and/or neck. The type of torticollis can be described depending on the positions of head and neck. This patients clinical documentation is consistent with a diagnosis of cervical dystonia, with possible orofacial dystonia as well. Botox is FDA approved for cervical dystonia, and is considered a first-line therapy. Botox is therefore appropriate and medically necessary for treatment of this patients dystonia.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested allogeneic stem cell bone marrow transplant for treatment of her Crohns disease. Findings:  Three physician reviewers found that in this patients case, the requested allogeneic stem cell bone marrow transplant is likely to be more effective than other available options.  This patient has exhausted standard regimens for the treatment of Crohns disease.  Her condition has been resistant to multiple standard treatment options.  There is some evidence in the medical literature indicating that allogeneic stem cell bone marrow transplant may be effective in controlling Crohns disease in this clinical setting.  There are limited options for the treatment of this patient.  In sum, the requested services are likely to be of greater benefit than other modalities.