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

The parent of a 13-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that growth hormone (GH) therapy for treatment of the diagnosis of idiopathic short stature (also called nongrowth hormone deficient short stature) was approved by the Food and Drug Administration in 2003. According to the FDA approval, GH is indicated in patients who meet the following criteria: have a height at least 2.25 standard deviations below the mean for age; have growth rates unlikely to permit attainment of adult height in the normal range; epiphyses are not closed; and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. In this patients clinical situation, the submitted documentation demonstrates that the patient meets the FDA criteria for GH therapy.The use of GH in non-GH deficient states associated with short stature (such as Turner syndrome, Prader-Willi syndrome, Noonan syndrome, chronic renal insufficiency and children born small for gestational age) is widely considered to be appropriate and restorative in nature within the endocrinology community. All indications for GH therapy intended to increase the final adult height are, in a sense, restorative in nature regardless of whether there is a documented GH deficiency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that People with autistic 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`(Myers and Johnson). Further, Turner and Stones report concluded that the total hours of speech therapy starting at age two was the most important factor in improved language at nine years of age. At age three, this autistic patient is an appropriate candidate for speech therapy. The American Speech-Language-Hearing Association white paper on autism states that speech therapy is necessary and ongoing until the patient can communicate appropriately in social circumstances. Taken together, these guidelines and recommendations demonstrate that speech therapy is medically necessary for this patient. Although this patient is severely impaired, two speech therapists have recommended speech therapy despite his developmental delays. While development of speech may be slow even with intensive speech therapy, the skills acquired through such therapy are necessary for this patient to develop communication skills.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Penlac nail lacquer  for the treatment of his onychomycosis. Findings:  The physician reviewer found that Onychomycosis, fungal nail infections, become more common as people age. The problem begins in a small portion of the hallux (big toe) toenail quite commonly and is capable of spreading to the entire nail and sometimes involves the skin and subungual tissues as well. For some patients, the fungal infection may develop into a dangerous and painful condition. For example, in a patient with diabetes, cellulitis and deep seated infections can occur. Currently, oral terbinafine for 12 weeks achieves the highest cure rate (around 60%); however, recurrences are as high as 50% in many studies.  A number of other conditions can resemble onychomycosis, so a precise diagnosis is necessary before therapy is begun. Approximately 40% of abnormal toenails are caused by conditions other than fungal infection. In the case of this patient, he had a fungal nail infection of uncertain severity or distribution. No additional risk factors were described in the records provided. Furthermore, topical therapies such as Penlac yield a cure rate of about 1 in 15 patients in this setting and recurrence is common. All told, the submitted evidence does not support the need for Penlac for treatment of this patient's fungal nail infection.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested an MRI for an evaluation of her pelvic pain. Findings:  Three physician reviewers found that the patient had severe pelvic and hip pain that persisted after delivery. Physical therapy was attempted and was unsuccessful. MRI provided the soft tissue and bone analysis necessary to make the diagnosis of tendinitis and partial thickness tears. MRI was the preferred method to evaluate the soft tissues in this clinical situation. The technique was clinically indicated for evaluation of the pelvis at the site of tendinous insertions. The diagnosis was made in this particular case using MRI
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a bone density study for evaluation of her multiple osteochondromatosis. Findings:  The physician reviewer found that the scientific literature does not reveal a link between osteoporosis and solitary/multiple osteochondromatosis. Although osteoporosis has been reported in association with unusual metabolic diseases (Faggiano and colleagues), there is no evidence that patients with multiple osteochondromatosis are at any greater risk of developing osteoporosis. Given the absence of an association between osteoporosis and osteochondromatosis, there is no clinical indication for a bone density study in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested inpatient residential care for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that according to Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, a rating of serious functional impairment alone (i.e., independent of other dimensions) requires care at a level of five which is residential care with 24-hour services with psychiatric monitoring. Serious functional impairment per CALOCUS is defined as a serious deterioration of interpersonal interactions with consistently conflicted or disrupted relations with others which may include impulsive or abusive behaviors. It also includes significant withdrawal and avoidance of almost all social interaction. The patient refused to attend school, no longer interacted with his peers, and refused to see a therapist. Thus, his symptoms were consistent with serious to severe functional impairment. Additionally, there was a highly stressful home environment due to conflict with his parents. Furthermore, the patient had a poor response to prior outpatient treatment with minimal engagement and acceptance of such treatment given his refusal to attend therapy. Therefore, inpatient residential care was indicated and medical necessary for this patients behavioral health problems. This finding is also consistent with the American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested laser treatment for the treatment of her redness and scarring secondary to a reaction to Efudex. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by infection, trauma, tumor or disease. Wrinkles or rhytids, pigmentation changes, keratoses, and telangiectasias are among the clinical signs of photodamage that is part of the normal aging process. Upon viewing the submitted color reproductions of the photographs, there is visible mottled pigmentation but no visible scarring or abnormal structures. The mottling is not severe enough so as to be considered out of the norm for an aging individual. Thus, the proposed therapy does not meet the requirements of Californias Reconstructive Surgery Statute. With regard to the medical necessity of the proposed therapy, the submitted documentation does not demonstrate the presence of a functional deficit that is likely to be resolved by laser therapy. There is no evidence of complaints of infection, pain or deterioration of the skin. While the patient has concerns over the appearance and texture of her skin, these issues are cosmetic in nature and do not constitute a functional impairment. As such, the proposed laser therapy is not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested prosthetic leg components (identified by HCPCS codes L5653, L5665, L5920 and L5950) for the treatment of her medical condition. Findings:  The physician reviewer found that HCPCS code L5653 is for an addition to lower extremity, knee disarticulation, expandable wall socket. The patient is an above the knee amputee. There is no evidence in the submitted clinical records demonstrating that this component was necessary to improve function or mobility in this particular patient. Therefore, the medical necessity of this component is not established. HCPCS code L5665 is for an addition to lower extremity, socket insert, multidurometer, below knee. Again, this patient is an above the knee amputee. The submitted clinical records do not demonstrate that this particular component would result in functional benefit for this patient. Therefore, this component was not medically necessary. HCPCS code L5920 is for an addition, endoskeletal system, above knee or hip disarticulation, alignable system. The Health Plan notes that alignable componentry was previously allowed at the time the new prosthesis was billed and the componentry was reused. Given this, the submitted documentation does not support additional billing for alignable componentry. Therefore, this component was not medically necessary. HCPCS code L5950 is for an addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber, or equal). The Health Plan indicates ultra-lite material for componentry was allowed at the time the new prosthesis was delivered. There is no evidence in the clinical records to support the subsequent use of ultra-lite material in this setting. Therefore, this component was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patients in-plan speech therapy evaluation states that the patient does not meet criteria for medically necessary speech therapy because there is no physical impairment of the articulators or of oral pharyngeal intake. While the speech therapist found that the patient did not demonstrate appropriate pragmatic and social language skills, the therapist recommended continued educational speech therapy for pragmatics/social language. While this defers pragmatic skill development to the school setting, much of pragmatic speech serves the dual purpose of being functional and educational. For example, if the patient cannot follow directions, the speech issues become more related to function. As noted by Bellini and colleagues, issues such as topic initiation and reading social situations must be treated outside of the structured environment of the school to successfully be achieved in society.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested psychiatric residential treatment center services for the treatment of his behavioral health issues. Findings:  The physician reviewer found that this patients discharge summary from the prior admission confirmed continued problems with depressed mood, poor coping skills, and irritability. The psychological evaluation completed also reports prominent symptoms of depression. Given the patients significant history of mood disturbance, substance use disorder, history of overdose, previous acute psychiatric hospitalization, non-compliance with outpatient treatment, and continued significant functional impairment, the services provided were medically necessary. This patient was non-compliant with previous treatment and clearly exhibited suicidal thoughts requiring one-to-one supervision and management. The services of a 24-hour subacute residential treatment facility were clinically indicated for this patient. Additionally, the level of care provided to this patient was consistent with the American Psychiatric Association (APA) practice guidelines and Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested adult psychiatric acute inpatient care for treatment of her major depressive disorder with anxiety and panic disorder.  Findings:  The physician reviewer found that based on Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services level of care criteria and the American Psychiatric Association (APA) treatment guidelines, this patient did not require the close observation provided by 24-hour acute inpatient psychiatric services. Review of the submitted records reveals that the patient received a risk assessment score of 6-8, indicating lower risk without the need for close observation. The admission mental status exam notes that the patient was alert, had normal speech, and thoughts were goal directed. Also noted is the absence of suicidal or homicidal ideation on admission as well as an absence of psychotic symptoms. No additional co-morbid conditions were noted at the time of admission. Applying the LOCUS and APA criteria, this patient could have safely been treated at a less intensive level of care, such as a partial hospitalization program which offers intensive, coordinated, multidisciplinary clinical services for patients who do not present an imminent potential for harm to themselves or others.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for selective internal radiation therapy using Yttrium-90 microspheres (SIR-Spheres) for treatment of her stage IV pancreatic carcinoma with liver metastasis.  Findings:  Three physician reviewers found that there are multiple prospective and retrospective studies demonstrating the use of Y-90 microspheres for metastases for colorectal cancer. The FDA has in fact approved the use of SIR-Spheres for this indication. Thus, treatment with SIR-Spheres is considered safe and effective for certain indications. At issue in this case is the use of SIR-Spheres for carcinoid tumors. In that regard, the most recent National Comprehensive Cancer Network (NCCN) guidelines include radioembolization as an accepted treatment with a level of evidence of 2A.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested a positron emission tomography/computed tomography scan for evaluation of his oral pharynx cancer. Findings:  The physician reviewer found that in clinical practice, it is widely accepted that PET/CT is a more sensitive test with which to diagnose head and neck tumor recurrence than any other stand alone imaging modality. In addition, the goal in treatment is to detect tumor recurrence prior to manifestation of symptoms in order to improve the patients prognosis. PET/CT plays a crucial role in the detection of metastatic disease or local recurrence in head and neck malignancies and is the standard of care. Schoder and colleagues found in their study of 68 patients that, PET/CT images were essential in determining the exact anatomic location for 100 lesions. The authors concluded that, PET/CT is more accurate than PET alone in the detection and anatomic localization of head and neck cancer and has the clear potential to affect patient care. For these reasons, the performance of a PET/CT scan in this patient more than one year after the most recent imaging study is medically reasonable and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested computed tomography (CT) to detect coronary artery calcification performed for evaluation of her medical condition. Findings:  Two physician reviewers found that based on the records provided, this patient has a history of atrial fibrillation, dyslipidemia, no other coronary risk factors, and no documented coronary disease. In this circumstance, CT screening for coronary calcium was not indicated. Current guidelines for management of dyslipidemia endorsed by several national organizations do not recommend routine CT screening for coronary calcium because there is a lack of data to suggest that a change in treatment based on the results leads to improved outcomes incremental to those achievable using standard risk factor profiling (see NCEP ATP III). The only circumstance where CT screening for coronary calcium may provide superior data is in a patient with intermediate cardiac risk (10-20% 10-year risk) in whom a decision to treat with cholesterol medication is uncertain based on standard clinical risk profiling alone (see Greenland and colleagues). However, based on the submitted records, this patient did not have an intermediate cardiac risk.I have determined the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee has requested  Saizen for treatment of the enrollees precocious puberty.  Findings:  The physician reviewer found that gonadotropin-releasing hormone agonists have been suggested to slow growth, a decrease which may be overcome through the use of growth hormone therapy. Growth hormone therapy in such cases will accelerate growth, which may augment final adult height. In this case, the patients bone age could advance further with respect to chronologic age, which would shorten her adult height. The literature to date is lacking in consensus with respect to this topic. The current medical literature does not support the medical necessity of the requested medication in this patients case, as the use of Saizen remains of unproven efficacy in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested electronic controlled thermal therapy post-operative cooling device for the treatment of her left knee status post arthroscopy and reconstruction. Findings:  The physician reviewer found that the use of cold therapy in the post-operative period has been practiced for nearly as long as knee surgery has been performed. The specific device in question uses ice placed in a bucket as the source of the lower temperature and needs to be filled less frequently than an ice pack. This convenience, however, has not been shown to add any additional benefit over treatment with simple ice packs. The maximum cooling that can be obtained through the post-operative dressing is the same and the two methods have similar outcomes. Therefore, given the absence of a proven medical benefit with the use of an electronic controlled thermal therapy device over a simple ice pack, the device cannot be determined to have been clinically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a Walk-Aid device (including electronic leads) for the treatment of his medical condition following cerebrovascular accident. Findings:  The physician reviewer found that in general, post-CVA foot drop/hemiparesis is managed with either a plastic molded ankle-foot-orthosis (AFO) or double-metal upright AFO, depending on various clinical factors. In certain instances, however, post-CVA patients may have significantly improved gait mechanics with use of a functional electric stimulation (FES) unit (like the Walk-Aid) when compared with a standard AFO (Ring, et al. and Hausdorff, et al.). This can only be determined through a detailed gait assessment, typically performed by a skilled physical therapist. When this is found to be the case, an FES unit is medically justified. In this case, no formal gait analysis or evaluation has been provided, nor is there specific objective documentation of the benefits of the Walk-Aid over conventional therapy, such as the AFO.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches. Findings:  Three physician reviewers found that the medical literature indicates that cervical discography is of equivocal help in terms of identifying a pain generator and predicting results from surgery. However, in this case, the patients history of chronic neck pain as well as associated fibromyalgia and multilevel degenerative findings on MRI are key factors. Regardless of the outcome of the multilevel discogram, this patient would be a poor candidate for cervical surgery.  Confirming a pain generator is particularly challenging given the comorbid diagnoses of fibromyalgia and chronic pain. For these reasons, the medical literature does not demonstrate that discography was indicated in this case, as it would not have been likely to alter the treatment plan
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a hip resurfacing procedure for treatment of his degenerative disease of the hip. Findings:  Two physician reviewers found that although hip resurfacing procedures have been employed for several decades, the early designs and procedures had a high rate of failure and were largely abandoned for many years. Newer metal-on-metal implants have had encouraging early results, leading to an increased interest in the approach, as noted by Grigoris and colleagues. However, several areas of controversy remain in the literature. Although there are potential advantages, such as retention of bone stock, an increased activity level and ease of revision, there are also concerns, such as the effects of metal ions and femoral neck fractures, which require further study, as noted by Quesada and colleagues. The best candidates for the procedure are younger than 60 years of age with good bone stock. At age 63, this patient exceeds the optimal age for the procedure. Furthermore, there is a need for additional studies to evaluate the efficacy of hip resurfacing over time.