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

The parent of a 15-year-old male enrollee has requested acute inpatient services for the treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patient remained at high risk for self harm behavior and was in need of the level of care provided. The services provided are consistent with the standards of care and practice guidelines established by the American Academy of Child and Adolescent Psychiatry.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain. Findings:  The physician reviewer found that there is insufficient evidence in the literature to support the benefit of the prescribed program of computer-assisted exercise over standard physical therapy for chronic low back pain. In contrast, standard physical therapy including strengthening and stretching exercise, modalities, and transition to a home exercise program is more consistent with standard clinical practice, and as the literature suggests, may result in greater improvement in symptoms. The evidence does not demonstrate that computer-assisted exercise results in any added benefit over standard physical therapy for the treatment of low back pain.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had evidently suffered a dislocation of her left TMJ disc. It had occurred sometime during the week prior to her visit. When she presented to the Emergency Department, the patient was able to eat, swallow and breathe without difficulty. She had not sustained any recent trauma. Although her symptoms were not improving, they had not suddenly worsened. A unilateral or bilateral condylar dislocation can be manually reduced in the Emergency Department, but that was not the diagnosis in this patient. A subsequent MRI revealed the left condylar disc to be dislocated, and this was treated with physical therapy. A mandible x-ray can assess only for boney pathology. If it had been completed in the Emergency Department, it could not have revealed the disc pathology. There was no emergent indication for an MRI in this case. The patient had already been evaluated by her dentist. Thus, it is unlikely that a prudent layperson would believe her health to be in danger without immediate medical attention. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested X-STOP procedure for the treatment of her lumbar spinal stenosis. Findings:  Two physician reviewers found that there is level I evidence that the X-STOP procedure is effective in treating lumbar spinal stenosis. It has been approved by multiple societies and proven effective and safe in several studies. Kuchta and colleagues concluded that, The interspinous device does not replace microsurgical decompression in patients with massive stenosis and continuous claudication, but offers a safe, effective and less invasive alternative in selected patients with spinal stenosis. The authors noted that their single center results indicated satisfactory short and long-term effect during a follow-up period of two years. Zucherman and colleagues suggested that, The X-STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X-STOP offers an attractive alternative to both conservative care and decompressive surgery. All told, there is adequate evidence to support the use of the X-STOP procedure in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested lipoprotein enzyme immunoassay in the management of cardiovascular disease, homocysteine testing, cardiovascular risk measurement of lipoprotein associated phospholipase A2, high sensitivity C-reactive protein, measurement of small low-density lipoprotein particles and concentration of LDL particles in cardiac risk assessment and management, and apolipoprotein testing for the evaluation of his cardiac risk. Findings:  Two physician reviewers found that this patient has known coronary disease and is status post myocardial infarction and stenting. In this circumstance, treatment guidelines that include lipid evaluation and management have been established, periodically updated by expert committees and endorsed by major national societies. These guidelines currently do not recommend routine performance of specialized lipid tests including lipoprotein-associated phospholipase A2, sub-classification of LDL and homocysteine.  Treatment change or addition based on the results of diagnostic testing at issue has not been shown to improve outcome incremental to that achievable by treatment dictated from standard risk factor and lipid analysis.  In this particular circumstance of known coronary disease, aggressive LDL reduction to less than 70mg/dl is recommended regardless of the results of any specialized lipid analysis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested magnetoencephalogram (MEG) for the evaluation of his epilepsy. Findings:  Two physician reviewers found that although MEG shows great potential promise as a tool for the functional mapping of the brain intraoperatively, it remains an experimental/investigational modality at present. It remains unknown whether MEG is superior to any currently available technologies for surgical planning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested a fingertip prosthesis for the treatment of her status post left small fingertip amputation. Findings:  The physician reviewer found that the medical literature indicates that digital prostheses can provide significant functional benefit in cases where there is evidence of impaired functionality. In this case, there is no documented evidence of impairment. The patients physician describes normal hand function. The physicians notes document full range of motion in the digit, no pain, and a normal gripping ability. The physician further indicates that the patient requests a finger prosthesis for cosmetic reasons only. In the absence of objective documentation of a functional problem, the medical necessity of the proposed fingertip prosthesis is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested bariatric lap band surgery for the treatment of her obesity. Findings:  The physician reviewer found that a study by Sjostrom and colleagues demonstrated that the only viable option for resolving the co-morbidities of obese patients and to improve their long-term life expectancy is weight loss surgery. There is no benefit in postponing or delaying the surgical treatment of this patient until she achieves a BMI of 40 or other co-morbidities are diagnosed. The patient has high cholesterol which increases her risk of cardiovascular illnesses. As such, lap band surgery is medically appropriate for this patient and has a proven track record of long-term success.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Biafine for the treatment of her ulcerations and erosions secondary to acne with irritation. Findings:  The physician reviewer found that there is insufficient medical literature supporting the use of Biafine (a triethanolamine emulsion) for the treatments of wounds, acne or cellulitis.  In the two cited trials (one in pig modeling of wounds), trolamine emulsion was not better than controls.  Biafine is not medically indicated for treatment of this patient. There are other formulary medications that are appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested X-Stop Interspinous Process Decompression for the treatment of his lumbar spinal stenosis. Findings:  Two physician reviewers found that this patient has a history of chronic back pain and pain in his legs. There is no history of sciatic symptoms. He has stenosis by MRI scan with canal diameter down to 6 mm at L4-5. There are no large, scientific, long-term studies of X-Stop versus laminectomy versus conservative care. All available studies are of small numbers. No studies have been blinded. Given the paucity of evidence to date, the superiority of the X-Stop procedure remains unproven.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested an intensive outpatient eating disorder program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the medical documentation indicates a period of increased anxiety and weight loss with a need for structure and supervision and therapeutic support to avoid further relapse while in IOP during the time frame in question. Thus, IOP during the time frame in question was clinically warranted and medical necessary for the patients medical condition and was consistent with treatment guidelines and standards of practice in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested an MRI of the left lower extremity for an evaluation of his thigh mass. Findings:  The physician reviewer found that this patient has ongoing left thigh pain with question of a palpable mass. The patient feels that there is a lump, and the patients physician has documented no palpable lump on two separate office visits. According to the American College of Radiology Appropriateness guidelines, the first imaging study for a palpable soft tissue mass is an x-ray.  If this exam is negative, then a magnetic resonance study or ultrasound of the area of concern may be appropriate. However, this patients physician has documented twice since the surgery that there is no remaining palpable mass. MRI for the evaluation of thigh pain only is not medically indicated. At this time, there is not enough clinical evidence to support MRI of the left thigh.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches. Findings:  Two physician reviewers found that the medical records suggest a transformation from episodic migraine to chronic daily headaches. Historically, frequent use of non-steroidal anti-inflammatory drugs (NSAIDs) and pain medication is noted. It is likely this patient has transformed migraine (i.e., chronic daily headache). Current evidence-based opinion is that Botox is most likely ineffective for patients with chronic daily headache. Based on four Class II studies, there is insufficient evidence to support a benefit of Botox for treatment of chronic daily headache.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested Avodart for the treatment of his benign prostate hyperplasia. Findings:  The physician reviewer found that Proscar and Avodart inhibit the conversion of testosterone to dihydrotestosterone. The latter hormone is the active form of testosterone stimulating growth of the prostate glands. There has been no direct trial comparing both drugs. This patient cites a figure of 18.5% as the incidence of impotence as cause for concern regarding potential side effects. However, as noted in the Proscar Side Effects and Interactions article, in a 4-year placebo-controlled study, 18.5% was in fact the incidence of impotence with Proscar, but the placebo arm of the study reported 12.2% impotence. The literature shows similar improvement of urinary symptoms and similar reduction of the prostate volume with both drugs; there is no evidence to support a finding that Avodart is superior to Proscar.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of an 86-year-old female enrollee has requested  for continued skilled nursing care for treatment of the enrollee, who is status post exploratory laparotomy and sigmoid colon resection. Findings:  The physician reviewer found that in order to be considered skilled level of care, services must be ordered by a physician and delivered by, or under the supervision, of a professional such as a physical therapist, registered nurse or licensed practical nurse. The documentation indicates, physical therapy was discontinued and the patient was transitioned to restorative nursing. This patients needs could have been met in a less intense level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a portable oxygen concentrator for the treatment of his respiratory failure. Findings:  The physician reviewer found that this patient has respiratory failure requiring continuous oxygen and oxygen with exertion. It has not been made clear why he is unable to use an E-tank oxygen cyclinder (E-tank) for his exertional projects. As long as the patient is supplied with a sufficient number of E-tanks, his needs can be met. There is rarely any medical necessity for a portable oxygen concentrator. Though more convenient, there is no medical indication for the proposed portable oxygen concentrator. Thus, the evidence is not sufficient to justify the medical necessity of the portable Inogen One Concentrator.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested Zithromax intravenous injection therapy for the treatment of the enrollees Lyme disease. Findings:  Three physician reviewers found that the evidence that the patient has chronic neuroborreliosis or post-Lyme encephalopathy is based on non-specific testing and symptoms that are non-specific.  Evidence for the use of long-term intravenous antibiotics for chronic neuroborreliosis or post-Lyme disease is inconclusive. The treatments are not without risk and there are insufficient data in the peer-reviewed medical literature to support a conclusion that they are effective. At this time, it has not been established that the benefits of the proposed therapy outweigh the risks, and the treatment remains of unproven efficacy for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for the treatment of her pelvic pain and muscle spasms. Findings:  Two physician reviewers found that although trials using Botox are promising, there are no large, randomized, placebo-controlled trials determining that Botox is statistically significantly better than current therapies for current myofascial pelvic pain. In the absence of these evidence-based studies, the superiority of Botox in this setting remains unproven. Based upon the evidence available at this time, continued treatment with established therapies are likely to be more efficacious for this patient than Botox.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a laparoscopic duodenal switch for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a body mass index (BMI) of 47. The duodenal switch operation is an established operation with proven superior outcomes data. These measures include not only the excess weight loss, but also resolution of comorbid conditions. Published data demonstrate less excess weight loss with the lap band procedure and gastric bypass. It also shows higher complication rates of reflux and dysphagia. The laparoscopic duodenal switch procedure is medically appropriate in this setting and is indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested proton beam therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that proton beam therapy for prostate cancer is not experimental, but is not medically necessary given that other treatment approaches (IMRT with/without IGRT) are highly effective and well tolerated. There is no literature to state that the outcome after proton therapy, either with respect to PSA control, tumor control or toxicity is better than IMRT. Thus, while radiation or surgery may be medically necessary, proton beam therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year old male has requested bilateral mastectomy for the treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the submitted evidence does not demonstrate the procedure at issue was reconstructive in nature as defined by Californias reconstructive surgery statute. The patients condition is a natural consequence of obesity in adolescent males and did not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested a consultation for a hip resurfacing procedure for the treatment of his osteoarthritis. Findings:  The physician reviewer found that hip resurfacing is a new procedure that is as good as total hip arthroplasty, but it does not have documented reliable improvement over the traditional total hip arthroplasty. The two papers reviewed highlight the disagreement among orthopedic surgeons on this issue. That being said, it is medically appropriate to allow the patient to consult another orthopedic surgeon in order to ensure he is aware of all treatment options and makes an informed decision regarding his treatment. A consultation for a hip resurfacing procedure is medically reasonable and indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested trigger point injections for the treatment of her pain. Findings:  The physician reviewer found that the patients condition is discogenic in nature. Trigger point injections are used only for myofascial pain, not discogenic pain or any other pain. The submitted documentation does not support the presence of myofascial neck or shoulder pain. Furthermore, the American College of Occupational and Environmental Medicine guidelines do not support the use of trigger point injections for neck pain. Thus, trigger point injections are not medically indicated for treatment of this patient. There are other modalities that are more appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a C5-C6 total disc arthroplasty for the treatment of his cervical disc disease (with myelopathy). Findings:  Three physician reviewers found that the classic treatment of cervical disc herniation is anterior cervical decompression and interbody fusion. The problem of a loss of range of motion and possible degeneration of adjacent segments remains, and the recent interest in cervical disc arthroplasty reflects this concern. Although early results have been encouraging (Bertagnoli and colleagues), there is still a need for longer-term follow-up studies to evaluate the efficacy and survival of the prostheses (Heidecke and colleagues). Studies are underway, but are not yet completed. At this time, no definite advantage of artificial cervical intervertebral disc replacement has been shown over discectomy and fusion (Peng-Fei, S. and Yu-Hua, J).
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested emergency ambulance transportation due to her medical condition. Findings:  The physician reviewer found that emergency transportation services are covered when a patient reasonably expects the absence of immediate medical attention to result in serious jeopardy to her health, and when a patient reasonably believes her condition requires ambulance transportation. Ambulance transportation is provided in order for patients to receive medical care during transport. The patient must reasonably expect that a delay in getting to the hospital would seriously jeopardize her health or that she requires acute medical intervention during transport. This patient reported pain in her right hip and low back that had commenced over several days. Even if she required a stretcher for transfer, this patient did not require any medical intervention during her transport. This patient could safely have been transported to the hospital by means other than ambulance. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male enrollee has requested sub-acute residential psychiatric treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the medical documentation supports the medical necessity for sub-acute residential psychiatric treatment in that: there was a deterioration in his level of functioning, with increased depression and impaired social functioning; there was evidence of his inability to be managed at a lower level of care; there was a need for mood stabilization and close monitoring of  his medications as they were adjusted; there were medical concerns with his medication adjustments such as the occurrence of  seizure-like episodes, which  required neurological evaluation including a magnetic resonance imaging scan and electroencephalogram and; there was concern about  hypomanic episodes as medication adjustments were initiated which required close monitoring. The provided sub-acute residential level of care for this patient was consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria and his treatment interventions were consistent with practice parameter guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a ten-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for the treatment of the enrollees short stature, poor growth velocity and growth hormone deficiency. Findings:  The physician reviewer found that this patient has delayed pubertal development but will not nearly attain his genetic height potential. However, his adult height prediction exceeds the cut-off level recommended by the FDA in July 2003 for growth hormone therapy for idiopathic short stature. Thus, growth hormone therapy cannot be recommended as medically indicated for this patient.