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

A 46-year-old male enrollee has requested the Bioness Ness L300 (functional electrical stimulation) and H200 (hand rehabilitation system) for the treatment of the enrollee, who is status post traumatic brain injury. Findings:  The physician reviewer found that there is very limited research demonstrating the efficacy of the Ness H200 for the treatment of upper extremity paresis. There are two case reports that suggest the requested equipment may improve motor function in patients nine months to seven years post-stroke with profound residual upper extremity weakness. A recent review of the literature identified two small clinical control trials (N=22 and N=19) and one single group pretest to posttest study (N=77) that demonstrated some improvement in hand function in chronic stroke patients with use of the requested equipment.  In the case under review, the records do not document a response to treatment, such as functional gains following a course of treatment with the equipment. Given the limited evidence supporting the efficacy of the Ness H200, the medical necessity of the device has not been demonstrated. Similarly, there is also limited research on the Ness L300. The device was shown to improve symmetry and speed of gait in 24 patients with chronic foot-drop. Another study performed by the same group compared the effects of an ankle foot orthosis versus a neuroprosthesis on gait mechanics in 15 patients with chronic foot drop. Investigators observed better balance control during ambulation with use of the neuroprosthesis.  In the case under review, there has been no formal assessment of the patient's gait, and the clinical need for the Ness L300 over a standard ankle foot orthosis has not been documented. While these studies suggest some benefit, there are inadequate well-randomized, controlled studies involving large numbers of patients demonstrating the use of a neuroprosthesis such as the Ness L300 results in a superior outcome compared to standard modalities, i.e. ankle foot arthosis. At this time, there is insufficient data supporting the efficacy of the Ness L300 to warrant its use in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested inpatient residential treatment for the treatment of the enrollees depressive disorder. Findings:  The physician reviewer found that the submitted physician progress notes do not demonstrate a risk of self-harm, a risk of harm to others or active psychotic features. The patient has been compliant with medications. The medical records do not demonstrate medical or psychological complications that require 24-hour monitoring. The nursing progress notes reveal that the patient is meeting her goals and objectives and is progressing well. The submitted documentation does not demonstrate an imminent risk of self-harm. Based upon this patients medical records and the American Academy of Child and Adolescent Psychiatry practice guidelines, the patient could have been treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested acupuncture for the treatment of his stated diagnosis of hemi-facial spasm. Findings:  The physician reviewer found that the submitted clinical evidence does not provide confirmatory evidence of a specific diagnosis. The medical records discuss trigeminal neuralgia, blepharospasm, and some form of a tic.  Per the MRI, there may be an inclusion cyst that is impinging. In the absence of medical record documentation that supports a specific diagnosis and describes the treatment modalities that have been tried and failed, the medical necessity of acupuncture is not established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a magnetic resonance spectroscopy (MRS) for an evaluation of her medical condition. Findings:  Three physician reviewers found that MRS is a technique that is clinically used to study brain tumors and to differentiate those tumors from other lesions and radiation necrosis. MRS has also been widely studied in other neurological disorders in an investigational manner. MRS is not typically used for any diagnostic purposes outside of brain tumors. The diagnosis of MS is usually based on typical MRI findings in association with clinical findings and spinal fluid analyses. MRS has not been shown to be of value in confirming a diagnosis of MS. While MRS is a test with high sensitivity, it has very low specificity and therefore is not effective as a diagnostic tool in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested cervical disc replacement for the treatment of his neck pain. Findings:  Three physician reviewers found that cervical disc arthroplasty is indicated for patients with cervical radiculopathy or myelopathy, neither of which is present in this patient (Acosta, et al. and Brown, et al.). In addition, cervical disc replacement is only indicated for a one-level procedure, and in this case a two-level procedure is being proposed. There are ongoing studies to determine the long-term safety and efficacy of cervical disc replacement. The longest study completed to date involved only two years of follow-up and included a small number of patients. Until longer-term studies have been completed showing safety and efficacy, cervical disc replacement remains of unproven efficacy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested adult substance abuse subacute/RTC rehabilitation services for the treatment of his substance use disorder. Findings:  The physician reviewer found that the submitted evidence reveals that this patients relationships, education, and job performance have all been affected by his substance use and alcohol dependence. The patient has endangered himself and others by driving while intoxicated. The patient has been in treatment multiple times, including outpatient rehabilitation over the past nine years, inpatient treatment a couple of years ago for two months, and has attended alcoholics anonymous with only short periods of abstinence. The records reflect that the patient made good progress during his treatment stay, in both individual and group settings, and that his medications were actively evaluated and titrated up until the day before discharge. The patient reported feeling that he was at a point of being motivated to change at the time of this admission. The providers notes indicate the patients triggers for drinking were addressed in an effort to prevent relapse and a detailed after-care plan was established. At the time of discharge, the question of ADHD had not been completely evaluated but several other factors contributing to the patients dependence were addressed. Given the patients history of a cycle of repeated dependence upon alcohol that had resulted in serious consequences, as well as his failure to respond to treatment at a less intensive level of care, treatment in a 24-hour subacute residential setting was appropriate and indicated during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a continuous positive airway pressure (CPAP) machine and related supplies for the treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that based on the results of the patients polysomnogram, a diagnosis of sleep apnea is not supported. An AHI of 2.2 events/hour is within the normal range which is 0.0 to 5.0 events/hour. Although the patients provider references the patients respiratory disturbance index, this measurement is not generally used to support a diagnosis of sleep apnea. Furthermore, this patient has several co-morbidities which could be contributing to her excessive somnolence and sleep disturbance. All told, a CPAP device is not indicated for this patient because there is inadequate evidence of obstructive sleep apnea based on the records provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested acute inpatient stay and bilirubin light treatment for the treatment of the enrollees jaundice. Findings:  The physician reviewer found that in 2004, the American Academy of Pediatrics published guidelines for management of hyperbilirubinemia in newborn infants born at more than 35 weeks gestation. Despite these guidelines, kernicterus has still occurred. Further guidelines and clarifications were recently published in 2009 in an effort to prevent the sequelae of severe hyperbilirubinemia. A number of risk factors for severe hyperbilirubinemia have been identified including pre-discharge transcutaneous or serum bilirubin measurement in the high-risk or high-intermediate-risk zone; lower gestational age; exclusive breastfeeding (particularly if weight loss is excessive or nursing is poor); jaundice observed within the first 24 hours; isoimmune or other hemolytic disease; previous sibling with jaundice; cephalohematoma or significant bruising; East Asian ethnicity. In a nomogram for designation of risk in term or near-term infants, a bilirubin of approximately 17.5 mg/dL at 96 hours of life would place the infant in the high-risk zone. In a second nomogram representing guidelines for phototherapy, an infant at medium risk for severe hyperbilirubinemia (term plus risk factors or near-term without risk factors) at 96 hours of life with a bilirubin level of 17 mg/dL or greater would merit phototherapy.Although the exact hours of life for the bilirubin levels obtained are not available for this patient, looking at the nomogram with an approximation of age places this infant in the high-risk zone at discharge at 24 hours, in the high-intermediate zone at 48 hours, and at the junction of the high-intermediate and high-risk zones at 96 hours. Her bilirubin level at the time of discharge is considered a risk factor, thus his bilirubin level at 96 hours of life justified hospital admission for phototherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested bilateral lumbar sympathectomy for the treatment of her hyperhidrosis. Findings:  The physician reviewer found that an article by Reisfeld and colleagues, which was submitted with this appeal, reports the results of 1312 patients with hyperhydrosis treated with endoscopic thoracic sympathectomy. However, the requested procedure is a lumbar sympathectomy, rather than a thoracic sympathectomy. A literature search of lumbar sympathectomy for the treatment of plantar hyperhydrosis reveals additional articles regarding the requested procedure. In 2007, Rieger and Pedevilla performed bilateral lumbar sympathectomies on 8 patients. They concluded that in all cases, pedal sweat secretion was completely suspended post-operatively. After a 3- to 8-month follow-up period, the anhidrosis persisted in all cases (100%). Five patients (62%) reportedly experienced minor compensatory sweating of the torso, and four patients (50%) had post-sympathectomy neuralgia. Thus, while the procedure appeared to be effective, there was a significant complication rate. Furthermore, the report was of low quality; used a small number of patients; involved a short period of follow-up; and lacked randomization or controls. The same group subsequently published a larger series (Rieger and Pedevilla 2009). This study involved 90 patients (59 men, 31 women) with severe plantar hyperhidrosis. Follow-up examination was carried out for all patients after a mean follow-up of 24 (with a range of 3-45 months) months. While all of the patients had evidence of postoperative sympathetic denervation of the feet, compensatory sweating occurred in 40 patients (44%) and post-sympathectomy neuralgia occurred in 38 patients (42%). While the authors concluded that endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis, this study was retrospective nature, involved a relatively short period of follow-up, and lacked randomization or controls. Loureiro and colleagues performed a randomized study in which 30 female patients with persistent plantar hyperhidrosis were enrolled. During the immediate post-operative period, 3 patients (20%) experienced prolonged pain (more than 10 days). Eight patients experienced worsened compensatory sweating (53.3%). The authors concluded that although endoscopic retroperitoneal lumbar sympathectomy diminished plantar sweating in women with plantar hyperhidrosis, about half of the patients develop increased compensatory hyperhidrosis in other areas of the body. All told, the efficacy and safety of lumbar sympathectomy for this indication has not been sufficiently established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested major suction assisted lipectomy of the anterior, lateral and posterior thighs bilaterally for the treatment of her excess lipodystrophy of bilateral thighs status post bariatric surgeries. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the presence of an abnormal structure of the body in the patient caused by infection, trauma, tumor or disease. While the patient has skin laxity and excess fat and skin of the thighs, the excess tissue is not so great so as to be considered abnormal. As such, the patients condition does not meet the requirements for reconstructive surgery as set forth by California law. Furthermore, with regard to whether the requested procedure is medically necessary, there is no visible area of skin breakdown or rash in any of the photos. While it is mentioned that the patient used creams for about one year, there is insufficient documentation of office visits or treatment of any skin condition. The records lack specific symptoms and documentation of office visits for skin breakdown or rash. As such, the medical necessity of the proposed procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for the evaluation of her for breast cancer.  Findings:  The physician reviewer found that this patient does not meet the current accepted criteria for screening for breast cancer using MRI. The current accepted practice is to perform a mammography and ultrasound of the breasts as screening and follow-up procedures as a first-line of defense in the detection of breast cancer. This patient has a history of lumpectomy; there is no indication in the submitted records that the original lesion was associated with positive margins or lymph node metastases. The patients given family history is positive, but there is no personal history of positive BRCA-1 genetic testing or positivity for the marker. Currently, the practice guidelines recommend that MRI be reserved for use as a problem solving tool given either equivocal mammographic or sonographic findings, or physical findings not explained by conventional imaging. This patient has had unremarkable and stable mammograms for several years. Thus, the patient does not meet current accepted criteria for MRI screening of the breasts and the requested diagnostic procedure is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees speech production. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best (Nelson and colleagues). According to a Cochrane Database meta-analysis of 25 studies by Law and colleagues, approximately 6% of children have speech and language difficulties. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.  This patient demonstrates articulation delay, and her skills fall significantly below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adults. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-month-old male enrollee has requested a cranial molding helmet for the treatment of the enrollees head asymmetry. Findings:  The physician reviewer found that cranial helmet therapy is indicated for infants with positional plagiocephaly who have failed conservative treatment with positioning and physical therapy. There is no indication that these modalities were utilized in this patient. It has been suggested the patient has asymmetric premature closure of the sutures or craniosynostosis. No imaging results have been provided confirming this assessment. In the neurologists notes he reported a little more flattening on the right side with a normal neurologic exam. However, there is no evidence the asymmetry has been quantified with anthropometric measurements. Thus, the medical necessity of cranial helmet therapy has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that the patients symptoms were acutely new. In addition, the pain involved the chest and left arm. The provider performed testing to exclude both an acute myocardial infarction and a pneumothorax, both of which are life-threatening medical problems. It is reasonable that a layperson with acute onset of chest and left arm pain would be concerned that a serious medical problem might have developed which required immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a total ankle replacement for the treatment of his left ankle pain. Findings:  Two physician reviewers found that total ankle replacement procedures have had a high failure rate in the past, but more recent designs and techniques have had more promising results. However, equivalence of arthroplasty with fusion has not yet been sufficiently established (Yalamanchili and colleagues). Reports of short-term results have been encouraging, but reports of mid-term results are few and often have not been validated by independent observers (Cracchiolo and Deorio). According to an article by Marx and Mizel, the role of arthroplasty as a viable alternative to arthrodesis remains the subject of debate. There remains a need for long-term and comparative studies (Haddad and colleagues). Until longer term studies have been completed, there is insufficient evidence to support the conclusion that total ankle replacement is a superior option in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a prophylactic knee brace for the treatment of his knee status-post surgery. Findings:  The physician reviewer found that the peer-reviewed literature generally produces statistically valid conclusions or consensus within the medical community when evaluating fairly common and clearly defined injuries. This patients presentation was different than most post ACL reconstruction patients. It was noted, that this patient had multiple diagnoses including ACL reconstruction, medial meniscectomy, lateral meniscus repair, microfracture of the medial femoral condyle, and chondroplasty of the femoral trochlea and patella. This is an unusual situation and thus peer-reviewed literature concerning this specific clinical scenario is lacking. However, given the multiple serious orthopedic diagnoses involved in this case, as well as the patients high risk occupation, it was medically reasonable and appropriate to utilize a prophylactic knee brace to attempt to prevent re-injury to his knee. The specific factors involved in this case placed the patient at high risk for re-injury and thus a prophylactic knee brace was clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested preservative-free and additive-free Vitamin B12 injections (hydroxocobalamin, acetic acid glacial and sodium chloride) for the treatment of the enrollees B12 level. Findings:  The physician reviewer found that the peer-reviewed scientific literature does not support the use of the requested injections for this patient. The classic case of Vitamin B12 deficiency is notable for anemia and an abnormal MCV count. In this case, the patient has a normal hemoglobin/hematocrit, normal MCV count and normal B12 level when tested. Patients with low normal, or even normal, B12 levels may be deficient. However, the literature supports measurement of methylmalonic acid and homocysteine levels, which appear to be more sensitive for the diagnosis than serum Vitamin B12 levels. There is no evidence of methylmalonic acid and homocysteine level testing demonstrating Vitamin B12 deficiency in this patient. The submitted documentation does not demonstrate the medical necessity for the requested preservative-free and additive-free Vitamin B12 injections.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) scan with computer-aided detection (CAD) for an evaluation of the enrollee who has a history of breast cancer. Findings:  Two physician reviewers found that the use of screening breast MRI in patients with a personal history of breast cancer continues to be the subject of debate. The American Cancer Society does not recommend screening breast MRI for patients with dense breasts or for patients with a personal history of breast cancer. As stated in the article by Saslow and colleagues, The panel also identified several risk subgroups for which the available data are insufficient to recommend either for or against screening. They include women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography. Currently, the accepted guidelines (Porter and colleagues) only recommend screening breast MRI in patients with personal history of breast cancer if they also have history of other high risk factors such as gene mutation. At this time, there is insufficient evidence in the medical literature to support the use of a screening breast MRI in this setting.