Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient was evaluated in the emergency department due to a right earache for the past seven hours. She was discharged with a diagnosis of otitis media and a given a prescription for oral Amoxicillin and ear drops. At issue in this case is whether a prudent layperson in the parents circumstances would believe their child was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients parent states that she was concerned that a delay in care could cause impairment of her daughters hearing. Upon presentation to the emergency department, the patient was described as being in mild distress. Her pain level was documented as a 6 on a 1 to 10 scale, which though significant, does not indicate severe pain. There was no evidence of discharge from the ear, hearing loss, sore throat, headache, nausea or chest pain. Vital signs were stable. Given the patients presentation, although her symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part without emergency medical care. As such, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for a vertical sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that the vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested for Genotropin injections for treatment of the enrollees long-term growth failure associated with idiopathic short stature. Findings:  The physician reviewer found that this patient is likely to represent a combination of familial short stature with eventually delayed puberty. No medical intervention is required in this setting as such patients are likely to achieve a normal adult height with respect to that of their family
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested for residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that she was not appropriate for transition to a less intensive level of care as she continued to pursue antisocial and eating disordered behaviors. The patient continued to drink alcohol and violated her treatment contract, and still requires the level of supervision provided in a 24-hour care residential treatment setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested the medication Intuniv for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that this patient reportedly experiences severe side-effects from stimulant medications and Strattera. However, his provider reports he has done well on guanfacine XR (Intuniv) and would like to continue on this medication. There is strong literature to support the fact that 80-90% of patients respond to stimulant medications (Pliszka).  However,  side effects can be intolerable. These side-effects are unfortunate and well-documented (Biederman), Although stimulant therapy has been the mainstay of ADHD treatment, some subjects do not respond to stimulants or are unable to tolerate the associated side effects. There are other alternatives to stimulants and Strattera, such as bupropion and tricyclic anti-depressants, however these medications do not have FDA-approval for this indication and are often not efficacious (Pliszka). Intuniv is an FDA-approved treatment for ADHD whereas guanfacine is not. As noted by Kratochvil, As of September of 2009, guanfacine in XR form is the first alpha(2)-adrenoceptor agonist to gain approval to treat ADHD, approved for the treatment of 6- to 17-year olds. In addition, Biederman indicates, A recent double-blind, multi-center trial supports the efficacy and safety of guanfacine extended release (GXR) for pediatric ADHD. This long-term, open-label extension was conducted to study the safety profile and effectiveness of guanfacine XR for up to 2 years. All told, it is reasonable for this patient to continue on his Intuniv trial as it is an appropriate medication for this indication and the patients physician has documented that it has been effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested a custom knee brace (L1846) for treatment of his knee, status post knee surgery. Findings:  The physician reviewer found that although functional knee braces are commonly prescribed after anterior cruciate reconstructive surgery, evidence for their effectiveness is lacking. No advantage has been found in their use as compared to the use of a neoprene sleeve, as noted by Birmingham and colleagues.  As noted by Smith and Davies, no significant difference has been identified between patients who wore postoperative braces and those who did not. A prospective, randomized, multicenter study did not identify any significant difference between braced and unbraced patients, as noted by McDevitt and colleagues. There is a lack of evidence regarding an effect on pain, motion, graft stability or protection from subsequent injury, per Wright and Fetzer. The custom knee brace (L1846) was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for Xolair for treatment of her asthma. Findings:  The physician reviewer found that the scientific literature demonstrates that Xolair is standard of care for patients who have been diagnosed with asthma, have an elevated IgE and have a positive skin test (such as is the case with this patient).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there is sufficient documentation to support acute hospitalization during the dates of service in question. This patient presented with complex psychiatric disorders. The level of care provided is consistent with the Child and Adolescent Level of Care Utilization System. Based on these criteria, the patients functional impairment was severe which would be rated a 5. His co-morbidity issues were major (Tourettes syndrome and ADHD seriously complicated by autism spectrum disorder) and would also be rated a 5. A rating of 5 in just these two domains alone requires treatment in a secure 24-hour setting. The level of care provided is also consistent with American Academy of Child and Adolescent Psychiatry Practice Parameters for treatment of children with autism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for Apligraf application surgery for treatment of his wound. Findings:  The physician reviewer found that there were no indications of technical reasons for the failure. In light of the patients treatment history, the likelihood of success following a repeated application of Apligraf is quite low. There is inadequate support in the medical literature for repeat application of Apligraf in the setting of prior failure for non-technical reasons.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for radiofrequency lesioning (ablation) for treatment of his pain. Findings:  Three physician reviewers found that the current medical literature is not conclusive regarding the efficacy of radiofrequency ablation for this patients condition. There are few studies available and they only involve small numbers of patient at this time. A 2008 study by Cohen, et al. found that while the results of a placebo-controlled study provided preliminary support for the use of radiofrequency ablation, larger, multi-center studies with long-term follow-up and comprehensive outcome measures are needed to confirm our findings, further establish safety, and determine how best to identify candidates for this treatment. All told, there is a lack of evidence supporting the superior efficacy of radiofrequency ablation over alternative treatment options in this patient population.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested artificial disc replacement surgery for treatment of her lumbar disc degenerative disease (with radiculopathy). Findings:  Three physician reviewers found that the possibility of clinically relevant increased adjacent segment degeneration following fusion, although not definitively established, has led to interest in artificial disc replacement to preserve motion. However, the efficacy of these implants over time has not been established (Resnick and Waters). Although short-term results have been encouraging, the need for further long-term randomized studies has been noted (Tropiano and colleagues). This was recognized in the initial 2006 approval by the FDA, which required further study over time following the approval of the procedure. Tools for collection of data have been established (Schluessmann and colleagues), and studies are in progress, but the results are not yet available. The efficacy of replacement and motion-sparing technology has not yet been demonstrated (Madigan and colleagues) sufficiently in the medical literature. All told, there is inadequate scientific evidence to support the efficacy of artificial disc replacement for treatment of lumbar disc disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for inpatient psychiatric care for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted evidence demonstrates that the patient was only marginally cooperative upon admission, but clearly emotionally unstable and was not safe to be treated at a less intensive level of care. In addition to his mood disorder, the evidence is suggestive of an Axis II disorder that makes the patient a greater a risk for impulsive acting out behaviors and a safety risk. He has severe functional impairment, as he is unable to perform activities of daily living. He continues to exhibit suicidal ideation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested adult substance abuse sub-acute/residential treatment center (RTC) rehabilitation for treatment of her behavioral health condition. Findings:  The physician reviewer found that this patient had a long history of alcohol problems. At admission, her condition was well-documented.  However, as her stay continued, the documentation was sparser. It does appear that she was having some withdrawal symptoms upon presentation. However, these were minimal, as she was taking Ativan, which was likely decreasing or eliminating her symptoms.  There are several factors that would signify need for a more intensive level of care upon the patients admission: 1) she had a history of suicidal ideation and suicide attempts in the past while intoxicated; 2) depression; 3) her apparent denial of the severity of her illness; 4) lack of cooperation with AA; and 5) long history of alcohol dependency. With examination of the American Psychiatric Association guidelines for patient placement in an RTC, several of the criterion are applicable in this case: 1) the patient did not meet the clinical criteria for hospitalization, but her life and social interactions have come to focus predominantly on substance use; 2) lack of sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting; and 3) demonstrates denial that could respond to interpersonal and group confrontation. According to these guidelines, the patient met criteria for a RTC placement upon her admission. However, the documentation does not support the continued need for the patient to have remained at this level of care. After ten days of treatment, she was still having some withdrawal symptoms and mood swings. However, there is no documentation after this date of any such problems or indications that the patient could not be safely or effectively treated in a less restrictive setting. After ten days of treatment, the patient could have been treated safely and effectively at a less restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found that there were no signs of oppositional defiant behavior and the patient was compliant with treatment. He had no negative acting-out behaviors at that time. The patient was described as a role model to peers, and it was noted that he was committed to sobriety.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 51-year-old male enrollee has requested for continued skilled nursing facility care services for treatment of his medical condition status post stroke. Findings:  The physician reviewer found that clinical evidence does not demonstrate the presence of any current skilled nursing needs. The patient is now more than three months post-stroke. At this time, he is able to ambulate long distances. Based on available scientific evidence, continued progress related to daily skilled therapy is not anticipated in this setting. While the patient may experience further benefit as a result of improvement in his neurological status, this will likely occur gradually over a period of time. At this juncture, the patients progress is not related to daily skilled therapy, but to the severity of the stroke and his potential for recovery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for continued acute inpatient hospitalization for treatment of his depression. Findings:  The physician reviewer found that this patient presents with severe depression and psychotic features along with hopelessness, poor eye contact, and impaired judgment. He remains at high risk for self-harm and at risk for impaired self care. The patient has not improved to the point that he is stable for transition to a less intensive level of care. He is in need of treatment in a 24-hour hospital setting with close observation, ongoing monitoring and intensive treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested Cialis for treatment of his age-related erectile dysfunction. Findings:  The physician reviewer found that Cialis is an accepted treatment and primary therapy for erection failure. The treatment of erectile dysfunction is goal-directed. Cialis is a phosphodiesterase (PDE) type 5 inhibitor, which is a class of drug that has been shown to be safe and effective. There are only a few particular clinical situations in which PDE type 5 inhibitors cannot be used safely. In this patients case, the underlying cause of his erectile dysfunction (ED) has been related to his age alone, and not due to other underlying factors. After the age of 40, there is a progressive loss of erectile ability which is presumed to be caused by early vascular disease. The studies by Laumann, et al., Chew, et al. and Johannes, et al. show that age alone is a significant risk factor for ED, with the risk being 2% to 8% in patients aged 40 to 49 years. The degree of the ED varies from partial to complete in such patients. Therefore, individuals in the patients age group are appropriate candidates for ED therapy using PDE type 5 inhibitors. In addition, this patients prior positive clinical response to Cialis is additional support to justify its medical necessity for treatment of this patients ED.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for use of a continuous passive motion (CPM) machine for treatment of the enrollees medical condition following right knee arthroscopic debridement and microfracture chondroplasty surgery. Findings:  The physician reviewer found that Steadman and colleagues recommend that for patients who had lesions on their femoral condyle and subsequently underwent microfracture surgery, they should be treated with a CPM machine commencing immediately in the recovery room, with the initial range of motion (ROM) at 30 to 70 degrees which is increased as tolerated by 10 to 20 degrees until full passive ROM is achieved. There is inadequate documentation in the form of physical therapy notes or follow-up office visits which validates the need for the use of a CPM machine past the three weeks.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has for keloid surgery for treatment of the enrollees keloids. Findings:  The physician reviewer found that the records do not demonstrate symptoms such as bleeding, infection, skin irritation, discharge, inflammation or change in color.  The presence of a keloid scar in the absence of a  functional problem does not make its removal medically necessary.  Earlobe keloids are not generally painful.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that vital signs were within normal limits. The patient did not appear to be in distress, but was ambulating with obvious discomfort. No pelvic deformity was noted. Distal neurovascular function was intact. X-rays of the patients pelvis and left hip were negative for any fracture or dislocation. The patient was diagnosed with left hip pain. She was advised that this pain could be caused by a lumbar radiculopathy. The patient was discharged with advice to follow-up with her primary care provider for possible physical therapy or orthopedic referral.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patients symptoms had been present for two months prior to his visit to the emergency department. He had already previously been evaluated by his primary care doctor and received prescription medication. There was no sudden change in his condition on the date of service at issue which would have caused a prudent layperson to seek emergency department care. The patient was not experiencing any acute neurologic deficits (such as vision changes, nausea or vomiting) and he denied any chest pain or shortness of breath. While the patients symptoms may have warranted a medical evaluation, a prudent layperson in this patients circumstances would not reasonably believe that this evaluation needed to be provided on an immediate basis. The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Abraxane for treatment of her metastatic melanoma.   Findings:  Two physician reviewers found that Abraxane is the albumin-bound form of paclitaxel and is being studied for the treatment of a variety of cancer types. There is a paucity of information regarding its use in the treatment of metastatic melanoma. Homsi and colleagues conducted a phase II trial wherein 30 patients with metastatic melanoma were treated with Abraxane. Three of the patients experienced partial responses, suggesting a similar efficacy to conventional dacarbazine therapy. The authors noted the need for further studies to support its use. Hersh and colleagues conducted a phase II trial wherein 74 patients with metastatic melanoma were treated with Abraxane. Their responses were thought to be equivalent to current standard chemotherapy regimens. These studies are the only studies conducted that focused exclusively on the use of Abraxane therapy alone, not in combination with other drugs. The results of these studies are not sufficient to support the conclusion that Abraxane therapy is likely to be superior to other conventional therapies in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an eleven-month-old female enrollee who is status-post double barrel colostomy with a low imperforate anus (IA) and a possible 2mm Fourchette fistula along with a surgically released tethered spinal cord are requesting coverage for a posterior sagittal anorectoplasty ((PSARP) with an interdisciplinary surgical team approach consisting of a pediatric surgeon, pediatric gynecologist and a pediatric urologist who are experienced in providing a PSARP.  Findings:  The physician reviewer found that Leavitt and colleagues provide the rationale for why a pediatric surgeon alone with experience in correcting anorectal malformations is sufficient for the vast majority of these cases. The study by Leavitt and colleagues showed that in young female patients (girls) with rectovestibular fistulae, only 17% had associated gynecological anomalies. Of those 48 patients, only 20 or 7% of the entire patient total required a repair that required the services of a pediatric gynecologist. Thus, 93% of the time, a pediatric surgeon alone would be all that is required to perform the appropriate operation. The study by Javid and colleagues involved a large series of girls with rectovestibular fistulae and confirmed that comparable outcomes can be achieved with surgical teams without the presence of a pediatric gynecologist compared to outcomes achieved by surgical teams with a pediatric gynecologist. There are no studies published that demonstrate superior outcomes in these types of surgeries with the involvement of a pediatric gynecologist.