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

A 54-year-old female enrollee has requested a nephrologist for treatment of her decreasing serum creatinine and glomerular filtration rates. Findings:  The physician reviewer found that this patient has mild chronic kidney disease (CKD) based on the GFR measurements provided for review. This determination is based on the guidelines published by the National Kidney Foundation, as the absence of hematuria or proteinuria argues against an active glomerular process. As stated by the authors of UpToDate reference cited above, Patients with CKD should be referred to a nephrologist early in the course of their disease, preferably before the plasma creatinine concentration exceeds 1.2in womenor the eGFR is less than 60 mL. As this patient does not have an average GFR measurement below 60 mL, referral is not clinically indicated at this time. Further evaluation and monitoring by the patients primary care physician is medically appropriate in this setting.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

An 18-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 patient's circumstances would belief he or she 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. This patients medical problem met the prudent laypersons criteria for the need to seek emergent care. His moderate pain became severe pain, (reported as 8 of 10 on a 0 to 10 pain scale, where severe pain is defined as 7-10). Additionally, the patients pain was associated with bleeding from the back of the throat. Both severe pain and pharyngeal hemorrhage are signs and symptoms of an emergency medical problem that should be evaluated immediately. Thus, this patient had a medical problem that became acute; waiting hours to days to be seen elsewhere would not have been prudent.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the World Health Organizations International Classification of Functioning, Disability and Health (known as ICF) is a classification of health and health-related domains. These domains are classified from body, individual and societal perspectives by means of two lists: 1) a list of body functions and structure; and 2) a list of domains of activity and participation. Since a patients functioning and disability occurs in a context, ICF also includes a list of environmental factors to be considered. The ICF acknowledges that every patient can experience a decrement in health and thereby experience some degree of disability. By shifting the focus from cause to impact, ICF suggests assessing all health conditions using a common measurement of disability. This definition places autism on the same spectrum of disability as laryngeal injury, traumatic brain injury, or stroke based on the similar deficits in speech experienced in patients with these conditions. Thus, based on the ICFs definition of health and disability, the requested speech therapy is necessary from a medical standpoint. Additionally, in applying Inkelas and colleagues criteria, this patients documented social communication deficits, echolalia, and decreased sustained conversations are functional deficits that are likely to benefit from skilled intervention. The literature is replete with data in support of young autistic patients obtaining clinical benefit from speech therapy services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested adult psychiatric acute inpatient hospitalization services for treatment of her behavioral health issues. Findings:  The physician reviewer found that the submitted records note an admission to inpatient service from a partial hospitalization program on the basis that the patient was suicidal. The medical records note that the patient was currently experiencing severe suicidal ideation, severe vegetative symptoms, severe mood disturbance and severe sleep disturbance. The patients history was positive for three prior serious suicide attempts. The patients global assessment of functioning (GAF) was reported to be only 22, which represents severe functional impairment. During treatment, the patient was described as disheveled and feeling hopeless with suicidal ideation. A few days after entering the inpatient hospitalization, the notes describe the patient with severely impaired judgment and indicate that she was also on checks every 15 minutes.  An overall analysis supports a finding of medical necessity for acute inpatient hospitalization of this patient for the dates of service in question, particularly given the patients severe mood disturbance and significant risk for self harm. The placement of this patient at this level of care is also consistent with practice guidelines set forth by the American Psychiatric Association for care of patients with major depressive disorders and suicidal behaviors.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested continued skilled nursing inpatient stay for acute physical therapy for treatment of his quadriplegia secondary to spinal cord injury. Findings:  The physician reviewer found that this patient had already obtained the maximum benefit reasonably expected from acute PT services as of the date in question. The patients current levels do not meet requirements for daily PT. While the patient continued to experience improvement in gait function, this occurred at a point when he was no longer receiving daily PT. The gains achieved by the patient beyond the date in question are likely due to restorative nursing and his progress with the nursing program confirms that acute PT services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested Actiq for treatment of his chronic pain. Findings:  The physician reviewer found that Actiq is FDA approved for use in patients with cancer pain. There is a lack of data from randomized controlled trials regarding the use of this medication in ambulatory non-malignant pain patients. Currently, the available evidence in this setting is limited to case series and individual case reports in the literature. The effectiveness of Actiq in the treatment of non-malignant pain has not yet been proven in randomized controlled trials. Studies regarding the use of rapid-onset opioids in chronic, non-cancer pain that also measure patient function are needed(article by Simon). Simon noted that other unanswered questions include the potential for an increased risk for opioid misuse, the potential for rebound pain and the potential for poorer compliance when analgesics are dosed as needed versus around the clock. All told, the current medical literature does not support the use of Actiq for treatment of this patients non-malignant pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Topamax for treatment of her low back pain.  Findings:  The physician reviewer found that Topamax is an anticonvulsant medication used to treat certain epilepsies as well as other conditions such as mood disorders and migraine headaches. Kline and colleagues indicate that there is some evidence that Topamax may be useful in managing certain patients with painful diabetic neuropathies. Nonetheless, this patient does not exhibit any clinical symptoms or physical findings that suggest neuropathic pain. Her symptoms are axial and responsive to facet injections, thus most likely representing mechanical pain. There is no convincing evidence that such pain is responsive to Topamax or any other anticonvulsant medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested post-acute inpatient rehabilitation services for treatment of his medical condition status post intracranial hemorrhage.  Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) guidelines suggest that patients may be appropriate candidates for continued inpatient rehabilitation when they are reasonably expected to make measurable and practical functional gains within a reasonable period of time. It is also assumed that these patients would not progress at a similar rate in a less intensive rehabilitation setting. This patient's progress appears to haved slowed considerably and it is likely that any future gains achieved in a post-acute inpatient rehabilitation program would be similar to those obtained in a less intensive setting. Approximately three months post intracranial hemorrhage, the records provided for review indicate that he had begun to plateau from a functional perspective. While the patient may continue to demonstrate recovery of function over time, it is likely that the recovery curve will be gradual. In light of this, as well as the paucity of randomized clinical trials demonstrating therapeutic benefit of the requested services in this setting , inpatient rehabilitation services are not likely to result in greater or more rapid functional improvement than a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested an MRI of the breast for evaluation of her non-mass-like enhancement of the breast. Findings:  Two physician reviewers found that this patient has an incidental finding in the right breast which is the opposite breast of original concern. The finding can only be seen on MRI, as targeted ultrasound and mammogram of the area were negative. Thus, MRI will be of greater benefit to the patient than any other study, since the abnormal finding could only be seen on MRI. The proposed MRI is medically appropriate and consistent with generally accepted standards in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested PET/CT scan for evaluation of her adenocarcinoma of the right parotid gland.   Findings:  Two physician reviewers found that there is no support in the literature to support ongoing yearly PET/CT scans to follow-up on apparently cured parotid adenocarcinoma. The National Cancer Center Network (NCCN) guidelines recommend regular follow-up physical examinations in this setting, as well as chest imaging as clinically indicated. The NCCN guidelines do not include PET/CT for regular follow-up for parotid adenocarcinoma. Additionally, PET/CT scans can occasionally detect false positives. It is well known that tonsillar activity can be normal in PET scans, and this patient underwent a surgical procedure that revealed normal tonsil tissue. The overall cure rate for stage 1 parotid cancer is as high as 96%. In this patients clinical situation, follow-up PET/CT scan is not likely to be of significant value unless there is clinical evidence for recurrence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  psychiatric residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient's primary issue is substanse abuse. However, he also has a diagnosis of ADHD. He was tried on a few medications, but based on the information provided, has not been under regular psychiatric management.  He had a few short stints of outpatient therapy as well. The records do not document any treatment in a partial day hospital program or an intensive outpatient program. His treatment at the wilderness program only involved weekly therapy. Overall, the patient has not had adequate trials of less intensive therapy to address his mental health issues. While some of the enrollees providers suggested that his substance/oppositional issues were related to poor family relationships, there is no documentation that adequate trials of family therapy were undertaken. Based on the records from the patient's residential treatment stay his need for psychiatric monitoring was minimal and his medication regimen was uncomplicated ( and only for the treatment of his ADHD). This patient was not very engaged in treatment and was often described as uninterested. The submitted documentation does not clearly demonstrate that family functioning was improving in treatment, which is a vital aspect of successful treatment (Green and colleagues). There is also little evidence-based literature to support that RTC treatment is superior to less restrictive forms of treatment (McCurdy and McIntyre). In conclusion, the medical necessity of the patient's past and present treatment at a psychiatric residential treatment level of care has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested a remote 30-day ECG monitor/report for evaluation of his atrial flutter. Findings:  Two physician reviewers found that although this patient had known sustained atrial flutter and fibrillation, given his age and history of diabetes, it is not inconceivable that some of his symptomatic arrhythmia, as well as asymptomatic arrhythmia, might have been ventricular, placing him at higher risk. Additionally, since first-degree AV block was documented, the possibility of higher degrees of asymptomatic AV block in a post-ablation patient would warrant a period of careful, real-time monitoring. Furthermore, the value of the remote ambulatory monitoring in assessing the patients response to therapy on a real-time basis is an added benefit of this type of monitoring. In this patients case, the remote 30-day ECG monitor/report was likely to be more efficacious than alternative methods of evaluation.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that 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 medical records relate that the parents reported that the patient awoke from sleep, screaming and could not be comforted/touched for one hour. The physician then had a discussion with the parents regarding a spinal tap to rule out meningitis. The patients symptoms were concerning enough that the treating physician considered a lumbar puncture; thus, it is also likely that a prudent layperson in the parents circumstances would consider such symptoms to constitute an emergency which required immediate medical attention.
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 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. This patient reported a one day history of swollen tonsils. The patients mother stated that she became alarmed by the appearance of a lump on the patients right tonsil. The patient was not experiencing any pain, fever, or difficulty breathing or swallowing. The appearance of a spot on a patients tonsil may be cause for concern, but the issue is whether these symptoms were sudden or severe enough to cause a prudent layperson to reasonably expect that the absence of receiving immediate medical attention could result in serious risk of harm. The patient had normal vital signs and had no evidence of airway compromise. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms do not meet criteria for an emergency.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression. Findings:  Two physician reviewers found that this patient presents with treatment-resistant depression, and she has not responded to multiple medication trials or electroconvulsive therapy. TMS therapy is FDA approved for the treatment of patients with major depression who have failed to respond to psychopharmacologic agents. Additionally, the literature supports the benefits and efficacy of TMS therapy. A study by OReardon and colleagues looked at whether TMS over the left dorsolateral prefrontal cortex is safe and effective for the treatment of major depression. The results showed TMS was significantly superior to sham TMS on all depression scales measured (MADRS, HAMD17 and HAMD24). Response rates were significantly higher with TMS on all three scales at weeks 4 and 6. Active TMS was well tolerated with a low dropout rate for adverse events (4.5%) that were generally mild and limited to transient scalp discomfort or pain. The study concludes that TMS is effective in treating major depression and is associated with minimal side effects. All told, TMS therapy is likely to be of greater efficacy than any other available treatment for this patients refractory and severe depression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female has requested a Home Pro-Time Monitor (PT/INR home monitoring equipment for evaluation of her chronic anticoagulation use.Findings:  The physician reviewer found that this patient requires long-term warfarin treatment for prevention of thromboembolic disease in the setting of chronic atrial fibrillation.  Treatment with warfarin during the last year has resulted in mostly therapeutic INR levels without documented bleeding complications and without the need for frequent (at least weekly) blood draws. The Health Plan requires documentation that INRs are drawn on at least a weekly basis. Patients who need chronic INR monitoring rarely require this monitoring weekly or more frequently. The Centers for Medicare and Medicaid Services coverage criteria requires that the patient be anticoagulated for at least three months prior to use of the home INR device; undergo a face-to-face educational program on anticoagulation management and demonstrate the correct use of the device prior to its use in the home; continue to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and self-testing with the device should not occur more frequently than once a week. Thus, as long as the patient undergoes an educational program on the correct use of the device, standard accepted Medicare criteria for coverage are met. A Home Pro-Time Monitor (PT/INR home monitoring equipment) is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that in this case is whether the duodenal switch procedure is medically necessary for this patient as opposed to the alternatives mentioned above. Duodenal switch has added risk over the three alternatives. Despite this increased risk, duodenal switch has been proven to be a superior procedure in the treatment of super morbidly obese patients with BMIs of 50 or above. However, this patient does not fall within this category. Additionally, due to this patient's family history of gastric cancer,the patient's possibility of developing dumping syndrome and since the patient is on anti-inflammatory medication, the RNYGBP and Lap-Band procedures are not appropriate.The other alternative mentioned is gastric sleeve (lateral sleeve gastrectomy). The lateral sleeve gastrectomy procedure eliminates the possibility of pouch dilatation or fistula formation and is a safer option for patients on anti-inflammatory therapy. Additionally, there are fewer incidences of morbidities with lateral sleeve gastrectomy than with duodenal switch. The evidence-based literature demonstrates there are no reported metabolic side effects or dumping with lateral sleeve gastrectomy since the pylorus is preserved.  The submitted evidence does not demonstrate that this particular patient requires a duodenal switch procedure. The Health Plan's alternative of lateral sleeve gastrectomy is a medically appropriate option in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested rosacea laser treatment for his rosacea.   Findings:  Findings:  Three physician reviewers found that laser treatment of rosacea is considered to be investigational for the treatment of rosacea at this time. Standard treatment involves consistent therapy with topical metronidazole-containing creams, as well as the use of low-dose oral antibiotics to reduce inflammation (Odom, et al. and Del Rosso). This patient does not appear to have been optimized on these regimens. In the absence of evidence demonstrating lack of benefit from a multi-modal approach that includes oral antibiotics and topical metronidazole-containing medications, the superiority of laser therapy over standard therapy has not been established.