Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested an osteochondral allograft and a meniscal allograft for the treatment of his left knee pain. Findings:  Two physician reviewers found that the submitted clinical evidence demonstrates that the patient is an appropriate candidate for osteochondral allograft and meniscal allograft. The presence of instabilities or misalignments are relative contraindications to the proposed procedures unless they are combined with corrective osteotomies. Although there is no final comment as to the alignment of the limbs by the patients orthopedist, the patients radiologist does state that there is satisfactory alignment. The patients knee is also stable; there is no discussion of any anterior cruciate insufficiency. While the literature to date is lacking in terms of long-term data on outcomes and risks associated with the proposed procedures, there is sufficient evidence demonstrating that this is the best treatment option available in this particular setting. Upon review of the entire clinical situation, especially considering this patients age of 25, total knee replacement or hemi-arthroplasty is not an acceptable alternative procedure. The evidence-based literature and the cumulative expert opinion support a decision that the planned procedures are likely to be superior to any available standard therapy in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a panniculectomy for the treatment of her abdominal pain secondary to hernia and ovarian surgeries. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The condition does not constitute an abnormal structure of the body because a pannus in and of itself is just a variant of a normal abdomen unless it contains a cancer or some other skin condition. The clinical records provided for review do not document the presence of any such condition. There is no documented abnormal structure directly related to the pannus caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that a large percentage of the population has some degree of pannus and the size of the patients pannus is not so great as to be considered abnormal. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment that has failed to respond to conservative management. The submitted photographs do not show any skin breakdown or rashes. A physical examination documented only mild intertrigo. There is no evidence that the patient has tried and failed standard treatments for this condition. Furthermore, the proposed procedure is not likely to resolve the patients reports of back pain. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested emergency ambulance transportation as a result of her medical condition. Findings:  The physician reviewer found that California law defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. The issue in this case is whether a prudent layperson would have sought ambulance transportation for nausea, vomiting, headache and abdominal pain. The submitted evidence does not demonstrate the patients health was in jeopardy if she was not treated immediately. The patients vital signs were normal and she did not receive any treatment while in the ambulance. In the ER, the patient received antiemetics and some intravenous fluids. She was discharged in stable condition three hours after her arrival to the ER. The patient was in stable condition throughout her stay in the ER. The evidence does not support the contention that the patients symptoms were so severe as to cause a prudent layperson to seek ambulance transportation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Zetia (10mg) for the treatment of his high cholesterol. Findings:  The physician reviewer found that the National Cholesterol Education Program (NCEP) Expert Panel recommends an LDL level less than 100 mg/dl for those patients with coronary artery disease. It was proposed that that the goal LDL level be reduced to less than 70 mg/dl for very high risk patients, but this patient does not fall into this category (Grundy and colleagues). Therefore, for this patient, his LDL level should be less than 100 mg/dl. There have been multiple clinical trials showing a decrease in the risk of coronary heart disease and all-cause mortality when statins are used to treated hyperlipidemia (LaRosa and colleagues) and they are the only class of drugs to have demonstrated a reduction in overall mortality. Therefore, statins are the first choice for treatment in patients with hyperlipidemia. If LDL cannot be reduced to the goal level with the use of statin therapy alone, then the addition of another agent (such as Zetia) is considered. As the Health Plan indicates, the submitted evidence does not demonstrate that this patient has had an adequate documented trial of the statin Lipitor 80mg to reduce his LDL to less than 100 mg/dl.  This should be the first-line treatment. If his LDL level were to remain above 100 mg/dl after an adequate trial of Lipitor 80mg, then Zetia should be considered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. The published data support the position that the co-morbidities and the associated illnesses of the obesity have a much higher chance of resolution with the duodenal switch operation than the alternatives of Roux-en-Y gastric bypass, adjustable gastric banding or the sleeve gastrectomy. The relative improved outcome is in some cases more than double that of the alternative procedures being offered. Buchwald and colleagues summarized the outcomes of different types of surgical weight loss procedures based on excess weight loss and resolutions of co-morbid conditions. The duodenal switch procedure was determined to show the most improvements among bariatric procedure alternatives (including Roux-en-Y gastric bypass, gastroplasty and gastric banding). There was significant hyperlipidemia improvement, diabetes resolution and excess weight loss reported with the duodenal switch procedure more often than with any of the other procedures surveyed. While the peri-operative complication and mortality rate is lower with the lap-band and Roux-en-Y gastric bypass, there is no evidence that the duodenal switch procedure has an unacceptable safety profile. The duodenal switch procedure has a better relative expected outcome, and as long as the patient is properly informed of the associated risks, the duodenal switch operation is medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Lexapro 10mg for the treatment of his generalized anxiety disorder. Findings:  The physician reviewer found that there is data to support the use of an antidepressant that has benefitted a family member. An article by Lin and Chen indicates that based on theories of pharmacogenomics, since the patients immediate family member did well on Lexapro, it may well benefit him. The authors state that, Evidence is accumulating to suggest that the efficacy of antidepressants results from the combined effects of a number of genetic variants. Additionally, while antidepressants are equally efficacious in theory, they are not equivalent in terms of side effect profiles. Paroxetine (Paxil) tends to cause more weight gain, sexual side effects and interdose withdrawal symptoms. Withdrawal symptoms are also seen with missed doses of venlafaxine (Effexor), which can also elevate blood pressure. In terms of its side effect profile and possible drug interactions, Lexapro is a cleaner drug than Paxil or Effexor. In sum, as this patient has already exhibited side effects to Luvox, it is medically reasonable and appropriate to treat him with Lexapro.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested lap-band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 42.2 and multiple co-morbid conditions, therefore, she meets the National Institutes of Health (NIH) criteria for bariatric surgery. The Health Plan indicates that the patient must obtain a presurgical weight of 253 pounds before surgery can be approved. Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for treatment of morbid obesity. There is no scientific data to support delayed surgical intervention in this setting. In the case of this patient, she is seeking authorization for the lap-band procedure. The medical literature has consistently shown the lap-band is efficacious and is associated with less morbidity than other weight loss procedures. The lap-band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested a Joint Active System (JAS) Bi-Directional Static Progressive Splint for the treatment of the enrollees arthrofibrosis. Findings:  The physician reviewer found that this patient does have a significant contracture of the left elbow which could affect many vocational, recreational, and some activities of his daily living. While the JAS Splint is considered a corrective appliance, a review of the available literature does not reveal any randomized controlled trials establishing the JAS Splint as being more beneficial or effective for treatment of chronic elbow contractures than standard modalities. One retrospective study (Doornberg and colleagues) included 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees). These patients were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. The authors concluded that static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate. Based on the information provided, a JAS Splint for this patients situation is not medically necessary as it does not appear that he has exhausted standard options. The patient should undergo a trial of physical therapy (which would include an exercise program designed to improve elbow extension) and dynamic splinting. If objective documentation of trial and failure of these modalities is provided, the patients request for a JAS Splint should then be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested Celebrex for the treatment of her tendinitis. Findings:  The physician reviewer found that in Rostom and colleagues review of the medical literature they found cyclooxygenase (COX)-2 inhibitors such as Celebrex offered better upper gastrointestinal (GI) safety and were better tolerated with fewer GI symptoms than other NSAIDs. Cullen and colleagues report that adding a proton pump inhibitor (PPI) is also an effective means of preventing gastrointestinal toxicity. Chan and colleagues conducted the only randomized controlled trial comparing a COX-2 with a COX-2 and PPI. The authors concluded that there was a significant decrease in the incidence of recurrent upper GI bleeds with combination treatment. However, these were very high risk patients and the patient would not fall into this category. While the majority of studies have looked at ulcer risk and not this patients symptoms of dyspepsia and reflux, in general, the COX-2 inhibitors have been better tolerated with fewer GI symptoms as reported in multiple studies. Since the patient has continued symptoms which are not controlled on twice a day dosing of Aciphex, it is medically appropriate to treat her with a COX-2 inhibitor such as Celebrex rather than a conventional, non-selective NSAID.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Qualaquin for the treatment of her nocturnal leg cramps secondary to fibromyalgia. Findings:  The physician reviewer found that nocturnal leg cramps can be a very debilitating problem for many patients and Qualaquin has been long recognized as an effective means of controlling such cramps. Historically, Qualaquin was available as an over-the-counter medication for decades. However, in 1995 the Food and Drug Association (FDA) determined that Qualaquin should require a prescription and more recently, the FDA has indicated that Qualaquin is only appropriate for treating plasmodium falciparum malaria. The FDAs action was based on reports of serious adverse effects caused by Qualaquin administration for leg cramps.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested partial hospitalization program services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that this patient was referred to a PHP based on clinicians input that she needed more intensive services to address her chronic eating disorder. At the time of those referrals and as documented on admission, there were no identified medical issues (such as severe weight loss, persistent binging/purging, electrolyte abnormalities, evidence of protein depletion or cardiac symptoms) to indicate the need for immediate medical interventions. Furthermore, the patient did not manifest any suicidal or homicidal ideation, delusions or marked mood changes. To the contrary, the admission documentation indicates that her mood and eating disorder symptoms had improved with the addition of Zoloft approximately three months prior to admission. She was also documented as being motivated for treatment and she had solid future oriented ideation around a specific career. While the psychiatrist indicates the potential for minimization and denial of severity, the patient does demonstrate a willingness to accept structure and treatment recommendations as manifested by her volunteering activities during her days off. Thus, a less intensive level of care such as the IOP and outpatient therapy services offered by the Health Plan would be consistent with the standard of care and medically appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested an ultralight wheelchair for the treatment of his T-10 paraplegia. Findings:  The physician reviewer found that this patient meets generally accepted medical necessity criteria (Medicare criteria) for a mobility assistive device (i.e., a manual wheelchair) as he has a mobility deficit that impairs his ability to perform mobility-related activities of daily living (MRADLs) within the home and this deficit cannot be ameliorated with a cane or walker because he is non-ambulatory. The patient is able to propel a manual wheelchair. He meets Medicare durable medical equipment (DME) criteria of medical necessity for an ultralight manual wheelchair, as it is necessary for treatment of his condition and is prescribed by his physician. The patients current wheelchair is inadequate to enable him to perform MRADLs within his home and to transport to work. Although the patient may not have current problems with his upper extremities, as a long-term paraplegic, it is necessary to prevent such deterioration through the use of an appropriate mobility device.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested speech therapy for the treatment of the enrollees auditory processing disorder and dyslexia. Findings:  The physician reviewer found that speech and language therapy is medically necessary for treatment of this patients auditory processing deficits. The American Speech-Language-Hearing Association (ASHA) broadly defines central auditory processing as the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Auditory processing includes the following: sound localization and lateralization, auditory discrimination, auditory pattern recognition, temporal aspects of audition including temporal integration, temporal discrimination, temporal ordering and temporal masking, auditory performance in competing acoustic signals, and auditory performance with degraded acoustic signals. Central auditory processing disorder is then, A deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors. Although it may coexist with other disorders, it is not caused by these other disorders. ASHA has emphasized that evaluation must be individualized, with testing based on complaints and symptoms. A wide variety of tests can be utilized to provide an appropriate assessment. Interpretation of such tests should be performed by individuals experienced in the complexities of central auditory processing disorders. Intervention should be implemented as soon as possible following the diagnosis to exploit the plasticity of the central nervous system, maximize successful therapeutic outcomes, and minimize residual functional deficits. This patient has been evaluated multiple times by a variety of specialists using many different assessment tools, revealing auditory processing deficits. Speech and language therapy to address these deficits is therefore medically reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested cognitive therapy services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that this patient is described as having high-functioning autism with significant language and socialization deficits. He was placed in a special intervention program by the age of three.  A component of the services at issue is music therapy, which is recognized as an accepted form of therapy for autistic children. The text by Berger is a standard source for information of the theories, history and applications for treating autistic children and supports the use of music therapy. Stahmer and colleagues also mention music therapy as a standard community treatment for autistic children. With regard to the cognitive behavior component of the therapy, while at this patients age it may be somewhat difficult for him to intellectually understand his disability, cognitive behavior therapy is often utilized in autistic patients. Hormer and colleagues consider a form of cognitive behavior treatment in their paper.  Furthermore, as Stahmer and colleagues point out in their paper, multiple approaches are necessary, as few specific treatments have been established as efficacious for some children with autism in research settings. Truly double-blinded studies in autism with follow-up until adulthood are lacking. Given the absence of such studies, it is acceptable to use expert opinion, which does accept cognitive therapy as efficacious in the treatment of autistic children.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient presents with a medical diagnosis of autism, a complex neurodevelopmental disorder. Impaired verbal and nonverbal communication and impaired social communication are commonly observed in individuals with autism. Speech and language therapy is well-recognized as one of the multiple therapeutic modalities utilized in the treatment of autism spectrum disorders. This is noted in the practice guidelines of the American Academy of Child and Adolescent Psychiatry and the medical literature.  In this case, speech and language therapy has been prescribed by a developmental pediatrician.  A formal evaluative report by a licensed speech and language therapist indicates a history of unusual speech in terms of pitch, volume, and rhythm. The patient also displayed unusual repetition of final sounds and syllables. The recommendation was continued therapy for speech, language, pragmatic and social communication skills for at least one more year.  The record indicates the patient has a medical disorder (autism) with documented deficits in communication. As such, speech therapy services were and are medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested 40 hours per week of skilled nursing care for the treatment of the enrollees autism and Hirschsprungs disease. Findings:  The physician reviewer found that the home health nursing evaluation does not document nursing needs sufficient to justify skilled nursing level of care. The submitted documentation does not indicate the patient is receiving any medications intravenously. In addition, the patient feeds orally and does not require tube feedings. Furthermore, the patients parent has been trained in the care of a button cecostomy. The parents can also monitor the patient for seizures as they have been doing when skilled nursing personnel is not present. All told, the patients needs do not require the level of skill or supervision that accompanies skilled nursing services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a portable ultrasonic nebulizer (and related accessories and supplies) for the treatment of her asthma. Findings:  The physician reviewer found that the submitted clinical and hospital records confirm the diagnosis of asthma with a history of hospitalizations and thoracotomy. The records provided indicate the patient has been using an albuterol sulfate nebulization solution and Pulmicort Flexhaler inhaler. The submitted records do not however demonstrate the medical necessity of the requested ultrasonic battery-driven nebulizer. The generally accepted medical practice is to prescribe a standard nebulizer. The records indicate that the patient already possesses a nebulizer. If replacement is necessary, a standard nebulizer is warranted for her condition. The patient states that she has managed her condition with use of an ultrasonic nebulizer for 10 years and failed earlier attempts with compressor type nebulizers. Ultrasonic nebulizers are used primarily to deliver drugs to the lower airway. This patient has asthma, which is a disease of the upper and mid airways; thus, the ultrasonic mode of therapy is not medically necessary for this patients diagnosis. Standard nebulizers are the most commonly prescribed for patients with asthma since they are considered the most reliable device for that purpose. They are impaction jet nebulizing devices which are capable of delivering the appropriate medications, as compared to ultrasonic vibrating crystal nebulizing devices, which are designed to deliver smaller particle medication deep into the lungs.