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

A 28-year-old female enrollee has requested for a magnetic resonance angiography (MRA) of the head, MRA of the neck and magnetic resonance imaging (MRI) of the brain for evaluation of her headache, seizure and facial paraesthesia. Findings:  The physician reviewer found that MR imaging of the brain should be considered as the study of choice in evaluating patients with demyelinating disease since computed tomography (CT) scanning will not be able to show multiple sclerosis (MS) plaques with reliability, even after intravenous (IV) contrast administration. It is not, however, the choice for imaging an acute ischemic attacks, unless other techniques such as diffusion weight imaging are applied. Imaging of the intra/extracranial vasculature could be achieved with CT angiography and/or ultrasound. However, CT angiography adds the risk of ionizing radiation exposure as well as reaction to the injected contrast. Ultrasound, even though valuable for imaging of carotid circulation, may be limited in the evaluation of the posterior/vertebrobasilar system. In both cases, MRA is very valuable using a two dimensional time of flight technique without requiring the use of contrast. It provides excellent visualization of the blood vessels and may be able to detect areas of stenosis and other abnormalities such as arteriovenous malformations and aneurysms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the role of speech and language therapy in autistic spectrum disorders is well discussed in the medical literature. Numerous publications, including those cited above, recommend or demonstrate evidence for speech and language therapy for children with autism. While there have been few studies offering a direct comparison of methods, many experts believe that children with autism benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Paul noted in his study that intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female enrollee has requested emergency services for 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 the patient 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 had been experiencing a fever on and off for one week. Although she had developed a cough on the day she was evaluated, the patient was not experiencing chest pain or shortness of breath. The patient was febrile, but was in no distress. Her temperature responded to oral ibuprofen. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the parents circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for nerve decompression for treatment of his pain due to peripheral neuropathy. Findings:  Three physician reviewers found that a study by Dellon demonstrated that removal of a site of anatomic narrowing of the tibial nerve in an animal study prevented neuropathic walking. Dellon concluded that decompression of superimposed nerve compressions in a patient with symptomatic neuropathy reliably relieves pain, restores sensation, and thereby prevents ulceration and amputation. However, despite this paper, there is a lack of prospective, randomized studies that conclusively demonstrate the efficacy for this procedure. In the absence of such evidence, the superior efficacy of nerve decompression in this clinical situation has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested selective internal radiation therapy (SIRT) with yttrium-90 brachytherapy for treatment of her hepatocellular carcinoma.  Findings:  Two physician reviewers found that the peer reviewed medical literature supports the use of SIRT with Y90-microspheres for patients with HCC who have failed to respond to conventional treatments. Hamami and colleagues observed stable disease or partial response in 80% of the patients studied. The authors concluded that radioembolization with Y90-microspheres is a safe and effective treatment for patients with advanced HCC. This patient in particular has been treated with chemoembolization and radiofrequency ablation since his diagnosis of HCC. Despite these therapies, the patients lesions have continued to progress, and therefore his request for treatment with SIRT is clinically appropriate to treat his unresectable HCC.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the role of speech and language therapy in autistic spectrum disorders is well published in the medical literature. Numerous peer reviewed articles recommend or demonstrate evidence for speech and language therapy for children with autism. While there have been few studies offering a direct comparison of methods, many experts believe that young patients with autism benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Pauls study indicates that intervention methods drawing from a range of philosophies and utilizing varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors. In this case, the patient has been receiving therapy with a picture exchange system, a modality that has demonstrated effectiveness, as concluded by Millar and colleagues.  While it is true that this patient does not exhibit defined trauma, surgical intervention or craniofacial abnormalities that would lead to the need for speech and language therapy, he does carry a diagnosis of autistic disorder, for which the standard of care is speech, language and communication therapy. Given this patients recent advances and relatively mild delays, the patient should be reassessed through the school system in the near future to determine if his needs can be accommodated through that venue. In the interim, the Health Plan should provide speech and language services in light of the patients current deficits. Given this patients current documented delays, services for speech and language therapy should be provided for a minimum of four months in order to support his recent significant gains. At that point, given the patients expected transition to the school system and his lack of need for intensive therapy, an evaluation should be made through the school system to determine the need for continued therapy. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his lung cancer. Findings:  Two physician reviewers found that in patients with locally advanced lung cancer, the typical planned radiotherapy dose includes a preoperative dose in the range of 50-55 Gy. This treatment can be done with the standard 3D-conformal technique without any excessive morbidity. There are no randomized trials comparing IMRT with 3D-conformal radiotherapy proving superior outcome with IMRT in terms of side effects or local control. In fact, there are published studies for IMRT in lung cancer, which suggest increased morbidity with IMRT. If a patient has previously received radiotherapy and retreatment is desired in same or adjacent area, or dose escalation is required for curative intent, IMRT would then be the preferred treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that Botox is medically indicated for blepharospasm and symptomatic torsion dystonia. This patient suffers from both of these conditions and has experienced relief from prior use of Botox. There is medical literature supporting the use of Botox for these conditions as referenced.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested BRCA 1 and BRCA 2 genetic testing for an evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that this patient has no history of malignancy, but does have two second degree relatives affected by breast cancer. Testing would be a reasonable consideration if either of the affected relatives was younger than 50 at the time of diagnosis, but the age at time of diagnosis is not available in the records provided for review. Thus, there is no clear indication for the testing performed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for Rocephin for treatment of her Lyme disease.   Findings:  Three physician reviewers found that there is insufficient evidence that this patient has, or has ever had Lyme disease. Based on the information that has been submitted, she has no recorded clinical history of a tick bite or rash which is consistent with this disease. The patient has no history of symptoms (cardiac, neurological or rheumatological) which would suggest that she has Lyme disease. Although there is a single positive IgM Western Blot recorded in the record, almost always, a positive IgM Western Blot without a positive IgG means a false positive.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested for two-level artificial disc replacement for treatment of his degenerative disc disease at C5-6 and C6-7. Findings:  Three physician reviewers found that while the short-term (two years or less) results of single artificial disc replacement compare favorably with anterior cervical discectomy with fusion (the current gold standard), the safety and efficacy of treating more than one level have yet to be demonstrated in appropriate clinical studies.  There is an absence of any peer-reviewed, published, randomized clinical trials demonstrating the long-term efficacy of multilevel replacement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested  for growth hormone therapy (Genotropin) for treatment of the enrollees growth hormone deficiency secondary to a non-functioning pituitary adenoma. Findings:  The physician reviewer found that this patients history is significant for chronic asthma and numerous allergies to foods, dust, pollens, molds and medication. The patient has no contraindication to Genotropin based on the information provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for Allegra 180mg for treatment of his prurigo nodularis. Findings:  The physician reviewer found that the documentation does not demonstrate that the patient has tried therapy with other preferred medications, including Doxepin, hydroxyzine or methotrexate. In addition, the medical literature supporting the use of Allegra for the treatment of prurigo nodularis is sparse, particularly at the doses suggested.  Treatment with intralesional steroids, thalidomide or other opioid antagonists has proven to be useful for treatment of this condition.  There is a lack of support in the medical literature for the use of Allegra 180mg, three times daily, in this clinical situation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a prudent layperson in the patients circumstances would believe 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. This patient had back pain with sciatica that had been present for three to four weeks by the time he presented to the emergency department. This chronology suggests that the patients symptoms were not acute in nature. While a patient could reasonably seek emergent treatment for pain, this patient only rated his pain a 1 of 10 (on a 10-point scale). Moreover, the patient did not report his cardiac symptoms to the provider upon evaluation, and there were no worrisome symptoms or findings noted in the patients chart. All told, a prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a WalkAide functional electrical stimulator for treatment of her right foot drop, secondary to multiple sclerosis (MS). Findings:  Two physician reviewers found that the WalkAide functional electrical stimulator can be a helpful and very promising device for patients with foot drop. However, standard therapies, such as ankle foot orthoses (AFO) are also very helpful for patients with foot drop. Although one of the patients providers states that the patient will have accelerated knee damage with the use of a traditional ankle foot orthosis versus the WalkAide, there is no evidence of such in the peer-reviewed literature. In addition, medical literature support for such a device is lacking. One published clinical trial in the medical literature regarding the WalkAide device (Stein and colleagues) studied 26 subjects with chronic foot drop of central origin. Outcomes were compared between ambulation with and without the myoelectric orthosis, with outcomes using the myoelectric orthosis superior to those without the orthosis. However, there was no comparison of the myoelectric unit with a comparable non-myoelectric ankle foot orthosis such as a thermoplastic dorsiflexion assist brace or a double metal upright brace. As such, no superior efficacy to conventional options was demonstrated for the device under review. Therefore, based on the medical literature at this time, there is insufficient data to determine that the WalkAide functional electrical stimulator is superior to traditional, standard therapies such as an AFO.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  The physician reviewer found that this particular case requires the use of MRI for detection of solid lesions in each breast as seen in this patients imaging history. In this case, the patients solid lesions were not seen on mammography or ultrasound. The fact the lesions have been called solid is an indication for follow-up MRI for further diagnostic purposes. Since the lesions are occult by mammography and ultrasound, it would not be possible to biopsy them to prove their probably benign etiology since they can be seen only with MRI and are not even palpable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that there is ample medical literature supporting its use in select cases of migraine. A portion of these data are found in the publications cited above. In this particular case, the patient has failed multiple first-line therapies for headache including multiple abortive and preventative medications
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested coverage for  speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care for these conditions is to provide speech therapy to address deterioration in previous communication and/or cognitive abilities. As such, speech and language therapy focused on improving communication and cognitive abilities is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for hepatitis C treatment without having to complete a six-month chemical dependency rehabilitation program for treatment of the enrollees chronic hepatitis C until she has successfully completed a six-month chemical dependency rehabilitation program. Findings:  The physician reviewer found that according to the standard of care in this setting, drugs and alcohol must not be used while a patient is receiving HCV treatment. Whether or not a patient completely or partially abstains from alcohol and illicit drug use prior to the initiation of HCV treatment is only relevant to a patients risk of relapse.this patient should be evaluated at a CDRP to determine whether she requires chemical dependency treatment in order to avoid the risk of relapse during HCV treatment, and if so, what length of chemical dependency treatment is indicated. In the absence of this evaluation, the medical necessity of HCV treatment is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested partial hospitalization program treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) is an evidence-based and objective instrument which is used to determine the necessary level of psychiatric care in the least restrictive setting possible. According to LOCUS criteria, as of the admission date, the patient scores as follows: 1) Risk of harm- moderate; 2) Functional status-moderate; 3) Medical, Addictive and Psychiatric Co-Morbidity - major; 4A) Recovery environment - moderate; 4B) Recovery environment, level of support  supportive; 5) Treatment and Recovery history- poor, and; 6) Engagement and Recovery Status - positive. This gives him a composite score of 21 which correlates with a treatment intensity level of medically monitored non-residential services. An example of this placement, per the LOCUS, is a partial hospitalization program. Furthermore, the patient met American Psychiatric Association guidelines for placement in a PHP during the period at issue. Specifically, he required intensive care, but had a reasonable probability of refraining from illicit use of substances outside a restricted setting; he remained at high-risk for relapse; and he was thought to lack sufficient motivation to continue in outpatient treatment. In summary, due to the patients past treatment failures, the excessive amounts of alcohol consumed, and the use of intravenous drugs, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested orally administered Lamisil 250mg for treatment of his onychomycosis. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the patient has any documented immune impairment. Additionally, there is no documentation by the physician indicating functional impairment due to onychomycosis, including loss of toenails or swelling. Based on the information provided, it does not appear that a fungal culture has been obtained. Furthermore, there is no documentation that the patient has comorbidities that would require treatment with Lamisil. In this patients case, orally administered Lamisil 250mg is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old female enrollee has requested  for a frenulectomy for treatment of the enrollees ankyloglossia.  Findings:  The physician reviewer found that the criteria for the diagnosis of tongue-tie vary and include an inability to raise the tongue tip to the upper alveolar ridge, dimpling of the tongue just behind the tip when elevation is attempted, or inability to protrude the tongue beyond the lower teeth. Most providers regard tongue-tie as significant when the shortened frenulum binds the tongue tip to the floor of the mouth so that the tongue cannot be protruded, but is merely rolled out. The release of tongue-tie, or frenulectomy, is recommended for these conditions. Except for a few infants whose poor suck is thought to be related to this condition, surgery should be deferred until four or five years of age. Most surgical releases, however, are done for cosmetic reasons as many parents regard tongue-tie as a deformity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for chemical dependency residential detoxification level of care  for treatment of her behavioral health condition. Findings:  The physician reviewer found that the evidence provided does not support this level of intensity of service. The patients past history noted alcohol dependence with an increase in use two months prior to admission to the residential detoxification program. The mental status exam (MSE) performed on admission indicated that the patients judgment was minimally impaired, she was cooperative, there were no major health issues and no major findings on MSE. The patient reported a history of anxiety. However, the records do not reflect severe co-morbid conditions and there was no major risk of self-harm. Thus, based on a review of the medical records and based on Level of Care Utilization System placement criteria and American Psychiatric Association practice guidelines, the patient would have been an appropriate candidate for a less restrictive level of care for the dates in question.