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

A 47-year-old male enrollee has requested discectomy and decompression for treatment of his disc herniation at L4-5.    Findings:  The physician reviewer found that radiculopathy is defined as significant alteration in the function of a nerve root. The most important clinical components required to support the diagnosis of a radiculopathy include: 1) subjective complaint of pain, numbness, and/or paresthesias in a spinal nerve distribution and 2) associated clinical findings such as loss of related reflexes, muscle weakness and/or atrophy of muscle groups in the related myotome, altered sensation in the corresponding dermatome(s) or positive nerve root tension signs (straight leg raise, femoral nerve stretch tests, brachial plexus tension tests) resulting in provocation of radicular pain. The patient in this particular case had subjective symptoms of an L5 radiculopathy, but no objective clinical findings such as weakness, numbness or reflex abnormalities. The MRI and CT did show evidence of L5 nerve root compression from a paracentral disc herniation, but the operation performed was an L4-L5 transpedicular approach for disc removal. Such an operation is only indicated for far lateral disc herniation and in this case, such a herniation would cause compression of the L4 nerve root. Since there is no subjective, objective clinical or radiographic evidence of L4 radiculopathy or nerve root compression, the surgery at issue was not medically indicated or necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested individual mental health psychotherapy 5 times per week for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the provider justifies the current treatment plan based on the fact that the patient has improved over the nine years that she has been engaged in therapy. The provider indicates further that the patient does not do well without the therapy and it should therefore be continued. Nevertheless, the records actually suggest the patients treatment is failing to address how the patient is being prepared to trust others or to deal with loss. Thus, it appears the patients therapy is not based upon the maintenance of a health benefit as the treatment plan is not progressive and does not utilize collegial consultation. Moreover, the records do not indicate that alternative modalities simultaneous to the patients treatment, such as group therapy, which have been very effective for those with trauma related diagnoses, have been attempted. For these reasons, the treatment modality has not been demonstrated to have been medically necessary for any number of psychotherapy visits per week. Thus, the medical necessity of the psychotherapy visits, or that these sessions be conducted by this specific therapist, has not been demonstrated in the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested physical therapy services with an out-of-network provider for treatment of his status post microdiscectomy. Findings:  The physician reviewer found that in the case under review, the patients S1 radicular symptoms flare quickly in the sitting position, and he was unable to tolerate the travel time to an in-network physical therapy provider. In order to benefit from the prescribed treatment plan, it is medically necessary that he receive this therapy in closer proximity to his home.  This service is only available from an out-of-network provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee has requested surgical correction of damage sustained from previous scrotal abscess for treatment of his redundant prepuce and phimosis.   Findings:  The physician reviewer found that since the requested surgery is being performed to improve function, the requested surgery is reconstructive in nature. Further, the requested surgery is proposed to help to create as normal an appearance as possible with a penis that is not buried or retracted. Thus, the surgery is medically necessary and should be covered. The patient has already consulted with In-Plan surgeons who have deferred treatment to providers at a tertiary center. As the procedure will require the services of both a plastic surgeon and a urologist at the same time in the operating room, it is reasonable to authorize treatment by an Out-of-Plan urologist as well as an Out-of-Plan plastic surgeon as a team approach is required in these complex cases.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a nephrologist for ongoing monitoring of his medical condition for treatment of his medical condition. Findings:  The physician reviewer found that in this case, a clear plan was conveyed by the nephrologist to the patients PCP. Given the PCPs training in internal medicine, the proposed treatment is within the PCPs expertise and the PCP can be expected to appropriately carry out such instructions. Further, this patients GFR is well above 30. Aside from the low GFR, this patient has no other findings to warrant any further nephrology evaluation. An ultrasound showed normal sized kidneys bilaterally, arguing against renal artery stenosis. The patients simple cyst in the right kidney can be adequately followed by his PCP. Thus, in the absence of a need for a biopsy or any severe metabolic abnormalities requiring the expertise of a nephrologist, follow up by the patients PCP is within the standard of care care in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Duac CS for treatment of her acne. Findings:  The physician reviewer found that the prescription ingredient in Duac is a combination of benzoyl peroxide 5% and clindamycin 1% in a gel. The Duac CS kit also contains a face wash that is available over-the-counter.  The formulary medication BenzaClin also contains benzoyl peroxide 5% and clindamycin 1%.  These products are known to be effective in controlling acne flares.  There is no indication that the patient has failed treatment with this medication.  The over-the-counter face wash in the Duac CS kit is available without a prescription.  The submitted documentation does not demonstrate that the patients acne would be better controlled using the non-formulary option.  In this patients case, Duac CS is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested an ankle foot orthosis brace for treatment of her pain. Findings:  The physician reviewer found that the requested equipment would improve the functioning of this patients foot and ankle and allow for comfortable ambulation.  According to the physical examination notes, this patient exhibits a classic posterior tibial tendon dysfunction, severe subtalar joint valgus, and collapse of medial column with associated symptoms including severe foot and ankle pain.  Tendinopathies of the posterior tibial tendon, peroneal tendon and Achilles tendon have been confirmed with MRI.  She is unable to ambulate comfortably, and she has failed more conservative treatment, including strappings of feet and ankles.  The requested ankle foot orthosis brace provides significant control to the ankle joint, subtalar joint and foot.  They are rigid functional devices that allow for excellent control of the above mentioned joints and still allow for ambulation.  With control of the above mentioned joints and associated tendons, the patient is afforded pain relief.  All told, an ankle foot orthosis brace is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Moreover, the AAN guidelines note that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. California State Assembly Bill 88 (Mental Health Parity Law) requires coverage for nine diagnoses for severe mental illnesses and serious emotional disturbances in children including autism. Speech therapy is a well-accepted treatment modality for children with autism. In this case, the patient has a diagnosis of autism with documentation of associated speech delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested breast reconstruction surgery for treatment of her breast hypoplasia. Findings:  The physician reviewer found that the submitted documentation does not document whether there are congenital reasons for the lack of breast development. The submitted information does not document whether the patient has seen an endocrinologist to ascertain the etiology of her breast hypoplasia. Further evaluation is needed before the medical necessity of the requested procedure can be established.  This patients condition may be an abnormal development of the breast. However, in the absence of evidence of an endocrinology evaluation this cannot be confirmed.  This may be caused by a developmental abnormality, although the submitted documentation does not demonstrate this.  The requested surgery will create a normal appearance to the extent possible, and it may offer more than a minimal improvement in the appearance of the patient. However, at this time, additional evaluation is needed to demonstrate that the requested procedure is reconstructive in nature or medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a PET scan for evaluation of his history of melanoma. Findings:  Two physician reviewers found that he was diagnosed with melanoma. The patient was treated with both radiation and adjuvant treatment.  Per the submitted documentation, there are no current complaints and no evidence of recurrent disease since his initial treatment.  Therefore, he has been disease-free for five years. The National Comprehensive Cancer Network issues guidelines for the treatment of melanoma, and these guidelines do not support PET scanning in this patients case.  The requested diagnostic procedure is considered a low yield procedure, and there is a cumulative risk of radiation exposure.  Since most recurrences manifest within five years, routine laboratory testing and imaging is not recommended beyond this period.  The medical literature does not show that routine PET scans in asymptomatic patients is likely to be of benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a Quickie Pulse power wheelchair and accessories (E2311, E2617, E1399, K0856, K0108 X 4, E2361 X 2, K0040 X 2, E0951 X 2, E2377, E2313, E1028 X 2, E1002, E2300, K0734, E0955, K0019 X 2, and E0956 X 2) for treatment of her medical condition. Findings:  The physician reviewer found that in this patients particular clinical situation, the following equipment is medically necessary: Quickie Pulse power wheelchair power wheelchair (K0856) and the 4-point transfer package (K0108); crutch holder (K0108);  joystick for wheelchair control with a swing-away mount (K0108); angle adjustable footplates (K0040); the quick-height adjustment (E1028); heel loops (E0951); gel cell battery (E2361); custom modular back system (E2617), lateral supports (E0956 X 2); and a gel seat cushion (K0734). This equipment is medically necessary as the patient is not functionally ambulatory at even household distances. Without this equipment, she will not be able to complete her activities of daily living in a safe and timely manner within her home. In addition, she is unable to use a cane, walker or a manual wheelchair due to right lower extremity paresis and her bilateral shoulder rotator cuff issues. The gel cell batteries are required to maintain her anticipated level of activity.  The gel seat cushion is medically necessary for skin breakdown and decubitis ulcer protection. The custom modular back support system is necessary to prevent scoliosis/kyphosis, respiratory compromise. In this patients particular clinical situation, the remainder of the disputed codes are not medically necessary; this includes the tilt in space seating system; TRx elevating seat module; R-net expandable controller; joystick for expanded controls; enhanced dual function control module through joystick; and the headrest with the adjustable and removal hardware. The tilt in space seating system is not medically necessary as the patient has no history of decubitis ulcers and can stand up to relieve pressure points as well as ease her back pain. The elevating seat module and related components are not medically necessary as the patient is able to stand, and thus these items are not required from a functional standpoint. Further, the adjustable headrest with removal hardware is not required for a medical reason.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested bilateral replacement of breast implants due to a ruptured right breast implant/injury for treatment of her medical condition. Findings:  The physician reviewer found that this patients initial bilateral breast augmentation was a cosmetic surgery. If a patient were to have painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, its removal with a capsulectomy would be considered medically necessary and not cosmetic. Such removal of the capsule and implant with or without placement of a new implant would alleviate any pain and would prevent migration of the gel to adjacent areas where it could cause additional medical problems. In this patients case, it is reported that her implants were saline and not silicone. In any event, surgery for visible but non-painful capsular contractures (Grade III), or palpable but not visible or painful capsules (Grade II) would be considered cosmetic in nature and not medically necessary. Replacement of this patients saline implants (originally placed for cosmetic reasons) with new breast implants would not be considered medically necessary. In the absence of the presence of silicone gel or painful capsular contracture (as is the case here as this patient has reported pain only immediately following the implant rupture), any implant related surgery including implant removal would be considered cosmetic and not medically necessary under general concepts of medical necessity. This determination is independent of whom or what caused the rupture of the saline implant. Furthermore, the patients present right breast condition, containing a ruptured right saline breast implant, does not constitute an abnormal structure of the body. It is a normal breast, as per the mammogram results, albeit with a deflated saline implant.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested inpatient treatment stay for treatment of his behavioral health problems. Findings:  The physician reviewer found that during the dates of service at issue, this patient was beginning to recompensate following necessary acute seclusion/restraint and anti-agitation medications. He remained labile, agitated and demonstrated little, if any, insight into his psychiatric concerns. His level of agitation, combined with the prior safety concerns posed at home, made it medically necessary for the patient to remain at an inpatient hospitalization level of care through the second day of treatment. Such intensity of service was required for his safety, monitoring and psychotropic therapy. However, from the third day of treatment through discharge, the patient was able to demonstrate reasonable control and improved insight which allowed him to participate in recommended therapies. This included acknowledgement of admitting the role of substance abuse as part of his mental health concerns. Thus, based on the patients medical condition from the third day of treatment onward, he could have been safely and appropriately treated at a lower level of care such as an intensive outpatient program level of care.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent 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. With regard to this patient, she presented with what was probably H1N1 flu for which she was already taking the anti-viral antibiotic, Tamiflu. Her temperature in the clinic was 103.5 degrees and in the ED, 2 days later, it was even higher at 103.6 degrees. At that time, a new diagnosis of a bacterial infection was made, specifically otitis media, which required the prescription of an anti-bacterial antibiotic in addition to the anti-viral antibiotic that the patient was already taking for the flu. The acute onset of a bacterial infection such as otitis media combined with a high fever that was actually increasing constituted a valid emergent condition for which the parent was reasonable in seeking immediate medical assistance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a colonoscopy for evaluation of her colonic polyps status post polypectomy.  Findings: The physician reviewer found that the current recommendations for surveillance colonoscopy for a patient with a family history of colon cancer in a first degree relative younger than 60 years of age continues to be indicated at 5 year intervals. Although the provider recommended a follow-up colonoscopy in 3 years at the time of the 2007 diagnostic procedure, the guidelines were updated in 2008 which suggest the 5-year interval is more appropriate in this patient subset. Thus, in that absence of a third relative who is a first degree relative of both her father and her paternal uncle, with a history of colon or rectal cancer or associated malignancy that concerning for Lynch Syndrome, the present guidelines for colon cancer screening and surveillance indicates a colonoscopy should be performed every 5 years. It should be noted that hyperplastic colon polyps are not known to increase the risk for colon cancer in a patient with or without a known family history of colon cancer. For these reasons, the patient should be evaluated with a surveillance colonoscopy at the standard 5-year interval.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 6-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 patients circumstances would believe he or she 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 developed an earache the day prior to the visit to the emergency department. On the day she was evaluated, the patient complained of a sore throat as well. The family denied any fever or vomiting. Her father reported she had been crying in pain. However, on arrival at triage, the patient appeared well. She was triaged as a level 5 out of 5, the least acute triage level. The physicians records note the patient was in no distress. Her exam was normal. The patient was treated only with oral Tylenol in the emergency department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. Her symptoms were not sudden or acute in onset. The patients symptoms on the date of service at issue did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients parents circumstances would not reasonably have expected the absence of emergency care to jeopardize their childs health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy (3 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism. Findings:  The physician reviewer found that although this patient has been participating in several hours of ABA therapy per week, he still presents with significant deficits. Such deficiencies are appropriately treated with speech and occupational therapy. He presently will be unable to participate in a formal school setting even with special education classes without the utilization of the proposed modalities. Given adequate evidence supporting the use of these therapies in the scientific studies and case series, speech therapy for 2 hours per week and occupational therapy utilizing sensory integration for 1 hour per week are medically necessary for management of this patients condition. It is crucial that the requested therapeutic interventions be individualized for the patient and tailored to address his specific deficits. This regimen should be continued for six months at which time each modality should be reassessed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested the test of variables attention (TOVA) and a second consult with a neurologist for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that the relevant published literature and published case series suggest that behavior rating scales are subject to observer bias for virtually every variable assessed.  Given the equivocal or negative of this patients biologic response to Methylin, performing a TOVA is reasonable for this patient and represents the best medical practice. It will require the expertise of a specialist in this field in order to obtain an unequivocal diagnosis. Further, the provider should be able to explore the possibility of treatment with appropriate pharmacotherapy (stimulant based or with another primary mechanism of action related to the patients biologic problem). Therefore, the requested evaluation with a neurologist to perform the TOVA to better assess this patients condition and his likelihood to respond to medical therapy has been shown to be clinically indicated should be approved.