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

A 49-year-old female has requested approval for past breast surgery performed on an emergent basis.  Findings:  The physician reviewer found that the patient underwent breast surgery outside of the United States. She reports that the procedure was performed on an emergent basis. The patients clinical history, pre-surgical work-up and operative report have not been provided. At issue in this case is whether a prudent layperson would have sought immediate medical attention on the date at issue. 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 patient maintains that she was extremely ill at the time she presented to her provider outside of the United States. Medical records detailing the patients clinical signs and symptoms at the time of presentation have not been provided. It appears a bilateral breast reduction was performed, although the operative report has not been provided. A letter from the patients surgeon states that the patient had surgery for fibrocystic changes however a bilateral excision procedure for fibrocystic changes is not an emergent procedure. No evidence of breast infection has been provided; even if the patients condition was related to a breast infection, it is likely that mastitis could have been treated simply with antibiotics. If the patient had developed a breast abscess, it is extremely unlikely that she would have bilateral abscesses at the same time, and typically an abscess would be treated with antibiotics, possible incision and drainage but not bilateral excision surgery. There is no documentation or history of trauma. Trauma to the breast would have to be extensive to involve bilateral excision procedures. If the patient had presented with pain from fibrocystic changes, simple pain management would have been appropriate with non-steroidal anti-inflammatory medication or even narcotic analgesics. A mass or breast lump is typically the most common reason for a breast biopsy however a breast mass does not typically present with acute breast pain and is not typically performed bilaterally. Further, the patients surgeon did not document or imply that this was a work-up for cancer, pathology, etc.  All told, the submitted documentation does not detail the specifics of the patients reports of illness or how the illness was related to the acute onset of pain, fever, or possibly a recent traumatic insult to the breasts. As such, there is no evidence to demonstrate that a prudent layperson would have sought immediate bilateral breast surgery on the date at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female has requested approval for past acute medical services provided for treatment of her failure to thrive and acute bladder infection.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient continued to have stable renal function.  The patients potassium level on a date at issue was only mildly elevated at 5.5.  It was not associated with arrhythmia, electrocardiogram changes, or symptoms such as muscle weakness.  No intravenous medications were provided to lower the potassium, and it was normal on subsequent laboratory testing.  Dialysis was not required, and she did not have volume overload, uremia, or severe acidosis.  She remained hemodynamically stable, without fever or new medical issue.  The patient did not have active psychosis on the dates in question, and she was not a danger to herself or others.  No parenteral sedative agents were required.  The patient was stable for discharge to a lower level of care as of the date at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested Botox injections for treatment of her migraine.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  Based upon the current medical evidence, Botox injections are not medically indicated for the treatment of this patient.  Botox may be indicated for patients with chronic migraines.  However, the criteria for chronic migraines are very specific.  In order to meet the criteria for chronic migraines, the patient must have an established history of migraine, must experience headaches on at least 15 days of each month for at least three consecutive months, and the majority of those headaches each month either have features characteristic of migraine or have been responsive to drugs which are relatively specific for migraines.  Per the submitted medical records, the patients medical condition does not meet the criteria for chronic migraines.  The medical records indicate that the patients chronic headaches may be attributed to another disorder, such as cervicalgia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 27-year-old female has requested 10 hours of direct ABA services per week with 2 hours per month of supervision and 2 hours per month of planning and assessment for treatment of autism.  Findings:  The physician reviewer found that although autism is a life-long condition, the literature pertaining to the treatment of adults with autism is quite limited. The bulk of ABA literature is concentrated in its application to young children. The medical communitys customary and usual prescription for autistic children is ABA therapy and the medical literature strongly supports the use of ABA therapy for the treatment of children with autism. However, when reviewing ABA as applied to adults, there is limited literature substantiating its favorable effect on the adult population. This is particularly true in individuals who carry a co-morbid diagnosis of autism spectrum disorder and intellectual disability, such as this patient. In this patients case, she has failed to demonstrate significant improvement following multiple years of individual ABA therapy. Comparison of her most recent progress report seven months ago, and the extensive evaluation performed seven months prior to that, shows no significant improvement, despite the mention of some positive behavioral changes in the progress report. Thus, given the lack of significant clinical evidence demonstrating improvement with ABA therapy, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested a series of Orthovisc injections to the right knee for treatment of his knee osteoarthritis.  Findings:  The physician reviewer found that viscosupplementation with hyaluronates is an accepted treatment for osteoarthritis of the knee (Bellamy, et al). It is most suitable for patients with mild to moderate disease, and is less effective in patients with moderate to severe disease (Jorgensen, et al). There is little evidence regarding the efficacy of repeated courses of treatment. Studies on repeated courses of treatment are in progress, but have not yet published results. Cases of induction of calcium pyrophosphate disease by hyaluronate injection have been reported, and remain a concern (Keith). In this case, the diagnosis of calcium pyrophosphate dihydrate crystal deposition disease has been made yet the concerns regarding efficacy of multiple repeated injections remain unresolved. Therefore, the requested series of Orthovisc injections to the right knee is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested counseling with a therapist who specializes in treating teenagers with families that have a hearing impairment for treatment of his anorexia nervosa.   Findings:  The physician reviewer found that based on review of the available records, this patient has complex parent-child relational dynamics, disordered eating behavior, distorted body image, anxiety, and depression. The current medical literature including the practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) and American Psychiatric Association (APA) do not provide guidance in this clinical circumstance. In addition, the patients records do not include an updated, comprehensive adolescent psychiatric evaluation which might support the requested intervention in this patients case. Given the lack of an indication for the requested counseling with a therapist who specializes in treating teenagers with families that have a hearing impairment, the requested services are not supported as medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female has requested approval for minimally invasive lumbar decompression for treatment of her back pain and bilateral lower extremity pain.   Findings:  Three physician reviewers found that the patient has a history of bilateral low back, buttock, and leg pain.  The pain increases with activity and decreases with rest.  She has tried multiple medications, physical therapy, and a TENS unit, without lasting relief.  A lumbar spine MRI, three years ago demonstrated moderate to severe central spinal canal stenosis at the L4-5 level with ligamentum flavum hypertrophy.  The requested procedure is not likely to be superior over other available treatment options.  Chopko and Caraway reported on 78 patients who had undergone the minimally invasive lumbar decompression procedure.  Six week follow-up was obtained on 75 patients, and outcomes were generally favorable.  However, this follow-up period is too short to draw any conclusions from this study.  Mekhail and colleagues reported on 58 patients who underwent the minimally invasive lumbar decompression procedure.  One-year data showed significant reduction of pain and improvement in physical functionality, mobility, and disability.   However, this was not a controlled or randomized trial comparing minimally invasive lumbar decompression to other procedures such as standard laminectomy.  Also, the one-year follow-up period is not long enough to determine the efficacy of this procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male has requested bariatric surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient meets the standard medical necessity criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. However, the surgeons assessment recommending pre-operative weight is based on clinical judgment. Further, pre-operative weight loss to 422 pounds is supported in the medical literature as resulting in significant improvement of visceral fat, thereby optimizing the patients intra-abdominal anatomy. Given the surgeons medical opinion that the patient should undergo weight loss as a pre-operative requirement to bariatric surgery, the requested procedure is not medically necessary until the weight loss has been achieved. Consistent with these findings, the requested bariatric surgery is not medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male has requested evaluation with the SIMSYS MoleMate Skin Imaging System.  Findings:  Three physician reviewers found that the patient has a history of melanoma and multiple atypical nevi.  He has had routine dermatologic surveillance at appropriate intervals as determined by his medical history.  The submitted documentation fails to demonstrate the superior efficacy of the requested services.  There is a lack of evidence demonstrating that evaluation with the SIMSYS MoleMate Skin Imaging System is of greater benefit than other available options.  Although the SIMSYS MoleMate Skin Imaging System is used as a diagnostic tool for cutaneous melanoma, the evidence of its higher accuracy, sensitivity, and specificity over dermoscopy is currently lacking.  In this clinical setting, dermoscopy remains the best diagnostic tool for the evaluation of patients pigmented skin lesions.    The published reports evaluating the utility of this system were investigated in primary care physician offices, not dermatology specialists.  Thus, the utility seen cannot be extended to dermatologists who have specialty training in the evaluation of nevi.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male has requested lumbar spine surgery at this time rather than two months from now for treatment of his low back pain.  Findings:  The physician reviewer found that fusion may be of value in the treatment of back pain resulting from an unstable or hypermobile segment or when there is mechanical instability or malalignment.  It is rarely indicated for routine discectomy or abnormal radiographic findings without appropriate clinical findings.  With an established indication, improvement can be expected.  The role of smoking in the incidence of postoperative complications has been reported.  In this patients case, there is documentation of the presence of an abnormality of the bony alignment in the lumbosacral articulation.  Although the patient has expressed a desire for the services of an out-of-network provider, the in-network provider has apparently expressed his willingness to undertake the procedure if the patient would cease smoking prior to the procedure.  In this patients case, the timing of the procedure is elective, as the medical records do not indicate an acute situation requiring lumbar spine surgery at this time.  All told, the requested lumbar spine surgery at this time rather than two months from now is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested surgery in this patients case.  The current medical evidence does not support the requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch in this clinical setting.  Based upon the medical records, there are no overt complications of her prior surgery.  The records noted poor dietary compliance.  Additionally, there is no behavioral evaluation supporting the requested procedure.  All told, the requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested intravenous antibiotics to be administered via central line (Groshong catheter) for treatment of his Lyme disease.   Findings:  Three physician reviewers found that the patient was bitten by a tick six years ago, and states he developed a rash at that time. He did not seek treatment for the rash. The patient subsequently developed multiple joint pains and fatigue. No other medical history is noted. The patient has subsequently been treated with multiple courses of antibiotics with no effect. No abnormal exam findings are noted. Lyme Western blot IgM and IgG is negative by CDC criteria. No lumbar puncture or synovial fluid analysis is included. Review of the submitted documentation reveals no clinical or laboratory evidence for the diagnosis of late stage Lyme disease. The records demonstrate no evidence for Lyme arthritis or neuroborreliosis. The IgG Western blot should be positive by CDC criteria to consider the diagnosis of late stage Lyme disease. Furthermore, the standard treatment for late stage Lyme disease is 3-4 weeks of intravenous ceftriaxone. There is no indication for further antibiotic treatment in this patient, as there is no evidence to support the efficacy of long-term or repeat courses of antibiotics. In conclusion, the diagnosis of Lyme disease has not been established based upon the documentation provided and long-term or repeated courses of antibiotics have not been shown to be efficacious for the treatment of Lyme disease in the peer-reviewed medical literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her recurrent breast cancer in the left axilla.  Findings:  The physician reviewer found that intensity modulated radiation therapy (IMRT) is a technique used to improve the dose conformality. The use of IMRT for the treatment of breast cancer is becoming a standard approach. In general, IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms, i.e., the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally. This patients situation is unique in that traditional radiation fields are not being used because the chest wall is not being treated, and in fact, effort is being made to avoid the chest wall. The use of IMRT in the treatment of breast cancer has been well studied in the scientific literature. Advantages of IMRT are to reduce the dose to the heart (which is relevant to this patient with a left sided tumor), lungs, skin and contralateral breast/chest.  IMRT can also improve the dose homogeneity of the treatment volume, and therefore reduce the hot spots that are often seen in the lateral chest wall. In general, with complex radiation targets, IMRT is useful in maximizing target coverage and minimizing normal tissue coverage. IMRT can be considered medically necessary to reduce the dose delivery to the lung and heart, and in this case, the chest wall. Given the specifics of this case, IMRT is superior to a 3D conformal plan as typical breast cancer radiation treatment fields are not being used, but rather a complex treatment of axillary and supraclavicular nodal irradiation is planned, with explicit planned avoidance of the implant. As such, the medical necessity of IMRT in this particular setting has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male has requested sixty-five hours per month of direct applied behavioral analysis (ABA) treatment and six hours per month of supervision for treatment of his autism.   Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA is an intensive behavioral intervention program that was first reported by Lovass in the 1970s. The literature pertaining to ABA therapy has documented substantial improvement in motor, verbal, and social interactive skills in autistic children.  Myers and colleagues state: The effectiveness of ABA-based intervention in ASDs has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. That ABA therapy is effective has been proven in multiple controlled studies including the references cited above. This patient has been diagnosed as autistic and ABA therapy remains the documented therapy of choice in this setting.Although this seven-year-old autistic patient has also been assessed with intellectual disability, the documentation reveals evidence of benefit from the extensive ABA therapy that he has received to date. He has shown improvement and has met some of the ABA goals. The patients age and intellectual disability are not deterrents to ABA therapy. The alternative of transitioning to special education and school-room socialization is not an adequate substitute for ABA therapy. The customary practice within the neurological medical community would be to continue ABA therapy in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested Bystolic 5mg for treatment of his hypertension.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication.  In this clinical setting, there is a compelling reason to prescribe a beta-blocker given the effectiveness of this medication class in both treating hypertension and suppressing atrial ectopy.  However, there is no unique medical necessity to prescribe one beta-blocker over another for this purpose, as long as the medication prescribed is tolerated and demonstrates effectiveness.  The current guidelines for the treatment of hypertension and atrial dysrhythmias also support the general class benefit of beta-blockers without recommendations of a single preferred agent.  Therefore, since the patient has not tried and failed or had an inadequate response to three formulary beta-blockers, Bystolic 5mg is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested group social skills training twice per week for treatment of the enrollees autism. Findings:  The physician reviewer found that successful performance in an organized school program will require some development of prerequisite social skills. Thus, it is important that the patient be introduced to socializing and interacting with his peers. Myers, et al. states that a social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. Reichow and colleagues performed a Cochrane systematic review of five randomized controlled trials which when combined suggest that there is evidence that social skills group therapy can improve social competence for children with autism spectrum disorders. While the above evidence demonstrates the importance of socials skills therapy, the patient is currently receiving ABA therapy and his current ABA treatment plan includes social skills and group skills development. As such, two weekly sessions of group social skills therapy in addition to the patients current ABA therapy regimen is not medically necessary.