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

A 51-year-old male enrollee has requested hernia surgery for treatment of his bilateral inguinal hernias. Findings:  The physician reviewer found that symptomatic hernias should be repaired, unless the patient cannot safely received anesthesia. The natural history of hernias is that they continue to grow, and whether they are symptomatic or asymptomatic can be subjective. Once a hernia is diagnosed, it should generally be repaired, unless the anesthesia risks outweigh the benefits.  This is due to the risk of incarceration and/or strangulation due to untreated hernias. As noted by Fitzgibbons and colleagues, if a hernia is completely asymptomatic, watchful waiting is reasonable.  Bax and colleagues noted that a decrease in surgical repair of inguinal hernias may lead to an increase in hospitalizations related to incarceration or strangulation. In this patients case, although he initially was asymptomatic, he is now complaining of pain.  Thus, the requested hernia surgery is medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested emergency services on an emergent basis for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstance would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patient had low back pain with radiation down his leg for one week prior.  The patient was ambulating without difficulty per the medical records. Vital signs and pulse oximetry were all normal on arrival.  The patient had been seen by his primary care physician and was taking mediations when he presented to the Emergency Department.  He did not have any concerning signs such as weakness or bowel or bladder dysfunction.  The patient had basic low back pain from hip arthritis.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested a power operated wheelchair for treatment of her ataxia. Findings:  The physician reviewer found that with regard to this patients ability to operate a manual wheelchair, she has a progressive neurodegenerative disorder that has resulted in significant disability. She has multiple severe impairments including upper extremity incoordination, lower extremity weakness, muscle spasticity, truncal ataxia, and poor endurance. She has required the use of a power wheelchair for several years now in order to safely perform her activities of daily living (ADLs) and all mobility-related activities. In fact, the majority of the patients records support her need for a power wheelchair. She is unable to ambulate and has impaired upper extremity coordination with poor endurance that would significantly limit her ability to self-propel a manual wheelchair. Therefore, after considering the information provided for review and the guidelines available in the medical literature, there is adequate documentation to justify the medical necessity of a motorized wheelchair for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested continuation of hospice care while receiving chemotherapy for treatment of his medical condition. Findings:  The physician reviewer found that the literature certainly suggests that palliative chemotherapy is an option for patients who have stage IV non-small cell lung carcinoma. In this case, the records reflect that the patient desires to continue aggressive therapy and therefore palliative chemotherapy was ordered. However, since this patient wishes to continue to pursue such treatment, he is not appropriate for hospice care at this time. The patients decision to continue to receive chemotherapy is not consistent with acceptance of mortality and thus does not demonstrate readiness for end-of-life care. Further, given the need to continue to monitor his response to treatment with labs and imaging, the services provided by hospice care are not medically appropriate for this patient. All told, the submitted evidence demonstrates that the patient is not ready to receive end-of-life care, and therefore, hospice care is not medically necessary at this time. If the patient decides that chemotherapy is no longer desired, or that it can no longer be tolerated, hospice care would then be medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested cervical artificial intervertebral disc surgery for treatment of his degenerative cervical disc disease. Findings:  Three physician reviewers found that the studies to date do not have sufficient longevity to rule out or properly assess the long-term complications associated with particulate wear debris from the device components. It is known through total joint arthroplasty at the hip and knee that complications of osteolysis can lead to loosening and need for revision. The experience of osteolysis is related to individual tissue reactions to particulate debris. The studies to date are not of sufficient length to demonstrate the full effect of artificial disc replacement. In addition to osteolysis and loosening, individual patient reactions can include myositis ossificans and loss of motion. It is not established that the initial improvement in range of motion seen after artificial disc replacement will be maintained over time. In this patients case, the requested cervical artificial intervertebral disc surgery is not likely to be the most beneficial treatment alternative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested Provigil 600mg per day for treatment of his bipolar disorder, attention deficit/hyperactivity disorder and obstructive sleep apnea. Findings:  Three physician reviewers found that this patient has had significant overall improvement with this dose of Provigil.  There is documentation that this medication dose has had positive improvement, without adverse effects from the medication. A significant fact in this case is that nearly all of the medications that the patient is currently prescribed are above FDA recommended maximum doses.  He appears to be an individual that does not respond to standard FDA recommended medication doses. This may be due to a faster than average metabolism. Psychiatric medications are often utilized at doses that are above those recommended by the FDA, as the response of individual patients to the same drug administered in the same dose varies considerably.  In this patients case, Provigil 600mg is likely to be more beneficial than other available standard treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested surgical repair of his soft palate for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that current clinical criteria for nasal surgical intervention and uvulopalatopharyngoplasty can be met with documentation of apnea/hypopnea index in the moderate OSA category (between 15-30 episodes/hour of sleep). According to the medical reports reviewed, the patient has not had any significant complaints of laryngeal obstruction or functional problems and there is no documentation of a trial of conservative management to improve such problems. Although the patients Health Plan has approved the surgical repair of the nasal septum, in the absence of a recent sleep study (performed within the last year) documenting moderate OSA, there is no indication to add the secondary procedure at the same time as the planned surgical repair of the nasal septum.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested bilateral lower extremity endovenous laser therapy (EVLT) for treatment of her bilateral varicose veins. Findings:  Three physician reviewers found that EVLT can be considered for the treatment of perforator veins in appropriate cases as noted by Marsh and colleagues. However, in this patients case, such therapy is not indicated. It is noted in this patients ultrasound report that her veins are being treated to prevent a complication from proposed sclerotherapy treatment. This is not a valid indication for performing EVLT. The records submitted do no indicate any other clinical rationale for why the patients perforators should be treated other than their anatomic proximity to the branches being considered for sclerotherapy treatment. In fact, there is no indication in the submitted documentation that this patient has any perforator reflux, or that these particular perforator veins are enlarged.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested diabetic shoes for treatment of his diabetes. Findings:  The physician reviewer found that foot care is an essential part of diabetes care. It is standard of care to provide therapeutic diabetes shoes to patients with type II diabetes mellitus who are at risk for ulcers and amputations. However, in this patients case the submitted documentation does not include a foot exam to determine whether his feet have deformities that warrant extra-wide therapeutic or custom fitted shoes. Furthermore, there is no documentation that this patient is indeed at risk for ulcers or amputation. In summary, the submitted medical records do not support the contention that diabetic shoes are medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested acute inpatient residential treatment and prospective admission to an acute inpatient residential treatment program for treatment of his obsessive compulsive disorder. Findings:  The physician reviewer found that this patient presented to an acute inpatient residential treatment program with mild to moderate signs and symptoms of obsessive compulsive disorder.  He was recently enrolled in a 30-day dual-diagnosis rehabilitation program which he determined helped him with both binge drinking and obsessive compulsive symptoms. According to the mental status examination, he did not appear to be significantly depressed or anxious and denied psychotic processes. Significant stressors in this patients life included a conflicted relationship with his father.  He also had lost some levels of independence due to legal and other sequelae of his alcohol dependence. Admission to an acute inpatient residential treatment program during the time period at issue was not medically indicated. There was no suicidal ideation, and the patient was not demonstrating symptoms necessitating acute inpatient residential treatment level of care. Furthermore, his desire to accept recommended pharmacotherapy (antidepressant therapy) was refused immediately at admission. Additionally, the requested future acute inpatient residential treatment program is not medically indicated at this time.  This patient does not require the level of 24-hour supervision provided by an acute residential inpatient center. All told, the services at issue were not and are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested transcranial magnetic stimulation (TMS) treatments for treatment of her behavioral health condition. Findings:  Three physician reviewers found that when diagnosing patients with treatment resistant depression, clinicians should identify risk factors associated with treatment resistance, including clinical subtypes of depression and medical or psychiatric co-morbidities that could affect the course of treatment (Gaynes and colleagues). This particular patient had co-morbidities of depression and OCD. The use of atypical anti-psychotics has been shown to have some efficacy as augmentation therapy in treatment resistant depression (TRD) and represent a standard alternative in this clinical settting. No evidence that such agents were tried prior to TMS has been provided. Currently, the efficacy in using TMS for psychiatric disorders such as OCD has not been established. The article by Slotemas and colleagues concluded that TMS is not recommended for the treatment of patients with OCD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested somnoplasty for treatment of his snoring.Findings:  The physician reviewer found that somnoplasty is not medically indicated for this patient. Obstructive sleep apnea is a potential medical problem that does require consideration of treatment. However, this patient had no symptoms of witnessed apnea. Per the submitted documentation, he had no symptoms of daytime somnolence, early morning fatigue or headaches. His only complaint was loud, excessive snoring which had been problematic for many years. The medical records specifically note a history of snoring since he was a teen. Examination did not reveal any oropharyngeal obstruction.  The medical necessity of somnoplasty has not been established by the submitted documentation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a magnetic resonance imaging (MRI) neurography scan of the upper extremity, for evaluation of her cervical and upper extremity pain. Findings:  The physician reviewer found that MRI neurography has been shown to provide evidence of injury to peripheral nerves in animal studies. In cases of brachial plexus neuritis, there are changes seen in the images which may be helpful in evaluation. In some cases, it has been of value in the visualization of brachial plexus abnormalities from a variety of causes, and the feasibility of the technique has been demonstrated. However, the amount of additional diagnostic information obtained from this technique, as compared to other studies such as EMG, is limited, and it remains a complementary study to clinical examination and electrodiagnostic studies.In this patients case, there was a lack of documentation of the indications for this procedure, with no discussion of correlation of other studies with clinical findings to point to the brachial plexus as the source of her problem. As such, the medical necessity of the MRI neurography has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested the Flexitouch system (E0652, E0656, E0669) for treatment of her lymphedema. Findings:  The physician reviewer found that lymphedema management should be highly individualized and designed to meet the needs of the individual patient. In the case under review, the patient has failed conservative management techniques and has demonstrated a good response to the prescribed therapy with the Flexitouch system. The treating physician noted the importance of using the device to address the patient's combined extremity and genital lymphedema. Device selection is critical to the success of home-based lymphedema therapy and should take into account the mechanism of action and functionality of the device, as noted by Mayrovitz.  Programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program. In this patients case, the Flexitouch system (E0652, E0656, E0669) is medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-month-old female enrollee has requested a cranial orthotic for treatment of the enrollees brachycephaly.  Findings:  Two physician reviewers found that this young patient had a misshapen skull which did not respond to conventional treatment of avoiding the back of her head to lie flat down. As reshaping of the skull is generally only successful during the rapid growth of the head during the first six months of life, the patient was referred by her fourth month for an external molding orthotic device. Research reports success and recommend utilizing an external molding device in reshaping skull deformities in infants. The cranial orthotic devices are not considered investigational however, as the technique has been a viable alternative to extensive cranoisyostosis surgery for at least 30 years. According to the information supplied by the manufacturer, orthotic bands and head molding helmets have been approved by the FDA since 1998. Thus, the argument that the device at issue is investigational in unfounded and the utilization of the orthotic band is clearly the treatment of choice for this patient. It is therefore medically necessary for this young patient to be fitted and to wear this orthotic device to prevent permanent skull deformity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested DIEP flap breast reconstruction surgery for treatment of her bilateral mastectomies. Findings:  The physician reviewer found that this patients breast condition qualifies as an abnormal structure of the body since her current condition is a result of surgical intervention for treatment of her ductal carcinoma in situ. In addition, the patients provider reports that the requested surgery is being performed in an attempt to create as normal appearance as possible. The patient has already been treated with implants that were removed secondary to side effects. Breast reconstruction techniques using free tissue transfer (TRAM and DIEP) are accepted reconstruction options and offer this patient an opportunity for significant improvement in the appearance of her breast abnormality. As such, the proposed procedure is considered reconstructive in nature in this setting. Thus, the submitted evidence demonstrates that the requested breast reconstruction using DIEP flaps is reconstructive in nature and 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 female enrollee has requested residential eating disorder treatment for treatment of the enrollees behavioral health condition.Findings: The physician reviewer found that the submitted medical records demonstrates that the patient was gaining weight at a satisfactory pace. Her weight was over 80% of her ideal body weight. According to the medical records, there is no indication of suicidal or homicidal ideation beyond the last authorized date of service, nor is there evidence of imminent serious risk of self-harm. The history notes that the patient had been successfully treated in a partial hospitalization program (PHP) setting in the past. American Psychiatric Association (APA) practice guidelines indicate that patients with a body weight greater than 80% of ideal body weight are suitable for treatment in a PHP. National Eating Disorders Association (NEDA) guidelines indicate the PHP level of care is appropriate for patients: whose eating disorder impairs functioning, though without immediate risk; who need daily assessment of physiologic and mental status; who are psychiatrically stable, but unable to function in normal social, educational, or vocational situations; and who engage in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques. Based on the clinical information provided, this patient met the PHP level of care criteria according to both the APA and NEDA guidelines. Given the chronicity and severity of her symptoms, continued treatment in a structured intensive setting was and is appropriate. However, the data reviewed fails to establish that the patient could not have safely stepped down to a PHP level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.A 55-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his adenocarcinoma of the gastroesophageal junction.Two physician reviewers found that intensity modulated radiation therapy is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. Intensity modulated radiation therapy generally implies inverse planning algorithms. Specifically, 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. Distal esophageal cancers, particularly gastroesophageal junction adenocarcinomas, behave similarly to and are treated similarly to gastric cancer, and these disease entities are often combined in large studies. In the studies by Milano and colleagues and Ringash and colleagues, intensity modulated radiation therapy reduced the dose to the liver and kidneys, as well as the heart and spinal cord. In a study of patients with distal esophageal cancer by Chandra and colleagues, intensity modulated radiation therapy was shown to reduce the dose-volume of normal lung. The submitted documentation does not justify the use of intensity modulated radiation therapy in this patients case. Arguably, the data supporting the use of intensity modulated radiation therapy for these indications are scant. The medical records submitted do not document the need to spare critical structures with intensity modulated radiation therapy. The radiation dose can potentially be escalated using 3D conformal radiation techniques, particularly if the final prescribed dose is to be on the order of 50-54 Gy (which is the standard dose used for preoperative chemoradiation as well as definitive chemoradiation). Thus, there is a lack of support demonstrating that intensity modulated radiation therapy would be better than standard 3D conformal radiation in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested an MRI with dye for evaluation of her status post C2 fracture. Findings:  The physician reviewer found that although the records of the trauma are complete, very little history is given as to how the patient did post-treatment and whether she has had any ongoing neurologic symptoms. There are no recent plain x-rays that have been performed to look at the bone and vertebral body alignment, per the submitted documentation. As for the dissection, no neurological symptoms other than headaches are reported, and there is no documentation than brain imaging has been requested.  The most important assessment in trauma is stability. The American College of Radiology Appropriateness Criteria state that trauma is an indication for an MRI of the cervical spine up to 12 months post trauma, but indicate that for patients with chronic neck pain and the absence of neurologic signs and symptoms, plain radiographs should be the initial study performed.  Thus, in this patients case, an MRI with dye is not indicated, as the submitted documentation does not demonstrate that plain x-rays have been performed.  In regards to the neck dissection, the requested MRI would not appropriately evaluate the dissection. In this patients case, an MRI with dye is not medically indicated at this time.