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

A 56-year-old female has requested physical therapy (pelvic floor, levator, coccygeal mobilization and strengthening) for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  This patient has a history of low back pain, and she has undergone a number of treatments for her problem, none of which have provided her any sustained relief of her pain.  Currently, she has been receiving vaginal floor physical therapy.  However, based on the information provided by the patient and her providers, she has not had any sustained improvement in her symptoms.  She has requested an ongoing approval for continuation of this vaginal muscle therapy, with no defined therapeutic conclusion.  The information provided by the physical therapist is sparse, with no clear documentation of her pathology, progress, and therapeutic goals.  It does appear that she received some benefit from pelvic trigger point injections, but the incremental improvement provided by the physical therapy is undocumented.  Although pelvic myofascial problems can contribute to pelvic pain syndromes, it is unclear that she has chronic pelvic pain, as the description of her pain is more related to her low back.  The current medical evidence recommends reevaluation of patients who do not respond to pelvic floor physical therapy after 8 to 10 weeks, possibly with additional testing or radiographic imaging.  In this case, the patient underwent treatments at a frequency of two to three times per week for months, with minimal improvement.  All told, the requested physical therapy (pelvic floor, levator, coccygeal mobilization and strengthening) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female has requested approval for inpatient mental health services, or in the alternative, mental health partial hospitalization/day treatment program level of care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that a careful review of the facts in the records provided for review demonstrate that the patient was treated in RTC for an eating disorder, and at the time of admission, she is listed as being in remission. Therefore, she has certainly benefited from the treatment, and apparently sustained her gains. Additionally, her provider notes that her substance abuse has declined from polysubstance abuse to episodic marijuana abuse, which is also an improvement. This patient sustained traumatic brain injury (TBI) after being discharged home from the RTC treatment. She is described as becoming aware of her cognitive deficits and having difficulties keeping up in school. This is described as the acute stressor that has driven her depression as well as her suicidal and self-injurious behavior. According to the records, the patients main problem is sensitivity to stress with over-reactions and irritability. This is a common occurrence after TBI and is treatable with medications and behavior therapy, both of which should be available at the PHP level of care. The PHP level of care should safely and adequately provide the support and direction clinically indicated for this patient at this time. Therefore, the requested inpatient services mental health services are not medically necessary. However, the PHP/day treatment program level of care services is supported as medically necessary for treatment of this patients medical condition from the date at issue and forward.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male has requested coverage for past intensity modulated radiation therapy (IMRT) for treatment of his malignant germ cell tumor in the right groin.  Findings:  Two physician reviewers found that the patient has a recurrent germ cell tumor of the groin.  A primary excision was performed fourteen years ago.  There was a recurrence eight years later, and the patient underwent a second excision.  Five years following that excision, a 2.2 cm right inguinal mass was found, and surgery with wide local excision was subsequently performed.  In general, IMRT is not an experimental technique, but rather 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 may be used when there is concern about sparing normal tissues from high dose exposure.  Due to the rarity of the condition, there is a lack of data regarding the use of IMRT specifically for germ cell tumor recurrence.  However, there are abundant data on the use of IMRT for anal cancer, in which the groin is treated, as well as gynecologic cancers.  IMRT allows for better relative sparing of normal tissues than conventional radiation.  Based upon the submitted medical records, the use of IMRT was likely to be of greater benefit in this patients case than conventional radiation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested coverage for Egrifta Tesamorelin Acetate 1 mg, for injection for treatment of his HIV related lipodystrophy.  Findings:  The physician reviewer found that lipodystrophy is an abnormal accumulation of fat. Currently, as stated in the press release from the FDA, Egrifta has been demonstrated to decrease abdominal fat. However, whether Egrifta decreases the risk of cardiovascular disease or improves compliance with antiretroviral drugs has not been studied. Thus, more clinical study is necessary to warrant a valid conclusion that functional improvement is definitive or maintained with this therapy. Based on the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible.  This patients abnormal collection may be caused by the treatment of HIV, which is an infection, but obesity may be a contributing factor as well. Overall, the supporting documentation does not specify the severity and detail of the patients condition. The treating provider only notes on examination that the patient has fat redistribution of the abdomen. The waist-to-hip ratio is documented, which is abnormal, but the patients obesity could also be a contributing factor. All told, there is insufficient medical documentation describing the severity of the patients condition to support the requested therapy as reconstructive in nature or medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested  thighplasty (thigh lift) for treatment of her excess skin status post bariatric surgery and weight loss.  Findings:  The physician reviewer found that obesity can be considered a disease. In this patients case, correction of this disease has led to the abnormal structures of significant skin overlap. The patient has a probable functional deficit related to the skin overlap. The patient complains of many functional deficits, including rashes, pain and difficulty with ambulation. This is supported by the medical documentation from the referring provider. The medical documentation is sufficient to suggest that a true functional deficit is likely present. The plastic surgeon is uniquely qualified to further evaluate this patient to determine the suitability of surgical correction. However, there must be sufficient documentation to determine whether this is primarily an aesthetic or a functional procedure. Thus, greater characterization of the abnormal state is needed to support the requested procedure as reconstructive in nature or medically necessary. Based on review of the available records, the requested surgery is not reconstructive in nature and not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male has requested approval for Euflexxa shots, four times per year for treatment of his shoulder pain.   Findings:  Two physician reviewers found that the patient has a history of shoulder pain, low back pain, and leg pain.  The medical records noted a diagnosis of shoulder osteoarthritis.  In an undated letter, the patient reported prior surgery to the left shoulder, with no benefit.  He noted that physical therapy has been ineffective.  The requested services are not likely to be of greater benefit than other treatment modalities in this clinical setting.  Hsieh and colleagues compared a cohort of 70 patients with adhesive capsulitis of the shoulder randomly placed into one group receiving hyaluronic acid injections with physical therapy and a second group receiving physical therapy alone.  Both groups experienced improvements in pain, disability, and quality of life after treatments.  However, no significant group effect was found for any outcome measurements.  The authors concluded that intra-articular hyaluronate injections did not produce added benefits for adhesive capsulitis of the shoulder.  There is a risk of either infection or sensitivity reaction to the injected material, especially with repeated injections.  All told, the requested Euflexxa shots, four times per year, are not likely to be more efficacious than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male has requested approval for residential rehabilitation treatment center services for treatment of his polysubstance dependence.   Findings:  The physician reviewer found that although the patient has a history of anxiety and secondary mood symptoms, the primary issue related to this course of treatment is this patients substance dependence.  For patients with addictive illnesses, the interpretation and application of clinical guidelines and patient placement criteria determines the appropriate level of care.  As noted by the American Psychiatric Association, residential treatment is indicated primarily for patients who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use.  Per the American Psychiatric Association, residential treatment is indicated for patients who lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this patients case, he has multiple psychosocial stressors, including unemployment, strained family relations, and daily drug use.  His social network and daily routine is built around his substance use.  The patient has failed outpatient treatment and questions his ability to stay sober in the community.  He has significant psychiatric comorbidity with increasing affective symptoms, and he has had multiple acute admissions in the past year.  Considering this patients clinical presentation, residential placement is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male has requested a laminectomy (63012) with removal of abnormal facets and/or para interarticularis with decompression for treatment of his low back and left leg pain.  Findings:  The physician reviewer found that the patient has grade I spondylolisthesis and spondylolysis L5 status post recent L5-S1 instrumented fusion after an anterior lumbar interbody fusion (ALIF). Despite previous treatment, he continues to experience back and left lower extremity pain, which was present before the fusion. He had a recent electromyography that showed an L5 radiculopathy. A computed tomography (CT)  and MRI showed his solid fusion, without evidence of canal or foramen stenosis, and no loosening of screws. Despite both an anterior and posterior solid fusion, the provider has recommended a laminectomy for micromotion (Gill Procedure).  Based on review of the available records, this patient has a history of back pain and lumbar radiculopathy due to spondylolysis/spondylolisthesis, for which he has undergone an ALIF and more recently, a posterior instrumented fusion. The records indicate that he continues with the same symptoms. However, his most recent CT and MRI scans do not show any new or compressive findings. In addition, there is no evidence of infection, fracture, disc herniation, or canal or foramen stenosis, as required by InterQual and Milliman criteria for laminectomy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 57-year-old female has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department with chief complaint of productive cough, congestion, dizziness, slight fever, shortness of breath and runny nose of two days duration. She reports a prior history of underlying lung disease for which she was followed by a pulmonologist. Vital signs in the emergency department included heart rate 99, respirations 18, temperature 98.1 degrees and oxygen saturation 99% on room air. The patient reported a 7 out of 10 pain level. Upon initial presentation, the patient exhibited labored respirations, cough, and decreased breath sounds. A chest x-ray was normal. The patient was assessed with upper respiratory infection, viral and prescribed guaifenesin 600 mg extended release.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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.Review of the submitted documentation demonstrates that the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to seek immediate medical attention. Specifically, the patient reported acute symptoms of cough, shortness of breath, dizziness and fever. Additionally, the patient had a history of significant lung problems in the past which played a role in her decision to seek immediate medical attention. All told, it was reasonable for the patient to believe that the absence of immediate medical attention in this setting could cause serious harm to her health, as her symptoms were concerning for serious impairment of breathing, worsening infection and risk for sepsis, and other infectious complications. As such, the patient met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested coverage for a motorized scooter for treatment of his hemiplegia affecting dominant side.  Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of a POV (power scooter). The determination of medical necessity for a POV is based on the following criteria: 1) The patient is unable to ambulate independently with use of an assistive device; 2) The patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) The patient has demonstrated the ability and willingness to safely operate a power-operated vehicle (POV); 4) A POV is needed to perform in-home MRADLs; 5) The patients residence will accommodate such a device. These criteria are generally used to support the medical necessity of a POV (Dicianno and Tovey). In the case under review, records indicate that the patient is capable of self-propelling a lightweight manual wheelchair in order to perform his MRADLs. Therefore, a power scooter does not meet generally accepted criteria for medical necessity for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male has requested approval for face-to-face mental health therapy for treatment of his behavioral health condition.   Findings:  The physician reviewer found that the central issue in this case is the patients formidable formal thought disorder, which represents the most debilitating of psychiatric disorders. The patient has chronic, serious mental illness and his resulting impairment presents a significant challenge to any plan of care. As such, the patient requires a comprehensive, multimodal treatment plan that includes, among other interventions, psychotropic medications. The most appropriate way to address the patients ongoing management is for the patient to follow-up with a therapist for assessment and treatment planning. Based upon the documentation provided, the Health Plan has offered this service to the patient in lieu of face-to-face therapy. A treatment planning session such as this invariably includes at least elements of supportive psychotherapy and is the most appropriate next step for this patient who is in need of comprehensive psychiatric services. As such, the medical necessity of face-to-face mental health services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male has requested chiropractic services for treatment of his hip pain and shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records do not clearly indicate the patients chief complaint.  The documentation only noted an ongoing chronic condition as the patients diagnosis.  Per the medical records, the notes from the treating chiropractor do not adequately describe the history of this patients condition.  Additionally, the documentation does not indicate the nature or duration of his pain.  Per the current medical evidence, a thorough patient history is crucial for appropriate evaluation and treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female has requested a functional electrical stimulator (RT300 FES Cycle Ergometer Rehabilitation Therapy System) for treatment of her tetraplegia.   Findings:  Two physician reviewers found that the patient reports that as a result of having discontinued use of the device she has experienced disuse muscle atrophy, increased spasms, and recurrent urinary tract infections. A letter of medical necessity completed by the provider indicates that the patient has had an excellent clinical response to the device during trials and that the device is medically necessary for ongoing in-home treatment of the patients condition. The health risks of inactivity/immobility following spinal cord injury have become increasingly well recognized and the benefits of a regular exercise program have been established repeatedly in the literature. Substantial barriers limit access to regular exercise in the SCI population and use of in-home FES ergometry has become increasingly common.  Numerous studies have demonstrated the clinical benefits of FES cycle ergometry in persons with spinal cord injury. Some of these health benefits have included improved circulation, cardiac function, and overall fitness. Given the ease of access of in-home FES ergometry and its health benefits in the spinal cord injury population, it is likely that the RT 300 FES cycle ergometer would be more beneficial than alternative standard therapies for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested authorization and coverage for weekly behavioral health treatment with one single child psychologist to ensure consistency and continuation of care for treatment of the enrollees autism and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that a review of the medical documentation supports medical necessity for weekly therapy sessions with a consistent provider for management of this patients medical condition. The medical records indicate the patient presented with symptoms of mood swings, tantrums, not following directions, aggression, threatening a peer with scissors, meltdowns. An evaluation by a psychologist notes global assessment of functioning (GAF) scores of 51-60. Medication management with a psychostimulant was later initiated and behavioral counseling was recommended. The medical records indicate the patient continued to have problems with aggressive behavior. A psychotherapy note reflects a treatment plan with goals that included decreasing symptoms of depression and anxiety. Given the patients GAF score range of 51-60 documented by the provider and symptoms of ADHD, which are well documented in the medical records, weekly sessions along with consultation with a child psychiatrist is consistent with the community standards of care and the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters. As noted in AACAP guidelines for children with ADHD, co-morbidity should be evaluated and the parameters will indicate the frequency of contact. This patients treatment plan should be reviewed regularly and modified if the patients symptoms do not respond. The need for more intense treatment, including parental involvement, may also be indicated. All told, the requested weekly behavioral health treatment with one single child psychologist to ensure consistency and continuation of care is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested approval for 10 hours per week of applied behavioral analysis (ABA) therapy and 2 hours per week of supervision for treatment of his pervasive developmental disorder, not otherwise specified.   Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient has behaviors consistent with pervasive developmental disorder, not otherwise specified as he meets 7 of the 12 criteria for the diagnosis based upon the DSM-IV. ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Granpeesheh, et al. and Sallows, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles. Studies have also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Sallows, et al.). The goals for older children often are to identify and remediate particular deficits such as the tantrums, poor peer relationships and social skills, and concerns for elopement and self-help exhibited by this patient. As such, the requested 10 hours per week of ABA therapy and 2 hours per week of supervision are clinically indicated and medically necessary for this patient.