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

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees depression. Findings:  The physician reviewer found that this patient was admitted to a residential treatment center after a suicide attempt.   He has a history of abusing several different drugs and had been to substance abuse inpatient treatment multiple times in the past.  These treatments do not appear to have had a significant effect on the patients substance problems.  The most concerning factor in this case is the fact that the patient has auditory hallucinations when not using substances.  His outpatient provider believed that he may be suffering from early onset schizophrenia.  The patient had a flat affect during much of his time at the residential treatment center and displayed constant poor judgment.  In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System is indispensable in determining the necessary level of care for children and to insure the level of care meets individual needs in the least restrictive setting possible. Per these guidelines, non-secure, 24-hour psychiatric monitoring was indicated at the time of admission. This indicates that he met criteria for a residential treatment center stay at the time of admission. Since his progress in treatment as of his discharge date was minimal, it appears that he continued to meet criteria for residential treatment center placement.  He also has a history of failed treatments in the past at an inpatient level of care. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.  In this patients case, the residential treatment center level of care was the least restrictive setting needed to treat this patient.  Thus, residential treatment provided during the time period at issue was medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested extracorporeal shock wave therapy (ESWT) for treatment of her plantar fasciitis. Findings:  Two physician reviewers found that according to the medical literature, there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined and there is a lack of information regarding the durability of the treatment effect or any long-term adverse effects of ESWT. In addition, there have been conflicting results among the randomized and controlled studies. All told, at this time there is insufficient evidence to conclude that the use of ESWT to treat this patients plantar fasciitis is likely to result in a better clinical outcome compared to standard interventions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested 36 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that this patients provider has carefully documented the patients treatment goals and specific steps demonstrating progress. In general, patients with ASD are often treated with ABA therapy. Many of the patients treatment providers are recommending ABA therapy for 36 hours per week to fully address the individual needs of the patient. This treatment plan is consistent with the relevant medical literature which supports the efficacy of ABA therapy for young patients with ASD. As noted by Foxx in his 2008 article, the most productive services are intensive and individualized to the patients needs. As the patients April 2010 progress report illustrates that he continues to have documented deficits related to ASD, yet has achieved many milestones toward his overall progress, the requested ABA services are clinically indicated and medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Chantix for treatment of her chronic obstructive pulmonary disease. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) has approved the use of Chantix for the cessation of smoking, however the current recommended maximum amount of continuous use is 24 weeks. In the medical literature, Williams and colleagues studied the long-term use of 251 patients treated with Chantix and found that at 52-week follow-up, 36.7% of patients treated with Chantix remained abstinent compared to 7.9% who received placebo. Despite this outcome, the safety and efficacy of long-term use has not been evaluated with sufficient studies and adequate follow-up to endorse its use after 24 weeks. It should be noted that serious and important side effects, including depression, suicidal thoughts, sub-capsular cataracts, and cardiovascular events have been reported with both short- and long-term use. Indeed, serious adverse events were found to be 2.5 times more likely to occur in the Chantix group compared to the placebo group in Williams and colleagues study. Thus, the extended use of Chantix is not clinically indicated beyond 24 weeks.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Menaflex meniscal implant for treatment of the enrollees knee pain. Findings:  Two physician reviewers found that the long-term result of use of the requested device remains unknown at this time. There is a lack of well-controlled, randomized, prospective clinical trials in the peer-reviewed literature supporting the use of collagen meniscal implants in the setting of adult patients who are status post meniscectomy.  There are no such studies involving skeletally immature patients. In this patients case, there is a lack of evidence supporting the superior efficacy of a collagen meniscus implant over alternative treatment options. As noted by Tice, the long-term safety and efficacy of the device has not yet been established.  In this patients case, Menaflex meniscal implant is not likely to be superior over alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested acupuncture for treatment of the enrollees cerebral palsy and back pain. Findings:  The physician reviewer found that there is a lack of evidence in the medical literature demonstrating that acupuncture is superior to standard therapies for the treatment of back pain for patients with cerebral palsy.  The articles by Zhang and colleagues and Liptak noted some benefit to acupuncture in reducing spasticity and tone. However, both articles note that further research is needed before acupuncture can be endorsed. This patient has been offered standard treatment to treat his pain, including physical therapy.  Physical therapy is considered standard of care for pain associated with muscle spasm for both chronic back pain and cerebral palsy.  In this patients case, acupuncture is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Lexapro for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient has a history of depression and apparently has responded to Lexapro, but there is no indication that he has been tried on one or more of the numerous medications on the Health Plans formulary. According to American Psychiatric Association practice guidelines, there are numerous antidepressants available in this clinical setting and there is not strong evidence that Lexapro is any more effective than any of the formulary medications. For instance, Celexa (a formulary medication) is very similar chemically to Lexapro and should be able to be substituted without any adverse consequence to the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested celiac testing for evaluation of the enrollees cramping, nausea and diarrhea. Findings:  The physician reviewer found that according to the guidelines published by the National Institutes of Health and the North American Society for Pediatric Gastroenterology Hepatology and Nutrition, screening for celiac disease was necessary for this patient due to his abdominal pain and diarrhea. The guidelines recommend that a total serum IgA and an anti-human tissue transglutaminase be obtained as an initial screen.  The guidelines note that further testing, including a small bowel biopsy or HLA typing be performed as indicated by a positive screen. Thus, this patient meets national criteria for screening for celiac disease. However, the testing performed was more extensive than either guideline recommends.  In this patients case, the serum IgA and anti-human tissue transglutaminase were medically indicated.  The antigliadin IgG, antigliadin IgA, anti-endomysial IgA, HLA-DQ2 and HLA-DQ8 were not medically indicated, per national guidelines.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested emergency services on an emergent basis for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe 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 presented with abdominal pain for two days. Although she described it as hard and cramping, she was not feverish, nauseated or vomiting. Although her appeal letter states she was experiencing chest pain, the chart specifically denies that the patient complained of chest pain or palpitations. The patient also had a known history of gastroesophageal reflux disease. It is unlikely that a prudent layperson in similar circumstances would have considered her health to be in immediate jeopardy. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested a tonsillectomy for treatment of the enrollees stated condition of sleep apnea. Findings:  The physician reviewer found that this patient does not meet current criteria for consideration of surgical removal of his tonsils secondary to obstructive sleep apnea syndrome. For the patient to meet medical necessity criteria for a tonsillectomy due to obstructive sleep apnea syndrome, thorough documentation of his symptoms of obstructive sleep apnea is required. The records submitted only document some tonsil hypertrophy, along with mild symptoms of noisy breathing and snoring with only minimal symptoms related to obstructive sleep disordered breathing. The medical literature supports the contention that patients with a documented positive polysomnogram fair much better with tonsillectomy surgery than those who are observed medically. In this case, polysomnogram results have not been provided. In summary, although many patients with obstructive sleep disordered breathing are significantly improved with tonsillectomy, the medical records submitted in this patients case are insufficient to confirm a diagnosis of obstructive sleep apnea.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested social skills training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that social skills deficits are a pervasive and enduring feature of autism spectrum disorders (Bellini and colleagues). Social skills deficits have been linked to deleterious outcomes such as social isolation, social anxiety and depression. This young patient has a history of anxiety and depression with hospitalization following a suicidal gesture. He was treated as an inpatient following a 5150 hold with reported suicidal ideation related to difficulties with school. The requested services for social skills training are therefore medically necessary in order to aid the patient in improving his social interaction skills and his ability to effectively communicate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-month-old female enrollee has requested  the formula supplementation Similac Alimentum for treatment of the enrollee, who has a history of constipation. Findings:  The physician reviewer found that the submitted documentation does not include diagnostic tests that substantiate the diagnosis of lactose intolerance. This patient has a history of constipation and eczema. There is no indication for using a hydrolyzed formula to treat constipation for infants less than one year of age, per the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines. Of note, there is no mention of constipation or lactose intolerance in office visit notes within the past seven months. The medical documentation also notes eczema. There is no documentation that a trial of the requested formula will improve this patients eczema. In this patients case, the formulary supplementation Similac Alimentum is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of an 18-year-old female enrollee has requested a partial hospital program (PHP) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient appeared to be stable with no substantive changes in her weight or depression. The titration of her medication appeared to be excessively conservative for a patient with severe depression, and there is no evidence that she was at risk for hospitalization. Her weight fluctuated, but overall her weight was above 80% of her ideal body weight of 130 pounds. In addition, there is no indication of physiological compromise related to her eating disorder such as abnormal labs or vital signs.In summary, the submitted records do not demonstrate that the patient was seriously at risk or could not have been safely treated in an alternate level of care during the period at issue. All told, in this patients particular clinical situation, American Psychiatric Association practice guidelines for PHP treatment were not met during the dates of service at issue.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested emergency services on an emergent basis for treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a reasonable and prudent person in the patients circumstances would believe he or she was experiencing an emergency medical condition requiring emergency medical services. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patients symptoms met prudent layperson criteria for emergent care. The patient had a high fever and was progressively feeling worse despite a visit to his primary care provider earlier in the week. The patients history, physical exam, and testing suggest a prudent layperson would be reasonably concerned as with the nighttime, his circadian rhythm caused his fever to spike and he reported feeling miserable. Congruent with the timing of this illness, media had been replete with warning signs and symptoms concerning for the H1N1 virus. Further, there are many conflicting directives about what patients should do when experiencing flu-like symptoms. For example, the Centers for Disease Control and Prevention (CDC) instructed patients to go to the ER when experiencing flu-like symptoms plus dizziness, which describes this patients symptoms at the time of presentation to the ER. There was much concern in the medical community that this novel flu (H1N1) was particularly virulent, and this patients symptoms were concerning for the H1N1 virus. Thus, given the patients course including symptoms persisting for one week then worsening with high fever, it would have been reasonable for a prudent person to be worried about a post-viral complication such as post-influenza pneumonia or bacteremia and therefore present to the ER for evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested continued neurological follow-up visits with a pediatric neurologist for treatment of the enrollees epilepsy. Findings:  The physician reviewer found that this patient had the onset of a generalized seizure at seven months of age. She subsequently has had at least nine generalized seizures and trials of three antiepileptic drugs.  She presently is incompletely controlled on Keppra.  Additionally, she has been diagnosed with a failure to thrive and microcephaly. Her problems are presently multifactorial.  A specific common etiology to unify her treatment has not been identified. This patients multiple neurological and general pediatric problems should be assessed and treated by a pediatric neurologist. A child who has required three anticonvulsant medications for seizure control is considered refractory.  A refractory patient requires care by a neurologist skilled in epilepsy control.  Treatment by a pediatric neurologist is standard of care in this clinical scenario.  In this patients case, continued neurological follow-up visits with a pediatric neurologist is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female is requesting revisional gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has morbid obesity. She had a previously attempted conversion from a LAGB to LRYGBP with complications that resulted in a gastro-gastric fistula with no real gastric bypass (as she is occluded to the roux limb). Therefore, the patient functionally has no weight loss procedure as the food that she eats enters her normal stomach and moves into the duodenum. The patient was recently reevaluated by a bariatric surgeon and underwent multidisciplinary evaluation. She was advised of the risks of surgery and is a reasonable candidate for surgical intervention. The previous complications were not due to lack of patient compliance, and although the patient is at risk of complications, she has been provided informed consent and would like to proceed. It is not possible to predict the amount of scar tissue in the gastroesophageal junction, however, based on the EGD and upper gastrointestinal (UGI) series, anatomically there should be enough stomach to create a pouch and therefore the procedure appears to be technically feasible. All told, this patient meets nationally accepted criteria for weight loss surgery and the proposed procedure is medically reasonable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a repeat colonoscopy for evaluation of her colonic polyps. Findings:  The physician reviewer found that considering this patients personal history of polyps coupled with her mothers diagnosis of colon cancer at age 60, it is reasonable for this patient to be followed in 5 years with a repeat colonoscopy. Despite the fact that the patients previous colonoscopy was negative, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology concur that, colon cancer prevention should be the primary goal of screening. To that end, Brooks and colleagues recommend patients with a personal history of hyperplastic polyps be followed with a colonoscopy in 10 years. However, given this patients additional factor of her family history of colon cancer, the requested diagnostic procedure is indicated five years after the previous study. Thus, the patients request for the follow-up diagnostic procedure is medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient. As with any weight loss surgical procedure, the patient should undergo appropriate pre-surgical workup including psychological evaluation and documentation of normal TSH level prior to surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested the prescription drug Byetta for treatment of his diabetes. Findings:  The physician reviewer found that this patient is of Asian-Indian ethnicity and the incidence of diabetes in this patient population is associated with an increased resistance to insulin. The rationale for the proposed medication regimen is intended to preserve beta-cell function and improve insulin resistance. This rationale is consistent with the current medical guidelines for the management of diabetes mellitus (Rodbard and colleagues). According to the submitted records, the treatment regimen has been successful and the patient is satisfied with the regimen. As a result of this regimen, the patient is losing weight and his insulin requirements are decreasing. In addition, he has resolved what appears to have been the beginning of diabetic retinopathy. He has no reported hypoglycemia and his provider is taking the necessary steps to prevent hypoglycemia. Byetta is medically necessary for this patient at this time. A discontinuation of Byetta would cause an alteration in this patients controlled diabetes and would cause a set back in his medical condition.