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

A 51-year-old female enrollee has requested a magnetic resonance angiogram (MRA) of the head and magnetic resonance imaging (MRI) scans of the brain and cervical and thoracic spine for an evaluation of her medical condition. Findings:  The physician reviewer found that this patient had a variety of symptoms including mild memory complaints, ear pain, fatigue and depression, among others. A neurologic exam by a primary care physician was normal, but a brain MRI was performed. She subsequently had neurologic exam by a neurologist, which was normal. No history was elicited to suggest diagnosis of clinically isolated syndrome, or multiple sclerosis, but extensive neurological imaging (MRA of the head and the MRIs of the brain and cervical and thoracic spine) was ordered as a follow-up of her prior MRI scan. The literature shows that a variety of non-specific findings may be discovered on unnecessary testing, such as the T2 white matter findings commonly seen in brain MRI of individuals with migraines, as appears likely in this case. No evidence is present in the medical records that the diagnostic procedures performed were medically indicated or necessary for the evaluation of the patients mild memory loss complaints, fatigue or for a follow-up of her previous brain MRI.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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 was taken to the operating room for an exploratory laparotomy and lysis of adhesions based on a CT scan of his abdomen. The scan demonstrated dilation of the small intestine. The colon, however, contained material on this study. This is incompatible with a complete small bowel obstruction in which the small bowel would be dilated with the collapse of the small and large intestine, distal to the obstruction. A patient may have a partial or incomplete small bowel obstruction which is characterized by dilated loops of small bowel with some material in the distal intestine. However, there are other conditions which may cause dilated loops of small bowel as well, such as intestinal pseudo-obstruction and ileus. Based on the documentation provided, it is not possible to confirm the patients diagnosis. However, even if the patient by history and physical was suffering from a partial small bowel obstruction, emergency surgery was not necessary as standard treatment protocol calls for the use of a naso-gastric tube for intermittent suction and bowel rest, as a majority of patients will respond to conservative treatment. Furthermore, the evidence provided does not demonstrate that the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to conclude that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to his health, impairment in bodily functions or serious dysfunction of a bodily organ or part. The patient presented with a chronic condition and had been having intermittent abdominal pain over an extended period. The patients lab data revealed a normal complete blood count and chemistry analysis. His vital signs were normal. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested an increase in Lyrica medication for the treatment of his peripheral neuropathy. Findings:  Two physician reviewers found that the medical literature yields limited information regarding the effects of Lyrica above the 600 mg/day dose. However, the manufacturers prescribing information indicates In clinical studies, some patients took as much as 2400 mg/day. The types of adverse reactions experienced by patients exposed to higher doses (greater than 900 mg) were not clinically different from those of patients administered recommended doses of Lyrica. In addition, the manufacturer indicates that even with a dose of 8000 mg, there were no notable clinical consequences. Given that this patient has had good results with Lyrica in the past, and in the absence of data indicating the proposed dosage is unsafe, 800 mg of Lyrica per day is medically reasonable and likely to yield better results for this patient than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested chiropractic services for the treatment of her back pain. Findings:  The physician reviewer found that there is sufficient evidence in this patients case to support the medical necessity of chiropractic services. The submitted records document the presence of altered spinal alignment, a decline in spinal motion and integrity, and an altered physiological function of the spine. Chiropractors are neuromuscular specialists and have particular expertise in managing these issues. The patient has reported good results from chiropractic care in the past and is likely to benefit from additional chiropractic treatment. She has undergone multiple other modalities without adequate relief. Furthermore, she experiences gastrointestinal upset from pain medication. Chiropractic services are the next appropriate step for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. She reports that she has tried diet and exercise plans. The Health Plan contends that the patient should have attended a medically managed weight loss program for at least six months within the last three years prior to pursuing weight loss surgery. However, there are no studies that show that patients who attempt such programs have different outcomes than those who do not undergo such attempts. In fact, studies indicate that the drop out rate increases for patients who are denied surgery. This patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity. With a BMI of 51, weight loss surgery is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested vitamin B12 cyanocobalamin injection (J3420) and subcutaneous hormone (estradiol) pellet implantation (11980) for the treatment of her medical condition. Findings:  Three physician reviewers found that this patient has been menopausal since her hysterectomy and removal of her ovaries. She apparently has had some benefit from estrogen replacement therapy, but still reports menopausal symptoms at her visits. The issue here is the choice of medications and the route of delivery. The American College of Obstetricians and Gynecologists and the American Association of Clinical Endocrinologists recognize approved therapies for estrogen replacement. These options include FDA-approved formulations which can be administered via oral, transdermal and vaginal routes. There is no submitted information in the records indicating that any of these formulations have been previously tried in this case. The patient has been receiving subcutaneous estradiol pellet implantations. This treatment is not FDA-approved and has not been studied for safety. It includes compounded formulations that may have erratic absorption resulting in less predictable bio-availability. At this time, there is insufficient peer-reviewed scientific data to support the use of subcutaneous estradiol pellet implantations for treatment of menopausal symptoms. There are other well-established therapies available in this setting. In addition, this patient does not have documented B12 vitamin deficiency; thus the use of B12 injections is not indicated. Furthermore, the use of B12 for the treatment of menopause is not FDA-approved and there is no evidence in the peer-reviewed literature that vitamin B12 injections are indicated for the treatment of symptomatic menopause. As stated above, there are other therapies available in this setting with proven efficacy based on high quality outcome data.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested eating disorder residential treatment services for the treatment of her behavioral health conditions. Findings:  The physician reviewer found that this patient could have been appropriately treated at a lower level of care. The literature contains numerous references to the viability of outpatient treatment for Eating Disorders. The relevant articles by Schaffner and Buchanan, and Dalle Grave, et al. confirm that step-care approaches to treatment (utilizing lesser restrictive approaches prior to more intensive settings) and the evidence-based use of intensive outpatient program (IOP) lead to positive outcomes in the treatment of eating disorders. Finally, it is also recognized that the patient carries a diagnosis of polysubstance abuse. Based on her records, the patient did not require a residential placement for this issue as she was without a severe co-occurring medical issue that complicated treatment; she did not require 24-hour/day monitoring for safety issues; her psychiatric issues were only mild-to-moderate; she had involved outpatient supports; and she demonstrated an ability to voluntarily attend 12-step meetings (as manifested by her attendance of meetings while on passes from the program).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Provigil for the treatment of his excessive sleepiness. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) approved indications for use of Provigil include excessive sleepiness associated with narcolepsy, shift work sleep disorder and obstructive sleep apnea/hypopnea syndrome. The records provided for review demonstrate that this patient has obstructive sleep apnea (OSA) diagnosed via a sleep test. He does not get optimal effect from CPAP usage and is severely affected by sleepiness to a dangerous degree as he is noted to have fallen asleep while driving. It is not entirely clear how long this patient is able to tolerate CPAP on a given night as he has been reported to remove his mask in his sleep. This fact is not unusual and many patients (approximately 30-45%) are unable to fully tolerate and use CPAP for treatment of OSA. In the absence of an effective treatment for his OSA, it is necessary for the patient to be treated with an alerting medication such as Provigil to avoid dire consequences from his sleepiness. As is often observed in clinical practice, even fully controlled sleep apnea in a compliant patient may still result in residual sleepiness. Thus, the patient should be approved for use of Provigil in conjunction with the CPAP device for sleep apnea and related sleepiness.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a cauterization inner nose procedure (nasal tissue reduction) for the treatment of her sleep apnea. Findings:  Two physician reviewers found that there is quite a bit of support in the literature for cauterization/ablation of the inferior turbinate in treatment of medically refractory nasal congestion secondary to turbinate hyperplasia. However, the main reason that inferior turbinates are operated upon for reduction of their size in the setting of obstructive sleep apnea is to facilitate the use of CPAP when it is not tolerated because of nasal congestion and nasal airway restriction.  In this case, there is no documentation that the intolerance of CPAP is secondary to nasal airway restriction. The records do not describe problems with nasal airway restriction. While multilevel surgery for sleep apnea is generally supported for better outcomes, there is no documented medical indication for this procedure in this particular case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested radiofrequency nerve ablation for the treatment of his back pain. Findings:  Three physician reviewers found that the requested treatment, radiofrequency ablation to the thoracic spine, is not likely to be more beneficial for this patients clinical situation than any available standard therapy and is not supported by the scientific literature. The literature notes that data regarding the efficacy of this procedure in the thoracic spine remains unproven. A systematic review by Boswell concludes, The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. In this case the patient stated that he received benefit from medial branch block which tended to localize the pain. However, the scientific literature indicates that the efficacy of localizing pain with injections followed by radiofrequency ablation for thoracic facet syndrome has not been established. As such, there is insufficient peer-reviewed evidence to support the requested treatment in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a referral to a dermatologist for the treatment of her steroid-induced ecchymoses/skin fragility. Findings:  The physician reviewer found that this patient complains of moles, painful liver spots and has a family history of skin cancer.  On physical examination, the primary care physician does not note any lesions that are suspicious for skin cancer.  The physician indicates that the patient suffers from steroid-induced atrophy and vascular fragility with easy bruisability. These diagnoses do not require treatment by a dermatologist, as there is no effective treatment for these conditions. The physician did not identify any suspicious moles of which the patient complains. The patient did not indicate specific lesions of concern at the time of the exam according to the medical records. Based upon the submitted documentation, the patient does not present with signs and symptoms for which referral to a dermatologist is medically warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested removal and reimplantation of a new implant in the left breast, and reimplantation of a new implant in the right breast for the treatment of her right ruptured silicone implant. Findings:  The physician reviewer found that reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease in order to improve function and/or create a more normal appearance. The surgery must also result in more than minimal improvement in appearance to be considered reconstructive. In the case of this patient, the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease. The patients photographs do not document an abnormal appearance. There appears to have been minimal capsular contracture, and as such, evidence of an abnormal structure is not visible. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the proposed procedures, while the right breast implant rupture meets clinical indications for removal (and has in fact been authorized by the Health Plan), replacement of the right breast implant is not medically necessary from a functional standpoint. Replacement of the right breast implant would be for cosmetic purposes only. Furthermore, removal and replacement of the left breast implant does not meet medical necessity criteria for removal and replacement, as these procedures are not indicated to remedy a functional impairment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a revisional duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that there is no medical evidence to suggest that the patients has experienced medical complications as a result of Roux-en-Y gastric bypass. There is nothing in the operative report from the original procedure, the recent air-contrast study or any of the submitted medical records to suggest the patient is experiencing a medical complication. In the absence of objective evidence of medical complications, it is presumed that the patients weight regain has resulted from non-compliance. Furthermore, revision to duodenal switch in the presence of a small gastric pouch can potentially be harmful unless the gastric pouch is to be increased in size to that of roughly a 150 cc pouch (a risky procedure, functionally similar to gastric bypass reversal) and should be avoided to prevent risk of malnutrition (malabsorption combined with a small pouch is equivalent to a distal or long limb gastric bypass which is generally considered a risky procedure). With regard to whether the requested revisional duodenal switch procedure meets the requirements of Californias Reconstructive Surgery Statute, I find that the patients obesity does not constitute an abnormal structure of the body. Obesity is the result of an abnormal accumulation of body fat rather than a structural abnormality. As such, the patients condition does not meet criteria for reconstructive surgery under California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested inpatient hospitalization psychiatric care with emphasis on dialectical behavior therapy for the treatment of his bipolar II and borderline personality disorder. Findings:  The physician reviewer found that although dialectical behavior therapy is a valid treatment modality, the most important issue here is the patient's imminent suicidal risk. Dialectical behavior therapy is not very effective in patients who are actively suicidal. In fact, dialectical behavioral therapy is usually discontinued in patients who become suicidal. The patient may be an appropriate candidate for dialectical behavior therapy once it is established that he is no longer actively suicidal and is at low risk of harm to self. However, such therapy can be provided in an intensive outpatient program, partial hospital program or in individual therapy. It is not necessary for dialectical behavioral therapy to be provided at an acute inpatient psychiatric unit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested an additional fifty-two (52) speech therapy visits for the treatment of the enrollees post traumatic encephalopathy. Findings:  The physician reviewer found that the relevant scientific literature includes an article by Simms which places language disorders in a framework that offers a rational approach to the evaluation and treatment of patients with speech and language disorders. Speech and language therapy is well justified based on this patients diagnosis which is clearly established and well-documented in this case. This patients delays are attributable to an underlying medical insult to the brain. Patients who undergo such trauma have legitimate medical illnesses and require extensive treatment of the concomitant results of the underlying injury or insult. This patient has shown steady improvement with speech and language therapy and should continue to receive such services at the frequency and duration that has been requested. Her treatment plan is comprehensive, has shown positive results thus far, and is likely to continue to be beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this patient has speech and language delay that adversely impacts his ability to communicate effectively. In addition to expressive language delay, he exhibits oral motor dysfunction, receptive language delay, auditory comprehension difficulties and articulation deficits. Speech therapy is imperative to treating these issues successfully. Speech and language delay must be taken very seriously in young children because the long-term consequences can be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and colleagues concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient has delays in multiple areas affecting his ability to communicate successfully. Speech and language therapy is medically indicated to maximize his skills in communication and oral motor functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested MRA of the brain for an evaluation of his headaches. Findings:  The physician reviewer found that this patient presented with new onset headache of short duration, with no postural features and normal examination. A variety of secondary headache disorders may present with new onset headache, characteristically with associated ominous features such as crash onset, abnormal vitals, nuchal rigidity or abnormal examination findings. No such features are recorded in this case. The probability of CSF leak or vasculitis was low prior to the testing. The medical literature contains evidence-based guidelines on indications for brain imaging in headache patients, based on reasonable probability of ascertaining structural causes of headache, which this case does not meet. MRA of the brain was not medically indicated in this patients case.