Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested an electrical stimulator for treatment of her condition status post anterior cruciate ligament reconstruction.  Findings:  Two physician reviewers found that the patient has a history of left knee pain.  The patient underwent an anterior cruciate ligament reconstruction with allograft and microfracture abrasion arthroplasty.  Arthroscopic partial medial meniscectomy of the left knee was also performed. In this patients case, the requested electrical stimulator is likely to be more effective than other treatment modalities.  Neuromuscular electrical stimulation is used to treat muscle atrophy.  Its use is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy.  This patient is status post extensive ligament and microfracture surgery.  Pilot studies demonstrate a superior effect of electrical stimulation compared to physical therapy alone in this clinical setting.  The inhibition of muscle activation and reversal of atrophy has been demonstrated in this patient population.  Thus, the requested device is likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested coverage for a past PET scan performed for evaluation of his cognitive dysfunction.  Findings:  Two physician reviewers found that the patient presents with a history of cognitive problems.  The submitted documentation noted difficulties with planning, tracking, and follow-up of information.  The patients symptoms have reportedly impacted his employment.  As part of his evaluation, the patient received an MRI of the brain approximately fifteen months ago.  The MRI report noted no findings to explain the patients neurological symptoms.  A PET scan was performed three months later.  Complaints of cognitive dysfunction are common in men and women in their 50s and 60s. In the absence of gross cognitive deficits as determined with common cognitive tools such as the Mini Mental State Examination (MMSE), formal neuropsychological testing is widely used and is the most sensitive modality to detect mild cognitive impairment.  PET imaging may be beneficial only to differentiate frontotemporal dementia from Alzheimers disease, and not as a diagnostic test for dementia.  In this patients case, the diagnostic procedure at issue was not likely to be more efficacious than standard testing for evaluating his condition.  The current medical evidence does not support the diagnostic procedure at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male has requested circumcision for treatment of his medical condition.  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently issued a revision to its policy on circumcision. This 2012 AAP statement indicates that given the limited risks of mechanical neonatal circumcision methods, circumcision is a reasonable choice in newborns although it is not a medical necessity. The AAP policy does not specifically recommend or advocate for circumcision later in life. While Morris, et al. and Weiss, et al. note there can be risks associated with an intact prepuce, based upon the documentation provided, there is nothing in the patients medical history to demonstrate he is at risk. Further, there is no barrier to normal hygiene in the patients physical or developmental progress. Moreover, according to Weiss and colleagues, circumcision beyond the neonatal period is not without risk. In this case, there is no clear clinical benefit to performing circumcision in a 14-year-old individual who has no history of adverse impact secondary to his uncircumcised status. As such, the medical necessity of the requested circumcision has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male has requested circumcision for treatment of his medical condition.  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently issued a revision to its policy on circumcision. This 2012 AAP statement indicates that given the limited risks of mechanical neonatal circumcision methods, circumcision is a reasonable choice in newborns although it is not a medical necessity. The AAP policy does not specifically recommend or advocate for circumcision later in life. While Morris, et al. and Weiss, et al. note there can be risks associated with an intact prepuce, based upon the documentation provided, there is nothing in the patients medical history to demonstrate he is at risk. Further, there is no barrier to normal hygiene in the patients physical or developmental progress. Moreover, according to Weiss and colleagues, circumcision beyond the neonatal period is not without risk. In this case, there is no clear clinical benefit to performing circumcision in a 13-year-old individual who has no history of adverse impact secondary to his uncircumcised status. As such, the medical necessity of the requested circumcision has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male has requested foot orthotics for treatment of his acquired flat foot.  Findings:  The physician reviewer found that review of the submitted information demonstrates that the requested orthotics are not medically necessary for treatment of the patients medical condition. Orthotic therapy has been shown to be very successful for a multitude of foot pathologies. In this patients case, there is no evidence of a detailed physical examination in the documentation provided. Other than a diagnosis of acquired flat foot, there are no specifics as to this patient's faulty foot biomechanics. Feet are dynamic and change over time. In the absence of an in-depth physical exam, the medical necessity of the patients continued use of orthotics is not established. The submitted evidence does not demonstrate the patient meets accepted clinical indications for the use of orthotics such as foot disfigurement, diabetes or developmental abnormality. The medical record documentation does not reveal any evidence of these pathologies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female has requested an ankle arthroscopy procedure and use of a cartilage graft for treatment of ankle pain.   Findings:  Two physician reviewers found that the submitted documentation noted a 2 12 year history of painful osteochondral lesion of the talus which has failed previous conservative and surgical treatment, including a debridement procedure.  In this patients case, the requested services are likely to be superior over other available treatment modalities.  Per the current medical literature, recent studies have shown favorable mid-term results in terms of improved pain and functional scores following osteochondral grafts of the talus.  In this clinical setting, the requested ankle arthroscopy and use of a cartilage graft is the preferred treatment.  An alternate treatment option is ankle fusion, and this is likely to result in significant subtalar arthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female has requested abdominoplasty revision and belly button repair status post abdominoplasty.  Findings:  The physician reviewer found that the patients current condition does not constitute an abnormal structure of the body.  The requested surgery is not being performed to either improve function or create a normal appearance to the extent possible.  The reviewed medical records do not document any functional impairment as a result of the prior abdominoplasty surgery.  Therefore, the proposed surgery would not improve any functional deficit.  The photographs do not show any deformity or pathologic scar resulting from the abdominoplasty, so the revision surgery would not correct any visible deformity.  The mere presence of a scar does not make its removal medically necessary.  In the absence of medical chart documentation of unstable scar prone to skin breakdown, impaired function, or symptoms, such as pain or itching, the proposed revision of a scar is not medically necessary.  Per the submitted photographs, although the patients umbilicus is slightly large, it is not so large as to be considered an abnormal structure of the body.  All told, the requested abdominoplasty revision and belly button repair are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested coverage for dental anesthesia services for treatment of his dental anxiety.  Findings:  The physician reviewer found that per the American Dental Association, sedation for dental procedures can fall into the following categories local anesthesia, minimal sedation, use of nitrous oxide/oxygen (when used in combination with sedative agents may provide minimal, moderate, deep sedation or general anesthesia), moderate sedation, deep sedation, and general anesthesia. The American Society of Anesthesiologists (ASA) discussed the definitions of moderate sedation, deep sedation, and general anesthesia. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired and patients may require assistance in maintaining a patent airway. General anesthesia is described as a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. In addition, cardiovascular function may be impaired.Monitored anesthesia care (MAC) is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the ASA, MAC should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. MAC care includes all aspects of anesthesia care with a pre-procedure visit, intra-procedure care, and post-procedure anesthesia management. This patients records do not support the use of the requested general anesthesia as medically necessary for the proposed dental procedure. Specifically, there is no indication for general anesthesia for the recommended procedure. The patient is hemodynamically stable and there is no documentation of any developmental disability. His cardiac condition is stable and he is able to fully participate in sports. There is no indication he cannot undergo the procedure with local, minimal sedation, use of nitrous oxide/oxygen, moderate, or deep sedation. All told, the requested general anesthesia with MAC is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 22-year-old male has requested coverage for past residential treatment center (RTC) services provided for 27 days.  Findings:  The physician reviewer found that the patient had a previously undiagnosed drug problem consistent with polysubstance dependence. Based upon the documentation provided, he had no prior history of chemical dependency treatment, substance rehabilitation services, detoxification or psychiatric treatment, such as hospitalization, psychotherapy or psychotropic medication management at any level of care. Upon discovery of the magnitude of the patients drug use, his family believed this situation to be an emergency and phoned a substance use crisis line which recommended acute treatment and dispatched an interventionist to the home.  After that meeting, the patient was transported to a residential treatment facility for further treatment. The patient has requested reimbursement for the residential treatment services provided during the dates at issue. 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.A psychiatric emergency may be based on a wide spectrum of biological, psychological, and social problems. Although the cause varies, the common thread among all such emergencies is the requirement of an intervention to avoid permanent harm and prevent unnecessary morbidity and clinical deterioration. Given that the patient and his family did not have previous experience with appropriate treatment protocols in this situation, it would not be unreasonable for a layperson to consider the presenting matter an issue of life or death. Thus, the familys decision to seek emergent care was consistent with the response of a prudent layperson in this situation. However, while the patient was in need of prompt care that included a multidisciplinary treatment plan with well-delineated treatment goals and objectives, by the day following his admission an emergency medical condition, as defined above, no longer existed. On the next day, the patient was not experiencing acute symptoms of such severity that his transfer to another facility or treatment setting was precluded. As such, while a prudent layperson in this situation would have sought immediate medical attention, there is no evidence that the patient was experiencing an ongoing emergency medical condition from the day after the admission through the end of the remaining 26 days.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested a pain management consultation for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested pain management consultation in this patients case.  There is lack of documentation regarding the patients response to conservative therapy.  Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications.  Niemisto and colleagues performed a prospective randomized controlled trial to examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain.  The authors concluded that the manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone. The study showed that specific treatment programs with proper patient information may alter the course of chronic low back pain.  All told, the requested service is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that in a recent report by Sheets and colleagues, the authors noted that proton beam radiation therapy resulted in a greater risk of gastrointestinal toxicity versus intensity modulated radiation therapy.  There is a lack of published clinical data demonstrating that proton beam radiation therapy could lower the risk of radiation-associated malignancies.  Per current National Comprehensive Cancer Network guidelines, proton beam radiation therapy is not recommended for routine use at this time.  In this case, the provider reported that proton beam radiation therapy is needed in order to reduce the risk of hip fracture. However, evidence to support this claim was not provided.  There are no compelling data to suggest that proton beam radiation therapy is superior to intensity modulated radiation therapy, in general, or with respect to bone sparing.  All told, the requested proton beam radiation therapy is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 33-year-old female has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department for evaluation of a rash. She complained of the gradual onset of an itchy rash beginning two days prior to her arrival in the emergency department.  The medical records indicate her vital signs were normal, and she was not in any pain (0/10 on the pain scale). The physical examination revealed hives (urticaria) on her arms, legs and chest. She did not have evidence of upper airway edema, and she was not wheezing or in any respiratory distress. Her blood sugar level was unremarkable at 107, and her urine was negative for evidence of infection although it did show trace blood of uncertain significance. Her pregnancy status was unknown. There is no documentation in the medical records that a urine or serum pregnancy test was performed. She was diagnosed with urticaria and given Benadryl 50 mg orally while still in the emergency department.  She was discharged from the emergency department with prescriptions for Benadryl and Prednisone and instructed to follow-up with her primary care physician within two days.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.A review of the submitted evidence demonstrates that the patient had an itchy rash but had no fever, was not in any respiratory distress, and was not in any pain. Although it was later determined the patient was pregnant, the patient stated that at the time of her visit to the hospital, she was unaware she was pregnant. There was no documentation in the medical records that a urine or serum pregnancy test was ordered. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested a third penile implant for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested third penile implant in this patients case.  Per the medical records, he underwent placement of an inflatable penile prosthesis eight years ago.  The documentation noted that the patient was not satisfied with the length of the device and desired to undergo placement of a larger device.  Subsequently, replacement of the penile prosthesis was performed the following year.  This patient is now requesting coverage for a third penile implant.  The current medical evidence does not support the services at issue in this clinical setting.  The requested third penile implant will involve a high risk for complications and infection.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female has requested coverage for past repetitive transcranial magnetic stimulation  for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the services at issue.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the treatment of individuals with depression.  In this particular case, the patient was enduring an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued other standard therapies used to treat her depression.  The current medical evidence supports the services at issue in this patients case.  Based upon the medical records and peer-reviewed literature, transcranial magnetic stimulation was indicated to treat this patients depressive symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested systemic hyperbaric oxygen therapy for treatment of the enrollees brainstem glioma.  Findings:  Three physician reviewers found that childhood brainstem gliomas are extremely rare (Pfister and Witt). Radiation therapy is the mainstay of treatment, but it is not without its complications, including necrosis and edema (Govindan). This patient received several radiation doses and is now experiencing similar complications. In the peer-reviewed medical literature, there is phase II data showing clinical improvement after treatment with HBOT, especially in some patients who have failed treatment with steroids (Kuffler; Wanebo, et al). Since the prevalence of brainstem gliomas is so small, one cannot expect a randomized clinical trial testing HBOT. However, the current medical evidence is sufficient to support use of HBOT in this patient given her severe radiation-induced side effects that cannot be managed by steroids alone.