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

A 50-year-old male has requested Oxycontin 40mg tablet (#60), twice per day for treatment of his cervical disc disease.   Findings:  The physician reviewer found that based on review of the available records, the requested Oxycontin is not medically necessary for treatment of this patients medical condition. Such narcotics and at the doses prescribed to the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic neck and wrist pain which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in this patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. In addition, Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested coverage for oxycodone liquid for treatment of the enrollees chronic pain syndrome, degenerative disc disease, and gastroesophageal reflux disease.  Findings:  The physician reviewer found that based on the records provided for review, the requested oxycodone liquid is medically necessary for this patients medical condition. The patient has a chronic pain condition due to degenerative joint disease of the spine. The patient also has severe digestive disease as documented by esophagogastroduodenoscopy and biopsy. The patient had multiple failed surgeries and tried several opioid medications without success. The patient displayed intolerance to oral medications as a result of her severe digestive disease. Liquid oxycodone at the current dose prescribed by her provider is an appropriate alternative to help reduce her chronic pain and maintain her functional status. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, injections and adjunctive medications to help reduce pain and improve the patients quality of life. Appropriately dosed opiates are considered adjunctive to this therapy with close monitoring by a certified physician (Fishman). In the medical literature, Staahl and colleagues performed a comparative study of oxycodone and morphine in a multi-model, tissue-differentiated experimental pain model. The authors concluded that a different pharmacological profile of oxycodone compared to that of morphine was shown, and noted that oxycodone may be a useful alternative to morphine in the treatment of visceral pain syndromes. Riley and colleagues performed a medical review to evaluate the efficacy of oxycodone in managing neuropathic and somatic pain, both malignant and non-malignant origin. The authors found that appropriately dosed oxycodone offers a fast onset of analgesia, controlling pain for hours and providing clinically meaningful relief of moderate to severe pain. In turn, the results included improved quality of life across a broad spectrum of pain types. The research indicated that oxycodone provides significant pain relief allowing relevant points of difference from other opioids and as such may be a suitable alternative to morphine. Therefore, the requested liquid oxycodone is supported as medically necessary for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested palivizumab for injection 100mg (5 doses) for treatment of his hypoplastic left heart syndrome.  Findings:  Two physician reviewers found that the patient was born prematurely at 35 weeks gestation.  He has a complicated medical history, including hypoplastic left heart syndrome status post Norwood procedure with Sano modification, borderline mild coarctation of the aorta following balloon angioplasty, chronic lung disease, obstructive sleep apnea status post tracheostomy tube placement, and seizures.  The patient has hemiparesis as a result of a stroke following one of his procedures.  The American Academy of Pediatrics guidelines for administration of immunoprophylaxis against respiratory syncytial virus (RSV) recognizes hemodynamically significant congenital heart disease and chronic lung disease as risk factors for severe RSV infection in children less than two years of age at the onset of RSV season.  However, there are individual cases of children older than 24 months of age with multiple severe cardiac and pulmonary conditions that may benefit from RSV immunoprophylaxis.  This patient has complex cyanotic congenital heart disease complicated by severe pulmonary hypertension and chronic lung disease.  In addition, he is technology dependent, with a tracheostomy and chronic oxygen requirement.  In this patients case, the requested services are likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male has requested laparoscopic gastric banding (Lap Band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all generally accepted criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. Specifically, the patient has a documented BMI that is greater than 35, and co-morbid conditions including obstructive sleep apnea, asthma, and GERD. The patient has reportedly failed dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. Consistent with these findings, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested coverage for past radiofrequency neurolysis for treatment of her lumbosacral spondylosis.   Findings:  Two physician reviewers found that the patient has chronic left-sided low back pain that appears to be facet related. The patient has had an anterior or transverse interbody lumbar fusion. According to the provider, the L4-5 and L5-S1 levels are fused but not posteriorly. The provider reports the patient has failed therapy, massage, medication therapy, TENS and acupuncture. The records indicate the patient had over 90% relief for the duration of the local anesthetic block administered and has responded well to the radiofrequency neurolysis. The patient in this case had blocks of the L3-4 and L4-5 facets for posterior element facet mediated lumbar pain after fusion. In many cases, posterior fusion destroys the anatomy of the medial branches and facet joints and fuses them completely. However, anterior and lateral fusions do not destroy the anatomy of the facet joint and often does not completely fuse or remove motion of the posterior elements. As in this patients case, the provider has blocked and ablated the nerves to the facet above the fused levels at L3-4. In addition, the provider ablated the nerves to the L4-5 joint. Given the patients response to medial branch block and the thorough work-up done by the provider, the procedure at issue is in accordance with the standard of care guidelines and interventional pain management guidelines. As this patient had previously failed conservative care and had good response to diagnostic blocks, the procedure at issue was likely to have been more beneficial than any available standard therapy in treating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female requested coverage for NeuroStar transcranial magnetic stimulation therapy provided over a one-month period for treatment of the enrollees major depressive disorder. Findings:  Three physician reviewers found that the patient has major depressive disorder.  A letter from the provider noted that medications such as Zoloft and Paxil did not yield a clinically significant response at therapeutic levels.  The patient endorsed irritability, hopelessness, increased levels of anxiety, excessive ruminations and difficulty completing tasks.  She has requested coverage for NeuroStar transcranial magnetic stimulation therapy.  In this patients case, the services at issue were not likely to have been more efficacious than other available treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond to medication therapy.  However, this patient has reportedly only been treated with two different antidepressants.  There is no information in the record to show that other first-line treatments have been tried.  The submitted documentation does not show that the selective serotonin reuptake inhibitors (SSRIs) have been augmented with medications such as Abilify or Seroquel, or with more traditional augmentation strategies, such as lithium or thyroid hormone.  There is also no evidence that the patient has been treated with any antidepressant of a class other than SSRIs.  Therefore, NeuroStar transcranial magnetic stimulation therapy provided during the timeframe in question was not likely to have been more effective than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested reimbursement for a wearable cardioverter defibrillator (LifeVest) provided for seven months for treatment of the enrollee, who has been diagnosed with severe non-ischemic dilated cardiomyopathy.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device at issue.  Based on the records provided, the patient presented with a newly diagnosed non-ischemic cardiomyopathy, with an ejection fraction reported to be 25% to 34% on imaging studies.  At the time of diagnosis, there was potential for recovery of left ventricular function with appropriate treatment, and there was no indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia or syncope due to sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time has elapsed (greater than 90 days) where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment.   Placement of a prophylactic defibrillator before this time has not been demonstrated to improve outcome.  The current medical evidence does not support the use of the device at issue in this clinical setting.  All told, the wearable cardioverter defibrillator (LifeVest) was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested reimbursement for mental health inpatient stay of four days.  Findings:  The physician reviewer found that the hospital progress notes and discharge summary indicate that the patient was no longer in any danger of harming herself and was stable enough for discharge by the third day. The letter from the provider reports that the patient was kept in the hospital on the third day so that a family session with her mother could be held on the fourth day. The mother was out of town until the evening of the third day and was not available for the session that day. However, the definition of medical necessity includes a statement that the care being provided is not solely for the convenience of the facility or the patient. In this case, the extra day of hospitalization was for the benefit of the family. Had the patients mother been available for the family session one day earlier the patient could have been safely discharged that day. Thus, medical necessity criteria are not met for the inpatient mental health services provided on the third and fourth days. All told, the services provided to this patient the first two days were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male requested reimbursement coverage for residential treatment services provided from a specific date and forward for treatment of his cocaine dependence and major depression. Findings:  The physician reviewer found that modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience, and mental wellness.  Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with substance dependence is a challenging endeavor.  Clinical guidelines and patient placement criteria have been developed to assist with the determination process.  In this patients case, his substance abuse dominated social and family dynamics.  Further, he currently lacks a harmonious living environment and social supports to facilitate recovery.  Therapeutically, the patient has not yet consolidated the treatment gains needed to succeed in a community setting.  Although he is described as motivated to participate in treatment, he remains at a high risk for relapse.  Additionally, there is a high risk that continued drug use will exacerbate his major depressive disorder to the extent that treatment in a less restrictive level of care cannot be safely provided at this time.  In this clinical setting, residential treatment services provided from the date in question and forward were and are medically indicated.  It is reasonable to anticipate up to a four-week residential placement before pursuing a transition to less restrictive setting, such as partial hospital or intensive outpatient programming.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested continued skilled nursing care and rehabilitation services for treatment of his acute pancreatitis, hypertension, and end-stage kidney disease.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  As of the date at issue the patient had plateaued with daily skilled therapy services.  He was stable on his medical regimen.  The patient was tolerating a full diet, and he had no complex wound care issues.  The documentation noted that the patient was able to ambulate 75 feet with a four-wheeled walker with stand by assistance, and he was able to transfer with stand by assistance.  He was stable with his activities of daily living.  Per the medical records, there is no medical indication for continued daily skilled nursing or therapy needs at this time.  The documentation does not demonstrate that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled nursing services.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 22-year-old female has requested coverage for past emergency services provided.   Findings:  The physician reviewer found that the patient presented to the emergency department with a chief complaint of a sore throat and fever since the previous day. She rated her throat pain as 9 on a scale of 1 to 10. The physician noted the patient had a fever of 102.6 degrees Fahrenheit and a rapid heart rate at 112. Her blood pressure and respiratory rate were normal. Physical examination revealed tonsillar hypertrophy (left side greater than right), tonsillar exudates, and cervical lymphadenopathy. A throat culture was performed, but a rapid strep screen was not obtained. A diagnosis of pharyngitis - strep presumed was made, and the patient was treated in the emergency department with four medications (all given orally): Motrin, Tylenol, Norco, and penicillin. She was discharged from the emergency department with a prescription for penicillin (10-day course) and Norco 5/325 #24 for pain. The patient was instructed to follow-up with her primary care physician in 2-3 days if not better.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.The patients symptoms on the date at issue met prudent layperson criteria for emergency care. The patient had a bacterial infection of her throat with abnormal vital signs (elevated temperature and heart rate) and was documented to be complaining of severe pain (9 out of 10). A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. All told, an individual in this patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old male has requested three to four weeks of acute rehabilitation services for treatment of his medical condition status post cerebrovascular accident.   Findings:  The physician reviewer found that based on review of the available records, the patient had a severe stroke and has aphasia. He will need an extensive period of recovery. The best predictor of stroke outcome is severity of stroke. The intensity of stroke rehabilitation has little impact on outcome (Zhu, et al). It may hasten the time to recovery but will have little to no impact on the outcome at six months (Kwakkel, et al). Care provided in a subacute unit is expected to achieve the same outcome. Overall, the patient is not expected to make full recovery and will remain with significant disability. Discharge to the community will result in similar outcomes as continued stay in the facility, but his needs may exceed what will work for him in the community (Langhorne, et al). The additional services provided in inpatient acute rehabilitation cannot be justified based on the patients needs and expected duration of therapy. All told, the additional services will not improve his outcome or increase his ability to return to the community (Belda-Lois, et al).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for six hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments.  Warren et al reviewed 34 studies of early intervention in autism. They concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al). The goals for older children often are to identify and remediate particular deficits. Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patients behaviors that need to be addressed include maladaptive behaviors of communication, complying with requests, increasing functional life skills as well as social and language skills. All told, ABA therapy is medically necessary for treatment of this patients medical condition at the requested frequency of six hours per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested coverage for a cranial molding helmet for treatment of torticollis and plagiocephaly.  Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although rare, some cases are severe enough to require surgery for correction (Gupta, et al; Graham, et al). Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (Biggs). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. In 2003, the American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants (Persing, et al). According to Graham and colleagues, for those infants who do not make progress with repositioning and tummy-time, with severe persistent brachycephaly (CI greater than 90%) at age 5 months, use of an orthotic helmet will correct the brachycephaly and any associated plagiocephaly. For infants with extreme occipital flattening, prolonged treatment may be necessary. This patient has abnormal head shape and torticollis that has been treated conservatively with repositioning, neck exercises, and physical therapy without improvement. Anthropometric measurements indicate significant brachycephaly with some degree of plagiocephaly. At this patients age, a cranial molding orthosis is essential to offer the best chance at normalizing his head shape. A cranial molding orthosis is thus medically necessary and appropriate.