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

A 70-year-old male enrollee has requested right eye canaloplasty surgery and prospective canaloplasty of the left eye for treatment of his glaucoma.  Findings:  Two physician reviewers found that a glaucoma specialist performed a canaloplasty on the patients right eye with results and has recommended the same procedure for his left eye. The provider in this case presents his rationale for the procedure in that canaloplasty is a safer, more effective alternative than traditional trabeculectomy. The current research confirms this concern as there is a significant complication rate with trabeculectomy, even in the best of circumstances. In addition, the American Academy of Ophthalmology (AAO) reported that canaloplasty is part of the current standard of care in glaucoma treatment and surgery. The services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Botox injections and prospective future Botox injections for treatment of her chronic migraines.  Findings:  Two physician reviewers found that in the past, the patients headaches have been quite disruptive to her life.  She has tried Advil, Vicodin, Elavil and Imitrex for her headaches, with minimal relief.  More recently, she has tried a course of Botox with documented substantial improvement in the number of her headaches.  Her headache specialist has recommended the continued use of this therapy. Although Botox is not a first-line therapy for chronic headache disorders, there is adequate literature supporting the use of Botox for refractory headaches. In this particular case, the patient has failed several first-line therapies for headaches.  In addition, she had a documented response to a prior trial of Botox.  In this clinical scenario, Botox injections were and are likely to be the most beneficial treatment option.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested excision of three sebaceous cysts for treatment of his sebaceous cysts. Findings:  The physician reviewer found that the patient is requesting coverage for excision of three epidermal inclusion cysts.  Based upon the submitted records, he has not had other therapies, including intralesional steroid injection for acute inflammation or incision and drainage.  The cysts are benign growths without malignant potential. Given that they are not interfering with normal function or enlarging rapidly, treatment is not considered medically indicated.  There is a lack of symptoms, such as rapid growth, pain, drainage or impeding on adjacent structures.  Thus, excision of any of the cysts is not medically necessary.  The cysts are not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The proposed treatment is meant to create a normal appearance, as one of the cysts is located on the glabella, between the eyebrows, although the surgery is not expected to offer more than minimal improvement in the appearance of the patient.  All told, the requested procedure is not reconstructive in nature and is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures. Findings:  Three physician reviewers found that the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain. A literature search revealed no studies demonstrating or even assessing the efficacy of a heating/cooling system for the treatment of low back pain. As such, this therapy should be considered experimental at this time absent additional clinical trials demonstrating the equivalence or superiority of the device when compared to standard alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested Botox injection therapy for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has been diagnosed with chronic migraine, and tried and failed prior preventives. To date, the use of Botox for treatment of patients with chronic migraine has been evaluated in phase 3 studies. The patients were treated with 155-195 Units and showed definitive statistical and clinical benefits in terms of reduction in of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives even in patients who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients. Moreover, based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox as a chronic migraine preventive therapy, at dosing of 155 Units. Of import is that there are no other FDA approved medications for chronic migraine. As Botox is FDA approved for the indication of chronic migraine, it is not experimental. Therefore, Botox should be approved as per FDA indication.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that the patient has been diagnosed with chronic migraine, and tried and failed prior preventives. To date, the use of Botox for treatment of patients with chronic migraine has been evaluated in phase 3 studies. The patients were treated with 155-195 Units and showed definitive statistical and clinical benefits in terms of reduction in of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives even in patients who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients. Moreover, based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox as a chronic migraine preventive therapy, at dosing of 155 Units. Of import is that there are no other FDA approved medications for chronic migraine. As Botox is FDA approved for the indication of chronic migraine, it is not experimental. Therefore, Botox should be approved as per the providers treatment plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested a Laparoscopic Adjustable Gastric Banding System for treatment of his obesity.   Findings:  The physician reviewer found that based on the records provided, the patient meets the criteria set by National Institutes of Health (NIH) for weight loss surgery. In addition, Choi and colleagues applied the standards from the NIH, which recommend bariatric surgery for patients with a BMI of greater than 40 or greater than 35 with significant co-morbidities. The authors observed positive health outcomes in patients with a BMI between 30 and 35 with conditions such as hypertension, diabetes, GERD, and obstructive sleep apnea. Given that this patient has a BMI over the recommendation for bariatric surgery and has significant co-morbid conditions including hypertension, sleep apnea and GERD, the requested surgery has been established to be medically necessary for management of his health issues.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a follow-up magnetic resonance imaging (MRI) of the breast for evaluation of her atypical ductal hyperplasia. Findings:  Two physician reviewers found that the issue in this case is not whether the patient is a candidate for a screening exam, which would be based on her lifetime risk. Rather, this case concerns whether a follow-up MRI is appropriate based on the patients BI-RAD 3 category level of risk. Based on American College of Radiology guidelines, a BI-RAD 3 category (Probably Benign Finding) warrants short-interval follow-up. As with mammography, six-month surveillance is appropriate in this setting. It is also appropriate to follow this patient with the same modality that revealed the initial findings (MRI).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested adjuvant Goserelin therapy for treatment ofher Stage IIIA infiltrating ductal carcinoma of the right breast.  Findings:  Three physician reviewers found that women with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer. The interventions differ however for those who are premenopausal versus postmenopausal.  The Early Breast Cancer Trialists Collaborative Group (EBCTCG) published an overview and meta-analysis which showed a significant survival benefit for those women treated with ovarian ablation or suppression. There is a large study published in 2009 which showed that adjuvant goserelin was as effective as tamoxifen.  In those women not treated with tamoxifen, significant benefit of goserelin was seen for survival and recurrence rate. The National Cancer Institutes Physicians Data Query lists both options (tamoxifen or ovarian ablation/suppression) for premenopausal women with node positive disease. All told, there is sufficient scientific evidence demonstrating that this patient should continue with and complete her five years of adjuvant goserelin/letrozole therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested physical medicine therapy (CPT code 97139) and electric stimulation therapy (CPT code 97014) for treatment of her lumbosacral sprain/strain and lumbar subluxation.  Findings:  Two physician reviewers found that from a review of the available records, the exact nature of treatments provided is not clear. Specifically, the provider does not reveal whether the patient was treated with traditional physical therapy and medications although there is a recommendation for use of heat at home. CPT Code 97139 (physical medicine procedure) does not clarify exactly what procedure was performed. Further, the second type of therapy rendered appears to be use of interferential current (IFC) for pain relief. A review article published by Fuentes and colleagues indicates that IFC as a supplement to another intervention may be more effective in pain reduction than a control treatment and placebo. However, the authors concluded that, It is unknown whether the analgesic effect of IFC is superior to that of the concomitant interventions. Thus, the physical medicine therapy and IFC treatments in the management of this patients condition remain investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested the office/outpatient visit, chiropractic manipulation, and ultrasound therapy treatment for treatment of her lumbosacral sprain/strain and lumbar subluxation.  Findings:  The physician reviewer found that the clinical notes lack specific protocol and fail demonstrate the causative factors leading to the patients chief complaints. Further, the records do not report the effectiveness of treatment with pain analogs, improvement in performing activities of daily living, or advancement with exercises. The provider does not document the patients trigger points, which exercises and chiropractic techniques were utilized, and the specifics as to location of electrical stimulation and ultrasound therapies. Overall, the provider is expected to keep and maintain adequate case records clearly showing progression of care, treatment effectiveness, clinical impressions and assessment of a patients condition from visit to visit. In this instance, the records do not support a finding of medical necessity for the physical medicine care provided this patient from the dates in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested laser treatment for treatment of her sun damaged skin.  Findings:  The physician reviewer found that use of laser therapy provides cosmetic improvement in the appearance of photodamaged skin by decreasing redness and the appearance of superficial blood vessels. The effect of chronic sun exposure induces damage which in this patient has not produced any malignant or pre-malignant lesions. Further, there is no evidence that photodamaged skin exacerbates multiple sclerosis. Use of laser therapy in this patient would be considered to provide cosmetic improvement only. Thus, the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a thyroid scan for evaluation of her hypothyroidism.  Findings:  The physician reviewer found that for parathyroid evaluation, a radioactive iodine scan is used to assess function of the thyroid (i.e., hot, cold, focality of overproduction of thyroid hormone). An ultrasound is used to examine the configuration of the soft tissue structures in the neck including the thyroid and parathyroids. Given that this patients laboratory testing, including TSH, T3 and free T4 are within normal limits, there is no medical reason for further evaluation of the thyroid at this time. The patients laboratory testing including calcium, PTH and TFTs are all within normal limits and the provider did not find any physical findings indicative of the need for further examination. For these reasons, the requested thyroid scan has not been demonstrated to be medically necessary for evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested a neurological consult in addition to follow up neurological consults for treatment of her seizure disorder.  Findings:  The physician reviewer found that a neurologic consultation for neurologic complaints is standard of care especially when the PCP feels it is warranted. Several symptoms related to the nervous system can occur independently or dependently of each other and it is the specialist who provides the correct diagnosis. In a majority of cases involving neurologic disorders, PCP providers do not like to prescribe medications especially when there are significant side effects and laboratory studies needed in order to adequately monitor the patient. In 2008, due to the FDA memorandum on the risk of suicide, many providers who did not specialize in neurology but managed patients with epilepsy, began referring the patients to neurologist or epileptologist for standard of care treatment. In addition, the complexity of dosing and polypharmacy coupled with the need to monitor side effects makes the PCP reluctant to manage these patients and instead prefer to send them to the specialist who can provide the best care for such condition.In the absence of proof in this patients records that a neurologist is monitoring her AED usage, a referral to a neurologist is appropriate and within the standard of care. The frequency of visits is contingent upon the neurologic diagnosis and treatment being received. In this case, as the patient is on an AED therapy she should be seen at minimum of twice per year for routine follow ups, and more often as the situation dictates. Therefore, the requested follow up visit to a neurologist is warranted. Moreover, the records suggest an additional reason for referral due to head pain, which is a new complaint and also justifies a neurologic consultation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested emergency services for treatment of the patient's right eye redness. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient 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.The patient had a red eye symptom for one day prior to the emergency room visit and had no chronic medical conditions. The patient was in no acute distress, and there were no other associated symptoms according to the Emergency Room records. Vital signs and pulse oximetry were normal on arrival. The patient did not have any concerning signs such as inability to see, swelling, mass, inability to move the eye side to side, trauma, or fever.  The signs and symptoms the patient was having before his visit to the Emergency Room did not put the patients health in serious damage, serious impairment to bodily functions or serious dysfunction as judged by a prudent layperson. A prudent layperson would not think that signs of pink eye or eye infection and lacking any more concerning symptoms would warrant an urgent visit to the Emergency Room. While it is reported that the patients parent was advised by a hospital nurse to bring the patient to the Emergency Room, objective evidence confirming this conversation has not been provided. All told, a prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested the Walk-Aide functional electrical stimulation device for treatment of her multiple sclerosis.  Findings:  Three physician reviewers found that the device at issue (WalkAide) is primarily a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways during the swing phase of gait. The same result, however, is accomplished using a conventional (passive) ankle foot orthosis (AFO) such as a molded thermoplastic AFO. There are a few studies in the literature on functional electrical stimulator (FES) devices such as the WalkAide, but they have not generally compared FES devices against conventional AFO equipment. Sheffler and colleagues reported on a recent small clinical trial and found no significant functional improvement with use of a transcutaneous peroneal nerve stimulation device over a conventional ankle foot orthosis. Overall, FES devices for treatment of foot drop are experimental, investigational and unproven with respect to effectiveness and outcomes in comparison to conventional orthotic options for foot drop related to MS or other neurological conditions. In the present case, the patient is documented to have only mild weakness at the right ankle dorsiflexor. Further, it is not evident that she has been trialed with an optimally fitted conventional AFO. Since it has not been established that a custom molded AFO is inadequate to assist this patient in her foot drop secondary to MS, the use of the WalkAide was appropriately classified as investigational in this instance. Accordingly, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees pervasive developmental disorder, not otherwise specified.  Findings:  The physician reviewer found that ASD is a chronic neurodevelopmental disability that requires chronic management. Myers and colleagues noted that, The primary goal of treatment is to minimize the core features and associated deficits, maximize functional independence and quality of life, and alleviate family distress. Further, Pauls 2008 article noted that young patients with ASD have deficits in social interaction, impairment of communication and restrictive, repetitive and stereotypic patterns of behavior. The author commented that, Fluency and flexibility of expressive language are key components of the distinction between high and low functioning autism in school age children or adolescents. For treatment, it was suggested that speech therapy be considered a necessary tool for social function of communication and integration in society. In addition, Landa recommends early intervention to improve cortical specialization of the patients perceptual system and assist in intra- and inter-regional integration. With regard to occupational therapy (OT), Myers and colleagues support its effectiveness in young patients with autism in assisting with self-care skills, development of play skills, improvement of attention and organization, and pre-vocational training. They also found OT to help improve social skills and prepare autistic patients for independence. OT was associated with advancement in play skills, which in turn was correlated with improvement in speech and language skills (Landa). The data indicate that communication is more than just verbal language and OT assists young patients in learning appropriate social skills and interpersonal interactions with peers through play therapy using a naturalistic approach. Given the current status of the data, speech therapy and occupational therapy are considered routine interventions for autism. Moreover, these treatments should be introduced as early as possible to improve patients neurodevelopmental deficits. There are a growing number of articles which have documented the effectiveness of these treatment modalities. All told, this patient is an appropriate candidate for these medically necessary services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested group speech therapy for one hour per week for treatment of the enrollees autism. Findings:  The physician reviewer found that in this case, the patients speech therapist is recommending a one hour group speech therapy session in addition to the two hours of individual therapy indicating that the focus will be on improving the patients social and interactive skills with her peers. As this patient will soon be in a school classroom, she will be entering a group format for her education and will require communication skills with her peers in a variety of environments. For this purpose, it is necessary that she be exposed to larger groups of children in a structured setting prior to entering school. In addition, the treating speech therapist is the most qualified professional to determine the patients projected language needs. Given that the provider strongly suggests one hour of group therapy in two separate reports, it would be appropriate to add the additional hour of group therapy to her speech therapy sessions. Speech therapy has been documented in controlled studies as improving speech in autistic children (Goldstein and colleagues). The authors reiterate the need for speech therapy in autistic children and describe various forms of speech therapy for this population. Consistent with these recommendations, the requested additional one hour of group speech therapy has been demonstrated to be medically necessary for this patient.