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

A 57-year-old female enrollee has requested assessment of emerging factors test for coronary heart disease for evaluation of her history of elevated cholesterol. Findings:  Two physician reviewers found that current guidelines do not recommend routine use of advanced lipoprotein tests because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. To date, the most useful measures obtained from lipoprotein tests relate to atherogenic particle number. However, at this time, the non-HDL cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength. LDL size is correlated with atherogenic particle number, but it has no clear benefit over measuring particle number in most studies to date. LDL sub-fractions measurement does contain some information regarding risk, but whether this is incremental beyond the current standard of care is unclear at this time.  In this particular patient, previous fasting lipid studies showed extremely high LDL and severely low HDL, necessitating intensification of statin therapy with continuation of high dose niacin and adding other potentially useful agents. As such, and given the other known baseline coronary risk factors (hypertension hyperlipidemia and post-menopausal state), there is no additional diagnostic or prognostic information to be gained by the requested testing.  This patient is already at high risk for a cardiovascular event due to the presence of multiple traditional risk factors. All told, assessment of emerging risk factors for coronary heart disease is not likely to be more efficacious than alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested Lyme disease treatment for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation includes no confirmatory evidence of any infectious disease. While it is stated that the patient has a diagnosis of Cryptosporidiosis, there is no objective documentation provided to support this diagnosis. Further, the diagnosis of CMV infection is not validated by the submitted documentation. As detailed above, all of the testing for Lyme disease was negative by standards established by the CDC. Moreover, evidence of Bartonella is not provided. All told, there is a lack of objective evidence confirming the diagnosis of Lyme disease in this patient. In the absence of such evidence, the medical necessity of the proposed treatment is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech and language therapy for treatment of the enrollees developmental delay and autism. Findings:  The physician reviewer found that deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the young patient has for developing adequate skills to function in the community. In the published literature, Myers and colleagues noted that, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Children with autism have deficits in speech and language, as well as social interaction and pragmatic communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are the most appropriate providers. For these reasons, the requested speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a then 1-year-8-month old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients mothers 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 patients mother indicates the patient was coughing and having difficulty breathing. Records from the ER describe the patient as being playful with normal vital signs. With normal vital signs, no fever and activity within normal limits, this patients condition would not have lead a prudent layperson to believe the patient was experiencing symptoms that required immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested inpatient care services for treatment of his substance abuse. Findings:  The physician reviewer found that the records reviewed suggest that the patient had attained sobriety while in the IOP program. There is also evidence of a co-morbid psychiatric condition, which was not adequately treated and may have been interfering with his recovery. However, the data reviewed fails to support the conclusion that he met dimensions 5 and 6 of the American Society of Addiction Medicine (ASAM) patient placement criteria for residential treatment. Further, the records do not indicate that he could not have been safely and effectively managed in a less intensive setting with adjunctive psychiatric follow-up. Hence, the residential treatment at issue was not medically necessary according to both ASAM and American Psychiatric Association (APA) practice guidelines. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested occupational therapy utilizing sensory integration techniques for treatment of the enrollees flaccid hemiplegia. Findings:  Two physician reviewers found that in the available medical literature it becomes clear that the requested occupational therapy with sensory integration is medically indicated for this patients flaccid hemiplegia. Specifically, this conclusion is based on the articles by Yu and colleagues, and Bumin and Kavak. Cerebral palsy is a chronic condition and this patients history clearly demonstrates acute impairment of her ability to learn different motor strategies for maximizing function of her limbs affected by her flaccid hemiplegia. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease such as the pathogenetic process that gave rise to this patients cerebral palsy and speech and language delays, still exists, and can be utilized to improve overall neurologic health. Thus specific treatment, including occupational therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, sensory integration-based occupational therapy for this patient is necessary to reduce the physical and mental effects of the underlying neurologic condition and to achieve maximum function in maintaining daily activities affected by this patients flaccid hemiplegia. Thus, in this instance, the requested occupational therapy utilizing sensory integration techniques should not be considered investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that the requested services of speech therapy for this patients speech and language delays are medically necessary based on an overall evaluation of the relevant medical literature. Lane and Schaaf discussed the notion of plasticity in the developing brain in terms of rehabilitation outcomes in young patients with developmental deficits. The authors noted that although the patients present with underlying neurologic disease, such as the pathogenetic process that gave rise to this patients cerebral palsy and speech and language delays, therapy can be utilized to improve overall neurologic health. Thus specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy for this patient is necessary to reduce the physical and mental effects of her underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested services relating to an autologous stem cell transplant clinical trial for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  Three physician reviewers found that although there is some promising preliminary data, the benefits of the use of stem cell transplant for chronic inflammatory demyelinating polyneuropathy have not yet been proven.  Its use cannot be supported for this condition until larger, controlled, clinical trials can demonstrate safety and efficacy for this population.  The literature provided above demonstrates one very small preliminary study of stem cell transplant for this condition.  The other studies demonstrate how a stem cell transplant can initiate chronic inflammatory demyelinating polyneuropathy and provide a sample of the significant safety concerns of this potential therapy.  Given these significant safety concerns, and the fact that efficacy has not been proven, the requested services are not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing this patients medical records, it becomes clear that the requested speech therapy and occupational therapy are medically necessary for treatment of his delays secondary to autism. This conclusion is based on an overall evaluation of the relevant medical literature. Lane and Schaaf discussed the notion of plasticity in the developing brain in terms of rehabilitation outcomes in young patients with developmental deficits. The authors noted that although the patients present with underlying neurologic disease, such as the pathogenetic process that gave rise to this patients speech and physical delays, therapy can be utilized to improve overall neurologic health. Thus specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy and occupational therapy are medically indicated for this patient to reduce the physical and mental effects of his underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested Botox injections for treatment of her temporomandibular pain and headaches.  Findings:  Two physician reviewers found that the medical records indicate that the primary reason this patient was treated with Botox has been migraine headaches. While Botox is experimental for the treatment of TMJ dysfunction, it is FDA approved for the treatment of migraines. In the scientific data, Diener and colleagues reported on large studies evaluating the safety and efficacy of Botox for migraine. The authors found numerous studies with positive outcomes capable of reproduction outside of the research environment. This patient has been treated with multiple medications and narcotics including methadone. The records document that the frequency of visits to her provider and need for pain medications were decreased when treated with Botox. Given this patients response to Botox therapy, the treatment should be approved for her migraines. With regard to frequency of treatment, Botox should not be administered more than every 3 months as the results last approximately 3-4 months.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested 14 treatments of Avastin in combination with chemotherapy (carboplatin and Gemzar) for treatment of her metastatic ovarian cancer.  Findings:  Two physician reviewers found that the treatment of relapsed ovarian cancer can be quite complicated.  There are many agents that have good response rates.  One of the first determinations to make in relapsed patients is whether the tumor is platinum sensitive or resistant. Additionally, the longer the treatment-free interval, the higher the probability of response to platinum chemotherapy.  This patient went approximately 18 months without therapy and would be estimated to respond well to platinum.  The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials and is now considered the standard.   Phase II studies with Avastin have shown promise in patients with platinum-refractory disease, which is not the case here.  In the setting of this first relapse, there is a lack of medical evidence indicating that the addition of Avastin would confer improved survival.  All told, 14 treatments of Avastin in combination with chemotherapy (carboplatin and Gemzar) were not likely to have been superior over other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a heating/cooling device for treatment of her stated condition of arterial venous malfunction.  Findings:  Two physician reviewers found that there are few published articles reporting on the use of cryotherapy in the setting of musculoskeletal injury and post-operative care. In 2004, Hubbard and Denegar reported that, Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury. There are more data with regard to the use of an active cooling device in treatment of the knee during the early inpatient hospitalization period following knee surgery (Saito and colleagues). Overall, the studies do not indicate or suggest that the use of the cooling devices is indicated for use in the post-operative period outside of the hospital, or that such use results in better outcomes over the use of basic cooling measures such as regular ice bags. The device at issue in this case is an active cooling device. There is no high grade published literature supporting the clinical efficacy of this device in this patients clinical condition. Moreover, this device would not have been expected to significantly improve the patients health or functional outcome over cooling provided by topical ice packs and elevation.  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: Urgent Care
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested emergency services for treatment of the presence of menstrual period over three weeks and cold symptoms.  Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson in the enrollees circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.A prudent layperson experiencing vaginal bleeding for three weeks, dizziness for two weeks, and fever with a history of dysfunctional uterine bleeding and uterine fibroids in the past would not believe she was experiencing a medical emergency under these circumstances. While the patient contends that she had been diagnosed with uterine fibroids/leiomyomas and was concerned her symptoms would be life threatening, a prudent layperson in this situation would not consider chronic symptoms of prolonged and heavy vaginal bleeding and dizziness to be a life threatening condition. Although the patient maintains that previous discharge instructions she received from the ED indicated she should seek immediate medical attention in the event of a sudden increase in pain or symptoms associated with her uterine fibroids, the patients symptoms had been occurring for two to three weeks at the time she sought care in the ED. As such, a prudent layperson in these circumstances would have sought care from her primary care provider. Furthermore, the additional symptoms of fever, runny nose and flu symptoms also would not be considered a medical emergency according to a prudent layperson. While the patient indicates she was experiencing a high fever, there is no objective evidence of such at the time she sought emergency services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without contrast (CPT 72148) for evaluation of her chronic low back pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient does not have absent reflex, muscular weakness or atrophy. Although she has some change in symptoms since her previous MRI, there is no contraindication to the patient undergoing a course of physical therapy prior to approval of a repeat MRI scan.  Therefore, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59 year-old female enrollee has requested the medication Sutent 25 mg for treatment of her uveal melanoma.  Findings:  The physician reviewer found that this patient has a rare disease, ocular melanoma, with sparse data in terms of clinical studies in the medical literature. Flaherty and colleagues reported on one series of patients with metastatic uveal melanoma. The authors found poor outcomes once uveal melanoma metastasized, thus they concluded that prevention of metastasis is optimal. To achieve this goal, adjuvant therapy has been utilized in well selected patients. In contrast to cutaneous melanoma, the ocular tumors have a high rate of KIT mutations making this an attractive target with tyrosine kinase inhibitors, such as Sutent. The abstract cited by the treating oncologist presents Sutent use in stage IV patients and the results only document 2 partial remissions and 12 patients with stable disease. While this cohort with hepatic metastases has a very poor prognosis and may not be an accurate depiction of Sutents potential, there is a lack of other outcome data from IRB-approved clinical trials documenting beneficial results in patients without metastatic disease. All told, there is inadequate published data to support the use of Sutent in this particular setting. As such, the medical necessity of Sutent as adjuvant therapy for this patient has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested emergency services for treatment of his medical condition.   Findings:  The physician reviewer found that the issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. This patient had a headache of undetermined etiology which was described as extreme in its pain, and was unremitting over four days. He consulted his primary care provider. A letter from his primary care provider states the patient was advised to go to the emergency room by our office... In light of the patients pain level as well as the advice he received from his primary care provider indicating that he should go to the emergency room, a reasonable and prudent layperson in this situation would have believed he was experiencing a medical condition requiring immediate medical attention. Therefore, the patient met prudent layperson criteria for emergent care on the date of service in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-month-old female has requested a laser frenulectomy procedure for treatment of the enrollees condition.  Findings:  The physician reviewer found that given that two of the providers who evaluated the patient noted findings describing a thickened frenulum (posterior ankyloglossia), it is likely that this was an appropriate diagnosis. As reported in the relevant medical literature, the posterior ankyloglossia can sometimes be missed (Chu and Bloom). For treatment, laser has been found to be an effective method of improving the difficulties secondary to this medical problem (Puthussery, et al). The thickened short frenulum can be treated with other methods, but considering that this patient has improved since the laser frenulotomy, the requested laser frenulectomy has been demonstrated to be medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested an occipital nerve stimulator for treatment of his occipital neuralgia. Findings:  Three physician reviewers found that with review of the all of the documentation provided including the additional records provided by the patient does not demonstrate that occipital nerve stimulation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is still a lack of evidence that the patient has tried and failed anticonvulsant or antidepressant therapy. These medications are cited in peer-reviewed literature as safe and efficacious therapy in occipital neuralgia. There is a lack of scientific literature establishing occipital nerve stimulation as a superior modality compared to these standard treatment options. Therefore, the contention that the patient is likely to derive greater benefit from occipital nerve stimulation than from standard modalities remains unsupported.