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

A 59-year-old female enrollee has requested for Actiq 400mcg lozenges for treatment of her pain. Findings:  The physician reviewer found that there is a lack of randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are several case series and individual case reports in the literature. Its effectiveness in non-malignant pain remains unproven in randomized controlled trials. Bennett and colleagues described several alternatives to this medication. Per Simon, current limitations to the use of rapid-onset opioids in non-cancer pain include the fact that published studies have focused on patients with cancer-related pain. Simon noted that studies in chronic, non-cancer pain that also measure patient function are needed. Additional unanswered questions include the potential for an increased risk for opioid misuse, potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around-the-clock. Fishman discussed the measurement of pain using a visual analog scale demonstrating the effectiveness of the opiate and the use of an opiate maintenance log agreement along with periodic urine toxicology tests. The documentation provided does not address the use of visual analog scales that demonstrate opiate responsiveness, and there is no documentation of other classes of medications that have been tried. Nor does the submitted documentation include evidence of an opioid maintenance agreement or of any toxicology testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Botox injections for the treatment of her migraine. Findings:  The physician reviewer found that this patient has had episodic migraine at high frequency. She has required acute, abortive therapy as well as preventive therapy. She has been refractory to beta blockers, but has had reduction of headache severity and frequency with Botox therapy. A literature review shows that Botox can be beneficial for individuals with chronic headache as well as high frequency episodic migraine. The medical necessity of Botox therapy for this patient should be determined by whether she has a significant disease burden, as well as whether Botox therapy has a significant probability of success. In this patients particular clinical situation, Botox therapy does have a significant probability of success and the patient does have a significant disease burden.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for the Flector 1.3% patch for treatment of her osteoarthritis and tendonitis.  Findings:  The physician reviewer found that it appears that this patient has significant osteoarthritis in her ankles. Generally, NSAIDs, including topical forms, are indicated for treatment of acute and chronic musculoskeletal inflammatory pain. It is reasonable to prescribe the administration of topical forms of NSAIDs to patients who have gustatory dysfunction. Continuation of oral NSAIDs in patients who experience gastrointestinal (GI) side effects is contraindicated, as these can cause significant pain and discomfort and can be fatal in extreme cases.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Actonel 35 mg/wk for treatment of her osteoporosis. Findings:  The physician reviewer found that scientific evidence comparing Actonel to Fosamax is limited. In one head-to-head comparison study of Actonel versus Fosamax (sponsored by the manufacturer of Fosamax), the authors concluded that patients receiving 70 mg (once weekly) of Fosamax had greater gains in bone mineral density (BMD), were more likely to maintain or gain BMD, and had greater reductions in bone turnover markers than patients receiving 35 mg (once weekly) Actonel (see Bonnick and colleagues). The authors further reported that no differences were seen in occurrence or discontinuations due to upper gastrointestinal adverse experiences in this study. Additional studies comparing these two agents are lacking. Nevertheless, based on the records submitted, there is no compelling medical reason in this clinical situation which precludes this patient from using Fosamax. There is no indication from the records provided that Fosamax will not be effective for this patient or will result in untoward side effects.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested right knee meniscal allograft replacement, medial major debridement, chondroplasty and anterior cruciate ligament reconstruction surgery for treatment of his right knee instability secondary to chronic anterior cruciate ligament insufficiency.  Findings:  The physician reviewer found that the current status of the use of paste graft is not supported in the clinical literature as having equal or better outcomes than standard alternative procedures. The primary support for paste graft procedures is based on small case reports or anecdotal reports of benefit. There is insufficient scientific literature to allow for a meta-analysis comparing the proposed surgery to other procedures. All told, there is not enough reliable data to establish the role of a surgical procedure utilizing paste graft procedures and meniscal allograft replacement in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested LifeVest wearable cardioverter with external defibrillator for treatment of his medical condition status post myocardial infarction.  Findings:  Two physician reviewers found that based on the records provided, this patient suffered an acute cardiac arrest in the setting of ischemia and non-ST segment elevation myocardial infarction after an exercise stress test. He was subsequently stabilized and underwent urgent coronary revascularization.  At the time of cardiac catheterization, his ejection fraction was reported to be 50-55%. In this circumstance of ventricular fibrillation during a myocardial infarction, relatively preserved ejection fraction (greater than or equal to 50%), and subsequent coronary revascularization, further risk of sudden cardiac arrest is not elevated to a degree where an implantable cardiac defibrillator (ICD) is medically indicated. Moreover, the documentation does not indicate that the patient had reduced ejection fraction of less than or equal to 35% and did not suffer recurrent ventricular tachycardia or ventricular fibrillation after coronary revascularization on the said date. A wearable external defibrillator would be indicated only if the criteria for an ICD were met and an ICD could not be placed, needed to be delayed, or required explantation. The criteria for ICD placement appropriately requires a period of time, generally 40 days post myocardial infarction or 3 months after newly recognized cardiomyopathy, prior to ICD placement. As noted by Gronefeld and colleagues, the efficacy of prophylactic defibrillators used earlier than 40 days after myocardial infarction, or at the time of coronary bypass has not been proven in the medical literature. In summary, a prophylactic wearable defibrillator has not been shown in the medical community to have clinical value in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested autologous chondrocyte implantation of the right knee, along with ligament reconstruction with allograft for treatment of the enrollees articular cartilage defect of the patella. Findings:  Two physician reviewers found that review of the scientific literature and the patients medical records reveals two main problems with utilizing autologous chondrocyte implant in this case. First, there is a lack of comparative studies comparing the proposed methodology to previous methodologies. Second, the defects in this patients patella are no longer limited to the single defect that was noted at the time of her first surgery; the defects are now widespread. Based upon the MRI, the patient now presents with a much larger problem involving multiple areas of cartilaginous damage. An operative procedure to replace the patella in its normal groove is warranted, and there are multiple techniques that can be utilized by orthopedic surgeons to accomplish this. In this patients case, the requested procedure is not likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested a pneumatic vest airway system (the Vest Airway Clearance System) for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that persistent bacterial bronchitis (PBB) is a clinically diagnosed condition characterized by the following: chronic wet cough lasting more than four weeks, resolution of the cough following antibiotic therapy, and absence of other conditions that could be responsible for the cough. Children with PBB are often misdiagnosed with asthma, although PBB and asthma may coexist. Treatment is based on eradicating the bacteria with antibiotics and measures to improve cough effectiveness and keeping the airways free of infection to allow healing (Chang and colleagues). Manual chest physiotherapy (CPT) is one way in which to facilitate airway clearance. Children with recurrent PBB should undergo evaluation for bronchiectasis and its causes. There is some concern that PBB may be antecedent to bronchiectasis. CPT, while effective initially, can become less so as a child grows. It is also undesirable in patients with gastroesophageal reflux (as this patient has), as the positioning required may exacerbate this condition. High-frequency chest wall oscillation (HFCWO) such as the Vest Airway Clearance System was developed to improve airway clearance in those patients where the normal mucociliary transport system has failed (e.g., chronic bronchitis, bronchiectasis, cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. Research confirms the utility of these systems in airway clearance. In stable outpatients with cystic fibrosis, high-frequency oscillation and chest physiotherapy were found to have comparable augmenting effects on expectorated sputum weight without changing PFTs or oxygen saturation (Scherer and colleagues). Systems such as the Vest Airway Clearance System are now clinically established as appropriate therapy for patients with airway clearance problems. Although it has been best studied in patients with cystic fibrosis, its use has been expanded to include a wide variety of patients with similar difficulties. It is therefore medically necessary and appropriate to provide the VACS therapy system to this patient to facilitate his mucus clearance, particularly in light of his GERD.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested emergency services for treatment of her medical condition.  Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had been experiencing a cough for the past five or six days. She had no concurrent symptoms such as a fever or vomiting. Although she was pulling at her ears, on the night she was evaluated the patient did not appear to be in any distress. The physicians notes document that the patient was alert and animated. The patient did not require any pain control or any medications in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms do not meet criteria for an emergency medical condition. A prudent layperson in the parents circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested continued physical therapy for treatment of her thoracic outlet syndrome and cervicalgia. Findings:  The physician reviewer found that the goals for this patient included further reduction in pain with various activities, increased upper extremity strength and increased cervical range of motion. Therapy notes document that the patient is responding well to physical therapy at an appropriate pace of recovery. Specific goals justifying additional therapy have been established, and these goals should be achievable in a reasonable and predictable period of time. Physical therapy is an effective treatment for cervicalgia, as noted by Hoving and colleagues. It is also the initial treatment of choice for thoracic outlet syndrome. Continued physical therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Lyrica for treatment of her peripheral neuropathy.  Findings:  The physician reviewer found that this patient has chronic neuropathic pain. Lyrica is often useful for the treatment of neuropathic pain from a variety of sources. The Health Plan denied the request for Lyrica noting that there is only FDA approval of the use of Lyrica for post-herpetic neuralgia (PHN), diabetic neuropathy pain, fibromyalgia, and epilepsy. PHN and diabetic neuropathy are often the most-studied conditions in new medication trials for neuropathic pain due to their relatively high prevalence. Medications useful for the treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. The clinical literature supports the benefit of Lyrica not only for diabetic peripheral neuropathic pain, but also for other painful neuropathies. Treatment in this case can reasonably be extrapolated from the clinical data and experience with the use of Lyrica for the treatment of diabetic neuropathy, as well as this patients prior beneficial experience with Lyrica. Based on such data, the use of Lyrica in this particular setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old female enrollee has requested the medication Benicar (20 mg in the a.m. and 20 mg in the p.m) for treatment of her hypertension. Findings:  The physician reviewer found that the use of a total daily dose of Benicar (olmesartan) 40 mg is medically necessary for this patients clinical situation. In head-to-head studies, Benicar delivered superior blood pressure reduction when compared with other angiotensin-II receptor antagonists at their recommended doses. According to the manufacturer, the dosage of Benicar must be individualized with an initial starting dose of 20 mg. For patients requiring further reduction in blood pressure after two weeks of therapy, the dosage may be increased to the maximum effective dose of 40 mg. A Benicar regimen effectively lowers blood pressure in the elderly patient population. According to the manufacturer, no initial dosage (20 mg) adjustment is recommended for elderly patients due to a concern with modest accumulation in some patients. This admonition is based on the age of a patient, which is one of the criteria used to estimate kidney function in patients, and thus their susceptibility to accumulation. However, a maximum dose of 40 mg is not necessarily contraindicated based on the patients age alone. According to this patients blood test, she has neither hyperkalemia associated with a low glomerular filtration rate (GFR) nor pre-renal azotemia, both of which are contraindications to using Benicar. All told, a total daily dose of 40 mg of Benicar has been effective in controlling this patients hypertension, and there is no evidence this dose is contraindicated based on the information provided.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he or she was experiencing an emergency medical condition. 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient presented with visible exudate, or pus, on the pharynx. On physical examination, the provider recorded pain, fever, and difficulty swallowing. All of these symptoms are characteristic of a bacterial infection that a prudent layperson would consider to require immediate medical attention. The patient was prescribed an antibiotic and was able to begin treatment immediately for his condition in lieu of waiting for the end of the weekend to be seen by his primary care provider by which time his condition could become even more acute.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested emergency services for the treatment of her medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients 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.This patient presented with complaints of back pain for a six day duration. She had been evaluated in the ED for the same symptoms three days prior.  She was medicated and referred back to her primary care physician. She did not contact her primary care physician following the initial ED visit. The medical records do not document any acute neurologic deficit. The patient appeared in no distress. She had not sustained any acute injury. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergency basis. A prudent layperson in the patients circumstances would not have reasonably believed she was experiencing a medical condition that required immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested a referral for speech therapy for treatment of the enrollees delayed speech and stuttering. Findings:  The physician reviewer found that stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder (see Ward and Lawrence and Barclay).This patient presents with multiple speech and language difficulties. It is important to address these deficits with a referral for speech therapy in order to improve his communication skills and prevent difficulties in the future that may not be as amenable to therapy at that point
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested social cognitive speech therapy and sensory integration occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the World Health Organizations International Classification of Functioning, Disability and Health (ICF) considers occupational and speech therapies to have medical value in patients who qualify based on ICFs definition of health, function and disability. While school therapies will often focus on socialization, communication, social interaction, and pragmatics, there are many aspects of pragmatic, expressive and receptive language that will not be taught by the school programs. These include safety issues in the home, dressing skills and activities of daily living (ADL), social interactions with siblings, and home skills including following parental direction, parent education and treatment of sensory issues related to the home and community. Treatment of these issues involves both social cognitive speech therapy and sensory integration occupational therapy, as these issues are often intertwined. These problems include a behavioral component and directly affect the patients function outside the school setting. In this case, the out-of-network speech therapy evaluation documented the patients speech issues. The evaluation indicates that the patients primary deficits involve auditory learning and processing language. Based on the patients deficits as documented in the out-of-network speech therapy evaluation, social cognitive speech therapy services are medically appropriate and necessary for this patient. The patients speech and language deficiencies affect his functional capacity across multiple settings (i.e., home, school and community) and as noted above, school-based therapy will not address all aspects of the patients pragmatic, expressive and receptive language delays. Concerning the request for sensory integration occupational therapy, the occupational therapy evaluations provided are insufficient in that no standardized testing was performed and activities of daily living were not adequately evaluated or documented. Neither the in-network nor the out-of-network evaluation includes a thorough evaluation of the patients sensory issues. As such, this patient requires further assessment utilizing standardized testing for both sensory integration and activities of daily living in order to determine the medical necessity of occupational therapy services utilizing sensory integration techniques. Accordingly, this patient should undergo a full occupational therapy evaluation to determine whether he has any current needs that require the services of a skilled occupational therapist.