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

A 65-year-old male enrollee has requested bilateral laminotomy with spinal instrumentation and fusion at L3-S1 for the treatment of his stenosis with radiculopathy. Findings:  Three physician reviewers found that spinal fusion is indicated for instability or spondylolisthesis. This patients records do not support such a diagnosis and thus do not demonstrate that he is a candidate for the proposed surgery. The effectiveness of dynamic stabilization systems remains unproven; some systems are currently in the midst of a post-market surveillance study to determine the long-term safety and efficacy. With the paucity of studies on dynamic stabilization and no long-term, randomized controlled clinical trials to support this procedure, it is not likely to result in a superior outcome for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested bilateral total hip arthroplasty for the treatment of her osteoarthritis and vascular necrosis. Findings:  The physician reviewer found that total hip arthroplasty is a well-proven and appropriate procedure for significant hip arthritis. However, while this patients diabetes is not likely a contraindication to the procedure, her current weight may be considered as such. Biomechanical studies have shown that the forces in the hip joint generated by walking are 2.5 times a patients body weight, and the patients current weight will likely place additional stress on the hips. The literature does not specifically list obesity as a contraindication to the procedure, however it is unreasonable to expect the results of the arthroplasty to last in terms of longevity and an individual of this patients age is likely to require several revisions without loss of excess weight prior to surgery. Thus, while the patient does require surgery, and the requested procedure is appropriate, she must first lose weight in order for the results to be worthwhile. While there are no absolute guidelines regarding a patients weight prior to hip arthroplasty, for a patient of this height, a weight reduction to 200 pounds with maintenance over time would be consistent with generally accepted standards in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested electroconvulsive therapy (ECT) for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that electroconvulsive therapy (ECT) is not an appropriate or indicated treatment for this patients mental illness. According to guidelines developed by the American Academy of Child and Adolescent Psychiatry, before an adolescent is considered for ECT, the patient must have a diagnosis of severe, persistent major depression or mania with or without psychotic features; schizoaffective disorder; or schizophrenia (Ghaziuddin, et al.). This criterion is not met. This patient has poor coping skills, suicidal behaviors and acting out behaviors that indicate Axis II pathology, most likely borderline traits or personality disorder (Lewis). Review of the scientific literature does not reveal support for the use of ECT for treatment of this patients mixed diagnostic compilation. She does not have a clear history of any sustained psychosis. The efficacy of ECT in this setting is not evidence based and the therapy poses the risk of side effects. This patient has not undergone adequate medication or therapeutic treatment, and does not have a diagnosis that qualifies her for ECT treatment consideration.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested ritixumab (Rituxan) for the treatment of her progressive multiple sclerosis. Findings:  Two physician reviewers found that this patients disease is progressing despite Rebif therapy. A number of immunomodulatory and immunosuppressive therapies have been tested for efficacy in the treatment of primary progressive MS and none have shown to be effective. Rituxan has recently been studied (Hawker and colleagues). In that study, while there was a subclass of younger patients (less than 51 years of age) who may have had some positive response to the treatment, Rituxan showed no effect on overall accumulation of disability in patients as compared with placebo. Furthermore, the article by Hauser and colleagues submitted with this appeal pertains to patients with relapsing forms of MS. In summary, the medical literature does not reveal that Rituxan has utility in the treatment of primary progressive MS. In addition, Rituxan therapy carries risk of infection and side effects such as progressive multifocal leukoencephalopathy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested an MRI of the knee for an evaluation of her knee pain. Findings:  The physician reviewer found that according to the American College of Radiology Appropriateness Criteria, the decision to perform an MRI of the knee should be made after detailed physical examination of the affected joint. The submitted records do not show that such an examination has been performed in this case. Orthopedic evaluation should precede the request for an MRI of the left knee, particularly in this patient who has already had arthroscopic surgery on the same knee.  It may be that an examining orthopedist will recommend an MRI once a detailed physical evaluation has occurred.  However, an MRI of the knee is not medically indicated without such orthopedic evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a PET scan for an evaluation of his prostate cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of PET scanning for the assessment of metastatic prostate cancer or for the assessment of response to chemotherapy. This patient is currently receiving chemotherapy, per the most recent medical notes submitted. If this patients disease is progressing, this can be documented by PSA testing or other imaging studies, such as a nuclear medicine bone scan or CT scan of the abdomen/pelvis. Current medical literature does not support the use of PET scanning in this clinical situation. The PET scan was not necessary as there are other well established diagnostic modalities available in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested Supartz injections for the treatment of her knee pain. Findings:  The physician reviewer found that while viscosupplementation is an accepted treatment for osteoarthritis of the knee, patients with radiographic advanced disease with extensive joint space loss are less likely to benefit than those in the earlier stages (Wang, et al.). Furthermore, conservative measures such as NSAID medications, intra-articular steroids, and physical therapy are generally employed prior to the use of viscosupplementation.  In this patients case, there is documentation of x-rays showing severe degenerative changes of osteoarthritis. Additionally, there is no documentation of conservative treatment with medications and injections prior to the request for Supartz injections. All told, the patient is not an appropriate candidate for Supartz injections given the advanced stage of her disease and the absence of documentation of treatment with medications and injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested an electric scooter for the treatment of her impaired mobility. Findings:  The physician reviewer found that the submitted clinical evidence does not support the medical necessity of an electric scooter. The patient can independently ambulate within her house. In addition, the patients neurological physical examination demonstrated excellent strength with only minimal weakness on manual muscle testing and an electric mobility device is not indicated in this situation absent some other co-morbidity (such as a severe cardiomyopathy). In fact, an electric mobility device is contraindicated in this patients situation since an electric scooter would likely promote deconditioning, and thus worsen the patients underlying physical strength and cardiopulmonary endurance. Furthermore, although the medical records indicate that this patient reports that she is unable to propel a manual wheelchair due to numbness in her arms or fatigue in her arms, specific objective sensory deficits were not noted on exam. Finally, there is no documentation in the medical records of an actual manual wheelchair trial or physical/occupational therapy assessment using a manual wheelchair in the community, as would be the standard of care prior to progressing to an electric mobility device.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested filler and/or Botox injections for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation including photographic evidence reveals that the appearance of the patients scar is within the range of what most observers would consider an acceptable result following a biopsy of a suspicious lesion. In this sense, it is not an abnormal structure following a biopsy. Furthermore, the collagen and/or Botox injections would not improve the patients function and would provide little or no improvement in her appearance. As such, the requested service does not meet the requirements of Californias reconstructive surgery statute. As to the medical necessity of the requested service, multiple physicians have evaluated the patient and have indicated that the outcome is good given her skin type and the procedures that have been performed. In addition, the photograph shows a relatively inconspicuous and well-healed scar. There is little likelihood that the patients appearance will improve with additional interventions. As several of the patients providers have indicated, there is concern about the probable outcome of more treatment to the area. Based on the submitted photograph which shows a good quality scar, this patient is unlikely to derive any significant improvement with additional interventions, and as such, the proposed service is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested back surgery (laminectomy) for the treatment of his leg and back pain. Findings:  The physician reviewer found that this patient has multiple level degenerative changes noted on the CT myelogram. He is status post L5-S1 laminectomy. The patient has persistent low back pain and right lower extremity pain postoperatively. No provocative studies such as lumbar discography have been performed that might help to localize the symptomatic level in the lumbar spine. Neurodiagnostic studies did not confirm the presence of radiculopathy. There is no record of facet blocks and/or epidural steroid injection which could provide both diagnostic and therapeutic benefit. All told, a laminectomy at L4-5 is not medically indicated or necessary on the basis of the patient's clinical signs and symptoms, CT myelogram findings and normal neurodiagnostic studies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested a bilateral labiaplasty for the treatment of her congenitally enlarged labia minora. Findings:  The physician reviewer found that labiaplasty is performed to alter the size or shape of the labia majora or labia minora. To determine whether this vaginal surgical procedure is medically necessary, the Committee Opinion of American College of Obstetricians and Gynecologists (ACOG) has recently reported on the indications for the procedure. According to the ACOG, Medically indicated surgical procedures may include reversal or repair of female genital cutting and treatment for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The submitted documentation does not demonstrate that the patients condition meets criteria for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The ACOG indicates procedures such as labiaplasty are not medically necessary if the above criteria are not met. The submitted evidence does not demonstrate that a labiaplasty is medically necessary for this patient. With regard to whether the proposed procedure is reconstructive in nature, based on the documentation provided, the patients condition does not constitute an abnormal structure of the body. As noted above, the patients condition is not consistent with the indications of labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The patients labia are within the range of normal variation of pelvic anatomy. The structures are not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. As such, the patients condition does not meet the requirements for reconstructive surgery as set forth by California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested Veramyst 27.5 mcg for the treatment of her allergic rhinitis. Findings:  The physician reviewer found that fluticasone furoate (Veramyst) is a synthetic trifluorinated corticosteroid with anti-inflammatory activity. The exact mechanism by which this corticosteroid exerts its effects in the treatment of allergic rhinitis is unknown. While Veramyst has been shown to be efficacious in this setting, the medications on the Health Plans formulary list are equally effective as Veramyst. In this patients case, there is no objective evidence of unsuccessful treatment with the nasal steroids that are on the Health Plans formulary list. The patients provider stated that the patient has not met criteria for the use of Veramyst. Thus, there is no documented need for Veramyst in this case as there are comparably effective medications available to this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients records do not document a complication of the Roux-en-Y gastric bypass procedure. In addition, the patient admits to emotional eating since the Roux-en-Y procedure and a laparoscopic gastric band placed over the bypass will not necessarily prevent such cravings. Given the patients small pouch and lack of documented follow-up, aggressive dietary and behavioral counseling with exercise would be the next appropriate step in this setting. At this time, there is a paucity of studies regarding the long-term (greater than two years) outcome of patients who have undergone revision of previous gastric bypass. Thus, the proposed procedure remains of questionable efficacy and is indicated to remedy an anatomical failure of the previous surgery. In this case, anatomical failure is not demonstrated by the records provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested a powered intracapsular tonsillectomy and adenoidectomy for the treatment of the enrollees marked adenotonsillar hypertrophy and obstructive sleep apnea. Findings:  The physician reviewer found that this patient has symptoms of obstructive sleep apnea syndrome. His symptoms include adenotonsillar hypertrophy, loud mouth breathing, heavy snoring and frequent pauses in the sleep at night. Surgical intervention can dramatically improve these symptoms. Evidence-based medical literature documents improvement of symptoms of obstructive sleep apnea in pediatric patients who have documented adenotonsillar hypertrophy and undergo surgical removal of the tonsils and adenoids for improvement of the airway.  However, appropriate services can be provided through the in-network designated specialty physicians. Although the methods may very slightly in the degree of postoperative pain and postoperative recovery, the specific method of performing the surgery does not appear to have any relevant improvement of the outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested adolescent psychiatric intensive outpatient program for the treatment of the enrollees panic disorder with agoraphobia. Findings:  The physician reviewer found that the services at issue involve an intensive outpatient program involving exposure-based interventions. Connolly and colleagues review of the clinical literature suggests that exposure-based cognitive behavioral therapy (CBT) has substantial empirical support for the treatment of anxiety disorders in young patients. In fact, the authors state that early assessment and intervention are crucial, as are evaluation of co-morbid disorders, and analysis of severity and impairment. Modification of standard CBT for treatment of patients with panic disorder includes interoceptive exposure and education about the physiological process that leads to physical sensations like dizziness, shortness of breath, and sweating. The American Academy of Child and Adolescent Psychiatry (AACAP) discusses more than 30 publications, mostly case reports, which demonstrated the clinical benefits of exposure-based interventions for pediatric patients with OCD. Also, component analyses of CBT suggest that both exposure and response prevention are active ingredients of treatment. Exposure is believed to reduce phobic anxiety, while response prevention reduces the performance of rituals. Clinicians assess the patients obsessions and compulsions, contamination fears, symmetry rituals, counting, and hoarding to select the appropriate CBT strategy. Thus, clinicians who are trained and experienced in applying these techniques achieve the best results. After careful review of the evidence-based publications, I have concluded that intensive outpatient program treatment for this patient was and is medically indicated. This young patients symptoms are disabling and impair her ability to function in daily life. Further, she was being treated at a lesser level of care but her panic disorder persisted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested an additional 12 acupuncture treatments for the treatment of his neck pain. Findings:  The physician reviewer found that according to the National Guidelines Clearinghouse guidelines for acupuncture treatment, the recommended frequency and duration for courses of treatment is one to two acupuncture sessions per week for six to eight weeks for a total of twelve sessions. For chronic conditions, extended treatments are recommended to observe response to therapy. This applies to chronic pain of neuromuscular origin. If partial pain relief is achieved after twelve sessions, a follow-up course is recommended for twelve additional sessions. These guidelines were based on the recommendation of the Council of Acupuncture and Oriental Medicine. Based upon the records provided, this patient has obtained some relief with an initial course of acupuncture. As such, an additional course of 12 acupuncture sessions are medically appropriate and consistent with the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested use of Dynasplints (one adjustable knee extension and one flexion splint) for the treatment of the enrollees fracture. Findings:  Two physician reviewers found that this patient had application of a Dynasplint following his original surgery. Based on the scientific evidence available to date, the use of Dynasplint therapy in this setting would not have been predicted to result in substantial improvement. In fact, it was noted that this patient did not appear to make substantial progress in flexion following the original measurements that were obtained. He made modest gains in extension. Therefore, this patient did not see substantial improvement in flexion or extension. Thus, use of a Dynasplint was not of significant value during these dates of service. This patient used a Dynasplint again following another surgical procedure. There did not appear to be reasonable support for continued utilization of a Dynasplint, as the records did not document any significant further improvement beyond that which was originally seen in the first month or two following the procedure. Therefore, use of a Dynasplint after the enrollee's second surgery did not result in a superior outcome for this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would have sought immediate medical attention for his complaint of right toe pain. 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 patients symptoms had commenced gradually over the course of three days. He had a similar attack two weeks prior, and a known history of gout. Given that history, it is unlikely that one would reasonably believe his life or health to be in danger without immediate medical attention. While a flare of gout can be quite painful, the patient reported his pain as 5 out of 10 upon presentation to the emergency room. Although the patients symptoms warranted medical evaluation and perhaps modification to his prescribed pain medication regimen, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.