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

A 57-year-old male enrollee has requested intravenous Rocephin for treatment of his bacterial encephalitis and septic arthritis.  Findings:  Two physician reviewers found that the only Lyme disease testing in the record is a Western Blot for Borrelia antigens done three years ago.  The IgG was negative, while the IgM was positive. The submitted documentation does not demonstrate that this patient has Lyme disease.  He has no documented clinical symptoms suggestive of Lyme disease.  The only Lyme-related diagnostic information is the single positive IgM Western Blot for Borrelia burgdorferi.  However, this is not diagnostic of Lyme disease.  Individuals with an illness for longer than four to eight weeks, a positive IgM test alone is likely to be a false positive result (Steere). Thus, a positive IgM response should not be used to support the diagnosis after the first two months of infection. Even in the case of a confirmed diagnosis of Lyme disease, there is no evidence that treatment for more than 28 days with parenteral antibiotics is beneficial.  All told, the requested medication is not likely to be superior to standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a wearable cardioverter defibrillator for evaluation of her medical condition status post myocardial infarction.   Findings:  Two physician reviewers found that studies including the DINAMIT trial reported by Gronefeld and colleagues assessing the use of prophylactic defibrillators have not demonstrated improved patient outcomes. Based on these trials a prophylactic wearable or implantable defibrillator is not considered an established standard in the medical community in this circumstance, in the absence of syncope, sustained ventricular tachycardia, or ventricular fibrillation. A prophylactic wearable external defibrillator would be indicated only if criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be delayed, or required explanation.  Based on the records provided, the patient is status post recent anterior myocardial infarction treated with coronary stenting. At that time, the use of the implantable cardioverter defibrillator would have been considered investigational and not likely to be more beneficial than standard therapy since the patient had no documented sustained ventricular tachycardia, no reported ventricular fibrillation or syncope, and had not waited at least 40 days to assess for an improved ejection fraction. Essentially, the criteria for placement of a prophylactic defibrillator in this circumstance appropriately required a period of time for verification of persistently decreased LVEF prior to defibrillator placement.   Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested custom compounded topical bioidentical hormone replacement therapy (CS-progesterone 100mg/gm cream, CS-testosterone 2mg/gm cream and CS-E2 0.4/E3 1.6mg/gm cream for treatment of her postmenopausal symptoms.  Findings:  The physician reviewer found that there is a lack of evidence regarding the safety and efficacy of compounded bioidentical hormones.  Due to issues related to compounding, dosing is frequently inconsistent.  There are numerous FDA-approved hormone therapies available, with oral and non-oral route options.  There are a number of oral choices that have not been tried. Non-oral options include transdermal patches, gels and sprays and vaginal rings.  According to the record, it appears that she tried such an option on only one occasion.  There is no evidence from the submitted documentation that alternate covered treatments have been tried and failed.  All told, the requested custom compounded topical bioidentical hormone replacement therapy (CS-progesterone 100mg/gm cream, CS-testosterone 2mg/gm cream and CS-E2 0.4/E3 1.6mg/gm cream) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Serostim 6 mg/vial injections for treatment of his wasting secondary to autoimmune deficiency syndrome.  Findings:  The physician reviewer found that it is well established that use of Serostim can ameliorate AIDS associated weight loss or wasting syndrome and is often prescribed for that purpose. With regard to this patient however, the documentation of treatment with Serostim for an extended period is not provided to evaluate whether the patient realized any clinical response. The usual practice is to stop treatment after 12 weeks to determine if the patients weight remains stable, but this information was not available for review. Further, only a statement from the Health Plan that the patient had lost three pounds while on the requested medication offers any record of the patients weight loss and/or gain. Finally, there is inadequate evidence the patients testosterone has been measured, anabolic agents have been given or that BIA, body cell mass or DEXA measurements have been done. Given that all of these measures are part of the appropriate criteria for use of Serostim, the evidence for its use in this patient is not well documented and the continued use of this drug has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested inpatient residential treatment for treatment of her opiate and alcohol dependence.  Findings:  The physician reviewer found that the patient was placed on detox protocol for opioids on the said date, and significant lethargy during detox was noted.    During the time period, progress notes indicated that the patient was pleasant and sociable, with no somatic complaints.  Notes dated soon after indicated no cravings.  A week later, the medical notes indicated no cravings and no withdrawal. At this time the patient was cheerful, with full participation in the program.  She was taking Tylenol or ibuprofen for occasional back and neck pain. She was seeing a chiropractor. A week later, there were no cravings and no withdrawal. The patient remained cooperative and motivated during her stay, per the discharge summary. In this patients case, monitoring in a 24-hour setting was medically indicated from during the time period, given the patients chronic pain and medication adjustment.  Following detox, transitioning to a lower level of intensive outpatient care at the time would have been consistent with American Psychiatric Association treatment guidelines.  The patient was cooperative, with no medical complications or severe psychiatric comorbidity.  All told, inpatient residential treatment from the dates in question was medically indicated, and inpatient residential treatment was not medically indicated during the second time period at issue. I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested partial hospital program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the providers who evaluated this young patient at the time of admission documented that he required long-term treatment in an inpatient setting, with an eye towards gradually stepping him down through levels of treatment. The patient presented with questionable psychotic symptoms intermittently, including auditory hallucinations, and some paranoia, and not only in the context of substance abuse. The psychologist who evaluated and treated this patient over a period of months stated that the patient, presented with one of the most serious cases of major depression I had ever treated during his 17 years of practice. In addition, the patients medications were still being titrated during his inpatient stay, and events were further complicated by the evolution of tics, necessitating holding his medication, treating the tics, and resuming his medications. Moreover, he continued to have intermittent, recurring sleep disturbance, suicidal ideation, and a desire to use substances throughout his inpatient hospitalization. Thus, it was reasonable for the patients providers to have expected that any attempts at treatment would require long-term therapy with gradual advancement in order to best serve the patients interests. Given the gravity of his symptoms, the patient was only transitioned to a lesser level of care when his providers determined that he could be safely and adequately managed in a partial hospital program (PHP), where he remained for services during this period of time. For these reasons, the PHP services provided from the dates in question have been demonstrated as medically necessary and appropriate for treatment of his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  residential treatment center (RTC) level of care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the providers who evaluated this young patient at the time of admission documented that he required long-term treatment in an inpatient setting, with an eye towards gradually stepping him down through levels of treatment. The patient presented with questionable psychotic symptoms intermittently. The psychologist who evaluated and treated this patient over a period of months stated that the patient, presented with one of the most serious cases of major depression I had ever treated during his 17 years of practice. In addition, the patients medications were still being titrated during his inpatient stay, and events were further complicated by the evolution of tics, necessitating holding his medication, treating the tics, and resuming his medications. Moreover, he continued to have intermittent, recurring sleep disturbance, suicidal ideation, and a desire to use substances throughout his inpatient hospitalization. Thus, it was reasonable for the patients providers to have expected that any attempts at treatment would require long-term therapy with gradual advancement in order to best serve the patients interests. Given the gravity of his symptoms, a lesser level of care would not likely have been adequate for managing the patients condition. For these reasons, the RTC services at issue have been demonstrated as medically necessary and appropriate for treatment of his condition on the said dates.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested Itraconazole 100 mg. for treatment of his HIV related eosinophilic folliculitis.  Findings:  The physician reviewer found that this patient has a chronic, debilitating and disfiguring condition related to his HIV infection that has failed to respond to corticosteroids. His EF is most likely related to a fungal infection and should improve on systemic Itraconazole treatment. Topical tacrolimus is not recommended because it induces immunosuppression, which may worsen the immunodeficiency caused by the HIV virus in this patient. Further, it is not practical to use topical tacrolimus on the large areas involved in this patient and topical tacrolimus may worsen his condition due to its adverse effects such as burning and itching. Given his lack of response to corticosteroids and contraindication to tacrolimus, the medical necessity of the requested Itraconazole has been demonstrated in this clinical setting. For the reasons discussed above, I have determined the requested medication is medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an MRI of the cervical spine for evaluation of her neck pain.  Findings:  The physician reviewer found that this patient has chronic neck pain and upper extremity tingling following an industrial injury 10 years ago. Her current neurologic examination does not show any significant neuropathic or myelopathic findings. Her provider indicates the patients symptoms and examination are compatible with carpal tunnel syndrome and the provider suggested electrical studies. Recent review of the patients previous MRI scan did not show any significant canal or cord compromise. The patient has not had any recent trauma, infection, cancer or surgery on her spine. Further, she is not a surgical candidate since she does not wish to pursue surgical intervention. As such, the patient does not meet accepted guidelines for MRI imaging including Milliman, American College of Radiology, American College of Occupational and Environmental Medicine and Bussieres criteria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the unbalanced Robertsonian translocation involves the presence of extra genetic material to chromosome 21 with a phenotype similar to Down syndrome. This results in hypotonia, motor, cognitive and speech delays.  Low tone slows the acquisition of gross motor skills. Ligamentous laxity with hypotonia complicates the ability to acquire appropriate gross motor skills. Physical therapy with early intervention services in the home is needed for continued improvement in gross-motor skills acquisition. The long-term benefit of physical therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. This can lead to orthopedic and functional problems if not corrected. Children with Down syndrome have language delays. Expressive language abilities tend to be more delayed than cognitive and receptive language skills. Ongoing speech therapy is necessary to teach sign language as part of a total communication approach to overcome problems in verbal expression and to improve communication. Dysfluency and unintelligible speech are noted in children with Down syndrome and the goal of treatment is to build communication skills while preventing the frustrations and behavioral problems that sometimes result from the protracted period of poor verbal communication. Children with Down syndrome who receive speech-language treatment show better improvement than those who have no treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested 35 hours of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that studies have been conducted on ABA therapy comparing low intensity services (less than 20 hours per week) and high intensity services (greater than 20 hours per week). In addition, there is data collected analyzing intensive behavior therapy versus standardized care. Comparing patients who received ABA therapy versus those who received standardized therapy, there is a clear statistical improvement in cognitive, language and adaptive behavior skills in those treated with ABA. A study included in Spreckley and Boyds meta-analysis states that a non-systematic review concluded that for best practice, a minimum of 20 hours a week of ABA therapy over 2 years is appropriate. The authors commented that the intervention should take into account each patients strengths and weaknesses, and family circumstances, in order for young children with autism spectrum disorder to make gains. Given this patients documented deficits, the recommended frequency of 35 hours of ABA services per week was and is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollee's autism spectrum disorder. Findings:  The physician reviewer found that overall, children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with patients on the spectrum, handling the myriad of communication challenges that they face, are the most appropriate providers of this type of care. 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 patient has for developing adequate skills to function in the community. This patient exhibits severe delays in expressive and receptive language, thus speech therapy is therefore medically necessary and appropriate at the frequency requested. In addition, deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children, and may lead to difficulties establishing relationships and navigating the occupations of adulthood. Case-Smith and Arbesman noted that, Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. Further noted is the import of therapy focusing on the development of motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information. For these reasons, OT is well suited to affect positive change in children with ASD. As this patient exhibits significant difficulties with processing sensory information as well as difficulty with fine motor skills, motor planning, and self-help skills, OT is medically necessary and appropriate for this patient, at the frequency requested.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent 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. With regard to this patient, she presented with severe pain. This constitutes sufficient rationale for believing that an emergency medical condition exists, and is an acceptable reason for a prudent layperson to seek medical care emergently. Further, the date of service was a Sunday so a prudent layperson would have sought immediate care at the ED. The fact that the patients pain was resolving on its own and that she decided to leave against medical advice does not negate the appropriateness of her decision to seek medical care in the ED on the date of service in question. Thus, the patients situation meets the definition of emergency medical condition as set forth by California law.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female has requested bariatric surgery (Lap Band surgery) for treatment of her obesity. Findings:  The physician reviewer found that this patient has a BMI of 57.9. She has failed dietary efforts in the past, including numerous diets and medication. The patient completed a thorough multidisciplinary evaluation that did not reveal any obvious metabolic, dietary or behavioral barriers to surgery. She meets all standard guidelines for medical necessity of bariatric surgery, including the National Institutes of Health guidelines. Based upon the submitted documentation, medical clearance was obtained. In this patients case, the requested surgery is medically indicated.  The submitted documentation and current medical evidence support the medical necessity for the requested bariatric surgery (Lap Band surgery) in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested residential treatment facility level of care for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that the medical notes indicated that the patient was anxious regarding transferring to a lower level of care.  Progress notes on the said date indicated that she was following the meal plan. The submitted documentation dated the next day indicated that she was doing better and was more compliant with meals. The patient remains in need of intense treatment for her eating disorder, and she is participating in a partial hospitalization program.  Based upon the submitted documentation, residential treatment facility level of care is not medically indicated at this time.  According to American Psychiatric Association guidelines, partial hospitalization is warranted when the patient is cooperative, has at least partial motivation, when intrusive thoughts are present, when structure is needed for weight gain and when there are no major medical complications or severe comorbidity.  All told, the requested residential treatment facility level of care is not medically indicated for this patient.The medical notes indicated that the patient was anxious regarding transferring to a lower level of care.  Progress notes dated 11/12/10 indicated that she was following the meal plan. The submitted documentation dated 11/13/10 indicated that she was doing better and was more compliant with meals. The patient remains in need of intense treatment for her eating disorder, and she is participating in a partial hospitalization program.  Based upon the submitted documentation, residential treatment facility level of care is not medically indicated at this time.  According to American Psychiatric Association guidelines, partial hospitalization is warranted when the patient is cooperative, has at least partial motivation, when intrusive thoughts are present, when structure is needed for weight gain and when there are no major medical  complications or severe comorbidity.  All told, the requested residential treatment facility level of care is not medically indicated for this patient.