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

A 63-year-old male has requested approval for radiofrequency ablation of the sacroiliac (SI) joints and lateral branch nerves for treatment of his bilateral SI joint dysfunction.   Findings:  Two physician reviewers found that the patient has a history of back and buttock pain and anterior thigh numbness. The patient is noted to be status post fusion. A computed tomography (CT) guided medial branch injection demonstrated mild bilateral anterior lipping at the SI joints with mild scoliosis on the iliac side of the SI joint bilaterally. The patients diagnosis was bilateral sacroiliac (SI) joint dysfunction. The providers notes document great relief from bilateral SI joint intra-articular injections with recurrence of pain. The patients medications include Norco 1-2 pills as needed, Gabapentin 3600mg, and Baclofen 5mg three times per day. The patient is being tapered off Baclofen due to side effects and is planned to start Cymbalta. The patient has also been treated with Naproxen and Diclofenac. The provider has recommended radiofrequency ablation (RFA) of the SI joints.  There is inadequate clinical evidence to demonstrate that the radiofrequency ablation of the SI joint is likely to be more beneficial compared to standard treatments for SI related pain. As noted by Rupert and colleagues, the limitations of this systematic review include the paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodological flaws. The authors concluded that the indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. Overall, the requested radiofrequency ablation is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male has requested percutaneous discectomy with intradiscal electrothermal annuloplasty (IDET) to L2-3 and L4-5 for treatment of his lumbar spine pain.   Findings:  Three physician reviewers found that the patients chronic low back pain resolved to some extent with opioids and muscle relaxants. However, the patient continues to have pain with inability to sleep. There was no provocation discography or analgesic discography reportedly performed on this patient. Further, facet joint pain has not been ruled out. The provider has recommended percutaneous discectomy with intradiscal electrothermal annuloplasty (IDET) to L2-3, L3-4, and L4-5 disc levels. Based on the available evidence, IDET may be indicated for patients after appropriately assessing discogenic pain with provocation discography. This patients records do not indicate that this has been performed. In addition, the overall effectiveness of IDET has not been proven. The evidence for IDET in recent evaluation was shown to be limited. This patients provider has not performed any type of controlled diagnostic blockade with provocation discography or diagnostic facet joint nerve blocks. Consequently, at this point, it is unknown if this patient has discogenic pain. Further, it is highly unlikely for a patient to improve significantly when more than one level is involved, as in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male has requested coverage for past residential treatment center (RTC) services for treatment of his schizoaffective disorder, bipolar type.   Findings:  The physician reviewer found that based on review of the available records, after approximately one month of treatment, the patients symptoms were improving. He remained cooperative with treatment throughout his admission, and was never a behavior problem. He continued to exhibit psychotic thinking, but the patient had displayed psychosis for many months prior to admission. The main purpose for this hospitalization appeared to be medication trials to improve his symptoms. The records indicate that by the date at issue, the patient was fully compliant with his medications and was participating in his own treatment. As of this date, he could have continued to receive medication management and group and individual therapy at a lower level of care without jeopardizing his outcome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested cardiac computed tomography angiography (CTA) with contrast and calcium score without contrast for evaluation of his hypertension, diabetes mellitus, and shortness of breath.   Findings:  Two physician reviewers found that the patient has a history of diabetes, hypertension, obesity, hypothyroidism, prostatitis, dyslipidemia and obstructive sleep apnea. A clinic note documents dyspnea, a normal cardiovascular physical examination and a normal electrocardiogram. An echocardiogram  revealed normal left ventricular systolic function with an ejection fraction of 0.55 to 0.60, with moderate atrial enlargement. An exercise nuclear stress test revealed no provokable ischemia with a left ventricular ejection fraction of 0.47. Based on the records provided, the patient presents with increased coronary risk and symptoms of dyspnea. The patient has a normal cardiovascular physical examination, normal electrocardiogram, normal ventricular systolic function on echocardiography, and no provokable ischemia on nuclear stress testing. In this circumstance of an unequivocally negative nuclear stress test in a patient without chest discomfort or other abnormality suggestive of coronary ischemia additional evaluation with coronary CT angiography is not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations also do not consider coronary CT angiography appropriate in patients with an unequivocally negative nuclear stress test (Miller, et al). Additionally, if an assessment of coronary anatomy were thought to be necessary to assess for coronary stenosis, even with a negative stress test, then conventional coronary angiography is preferred given its improved accuracy compared to coronary CT angiography and the ability to intervene using percutaneous revascularization during the same procedure, if needed (Mark, et al).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female has requested  attachment therapy and functional magnetic resonance imaging for evaluation and treatment of her alcohol effects syndrome, bipolar disorder, attention deficit/hyperactivity disorder, and developmental delay.Findings:  The physician reviewer found that at this time, functional magnetic resonance imaging is not part of the standard armamentarium utilized by clinicians, nor is it recommended by reference texts or endorsed in current practice guidelines.  The efficacy of the requested study has not been established in this clinical setting.  The data yielded from functional magnetic resonance imaging is not likely to impact treatment decisions, as particular findings do not yet correlate with specific interventions.  Regarding therapy needs, this patient requires treatment for likely reactive attachment disorder and possible post-traumatic stress disorder.  Conceptually, such therapy is based on abreaction, context and correction, along with the establishment of parental figure consistency in a safe community setting.  This process can take years.  However, the particular modality of attachment therapy is not supported as an evidence-based therapeutic intervention.  Thus, the requested attachment therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female has requested  attachment therapy and functional magnetic resonance imaging for evaluation and treatment of her post-traumatic stress disorder, attention deficit/hyperactivity disorder, alcohol effects syndrome, and developmental delay.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  Current practice guidelines do not endorse functional magnetic resonance imaging in this clinical setting.  In terms of clinical application, the efficacy of functional magnetic resonance imaging has not been established in this setting.   Data yielded from the requested imaging is not likely to impact treatment decisions, as particular findings do not yet correlate with specific interventions.  Thus, the requested functional magnetic resonance imaging is not medically necessary.  This patient requires treatment for her post-traumatic stress disorder and likely reactive attachment disorder.  Conceptually, such therapy is based on abreaction, context and correction, along with the establishment of parental figure consistency in a safe community setting.  This process can take years.  Per the current medical literature, the particular modality of attachment therapy is not supported as an evidence-based therapeutic intervention.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS).  Findings:  Two physician reviewers found that the patient has a history of major depressive disorder, recurrent, severe. She has requested coverage for transcranial magnetic stimulation (TMS) treatment from a specific date and forward. She presents with depressed mood, psychomotor slowing, tearfulness, hopelessness and suicidal ideation. She has impaired functioning socially and occupationally. Her condition has been severe enough recently to require hospitalization. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Celexa, Prozac, Effexor, Cymbalta, Pristiq, Effexor, Wellbutrin, Remeron, Nortriptyline, Lamictal and Lithium which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect. The patient requests coverage for TMS treatment for her depression provided from the date in question and forward.  Schutter and colleagues reported that TMS had a moderate effect of TMS on treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. In addition, the American Psychiatric Association (APA) practice guidelines for treatment of depression state that the (A)cute phase treatment may include TMS. Connolly and colleagues also noted that, TMS was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Thus, although relatively new, TMS is an effective treatment and is FDA approved for the treatment of treatment resistant major depressive disorder. Based on these findings, the TMS therapy at issue was and is likely be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested coverage for epidural steroid injections for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested epidural steroid injections in this clinical setting.  This patient has a documented lumbar MRI consistent with her pain.  Additionally, her physical examination is consistent with lumbar radicular pain, including positive straight leg raise and left paraspinal tenderness. The patient has not obtained relief with physical therapy and a home exercise program, and there are valid concerns regarding potential addiction to Vicodin and muscle relaxants.  The current medical literature supports the requested services in this case.  Botwin and colleagues performed a prospective cohort study to identify the therapeutic benefit to fluoroscopically-guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis.  The authors reported that fluoroscopically-guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative disease.  All told, the requested epidural steroid injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male has requested coverage for past and future Orthovisc injections for treatment of his right knee osteoarthritis.  Findings:  The physician reviewer found that the use of hyaluronan is poorly documented in the literature. The articles published lend little support to hyaluronan in treating osteoarthritis of the knee. While there is an advantage to delay joint replacement as long as possible, the use of repeated hyaluronan injections is not without risk of possible allergic reaction or infection as complications. As a method of delaying joint arthroplasty, it is not reasonable to persist in a treatment which is poorly supported by double-blinded studies. The literature does not demonstrate that the hyaluronic acid molecule will disrupt the effect of inflammatory cytokines effecting osteoblastic and osteoclastic and chondrolytic changes within the knee joint. In addition, the processes of chronic inflammation and of degenerative osteoarthritis are not likely to be altered by the hyaluronic acid macromolecule. In the study by Strand and colleagues, subjective visual analog scales were used to assess the efficacy of single injection as compared to patients receiving phosphate buffered saline. While the design of the study is stated to be randomized, the method of blinding or whether blinding took place is not discussed. In the article authored by Colen and colleagues, consisting of a review of the use of hyaluronic acid in joints other than the knee joint, it was concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. All told, the repeated Orthovisc injections are not supported as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male has requested coverage for dental surgery services provided on an emergent basis. Findings:  The physician reviewer found that the patient presented to his dentist with symptomatic left sided facial edema and symptomatic tooth #14. He was immediately referred to an oral surgeon whose findings were consistent with left maxillary vestibular and left infraorbital space abscess secondary to tooth #14. The patient underwent removal of the tooth with incision and drainage of the affected spaces the same day. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.  The patient had a significant infection which was odontogenic in origin. It had spread beyond the alveolar process into the adjacent spaces. The patient also had significant clinical signs of infection which included fever and pain. The infection had progressed into a fascial plane that threatened adjacent structures. Left untreated, the patient was at risk for worsening of the infection with potential involvement of adjacent anatomical structures such as the orbit and cavernous sinus. Treatment goals for such an infection are to treat surgically with supportive care including antibiotic therapy. All told, the patients symptoms on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or health and as such, would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested coverage for residential treatment from a specific date and forward for treatment of the enrollees mood disorder, not otherwise specified, dysthmic disorder, oppositional defiant disorder, attention deficit/hyperactivity disorder, cannabis abuse, and parent-child relational problem.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient had no prior psychiatric hospitalizations.  After several weeks of treatment at the residential treatment center level of care, the provider described the patients mood as euthymic, without any psychosis or suicidal behaviors.  On the date in question, the provider described the patient as pleasant and cooperative.  He reportedly had limited insight, but was more engaged in therapy.  No aggressive or disruptive behaviors were described.  As of the date in question, the residential treatment was not and is not medically indicated.  He had no medical or psychiatric problems that required 24-hour level of care.  All told, residential treatment from the date in question and forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for resumption of speech therapy using the PROMPT method for treatment of the enrollees childhood apraxia of speech.  Findings:  The physician reviewer found that based on review of the available records, this patient has a serious developmental speech delay with a moderate expressive delay in speech and a severe articulation dysfunction. The etiology of his articulation defect or childhood apraxia of speech is due to a congenital delay in the maturation of his oral/lingual nervous system. Given his condition, the speech therapy available in the public school setting is inadequate with limited group sessions and lack of individual therapy. For any significant reasonable expectation of improvement, this patient will require individual speech therapy. Childhood apraxia of speech is a serious childhood speech deficiency. In Lewis and colleagues study, 10 children diagnosed with childhood apraxia of speech were evaluated at age 4 and reassessed at age 10. At age 10, their improvement was limited when compared to children with other speech disorders. In addition, the patients demonstrated serious deficiencies in reading and spelling. The authors recommendation was for intensive speech therapy at four years of age. There is a significant medical literature supporting speech therapy in patients who are age three and up. Sharp and Hillenbrand state that reviews of the literature demonstrate the necessity and effectiveness of speech therapy in children over the age of three years with articulation and speech dysfunction. The PROMPT method of speech therapy is based on actual hands on the muscles of the mouth and jaw as a primary adjunct combined with speech therapy (Hayden). PROMPT therapy has limited literature in the peer-reviewed medical and speech pathology literature. However, Rogers and colleagues describe the utilization of the PROMPT technique, which suggests a significant legitimacy for the technique. This patients records demonstrate improvement utilizing the PROMPT method. All told, it is medically necessary that this patient receive individual speech therapy for two hours per week for the next six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female has requested coverage for a power wheelchair for treatment of her degenerative joint disease, diabetes mellitus, shortness of breath, and bilateral carpal tunnel syndrome.  Findings:  The physician reviewer found that the documentation provided for review supports the medical necessity of a POV for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, the records indicate that the patient is non-ambulatory despite use of an assistive device and unable to self-propel a manual wheelchair due to bilateral CTS. She was previously using a power wheelchair and her home is noted to be able to accommodate the device. Therefore, the records support the medical necessity of the prescribed power wheelchair for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female has requested compression stockings for treatment of her peripheral edema.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The current medical evidence does not support compression stockings in this clinical setting.  Per the medical literature, measured compression stockings are indicated for the treatment of lymphedema and chronic venous insufficiency.  Per the submitted documentation, the patient does not have an established diagnosis of congestive heart disease, decompensated liver disease, or lymphedema.  There is no history of venous insufficiency or chronic stasis ulcers.  The medical records do not indicate a history of thrombophlebitis or deep vein thrombosis.  The documentation notes obesity, which is likely to contribute to this patients mild peripheral edema.  All told, the requested compression stockings are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male has requested  past and future coverage of Oxycontin for treatment of his fibrous dysplasia.  Findings:  The physician reviewer found that based on review of the available records, the patient has been stable on Oxycontin for several years on a consistent basis with no diversion issues. The provider reports that the patients pain has been well controlled over the past several years with Oxycontin. In addition, a change to another medication may be difficult to titrate and may not manage the patients chronic pain as well as the Oxycontin. Chronic narcotics can be difficult to titrate and the cross-reactivity may provide adequate pain relief, but transition can be quite difficult. Given the adequacy of pain control provided to this patient with Oxycontin for his painful conditions, and the lack of adverse events or improper use, the requested medication is supported as medically necessary in this patients case.