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

A 41-year-old female enrollee has requested chiropractic treatment and/or physical therapy services for treatment of her rotator cuff syndrome and cervicalgia. Findings:  The physician reviewer found that this patient suffers from symptoms of right shoulder pain secondary to bicipital tendonitis and rotator cuff impingement which have previously benefited from physical therapy treatment. Non-surgical treatment, based on the imaging results is appropriate for this patients condition at this time. This patient has a need for therapy which increases her shoulder range of motion and decreases her pain. As noted in an article by Camarinos and Marinko, manual physical therapy has been shown to be effective for painful shoulder conditions. Given the patients previous response to physical therapy, she is likely to benefit from a repeat course of therapy at this time. Therefore, the requested physical therapy is medically necessary to treat this patients right shoulder condition. This patient also suffers from cervical pain which was started or aggravated after a motor vehicle accident. The patients chronic cervical pain has responded well to chiropractic therapy in the past, but she still suffers from residual pain. A review of the literature by Gross and colleagues assessed whether chiropractic manipulation and mobilization relieves pain or improves function/disability, improves patient satisfaction, or has a perceived effect in adults with mechanical neck disorders. The authors found that mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. This patient has in fact benefitted from previous chiropractic therapy. Therefore, additional chiropractic therapy, including mobilization and manipulation, is medically necessary to treat this patients cervical pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for the medication Glumetza for treatment of her medical condition. Findings:  The physician reviewer found that Gastrointestinal (GI) side effects, are well-known in relation to generic metformin, regular or extended release. These GI issues limit their use in individuals such as this patient. In this patients particular clinical situation, Glumetza would be a superior product to metformin due to the GI side effects present in this patient. The success of metformin in patients such as this one is documented by the study performed by Otta and colleagues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested an MRI of the right upper extremity for an evaluation of his right shoulder pain. Findings:  The physician reviewer found that the peer-reviewed literature supports the use of conservative measures prior to advanced imaging in patients with uncomplicated shoulder pain. The Australian Acute Musculoskeletal Pain Guidelines Group noted that imaging is not necessary unless there are alerting features of serious conditions. They reported that in the absence of alerting features, the diagnostic utility of imaging is minimal, and the results are unlikely to improve management. This patient presented with right shoulder pain and underwent a shoulder MRI the same day as his initial visit with his physician.  There was no clinical concern of infection or metastatic disease. Following the published guidelines, this patient should have undergone conservative therapy prior to MRI.   MRIs may be beneficial in differentiating chronic impingement from tears of the rotator cuff when a surgical approach is being considered, diagnosis is unclear or clinical examination is limited. Per the submitted documentation, this patient was not being considered for surgery, the diagnosis was not unclear and the clinical examination was not limited.  In this patients case, MRI of the right upper extremity was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for a bariatric surgery consultation for evaluation of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 42, this patient is likely to be considered an appropriate candidate for bariatric surgery based on nationally accepted criteria. The resultant weight loss that the patient is likely to achieve with bariatric surgery is likely to provide substantial improvement in her co-morbid conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested for Nuvigil for treatment of her excessive fatigue. Findings:  The physician reviewer found that she does not have a medical condition, specifically a sleep disorder, for which Nuvigil has been approved.  The efficacy of Nuvigil in migraine has not yet been evaluated in clinical trials.  The literature noted above addresses the use of Nuvigil in the setting of sleep disorders (i.e., narcolepsy), for which there is sufficient evidence of efficacy. The medical record includes documentation that the patient feels more alert with Nuvigil and has had some relief of her migraine symptoms with it. However, Nuvigil is often found to result in reports of subjective improvement regardless of whether or not a medical diagnosis exists.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for BRCA 1 and 2 testing for evaluation of her medical condition.   Findings:  Two physician reviewers found that National guidelines for genetic testing presume the availability of family history. In the case of an adoption, such as in this patients case, family history may not available. This can include details regarding hereditary origins, including whether the patient is of Ashkenazi Jewish descent (high-risk group) or not. This patient has a history of triple negative breast cancer which is known to be more common in women with BRCA 1 gene mutations.  As this patients family history was unavailable, the probability of a mutation based upon the known variables must be estimated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested for additional mechanical traction treatment of the lumbar spine (20 visits) for treatment of his chronic low back pain. Findings:  The physician reviewer found that there are studies that have shown that some subgroups of low back patients can benefit from mechanical traction (see Fritz and colleagues). However, some studies have shown that there is no objective benefit from mechanical traction in patients with low back pain (see Schimmel and colleagues). Although there is uncertainty in the medical literature and a need for further studies in regards to the efficacy of mechanical pelvic traction therapy, given this patients positive response to a regimen that included mechanic pelvic traction in the past, he should receive an additional 10 sessions of traction with the requirement that his provider provide thorough objective pre- and post-therapy functional ability and pain measurements.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for the Medtronic MiniMed Insulin infusion pump and necessary supplies for treatment of his diabetes. Findings:  The physician reviewer found that this is a patient with uncontrolled diabetes mellitus type 2.  His glucose monitoring records indicate that the patient has dawn phenomenon and unpredictable postprandial control. He has seen his medical provider at least three times in the past year, and he has attended diabetes education program. The patient is injecting multiple doses of insulin, and he has been testing three to four times a day, as documented by the submitted medical records.  This patient will benefit from the insulin pump.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested coverage for speech therapy services for treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative and cognitive skills which arise in the first years of life.  Early, sustained intervention is indicated, as is the use of various treatment modalities, including speech-communication therapy and behavior modification. While there have been few studies offering a direct comparison of methods, it is the prevailing opinion among specialists in the field that children with autism benefit from intensive, early intervention methods which focus on increasing the frequency, form and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors, as noted by Paul. In practice, children with pervasive developmental disorders often demonstrate language impairments similar to those who meet the stricter research definitions of speech-language impairment. This patient demonstrates pragmatic language impairment according to testing performed and this is a well-recognized condition in autism and pervasive developmental disorder. As such, the submitted documentation establishes the medical necessity of speech therapy services in this particular setting. Therefore, I have determined that the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested acute inpatient services and residential treatment services for treatment of his behavioral health problems. Findings:  The physician reviewer found that acute inpatient treatment during the time period in question was medically necessary. The patient has a well documented history of severe psychiatric impairment with major co-morbidity with diagnoses of polysubstance abuse, schizoaffective disorder and Aspergers syndrome. The patients unstable, psychotic behavior with poor impulse control, paranoia and fluctuating mental status exam warranted the level of care provided. This is consistent with Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) practice guidelines. In regards to residential treatment, it was medically necessary during the time period at issue. Due to severe co-morbidity, including polysubstance abuse, schizoaffective versus bipolar disorder and Aspergers syndrome, the patients overall medical needs were complex and required a specialized multidisciplinary team. Given the patients presentation during this period, the level of care provided was consistent with LOCUS and APA practice guidelines and was medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for CT lumbar and thoracic spine for evaluation of her back pain. Findings:  The physician reviewer found that one of the difficulties with advanced imaging studies (CT and MRI) is that abnormal findings are found in asymptomatic patients.  In regards to this patient, her clinical picture is consistent with uncomplicated back pain, as there are no neurological symptoms or findings, and there is no clinical concern of infection or cancer.  There is also no history of recent significant trauma.  The patient does not have any of the red flags listed above.  The patient has not had a trial of conservative therapy for four to six weeks.  If the patients symptoms do not improve or worsen with conservative therapy, then advanced imaging (CT or MRI) may be indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the proposed ABA therapy for the treatment of this patient with autism and intractable epilepsy is medically necessary based on overall evaluation of the literature. Even in the patients age group, plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including cognitive therapies (ABA) can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Additionally, the notion that an MRI finding of nodular heterotopia is incompatible with brain plasticity is speculative and is not supported by peer-reviewed literature. While heterotopias are frequently associated with a phenotype of cognitive impairment and seizures, they are rarely so pervasive that no brain pathways are spared.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested additional physical therapy sessions for treatment of her back pain. Findings:  The physician reviewer found that this patient has developed an acute worsening of her low back pain associated with restricted movement of her spine. These complaints have required increased narcotic use. The patient has not yet returned to her functional baseline. Additional physical therapy is both clinically appropriate and medically necessary for the management of this patients back pain (Chou and colleagues and Van Tulder and colleagues). Given that the patient has experienced some benefit from prior physical therapy yet continues to have exacerbations of pain, additional physical therapy services are medically reasonable and appropriate in this particular setting. It does not appear that the patient has plateaued and as such there is a reasonable likelihood that she will continue to benefit from physical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested breast augmentation with implants for treatment of her hypomastia. Findings:  The physician reviewer found that the submitted evidence does not establish that the patients breast condition is related to a chromosome 14 anomaly. Nor is there significant scientific literature supporting this contention. Based on the documentation provided, the patients breasts are normal and very small given the visible breast buds, normal nipple areola complexes and presence of pectoralis major muscles. There is no evidence of Polands syndrome, which would be classified as abnormal if present. The report from a genetics evaluation found that the patients lack of breast development represented a birth defect, yet the geneticist did not examine the patients breasts. Further, although the geneticist found a chromosomal abnormality with respect to the long arm of chromosome 14, he stated that the significance of this is totally unclear at this point. While the patients mother is concerned that complete lack of anatomical maturity of the breasts will alter the ability of the breasts to function as a sensual organ and will interfere with breastfeeding, these issues will not be corrected with the insertion of breast implants. All told, the documentation does not support the presence of an abnormal structure of the body in the patient caused by congenital defect, developmental abnormality, infection, trauma, tumor or disease. There is insufficient evidence that the patients condition is related to a congenital or developmental abnormality. Further, the tissue deficit is not so great so as to be considered abnormal. Thus, the patient does not meet the criteria of the reconstructive surgery statute. Moreover, there is no evidence that the patients condition results in a functional impairment for which breast augmentation would be considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for spinal surgery for treatment of her low back pain. Findings:  The physician reviewer found that Patel and colleagues conducted a retrospective study of consecutive patients treated by a single surgeon. The authors found statistically significant incidences of surgical complications as high as 36% in patients with a BMI of 40. These surgical risks and complications include wound infection, increased blood loss, increased surgical time and increased risk of deep vein thrombosis and pulmonary embolism).  Patel and colleagues concluded that obesity is a prevalent condition in patients undergoing elective fusion for degenerative spinal conditions and may increase the prevalence and incidence of perioperative complications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested adult substance abuse inpatient sub-acute/residential treatment center rehabilitation for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient reported that he used alcohol on the day of admission. Since the patient used alcohol on the day of admission and due to monitoring for withdrawal with a detoxification protocol, the 10-day inpatient stay was reasonable and medically necessary. However, the medical necessity for inpatient level of care is not evident. The medical records indicate that he was doing well, with no depression or anxiety reported, and he was participating well in group sessions. There were no major findings on a mental status exam (MSE), or any major medical issues. His functional impairment was not in the severe range, and co-morbidity issues were not major; he remained motivated and cooperative during treatment. Based on Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) guidelines, the patient was a candidate for a range of intense treatment interventions at a less restrictive level of care than inpatient sub-acute/residential.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Adderall, 150mg per day for treatment of her attention deficit disorder. Findings:  The physician reviewer found that side effects of stimulants are dose-dependent and include increased blood pressure. Side effects can often be managed by lowering the dose. Rostain also notes that attention deficit/hyperactivity disorder medications may increase blood pressure and heart rate in adults. In this patients case, the use of Adderall, 150mg per day is contraindicated in light of the associated blood pressure risks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees panhypopituitarism. Findings:  The physician reviewer found that this patients growth chart shows that his growth in height has deteriorated. He has had repeated low levels of the growth hormone dependent IGF-1 and IGFBP-3. In January 2010, his height had declined to the 10th percentile. The patient meets clinical indications for growth hormone therapy. He is lacking growth hormone and, without it, his height will continue to decline. Given the clinical situation and repeatedly low levels of IGF-1 and IGFBP-3, growth hormone stimulation tests are not required to establish the medical necessity of growth hormone for this diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested the osteochondral autograft procedure for treatment of his avascular necrosis of the talar dome. Findings:  Two physician reviewers found that interest in preserving tibiotalar motion has led to the development of alternatives to ankle fusion in the treatment of avascular necrosis of the talus. Various approaches, including autologous osteochondral grafting, have been explored, and some results have been encouraging.  However, randomized clinical trials are needed to compare the outcomes of the different surgical treatments.  Additionally, questions have been raised as to the potential morbidity of the donor sites. The various treatment strategies are in need of sufficiently powered, randomized, clinical trials with uniform methodology to compare outcomes.  The superior efficacy of the osteochondral autograft procedure has not been established in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested mastopexy of the left breast and reduction of the right breast for treatment of her breast asymmetry. Findings:  The physician reviewer found that the patients application notes a diagnosis of Polands syndrome. Polands syndrome is a more severe defect that involves absent breast tissue including the nipple, possibly absent pectoralis major muscle and, in more severe cases, anomalies of the arm. The submitted documentation does not support a diagnosis of Polands syndrome. In addition, although the documentation provided shows a smaller left breast, it does not support an abnormal structure of the body in the patient caused by infection, trauma, tumor, congenital defect, developmental abnormality or disease. The breast tissue deficit and asymmetry is not so great so as to be considered abnormal. Thus, the California statute regarding reconstructive surgery does not apply. Furthermore, the submitted clinical evidence does not demonstrate that the patients breast asymmetry and ptosis result in a functional impairment such as pain or skin problems. In the absence of evidence of a functional deficit, the medical necessity of the proposed surgery is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for BRCA 1 and 2 genetic testing for evaluation of her medical condition. Findings:  The physician reviewer found that there are a variety of guidelines published in an effort to make a determination as to whether there is a reasonable enough probability of finding a mutation to justify the analysis. This patient is not from Ashkenazi Jewish descent (a high-risk group). Secondly, she does not have a family history suggestive of BRCA positivity. The only indication for testing in her case is the fact that she has a history of right breast cancer, diagnosed at age 47. A variety of guidelines have been developed for this situation. National guidelines (see National Comprehensive Cancer Network guidelines) indicate that BRCA testing should be performed: if the patient was diagnosed with breast cancer when less than 45 years of age; if the patient was diagnosed under the age of 50 when there is at least one close relative who was diagnosed with breast cancer under the age of 50, or one relative diagnosed with ovarian cancer. This patient does not fulfill these criteria. Based on the evidence provided, the patients risk of being BRCA positive is less than 10% and she does not meet accepted indications for BRCA 1 and 2 testing.