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

A 49-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that TMS has FDA approval for the indication of major depression that has failed to respond to an adequate trial of antidepressant medication. The indication is for acute treatment only, not for maintenance. In the study that the FDA used to approve the TMS device (OReardon et al.), and an independent re-analysis of that studys data (Lisanby, et al.), patients with a higher degree of antidepressant resistance than a single antidepressant failure do not consistently show a response to TMS greater than sham treatment. These findings were confirmed by two independent clinical trials (George, et al. and Avery, et al.).  In addition, the response rate and effect size of the response to TMS for patients who have failed a single antidepressant is comparable to, not markedly superior to, the response expected from another antidepressant trial or a trial with augmentation. (Lisanby et al., OReardon, et al. and Rush). Further, the study of maintenance TMS involved the use of TMS as a supplement to medication maintenance and was considered to be of unproven efficacy (Janicak, et al.).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested speech therapy, at a frequency of two times per week, and occupational therapy, at a frequency of one hour per week for treatment of the enrollees motor hypotonia and expressive speech and language developmental delay.  Findings:  The physician reviewer found that this patient has multiple delays that impact her ability to function in an age-appropriate manner. She has difficulties with expressive language, self-care, fine and gross motor skills, and feeding skills. These difficulties are preventing her from acquiring the usual skills of childhood, and persistence can lead to difficulties navigating the educational system and interacting with peers. Successful feeding clinics incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition to significant expressive language delay that merits speech and language therapy, this patient exhibits feeding issues that affect her ability to obtain adequate nutrition. Speech therapy is imperative to successful intervention.  Thus, the requested speech therapy, at a frequency of two times per week, is medically indicated.  In addition, with its focus on developing teaching self-help skills including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this case. Occupational therapy, at a frequency of one hour per week, is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested urgent care services for treatment of his complaint of body ache, insomnia and coughing. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would believe they were experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area.Review of the record demonstrates that the patient had symptoms most compatible with a routine viral syndrome with bronchitis. The records provided do not substantiate the presence of chest pain. In the absence of evidence of fever or chest pain, a prudent layperson would not be expected to construe this as a medical situation that required urgent attention to prevent serious deterioration of his or her health. A prudent layperson in this setting would have coordinated care through his primary care provider.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate) for treatment of his medical condition.  Findings:  The physician reviewer found that The standard of care for symptoms of runny nose, sneezing and nasal congestion with findings of septal deviation and enlarged turbinates is to maximize medical therapy prior to recommending surgical intervention. The submitted documentation does not demonstrate that this has been done. The medical records do not specify the degree of septal deviation or the degree of anatomic nasal airway restriction.  Thus, the submitted documentation fails to establish the medical necessity of the requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate). The available medical records do not demonstrate that the patients condition constitutes an abnormal structure of the body.  All told, the requested nasal septal/turbinate repair (rhinoplasty and resection inferior turbinate) is not medically indicated and is not reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested for ultraviolet home therapy lamp for treatment of the enrollees vitiligo.  Findings:  Two physician reviewers found that the medical literature, El-Mofty and colleagues concluded that, broadband UVA alone, without psoralens, and in appropriate doses may be of important therapeutic value in vitiligo. The device provided this patient is the National Biological Dermalight instrument which is equipped with a lamp emitting UVA light. Since the use of UVA light is supported in the clinical studies as a treatment option for vitiligo when first-line therapies fail, its use is likely to provide this patient more benefit than standard therapeutic alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for an upright magnetic resonance imaging (MRI) for evaluation of her shoulder pain.  Findings:  Two physician reviewers found that upright MR units are a type of open MR that has been approved by the Food and Drug Administration (FDA) as a medically accepted means of providing MRI for patients with severe claustrophobia. In addition, MRI is the exam of choice to evaluate internal derangement of the shoulder joint. This patient has shoulder difficulties that need advanced imaging however due to severe claustrophobia he has been unable to undergo a traditional open MRI study. As upright MR units are medically approved devices and this severely claustrophobic patient is in medical need of MRI of both shoulders, the requested upright MRI is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a Lap-Band procedure for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure at this time. In order to establish the medical necessity of the Lap-Band procedure, a thorough evaluation is indicated. Specifically, a dietary evaluation, psychological evaluation and medical clearance must be obtained prior to proceeding with the requested surgery. There must be documentation that treatable metabolic causes of obesity have been ruled out.  The medical records provided do not demonstrate that these evaluations have been performed.  All told, the requested Lap-Band procedure is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder. Findings:  The physician reviewer found that there is ample scientific data demonstrating that speech therapy and occupational therapy are safe and effective modalities for patients with autism. Given the documented deficits associated with this patients diagnosis of autism, it is medically necessary that he receive the requested speech therapy and occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that with regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested occupational therapy for treatment of the enrollees developmental delay and microcephaly.  Findings:  The physician reviewer found that the submitted medical records from the patients pediatrician, neurologist and geneticist contradict this finding. The workup performed by these providers clearly documents anatomic defects in the patients brain resulting in a global delay, thereby affecting his cognitive skills. Additionally, the fact that the patient has spasticity is a sign of physical pathology.Studies have shown that occupational therapy can prevent a deterioration or reversal of function and result in significant improvement in activities of daily living for children with developmental delay. A systematic review by Riethmuller and colleagues concluded that nearly 60% of the studies reported statistically significant improvements in motor development at follow-up. Their findings suggest that developmental therapy treatment affected gross motor gains for preschool children who exhibited moderate motor delays. In the case of this patient, there is documented evidence of significant developmental delay that requires therapeutic intervention. As such, the patient is an appropriate candidate for the requested occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested growth hormone (GH) Saizen 8.8 mg for treatment of the enrollees idiopathic growth hormone deficiency.  Findings:  The physician reviewer found that although the patients current height is more than 2.25 standard deviations below normal for age and gender, from a review of the available records, there is no evidence of poor linear growth velocity as measured longitudinally over time. The patients IGF-1 level was normal for bone age and pubertal stage. In addition, the results of provocative GH testing were normal. The patients adult height prediction, based on the bone age and height measurements is over 65 inches which is considered normal for a US adult male (Cohen, et al). For these reasons, the most likely cause of the patients short stature and delayed bone age is constitutional delay rather than true GH deficiency and as such he is expected to catch up to the normal curve in height when puberty arrives (Gharib, et al). Therefore, GH therapy is not medically necessary for this patient because he does not meet standard criteria for GH deficiency, nor is his predicted adult height short enough to qualify for a trial of GH therapy for treatment of idiopathic short stature, based on FDA guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested monitored anesthesia services provided during a colonoscopy performed for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates no indication for the use of MAC services during this patients colonoscopy. According to the American Society of Anesthesiologists (ASA) physical status classification system which assesses the fitness of patients before surgery, this patient was an ASA 1-2 risk (a normal healthy patient or a patient with mild systemic disease). This indicates he was not at increased risk for complications due to severe comorbidity. Further, he had no history of substance abuse or prescription narcotic/benzodiazepine use. All told, the patient was a healthy male who would not be predicted to have risks for sedation. As such, standard conscious sedation administered by a gastroenterologist was within the standard of care in this setting and would have been medically reasonable and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested computerized gait analysis for evaluation of the enrollees abnormal gait. Findings:  Three physician reviewers found that the relevant peer-reviewed medical literature supports computerized gait analysis in surgical decision-making process in children with neurologic disorders such as cerebral palsy. To date, there is insufficient scientific data demonstrating that computerized gait analysis is the equivalent of, or superior to, standard clinical evaluation performed by a qualified orthopedic surgeon in patients without a diagnosed neurological disorder. In this patient with intoeing from excessive femoral anteversion without evidence of a neurologic disorder, the use of the requested services has not been established as likely to be more beneficial in his evaluation and treatment than conventional evaluation modalities readily available.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old female enrollee has requested for Prolia 60mg for treatment of her osteopenia/osteoporosis. Findings:  The physician reviewer found that a recent article states, Given the absence of long-term safety data and the availability of other agents, denosumab [Prolia] is not recommended for osteoporosis prevention. The U.S. Food and Drug Administration (FDA) and the European Commission approved denosumab for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies. (Rosen)As noted above, the patient currently presents with osteopenia. Moreover, there is no indication in the office notes that the patient has been unable to tolerate Boniva or that Boniva has been ineffective. As such, the patient does not meet clinical indications for the use of Prolia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech therapy for one hour per week for treatment of his autistic disorder.  Findings:  The physician reviewer found that at issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health.  Thus, specific modalities can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, and self-help skills. Speech therapy is one such modality. It is well established that language skills and non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood. As such, speech therapy is a medically indicated and necessary intervention for this patient with communication deficits secondary to autism.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested genetic testing for hereditary hypertrophic cardiomyopathy for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there are 14 known genes that can cause familial hypertrophic cardiomyopathy (FHCM), and testing is available for 12 of them. Two genes, MYH7 and MYBPC3, account for 80% of FHCM, and 2 genes, TNNT2 and TNNI3, account for an additional 10% of cases.  Genetic testing in the setting of FHCM is medically indicated and appropriate in select patients to assist in identifying presymptomatic individuals who can be monitored closely to prevent tragic outcomes, such as sudden death, and to identify unaffected individuals who will not require annual screening to monitor for this condition. However, testing of a patient such as this patient, whose affected status has not been clarified, is not indicated.  A negative result in this situation would not be informative because one would not be able to interpret negative results definitively, as negative testing could result from either true unaffected status, or because the gene in the family cannot be identified by the current testing.  In the latter scenario, negative testing might falsely reassure the patient.  The standard of care in this setting is to perform testing on a clinically affected individual, such as the one living affected individual who has a pacemaker/defibrillator. If the mutation is identified in that individual, then testing for that specific mutation in at-risk family members is appropriate, after the patient has had sufficient counseling to understand the risks and benefits of testing.  Given that a mutation has not been identified in one of the patients family members, the patient is not currently an appropriate candidate for the requested genetic testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old female enrollee has requested speech therapy at a frequency of twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. As such, the speech therapy services should be covered since the said date with authorization for future services as medically necessary for her care. The patient should be re-evaluated in six months to assess her progress and ascertain whether additional therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for the medication Xifaxan 550mg for treatment of her history of constipation and abdominal distension. Findings:  The physician reviewer found that the American College of Gastroenterology position statement regarding the use of non-absorbable antibiotics such as Xifaxan, noted that there is a lack of data available supporting the long-term safety and effectiveness of these non-absorbable antibiotics for the management of irritable bowel syndrome symptoms. The current medical evidence does not support the use of Xifaxan in this patients case. The documentation fails to establish the medical necessity of the medication at issue in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that review of the record indicates the patient is significantly developmentally delayed.  However, he has made definite progress and has shown significant improvement in ambulation, communication (pointing) and self-help skills (feeds with a spoon). He has been diagnosed with cerebral palsy, a disorder of brain development.  As he has shown improvement while receiving physical and occupational therapy, it is highly probable that the patients expressive and receptive language delays will improve with individual speech therapy.    The scientific literature demonstrates that speech therapy can be extremely effective for a speech delay in this patients age group. The effectiveness of speech therapy in a young child is emphasized in several of the references cited above. A paper by Law et al., reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles. Goorhus-Brower, et al. specifically examines children with speech delay, including both cognitively normal as well as developmentally delayed children, and points out that both groups are candidates for successful speech therapy. All told, the benefit of speech therapy for young children with speech delay is well documented. The submitted medical records demonstrate the patient is an appropriate candidate for speech therapy, and therefore, the requested services should be authorized.