Persius/hicric huggingface dataset:
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 speech delay.  Findings:  The physician reviewer found that in child development, delay in speech acquisition 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. Speech therapy is the standard of care for patients with speech delay and as this patient presents with an approximate 57% delay in speech and language skills, the requested therapy is medically necessary for this patient for 1 hour per week.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested acupuncture for treatment of her back pain. Findings:  The physician reviewer found that low back pain generally tends to improve naturally with time but can also recur intermittently or become more severe or chronic in nature. With regard to treatment, there is insufficient high-grade, objective evidence that acupuncture causally improves health or functional outcomes in the setting of chronic low back pain. Specifically, there is no reliable and reproducible scientifically-based medical literature that supports the efficacy of acupuncture in this clinical setting. A recent review from Lewis and Abdi noted that, Most of the published articles about acupuncture in the biomedical literature consist of case reports, case series, or intervention studies with designs inadequate to assess its efficacy. Thus, it is imperative that further research be performed, both preclinical to help elucidate the mechanisms underlying acupuncture, and clinical to justify its clinical application. The authors concluded that, There is a paucity of high-quality research assessing efficacy of acupuncture in the management of [low back pain]. As such, the requested acupuncture therapy is not of proven efficacy for this condition and therefore not medically necessary in the management of this patients low back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested a minimally invasive lumbar decompression (CPT 0275T) for treatment of his spinal stenosis.  Findings:  The physician reviewer found that the concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based. Minimally invasive treatments have been undertaken in all areas of the spinal axis since the 20th century. Cervical disc disease has been treated using chemonucleolysis, percutaneous discectomy, laser discectomy, intradiscal thermoablation, and minimally invasive microdiscectomy techniques. However, until better scientific evidence is available, minimally invasive lumbar decompression is still considered a research technique.  Minimally invasive lumbar decompression remains unproven, as there is no established clinical efficacy present in the available literature. In sum, the requested procedure is not considered to be standard treatment within the medical community and is not medically necessary in the case of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested outpatient psychotherapy, at a frequency of five sessions per week, for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the data reviewed failed to support medical necessity for continued therapy five times weekly as of the date in question. The patient has clearly shown significant improvement. However, the therapist indicates that the turn-around in the patients condition has primarily occurred since 2008 at which time her significant other attained sobriety and there is no evidence that her improvement is related to the intensive therapy as opposed to her improved social situation. Additionally, there is no Axis II diagnosis despite ample indication that the patient meets diagnostic criteria for borderline personality disorder according to American Psychiatric Association (APA) guidelines. Further, there seems to be contradictory findings in the documentation provided, in that, the outpatient treatment report submitted by the therapist on the said date indicates that the patients global assessment of functioning (GAF) score decreased from 53 to 40, which is inconsistent with the therapists assertion that the patient is able to hold a job and maintain a successful relationship. A GAF of 40 would also seem to indicate that the current treatment program is not successful. Moreover, there have been no changes in medications, suggesting that the patient has benefitted maximally and APA guidelines do not support either daily psychotherapy for individuals with borderline personality disorder or long-term psychotherapy for patients with bipolar disorder.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested intravenous immunoglobulin (IVIG) with rituximab for treatment of her pemphigus vulgaris.  Findings:  Three physician reviewers found that rituximab has clearly been shown to be efficacious for the treatment of pemphigus vulgaris. IVIG has also been shown to be effective for this condition. There are some reports in the available peer reviewed literature of utilizing both therapies concurrently. However, based upon the documentation provided, it does not appear that this patient has undergone a trial of rituximab alone. Rituximab should be attempted as a stand-alone therapy prior to consideration of combining rituximab and IVIG. If a trial of rituximab as solo therapy is not efficacious in treating this patients condition, then combination therapy with rituximab and IVIG would be appropriate and should be pursued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested lower lumbar spine fusion surgery for treatment of his low back and left lower extremity pain.  Findings:  The physician reviewer found that this patient has chronic back pain. He has chronic knee pain with an abnormal knee exam. He is said to have an L4, L5, and S1 radiculopathy, however there is no evidence present in the records provided to support this diagnosis. The patient is said to have spondylolisthesis and discitis by his orthopedic surgeon, but this has not been confirmed =by any of the other examiners. He is not noted to have spondylolysis, scoliosis, angulation, fracture, -or instability of his lumbar spine which are the accepted criteria for lumbar fusion (Milliman Care Guidelines; Bambakidis, et al). Further, there are no localizing features that would indicate that the L4-5 or the L5-S1 levels are his pain generators. Thus, fusion at L4-5 and L5-S1 is not medically necessary or medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested biofeedback for treatment of the enrollees chronic back pain and headaches.  Findings:  Two physician reviewers found that studies for biofeedback have been difficult to perform in terms of a double blind study. Many of the published references are meta-analyses and reviews up to this point. That said, there have been a number of articles relating to psychological therapies available to adolescents with chronic pain. Notable pain syndromes treated with good results in regards to biofeedback included not only headache, but abdominal pain, fibromyalgia and temporomandibular joint (TMJ) dysfunction as well. Biofeedback does need to be performed in conjunction with adequate physical and interventional therapies. Behavioral therapy and biofeedback was found to be helpful in terms of treating the patients pain state. In sum, given this patients chronic pain syndrome, biofeedback is medically reasonable and appropriate and likely to be more beneficial for treatment of this patients medical condition than available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for skilled nursing facility (SNF) services for treatment of her status post hemorrhagic cerebrovascular accident. Findings:  The physician reviewer found that the patient has a high baseline level of function, including living independently in the community, ambulating without an assistive device, driving and working. Her care could have been transitioned to a custodial level with custodial level assistance and restorative nursing/nonskilled services for basic ongoing strengthening and reconditioning. There are no documented ongoing skilled nursing needs or medical needs requiring ongoing inpatient care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year, 7-month-old male enrollee has requested 1-2 sessions per week of speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in speech acquisition 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. Speech therapy is the standard of care for patients with speech delay and this patient presents with significant delays in speech and language skills. Therefore, the requested therapy is medically necessary for this patient for 1 hour sessions at a frequency of 2 sessions per week.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a DEXA bone density study for evaluation of her history of osteoporosis.  Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the DEXA bone scan performed on the date in question.  According to published guidelines, risk factors for developing osteoporosis include age greater than 65, post-menopausal women less than age 65 with a concerning clinical profile, family history of fracture, longstanding steroid use and gastrointestinal disorders. For patients younger than 65 years of age, evaluation for osteoporosis is recommended if the patient has a major risk factor or two minor risk factors. The guidelines for patients younger than age 65 do not consider being post-menopausal a major or minor risk factor, in and of itself. This patient did not have a major risk factor (such as parent history of hip fracture). She had only one minor risk factor, low body weight. Thus, the patient did not meet established guidelines for a DEXA scan.  All told, the DEXA bone density study performed was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency (Cohen; American Academy of Pediatrics; and Rasmussen, et al.). As a result, the prevention of secondary disability is important. Occupational therapy with early intervention services is often needed for continued improvement in fine-motor skills acquisition and helps to promote arm and hand movements that lay the foundation for later developing fine motor skills (Cohen and Rasmussen, et al.). Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing (American Academy of Pediatrics). This patient does not currently have significant, identified fine motor delays. Given the patients young age, re-evaluation of fine motor and adaptive abilities is recommended in four months. If delays greater than 25% are noted at that time, occupational therapy would be indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy services and occupational therapy services for feeding therapy, activities of daily living deficits and sensory-motor proprioceptive impairments for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that both the speech and occupational therapists have recommended continued therapy. The above references deal with the effectiveness of OT sensory-motor techniques for children. Schaff, et al. documents the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. Miller, et al. involved a controlled study of the effectiveness of sensory motor therapy in a childhood population. Dramatic improvements in behavior and attention were noted when patients received occupational therapy utilizing sensory motor techniques (Roberts, et al.). Children with speech delay can be readily treated (Law, et al.), and speech-delayed children, such as this patient, are ideal candidates for successful speech therapy (Goorhuis-Brower and Kniff).  The medical community standard is to offer both speech and occupational therapy to children with this degree of speech and developmental delay. All told, the requested therapies are medically appropriate and indicated to address this patients severe expressive language delay, feeding issues, deficiencies in activities of daily living and sensory-motor proprioceptive impairments Therefore, the requested services are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for continued outpatient psychoanalysis sessions for treatment of her major depressive disorder. Findings:  The physician reviewer found that stressors have been identified, and there has been a recent medication change.  Recent notes indicate no active suicidal plans.  Molenaar and colleagues published a randomized controlled trial which aimed to evaluate whether 16 sessions of psychotherapy combined with pharmacotherapy is more effective in relieving depression and improving social functioning than eight sessions of psychotherapy combined with pharmacotherapy.  The authors found that there was no clear difference between eight or 16 sessions of psychotherapy, both combined with pharmacotherapy, with regard to severity of depression and social functioning. The medical necessity for continued outpatient psychoanalysis sessions has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested motility clinic treatment for treatment of his history of abdominal pain and jaundice.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  There is no justification in the medical records that formal evaluation for a gastrointestinal motility disorder is warranted. Additionally, there is a lack of documentation demonstrating what specific gastrointestinal motility disorders are of concern in this patients case. There is a lack of objective evidence documented in the medical record supplied for review demonstrating that the patient has a gastrointestinal motility disorder.  There is no documentation of weight loss, vomiting, or symptoms of intestinal obstruction or pseudo-obstruction.  All told, the requested motility clinic treatment is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Erbitux for treatment of her colorectal cancer.  Findings:  Two physician reviewers found that Erbitux is one of a newer class of anti-cancer drugs, an inhibitor of epithelial growth factor receptor (EGFR). Erbitux has been approved for use in combination with chemotherapy in patients with metastatic colon cancer. In addition, Cunningham and colleagues found that Erbitux combined with irinotecan has clinically significant activity when given alone or in combination with irinotecan in patients with irinotecan-refractory colorectal cancer. However, more recent data has demonstrated that patients who benefit from the addition of Erbitux are those whose tumors do not have a codon 12 or 13 mutation of KRAS, as is the case with this patient. Similarly, Dempke and Heinemann found that KRAS mutations are predictive for lack of clinical response. The authors concluded that of the 394 patients randomized to receive Erbitux or best supportive care, patients with KRAS mutation did not benefit from the use of Erbitux. Since the use of KRAS mutation has become widely accepted for the selection of appropriate patients for treatment with Erbitux and this patient is noted to have such a KRAS mutation, the use of Erbitux is not likely to provide improved health outcomes when compared with conventional therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested 35 treatments of transcranial magnetic stimulation (TMS) for treatment of the stated condition of major depressive disorder.  Findings:  Two physician reviewers found that there is history of manic episodes for this patient, which is particular to bipolar disorder, rather than to unipolar depression. There is a paucity of large scale, randomized data to support the efficacy of TMS in the treatment of bipolar disorder. Additionally, there is inadequate evidence to support TMS as a more efficacious antidepressant therapy than electroconvulsive therapy. There are not randomized studies comparing TMS to ECT for treatment resistant depression or bipolar disorder. In this case, there is a lack of documentation that the patient has been tried on ECT or other standard therapies such as an adequate trial of evidence based psychotherapy. All told, there is insufficient evidence that TMS therapy is likely to be more effective for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for right breast reconstruction and bilateral breast reduction concurrent with right excisional biopsy with sentinel node biopsy for treatment of her invasive lobular carcinoma. Findings:  The physician reviewer found that there have been increasing reports on an oncoplastic approach to breast cancer which combines lumpectomy with immediate local reconstruction, there are no specific characteristics of this patients tumor or her breast size that indicates an oncoplastic approach would be necessary or preferred in this case. Breast reduction following treatment of breast cancer is best delayed until the completion of radiation therapy to determine the effects of the radiation on the size and shape of the breast, which can be quite variable and cannot be predicted prior to surgery. The indications for breast reduction should be reconsidered after the patients breast cancer treatment has been completed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested residential eating disorder level of care for treatment of her eating disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of anorexia for most of her adult life precipitated by abuse in her family. She started losing weight in early 2011, this represents greater than 90% of her IBW. In addition, the records do not document any acute medical problems such as electrolyte or fluid imbalance, nor did she have hypotension or cardiovascular problems. Therefore, according to the American Psychiatric Association (APA) treatment guidelines, this patient can be safely and adequately be managed on an outpatient basis as the medical necessity of the requested residential treatment program services has not been established.