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

A 45-year-old female enrollee has requested for supportive services, intravenous hydration and medications for treatment of her upper tract urothelial carcinoma recurrence. Findings:  The physician reviewer found that one standard regimen for advanced bladder cancer is MVAC (methotrexate, vincristine, doxorubicin, and cisplatin). This regimen is quite toxic, with many patients requiring hospitalization due to myelosuppression or mucositis. Therefore, not all patients are suitable candidates for this treatment.  Regimens with fewer drugs have been compared head-to-head with MVAC.  However, although they have demonstrated reasonable response rates, they have not performed as well in terms of survival advantage.  In a phase III trial, Sternberg and colleagues compared dose-dense MVAC with conventional MVAC. The former showed a statistically significant improved overall survival.  If one looks at the survival curves from this trial, one can see that 22% of patients who received the dose-dense MVAC had prolonged survival over five years.  The current medical evidence supports the requested services and medications in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delays. Findings:  The physician reviewer found that the patient has an identified delay in his receptive language skills of 34 to 44% and a delay of 68 to 84% in his expressive language skills. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Speech therapy has been shown to have a positive effect in children with expressive phonological and expressive vocabulary difficulties. Treatment for language disorders should be predicated primarily on the childs language profile and level of communication skills. (Feldman and Messick) Children who participate in speech and language treatment show greater improvements than those children who have no treatment (Messick and Feldman). Preschool children, with specific language impairments, demonstrated statistically greater improvement with intensive direct speech therapy when compared to no intervention or nursery-based intervention (Gallagher, et al.). All told, the requested speech therapy is medically necessary for treatment of the patients speech delays. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested speech therapy, occupational therapy and feeding therapy for treatment of his autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this patient with autism who has a moderate impairment of pragmatic speech and socialization deficits.  Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Rogers and Vismara). Currently, effective interventions exist to teach communication skills to children with autism (Goldstein). Language skills make a significant difference in the ability of children to control their environment and have been found to be an adaptive alternative to highly disrupted behaviors, as noted in this patient. Therefore, speech therapy is a medically necessary component of this patients treatment plan.With regard to the request for occupational therapy, a fine motor evaluation found the patients fine motor skills to be within functional limits for his age; gross motor skills were also age-appropriate. Occupational therapy to treat the sensory processing deficits in this patient is not medically necessary, as the efficacy of this therapy for sensory processing deficits remains unproven. Sensory integration therapy is sometimes used alone or as a part of a broader program of occupational therapy for children with autism spectrum disorders (Myers, et al. and Baranek). While unusual sensory responses are common in children with autism spectrum disorders (ASD), the efficacy of sensory integration therapy has not been demonstrated objectively. (Myers, et al.; Baranek; and Polatajko, et al.) Concerning the requested feeding therapy, the medical necessity of this modality is not established in this case. Concerns about food selectivity are typical in patients with autism spectrum disorder. According to the submitted physical evaluation, the patient has normal weight and height growth velocities. The patients feeding issues do not rise to a level that necessitates implementation of a therapeutic feeding program. Based upon the documentation provided, feeding therapy is not clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of an 84-year-old female enrollee has requested for Somazina for treatment of the enrollee, who is status post intracerebral hemorrhage. Findings:  The physician reviewer found that the medical literature does not indicate that this medication is likely to improve outcomes in this clinical situation.  The current literature shows that this medication is likely to be safe.  However, the efficacy of the requested medication has not been established at this time.  In a small trial by Secades and colleagues, the authors examined the efficacy of this medication in intracerebral hemorrhage.  The authors reported that although this medication appears to be a safe drug for intracerebral hemorrhage, with a positive trend regarding efficacy, these data should be confirmed in a larger trial.  All told, Somazina is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for Marinol for treatment of her chronic pain. Findings:  The physician reviewer found that the peer reviewed medical literature demonstrates that there is greater scientific support for the use of standard  medications for patients with chronic pain than there is for the use of Marinol.. In sum, there is a paucity of research indicating the efficacy of Marinol in the treatment of this patients condition. As such, the medical necessity of Marinol for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a reduction mammaplasty for treatment of her neck, shoulder and back pain.  Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, and skin breakdown, if they are present. However, the medical records provided do not document the presence of such symptoms. Nor do the available records document any physician visits or treatments specifically for the patients reported symptoms, other than the referral to a plastic surgeon. There also are no shoulder bra strap grooves in the submitted patient photos. All told, the documentation provided does not establish that a reduction mammaplasty is medically necessary to resolve a functional impairment. With regard to whether the proposed procedure is reconstructive in nature, the submitted photographs do not show a condition that would constitute an abnormal structure of the body. The patient has moderately sized breasts with grade II ptosis and the right breast is slightly larger than the left. Her condition does not meet the criterion of an abnormal structure of the body as required by Californias reconstructive surgery statute. Therefore, the requested procedure is not considered reconstructive in nature but rather is cosmetic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested authorization and coverage for Boniva (J1470) injections for treatment of the enrollees osteopenia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested Boniva injections.  Osteopenia is treated with Vitamin D and supplemental calcium and can be treated with bisphosphonate therapy.  Bisphosphonates inhibit osteoclast-induced bone resorption.  They increase bone density significantly and reduce the incidence of both vertebral and nonvertebral fractures.  Bisphosphonates can be administered orally or intravenously.  The oral preparations can cause esophagitis and are not appropriate for patients with a history of hiatal hernia, severe gastroesophageal reflux or peptic ulcer disease.  Boniva is medically appropriate for the treatment of osteoporosis.  However, this patient has a diagnosis of osteopenia.  Boniva injections are not indicated for the treatment of this condition.  Of note, the patient has osteopenia of the hip, and the medical literature indicates that Boniva reduces the risk of vertebral fractures, but not nonvertebral fractures.  All told, Boniva (J1470) injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested reimbursement for a three-night home sleep study for evaluation of the enrollees sleep disturbance. Findings:  The physician reviewer found that the medical records provided indicate that the patient had a high pre-test likelihood of having sleep apnea. Therefore, the patients provider ordered a home sleep study. A home sleep study is a reliable test to evaluate patients for obstructive sleep apnea. However, the available peer-reviewed medical literature indicates that one night of a home sleep study is adequate for assessing patients for obstructive sleep apnea. There is no indication in the literature that additional nights are needed to accurately assess a patient for obstructive sleep apnea. All told, one night of the sleep study at issue was medically indicated and should be covered. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees significantly delayed expressive language skills as well as speech production.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male has requested social skills group therapy for treatment of his autism. Findings:  The physician reviewer found that Meyers and colleagues state that families of autistic children can facilitate joint attention and other reciprocal social interaction experiences throughout the day in the childs regular activities. Further, a controlled study comparing target treatment of 51 socially dysfunctional children who were divided into two treatment arms, community based and individual treatment, found that the community based group social treatment was much less effective in improving social behavior than individualized targeted treatment, similar to what this patient has been receiving via his sessions with the Plans Child Psychiatry Department (Casenhiser, et al.). Given the available peer-reviewed medical literature, the requested social skills group therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for future positron emission tomography (PET) scans for evaluation of the enrollees pancreatic cancer.  Findings:  Three physician reviewers found that the patient was found to have a left ovarian tumor compatible with mucinous cyst adenocarcinoma, probably pancreatic in origin. An initial computed tomography (CT) scan failed to detect the pancreatic tumor as well as the patients intraperitoneal and omental metastases. A subsequent positron emission tomography/computed tomography (PET/CT) was positive for the tumor. Thus, staging and therapeutic decisions have depended on the PET/CT results particularly in light of the understatement of disease by conventional CT. The patient has requested authorization and coverage for future PET/CT scans for follow-up.  However, the Health Plan has denied the request stating there is no literature supporting the use of PET/CT to prolong survival and therefore its use in this clinical setting is investigational.  In this patients case, conventional CT has proven to have some limitations in efficacy as the original pancreatic tumor was not visualized and the degree of intraperitoneal metastases was understated. By contrast, the physiologic capabilities of PET/CT have been illustrated to be of benefit in this patients disease as PET/CT has allowed not only a more detailed diagnosis and staging but also allows for evaluation of treatment success due to the physiologic properties of PET imaging. While it is unresolved whether survival is prolonged by the use of PET imaging in pancreatic cancer, given that PET/CT has been a valuable diagnostic tool in evaluating this patient when CT alone was inadequate, the requested PET/CT is more likely to continue to reveal the tumors PET avid response.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for residential treatment services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the records indicate that the patient was at imminent risk of serious harm to self or others as documented in the mental status examination. Based on review of the records, this patient meets the American Psychiatric Association (APA) guidelines for admission to RTC during the period under review and thus the admission was medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested authorization and coverage for a lumbar traction unit for in-home use for treatment of chronic low back pain.   Findings:  Two physician reviewers found that the patient has been diagnosed with chronic low back pain, which has worsened recently. The patient has a herniated disc at L4-5 and underwent a physical therapy assessment and physical therapy in conjunction with a home exercise program was recommended. A few weeks later it was noted that the patient has had good relief of his pain with a trial of home traction and a home lumbar traction device was recommended, along with continuation of his current rehabilitation program. The patient has requested a home lumbar traction unit, which has been denied by the Health Plan. Lumbar traction is not likely to be more beneficial than available standard therapies for the treatment of this patients condition. There is insufficient scientific evidence to clearly demonstrate the benefit of lumbar traction versus the available standard therapies. The peer reviewed medical literature provides contradictory evidence on the effectiveness of a wide range of commonly used treatments for low back pain including traction. Based on the current evidence, intermittent or continuous traction as a single treatment for low back pain cannot be recommended for mixed groups of patients with low back pain with and without sciatica (Clarke, et al.). In sum, the inconsistencies in the peer-reviewed medical literature and the fact that there are other available therapies that have been proven efficacious in the treatment of low back pain, demonstrate that there is insufficient evidence to prove that a traction device would be more beneficial for treatment of this patients medical condition than any available standard therapy. Further studies are needed to prove the safety and efficacy of the requested device in the treatment of low back pain. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees receptive and expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25 % (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders and children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee requested authorization and coverage for a referral to a dermatologist for treatment of skin lesions.  Findings:  The physician reviewer found that the patient is requesting coverage for evaluation and treatment of persistent lesions on the extremities. The patient reports having previously been evaluated by a dermatologist and was treated with liquid nitrogen cryotherapy.  The medical records available from his primary care provider do not offer a diagnosis for his current condition.  The primary care provider does recommend evaluation by a dermatologist, which was denied by the Health Plan.  Given that the diagnosis of the current condition is not clear and will not be determined until the patient is evaluated by a dermatologist, the patient does meet medical necessity criteria for a specialty evaluation.  The request for coverage for evaluation by a dermatologist should be authorized for at least one visit, so that an accurate diagnosis can be rendered, given that cure rates of skin cancers are dependent on early diagnosis and treatment (Tuong, et al.; and Tolpinrud, et al.).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of her major depression.  Findings:  Two physician reviewers found that there is a lack of peer reviewed literature supporting maintenance treatments with TMS. The current peer reviewed medical literature indicates that the value of TMS in the treatment of refractory depression is limited. The use of TMS for any indication other than the FDA approved criteria should be considered off label, as the current research does not show it to be more effective than pharmacotherapy in cases of refractory depression. TMS is FDA approved for patients who have failed a single trial of anti-depressants. This patient has shown only limited improvement on multiple anti-depressant medications. In sum, there is no evidence in the current literature to indicate that maintenance TMS or an additional course of TMS is likely to be more effective than any standard alternative treatment for major depressive disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of four-year-old female has requested occupational therapy and speech therapy for treatment of her autism. Findings:  The physician reviewer found that children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. (Case-Smith and Arbesman) With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in children with ASD. (Smith-Roley, et al.) Occupational therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested authorization and coverage for extracorporeal shock wave therapy (ESWT) for treatment of shoulder pain.  Findings:  Three physician reviewers found that the patient has bilateral shoulder pain and limited range of motion.  The patients recent MRI shows mild acromioclavicular (AC) joint arthrosis and supraspinatus tendonitis. No tears or calcific deposits were noted on the MRI.  There are no supporting documents to denote any failed therapy or clinical notes to document treatments tried, or physical exam or history. The patient has requested authorization for extracorporeal shock wave therapy (ESWT). The Health Plan has denied this request, which is the subject of this review. The literature shows there is some benefit in the treatment of calcific tendonitis with ESWT, however, no calcific deposits were noted on the patients MRI.  Even in patients  with calcific tendonitis, the level of literature support for ESWT is considered low, as there are little to no large scale studies available. Further, there is a paucity of data demonstrating the effectiveness of ESWT in the treatment of joint arthrosis or supraspinatus tendonitis. In addition, no records have been provided to document the patients symptoms and physical limitations or to document that the patient has tried traditional physical therapy with anti-inflammatory modalities without adequate relief.  As such, the Health Plans denial should be upheld.