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

A 35-year-old male has requested Cialis 20mg (six tablets per month) for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that PDE5 inhibitors block the degradation of cyclic guanosine monophosphate (cGMG) by the enzyme phosphodiesterase type 5.  The process of sexual stimulation involves the release of nitric oxide in the vasculature of the corpus cavernosum of the penis. Nitric oxide results in increase of cGMP and leads to the relaxation of smooth muscle in the blood vessels supplying the corpora cavernosa. The result is increased blood flow leading to erection.  In sum, the PDE5 drugs improve erection by improving blood flow to the penis.  As part of his workup and evaluation, the patient had a penile ultrasound test which showed normal blood flow to the penis and normal response to injection.  This would indicate no impairment of blood flow to the penis, either at rest or with stimulation. Therefore, the requested medication is not medically indicated, as testing has demonstrated normal blood flow.  All told, the requested Cialis 20mg (six tablets per month) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high, based on the few studies that have included such information in autism or pervasive developmental delay. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the person with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy, studies have shown that occupational therapy prevents a deterioration or reversal of function and results in significant improvement in activities of daily living. In 2008, Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and showed that in all six areas occupational therapy significantly helped the patient. Additionally, this patient carries a diagnosis of Fragile X syndrome. In an article describing children with Fragile X syndrome, with and without autism, the authors were able to demonstrate that the relationship between lower IQ or even lower fine motor skills in those with Fragile X syndrome and ASD compared to Fragile X syndrome alone might be explained by additional genetic or medical insults to the brain. These insults would introduce barriers to the motor or cognitive or social development of these children in addition to the Fragile X syndrome diagnosis. (Zingerevich, C., et al.) Occupational therapy usually addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children with Fragile X syndrome. In addition, a therapeutic regimen that includes occupational therapy can help focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.This patient has documented sensory deficits, as well as delays in his self-help skills, which need to be addressed as stated in the guidelines from the American Academy of Neurology (AAN). Therefore, it is recommended that the requested occupational therapy be provided with reassessment every six months to determine if ongoing occupational therapy is needed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested authorization and coverage for a carcinoembryonic antigen (CEA) test. The Health Plan has denied this request indicating that the requested diagnostic test is not medically necessary for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that there is no available peer-reviewed medical literature which indicates that CEA testing is reasonable as a screening test for colon cancer. The medical literature indicates that this test is not helpful in screening for gastrointestinal malignancy. Although the literature indicates that this test may be useful in following patients who have previously been treated for an established gastrointestinal malignancy, this remains controversial and this patient has no personal history of cancer.  At this time, there is a lack of scientific evidence demonstrating that CEA testing is clinically useful in this patients situation. Therefore, the Health Plans denial was appropriate and should be upheld.
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 this patient has an identified delay in expressive speech of greater than 50% with mild delays in receptive speech. Speech therapy is indicated with any delay greater than 25%.  (Feldman & Messick). The literature includes a meta-analysis by Law, et al., in which the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty was noted. Feldman & Messick state that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). In accordance with the available peer reviewed medical literature and the medical records provided, this patient has a history of severe expressive language delay and should receive appropriate intervention including speech therapy. Thus, speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested four months of treatment at the residential treatment level of care for treatment of the enrollees bipolar disorder, attention deficit/hyperactivity disorder and polysubstance dependence.  Findings:  The physician reviewer found that the records indicate that his suicide attempts were impulsive which makes them hard to predict. The patient has a history of gang involvement and has remained highly impulsive. Whether a four-month stay at a residential treatment level of care is medically necessary will depend on the patients future clinical status and response to treatment. At this point in time, the documentation provided does not support the medical necessity of a four-month admission. The patients progress will need to be continually monitored to determine the effectiveness and appropriateness of 24-hour supervised treatment. With regard to the frequency that concurrent review should be performed by the Health Plan, weekly evaluations are consistent with the standard of care in the psychiatric community and are appropriate for a patient being treated at this level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees motor speech delay.  Findings:  The physician reviewer found that this patient has a phonological and articulation speech disorder. Speech therapy is helpful in managing the speech sound disorder, allowing the patient to identify and practice mature patterns of speech. An extensive review of the literature, including meta-analysis, by Law et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. An additional study notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman & Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). The treatment for articulation disorders is different from phonologic disorders. Articulation treatment techniques include how to produce target consonants, modeling, imitation, and using sequential steps to approximate accurate sound production. Phonologic disorders use a target rule to provide a difference in meaning (Feldman & Messick). The goal of therapy is always improvement in functional communication. Additionally, children with phonological and articulation disorders often experience embarrassment and poor self-esteem and speech therapy may reduce the negative consequences of the disorder and provide remediation. Thus, the speech therapy at issue was and is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested treatment on a monthly basis for her multiple medical conditions. Findings:  The physician reviewer found that the patient has been followed by an out-of-network physician who has recommended treatment consisting of pain medication, trigger point injections and caudal ESIs. Based on the documentation provided, the patient does not meet Medicare or other standard of care guidelines for caudal ESIs. Current standards of care strongly suggest that caudal ESIs have been replaced with fluoroscopically guided transforaminal ESIs in the long-term interventional management of radiculopathy due to spinal pathology, such as herniated discs and/or spinal stenosis. Therefore, the recommended caudal ESIs are not medically necessary at this time. The Health Plans recommendation for an evaluation with an in-network pain management specialist is appropriate for the patient to discuss other treatment options that are consistent with the current standards of care for the treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-year-old male enrollee has requested the Stander Easy Stand 5000 (E0641)for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that this patient has documented spastic diplegia/cerebral palsy, which have been managed with medications, physical therapy and surgery. Individuals with paraplegia are at risk of contractures, osteoporosis and skin breakdown. A review of the available, peer-reviewed scientific literature demonstrates that weight bearing reduces the risk of osteoporosis. Additionally, standing frames have been studied for the management of weight bearing and small studies have resulted in significant improvements in hamstring length in non-ambulatory patients with cerebral palsy and may increase the patients ease of performing their activities of daily living. The use of a standing frame has a significant possibility of improvement in health outcomes. Therefore, the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested canaloplasty for the left eye for treatment of her open-angle glaucoma.  Findings:  Two physician reviewers found that although penetrating glaucoma surgery continues to evolve, Filippopoulos and Rhee recommend reservation of surgical intervention for patients who have failed pharmacologic treatment and/or laser trabeculoplasty. Cheng and colleagues found that canaloplasty was associated with fewer complications than trabeculectomy. Thus, the use of canaloplasty may offer this patient superior health benefits when compared with standard therapy. As such, the requested canaloplasty is medically appropriate for treatment of this patients open angle glaucoma applying the current standards of practice and likely to be more beneficial for treatment of her condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder.  Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that speech therapy and occupational therapy are medically necessary interventions for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy and occupational therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, 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 developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 20-month-old male has requested speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the available peer reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech therapy (ST) and occupational therapy (OT) services for treatment of his autistic spectrum disorder (ASD). Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that ST and OT are medically necessary interventions for the treatment of patients diagnosed with autism. Laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain still exists, and ST and OT can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, 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 developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested duodenal switch bariatric surgery without documentation of participation in a 12-week weight loss program and/or 10% body weight loss for treatment of her obesity.  Findings:  The physician reviewer found that although this patient is morbidly obese and may be a candidate for bariatric surgery, all patients should have made reasonable efforts to lose weight and complete a multidisciplinary evaluation that includes dietary and behavioral evaluations. Bariatric surgery requires careful patient evaluation and the weight loss program recommended by this patients surgeon appears to be multidisciplinary (behavioral and dietary) in nature as part of pre-operative weight loss. As noted by Elder and Wolfe in the peer reviewed literature, Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive pre-surgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. Further, the authors stated that, comprehensive pre-surgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Consistent with these recommendations, the National Institutes of Health (NIH) consensus guidelines require documentation of failed weight loss attempts, which was not submitted with this patients records. Thus, although the patient has indicated that she has undergone adequate weight loss programs, without documentation of supervised efforts at pre-surgical weight loss, the medical necessity of the requested referral has not been established at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested intensive outpatient program level of care for treatment of her eating disorder. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for intensive outpatient program services. There is no evidence of suicidality, and the patient has gained and maintained a satisfactory amount of weight.  There have been urges to binge and purge, but there is no indication of significant physiological compromise. The most recent information indicates that she was slightly above her ideal body weight. American Psychiatric Association guidelines recommend outpatient treatment for patients who are above 85 percent of their ideal body weight.  There is no indication of current coexisting medical, social or psychiatric conditions which would contraindicate a less intensive level of care.   All told, continuation of intensive outpatient program level of care was not and is not medically necessary for the treatment of this patient.  This patient could have been managed safely and effectively in the context of weekly one-hour mental health eating disorder outpatient therapy according to current evidence-based standards and expert consensus.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature.   Findings:  The physician reviewer found that the patient, a then seven-year-old male, presented to the emergency department complaining of an itchy rash on his arms and abdomen for one week. The rash began after the patient spent a night at a friends house, and his friend developed a similar rash.  No fever, chills, headache, neck stiffness, or nausea/vomiting were noted. Vital signs were normal and he had no pain.  He was evaluated by a physician who diagnosed him with a rash and discharged him from the ED with a prescription for hydrocortisone cream and Benadryl.  At issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, believe the patient was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted evidence indicates that the patient had a rash that had been ongoing for one week. The rash was not associated with any other concerning symptoms such as fever, chills, headache, neck stiffness, or nausea/vomiting.  In addition, the rash was not painful. Thus, the patients condition was not such that a prudent layperson would reasonably conclude that the patient required treatment on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested for speech therapy, occupational therapy, and physical therapy for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that 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. With regard to occupational therapy, Case-Smith and Arbesman concluded that the research literature offers strong positive evidence for providers to use comprehensive, individualized analysis of the patients performance to develop the intervention strategies. The research evidence also supports the use of family-centered, interdisciplinary approaches. Many of the studies used play-based or activity-based interventions such as those implemented by occupational therapists. In the medical literature, Shevell and colleagues concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. Additionally the American Academy of Neurology (AAN) practice parameters recommends evaluation of children with non-progressive global delay since a specific etiology can be determined in the majority of children with global developmental delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested custom foot orthotics for treatment of the enrollees pain.  Findings:  The physician reviewer found that based upon the submitted documentation, the requested custom foot orthotics are medically necessary for the patients medical condition.  This patient possesses biomechanical abnormalities to her foot that places significant strain on her muscles, tendons, ligaments, and joints.  This has resulted in significant pain.  This pain has limited her ability to ambulate or exercise comfortably.  Custom foot orthotics are devices used to support and control the foot and alleviate these stresses, allowing for pain-free ambulation.  The current medical evidence supports the requested custom foot orthotics in this clinical situation.