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

A 65-year-old male has requested coverage for a referral to a radiation oncologist for treatment of prostate cancer. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service in this patients case.  It is medically necessary for this patient to be followed by a radiation oncologist.  While urologists treat prostate cancer, they do not do so with external beam radiation.  Radiation oncologists follow patients for toxicity after radiation, including rectal bleeding, urinary symptoms, and sexual function.  It is medically appropriate for this patient to be followed by a physician who is accustomed to managing radiation-related outcomes and toxicities.  The current medical evidence supports the requested service in this clinical setting.  All told, the requested referral to a radiation oncologist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The peer-reviewed medical literature has demonstrated positive results for this intervention.  TMS has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this patients case, he has trialed multiple medications, including augmentative strategies.  Additionally, he reportedly has been actively participating in psychotherapy.  Per the current practice guidelines and peer-reviewed medical literature, TMS therapy is medically appropriate in this clinical setting.  All told, the requested TMS therapy is 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 enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees severe apraxia of speech and expressive language disorder. Findings:  The physician reviewer found that  the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As reported 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.  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.  Broomfield and colleagues noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech therapy, particularly for children with primary expressive language disorder.  Verbal apraxia involves impairment in planning and coordinating movements for speech production.  For patients with apraxia of speech, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a deficit in motor programming and sensorimotor processing at the central level.  It is a neurological disorder that requires intensive treatment.  If left untreated or inadequately treated, communication at all levels may ultimately be impaired.  The literature supports intensive speech and language therapy for verbal apraxia as well as expressive language delay.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested authorization and coverage for individual psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring.  Findings:  The physician reviewer found that based on review of the available records, the patient is pursuing treatment from an independent provider who has recommended continuation of individual therapy. The provider states that psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring is indicated for this patient. However, there is inadequate documentation supporting this specific approach. The independent provider will be offering medically similar treatment to the services available within the patients Health Plan. The records suggest that the apparent tension and poor rapport between the patient and his therapists has likely hindered progress. The patient indicated that he has seen many therapists who have used many modalities over the years which were ineffective. The patient does require individual psychotherapy on an ongoing basis. However, the requested individual psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring approach is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male has requested an electric motorized scooter for treatment of his respiratory distress and difficulty with ambulation.  Findings:  The physician reviewer found that the documentation provided for review does not establish the medical necessity of a POV for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, the clinical records do not support the medical necessity of the prescribed POV. A general physical examination notes normal gait and ability to participate in an exercise program and records document unlabored breathing, normal gait, ability to stand without difficulty, and intact cerebellar function. Consistent with this patients level of mobility and ability to perform MRADLs within the home, the requested equipment is not supported as medically necessary.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested reimbursement for services provided on an emergent basis. Findings:  The physician reviewer found that the patient is a 64-year-old male who underwent urgent/emergent evaluation, resuscitation and bladder tumor resection and fulguration. The pathology specimen showed high grade transitional cell carcinoma and although the operative report states resection was carried out through to the perivesical fat, no muscle was found on pathology to assess the depth of tumor penetration for accurate staging and planning of treatment options. The patient underwent an out-of-network resection six weeks later on the date in question and was found to have no muscle invasion. He is seeking coverage for the out-of-network procedure on the grounds that it was required on an emergent basis. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as 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 to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients situation on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of immediate treatment to jeopardize his or her health. In the face of a high grade bladder tumor on biopsy and failure to obtain muscle samples in the area of the tumor, repeat resection was appropriate within six weeks of the original procedure. The patients family states that they had been informed that a repeat biopsy could not be performed by an in-network provider for more than two to three months. A prudent layperson in this situation would reasonably believe that a delay of potentially several months would place his or her health in serious jeopardy. Furthermore, the peer-reviewed literature supports the benefit and need for resection in a timely manner in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested reimbursement for substance abuse residential treatment center services provided at Passages Treatment Center for almost one month.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Modern psychiatric practice aims to provide care in the least restrictive setting that is likely to effectively address the issues which are causing functional impairment.  Providers rely on practice guidelines, peer-reviewed literature, and placement criteria when determining the appropriate level of care.  Per the American Psychiatric Association, residential treatment is indicated for patients who do not meet the criteria for hospitalization but whose lives focus predominantly on substance use.  The American Psychiatric Association notes that residential treatment may be indicated for patients who lack substance-free social supports to maintain abstinence in an outpatient setting.  In this patients case, her alcohol use dominated social and family dynamics.  She lacked adequate social supports to facilitate recovery.  Additionally, she had failed a less restrictive setting prior to the disputed services.  The current medical evidence support substance abuse residential treatment center services in this clinical setting.  All told, the substance abuse residential treatment center services provided were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female has requested genetic testing for breast cancer gene for evaluation of her risk for developing breast cancer.  Findings:  Two physician reviewers found that the patient is a 45-year-old female with a significant family history of breast cancer. Her mother had breast cancer at 80, as did her maternal grandmother at 60 years of age, and her maternal aunt at 65. The patient does not have a diagnosis of breast cancer. BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a patients chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be enacted, or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer. The U.S. Preventive Services Task Force indicates that genetic testing is not applied universally, but rather to patients that exhibit family histories that are suggestive of inherited predispositions. A large study by Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors reported that family history included at least one first or second degree relative with breast or ovarian cancer. This study is impressive for its size and for its separate analysis of patients of Ashkenazi and non-Ashkenazi descent. Similarly, this patients pedigree may not be obvious since there are two second degree relatives with breast cancer, and one first degree relative with breast cancer diagnosed over age 45. Genetic testing is commonly applied to familial cancer syndromes. The National Cancer Institute (NCI) guidelines stipulate that BRCA testing is reasonable in this clinical setting. All told, there is sufficient evidence to test this patient for BRCA1 and BRCA2 mutations.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested speech therapy for treatment of her speech delay.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested speech therapy in this patients case.  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.  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 seriously in young children, because the long-term consequences may be substantial.  Per 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.  This patient has a history of prematurity.  She demonstrates severe receptive and expressive language delay as well as behavioral problems, which negatively impact her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  The current medical evidence supports speech therapy in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male has requested coverage for a power wheelchair for treatment of his spastic hemiparesis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested equipment in this patients case.  The determination of medical necessity of a power wheelchair is based upon specific criteria.  These criteria include whether the patient is unable to ambulate independently with use of an assistive device, and whether the patient does not have sufficient upper extremity function to propel a manual wheelchair.  Additional factors include if the patient has demonstrated the ability and willingness to safely operate a power-operated vehicle, whether a power wheelchair is needed to perform in-home mobility-related activities of daily living, and if the patients residence will accommodate such a device.  In this patients case, the clinical records support the medical necessity of the prescribed power wheelchair.  All told, the requested power wheelchair is medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested coverage for third Hyaluronan injections for treatment of her bilateral knee osteoarthritis.  Findings:  Two physician reviewers found that the patient has bilateral osteoarthritis of the knees. The provider noted that the patient was not able to take anti-inflammatory medications due to reflux and dyspepsia, for which she was on Protonix. The patient wrote in her appeal letter dated that she had tried alternative treatments such as Tylenol, cortisone injections, physical therapy and weight control, yet her knee function was still compromised. The Health Plan has denied the patients request for a third series of Orthovisc injections for her bilateral knees as investigational. Although routine use of repeated series of viscosupplementation is not supported in the peer-reviewed medical literature, its use may be reasonable in this clinical setting. There are some data demonstrating the efficacy of a repeat series of injections. One systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee concluded that repeat courses of the hyaluronans are safe and effective in the treatment of pain associated with osteoarthritis of the knee (Pagnano and Westrich). Another study reported that repeated cycles of intra-articular sodium hyaluronate treatment was efficacious during a 54-month follow-up period in continuing to delay time to total knee replacement in patients with knee osteoarthritis (Turajane, et al). In addition, Raynauld and colleagues randomized controlled trial on effectiveness and safety of repeat courses of hylan G-F 20 in patients with knee osteoarthritis provided support for repeat treatments. One author cautioned that repeated viscosupplementation is not a cure for arthritis, but only provides comfort and functional improvement to temporarily avoid knee replacement (Spitzer, et al). Considering the alternative of invasive total knee replacement, this patient may receive benefit with a repeat a series of Orthovisc injections. While it is hard to predict which patients will respond based upon imaging or clinical indicators, those who experienced relief, and then recurred more than six months later, are likely to do well again. All told, the requested Orthovisc injections are likely to be more beneficial than any available standard therapy in managing this patients medical condition at this time.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that the patient presented to the emergency department on the date in question with the following complaints: urinary urgency, urinary frequency, shooting pain in her lower abdomen and hematuria. She had a personal history of urinary tract infection and a family history of kidney stones. A urine dip showed positive leukocytes. The emergency physician diagnosed the patient with acute urinary tract infection. Treatment with Cipro was initiated in the emergency department.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as 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 to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson would have sought immediate medical attention on the date of service in question.  In this case, the absence of immediate medical attention could reasonably have been expected to result in unnecessary pain and suffering as well as potential worsening of the acute infection to include pyelonephritis and sepsis, both of which could lead to serious impairment to bodily functions. Therefore, the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers et al., Warren et al. and Grey, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. They concluded that studies of Lovaas-based approaches and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). This patient was diagnosed with autism by the regional center based upon a developmental evaluation which documented significant deficits in communication, social interaction and play skills. The patients diagnosis of intellectual disability does not preclude her from potentially deriving benefit from ABA therapy. The proposed therapy will address behavioral concerns including daily living skills, socialization and language skills. Given the patients documented deficits in these functional areas, ABA therapy is medically appropriate and necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested coverage for inpatient psychiatric hospitalization level of care from a specific date and forward for treatment of the enrollees depression, anorexia nervosa, and malnutrition.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with symptoms consistent with severe anorexia nervosa. In this case, the patient has a markedly disordered body image and does not have the motivation to get well. She is chronically depressed and has expressed a desire to kill herself by starvation. Her weight is 86% of her IBW, but she continues to have tachycardia upon standing. Overall, the patient does not seem to have developed the insight or the motivation to succeed in a less restrictive treatment environment. She feels that the required amount of food she is given is making her fat and sick. She also overestimates the amount of food she has eaten, stating she has eaten 100%, when the providers indicate that she may have barely eaten 50%. She has not progressed in the amount of food she has eaten during this admission. She also indicates that she has gained a considerable amount of weight, when the records document that she has not gained any weight. The American Psychiatric Association (APA) treatment guidelines state that it is important to consider a patients overall clinical and social picture rather than simply rely on weight criteria. Further, the APA notes that weight level per se should never be used as the sole criterion for discharge from inpatient care. Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge. It is clear from the records that this patient has not learned to maintain her weight and is actively fighting the staff when they work to help her gain the weight in the first place. This patient is not ready for discharge and would quickly relapse in a lower level of care. For these reasons, continued inpatient level of care is supported as medically necessary from the date in question and forward.