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

A 30-year-old female enrollee has requested authorization and coverage for use of Alloderm in the nasal septal repair surgery. The Health Plan has denied this request indicating that the requested service is considered investigational for treatment of the enrollees nasal septal perforation.  Findings:  Two physician reviewers found that the patient has a documented symptomatic nasal septal perforation. She has attempted non-surgical and symptomatic treatment without success. Physical examination and a computed tomography (CT) report confirm the diagnosis of a nasal septal perforation that measures approximately 1 cm. The providers recommendation is for surgical repair of the septal perforation with use of Alloderm. The use of Alloderm was denied by the Health Plan stating that the requested service is considered investigational and experimental. The patient is documented to have a symptomatic nasal septal perforation. Septal perforation repair is recommended and is justified. As discussed by Romo and colleagues, septal repair is complicated due to various factors including the lack of available tissue for closure. The approach described in this reference provides different algorithms for different-sized defects. The technique described for a 1 cm perforation is similar to what is requested by the treating surgeon in this patients case. A material is interposed between the mucosal flaps that are used to close the perforation and the provider has selected Alloderm. This use of Alloderm is consistent with the findings from Kridel and colleagues who concluded that, The need for a connective tissue interpositional graft is generally accepted by all authors who use intranasal mucosal flap advancements. The interposed graft maintains a barrier between the corresponding repaired flaps during healing and, therefore, decreases the risk of incisional breakdown and reperforation. The authors noted that while other materials may be used in lieu of Alloderm for this interposition, however other materials would require additional incisions creating possible donor site morbidity or other complications. From experiences in breast reconstruction and other applications, Alloderm is noted to provide a scaffold for the ingrowth of tissue, and is therefore a reasonable clinical option to aid in the closure of a septal perforation. Thus, based on this information, the recommended procedure of septal repair with Alloderm is likely to be more beneficial than standard alternatives in the surgical repair of this patients septal perforation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested nose surgery (rhinoplasty) for treatment of her nasal septal perforation.  Findings:  The physician reviewer found that based on review of the available records, this patients abnormal structure of the body is the perforated septum that was caused by trauma, specifically steroid nasal sprays. The provider has recommended surgical intervention consisting of open rhinoplasty. This approach is frequently utilized to expose the nasal septum and allow insertion of the graft to close the perforation. It is used as a reconstructive technique and not to alter the appearance of the nose (Watson, et al). The use of alloderm as a grafting material is a standard material for flap reinforcement and perforation closure (Ayshford, et al). All told, the requested surgery is medically necessary as planned by the treating provider and should provide this patient with relief from her symptomatic condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested coerage for past post-nasal chemical peel and future nasal chemical peel services for treatment of her obstructive sleep apnea (OSA) and chronic rhinitis.  Findings:  Two physician reviewers found that chronic rhinitis is a non-specific diagnosis. Appropriate treatment of rhinitis requires adequate work-up to determine a specific cause (Settipane). Numerous therapies are available once a diagnosis has been made (Tran, et al and Snidvongs, et al). However, no specific diagnosis of the patients chronic rhinitis was documented in the records provided for review. In fact, all of the physical examinations noted a normal nose, and only one apparent treatment (Atrovent at a low dose) was reportedly attempted. Treatment with sprays was performed, but the nature of these therapies was not further described. For these reasons, the nasal chemical peels treatments were not likely to be more beneficial for treatment of the patients medical condition as they were not within standards of good medical practice within the organized medical community, and were not the most appropriate service which could safely be provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for 35 transcranial magnetic stimulation treatments for treatment of his major depressive disorder. Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends.   Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  In sum, the requested 35 transcranial magnetic stimulation treatments are not likely to be of greater benefit than other available treatment alternatives in this patients case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested reimbursement for hysterectomy services provided in Lima, Peru. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis.  Findings:  The physician reviewer found that this case involves a female patient with a history of uterine fibroid, menometrorrhagia and anemia. The patient presented to her provider with complaint of menometrorrhagia with two days of heavy bleeding and clotting. The provider noted the patient had been seen by her gynecologist who recommended either ablation or hysterectomy secondary to fibroid uterus. The patient subsequently traveled to Peru. Prior to her leaving for Peru, her physician increased her iron and recommended she have additional labs performed when she returned. When she was in Peru, the patient consulted a physician with complaint of vaginal hemorrhage which had caused anemia that had been treated with iron. It was noted that prior to the patients leaving for Peru, her Hgb was 9.8. The physician in Peru noted the patient had a new episode of vaginal hemorrhage with anemic symptoms. The physician indicated a total hysterectomy was performed based on emergency indications. Anesthesia records document the patients Hgb was 10.6 and her Hct was 34.6.At issue in this case is whether a prudent layperson would have sought urgent services. `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area.Uterine leiomyomas are benign tumors. Since histological confirmation of the clinical diagnosis is not necessary in most cases, asymptomatic uterine leiomyomas can usually be followed without intervention. In patients who experience heavy bleeding and resultant anemia, treatment should be undertaken such as was suggested by this patients local gynecologist. However, as long as the patient is stable and does not have a marked decrease in Hgb or worsening of her clinical condition, there is no need for urgent surgical intervention.The records from Peru document that the patients anemia had improved since her previous labs were performed. The records also show that the patients symptoms were not unforeseen, as she knew she had uterine fibroids, heavy menses and anemia prior to traveling to Peru. The records from Peru also demonstrate that the patient's condition was not worse while she was there. Thus, a prudent layperson in this patients situation would not have sought urgent surgical intervention while in Peru.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder. Rather, at issue is the notion that plasticity in the developing brain still exists despite underlying neurological disease and 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 pathogenetic processes that give rise to expressive and receptive speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-ten-month-old male has requested occupational therapy for treatment of his autism. Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that occupational therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, a defined trauma, surgical intervention, or musculoskeletal condition is not necessary for abnormal gross and fine motor development that is seen in children with autism. Occupational therapy administered during critical developmental periods in childhood is a medically appropriate intervention and is clinically indicated for this patient based on his documented deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 29-month-old female enrollee has requested speech therapy, occupational therapy and physical therapy services for treatment of the enrollees developmental delays.   Findings:  The physician reviewer found that speech therapy is medically necessary and appropriate to address this patients delays in speech and language skills. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. (Law, et al.) These reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, McLaughlin concluded that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. Occupational therapy is also medically necessary and appropriate to address this patients delays in fine motor skills and self-help skills. The patient has delays in fine motor skills, adaptive/self-help skills, and social skills. With its focus on teaching self-help skills and facilitating development of fine and gross motor skills, occupational therapy is well suited to affect positive change in this patient. Finally, physical therapy is medically necessary and appropriate to address this patients delays in her gross motor skills. As a result of hypotonia and low muscle tone, the patient has gross motor deficits impacting acquisition of stationary and locomotion skills. Physical therapy is ideally suited to optimize this patients gross motor skills, including locomotion, balance, and other deficits. In conclusion, this patient, who has hypotonia of an unclear etiology, has made gains during her therapy at the local regional center. However, she continues to fall behind her peers in all areas of development and acquisition of functional skills. Therefore, continued speech, occupational, and physical therapies are medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested intensive outpatient treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient presents with a history of bulimia nervosa and alcohol dependence. The records indicate that the patient was not at imminent risk of serious harm to her self or others and she did not have a co-occurring medical condition. Although her co-morbid substance abuse disorder did not put her at risk for withdrawal or delirium tremens (DTs) and her family was supportive and compliant with the requirements of the IOP, applying the treatment guidelines from the American Psychiatric Association (APA), this patient did meet the level of care criteria for the IOP program during the said timeframe. Specifically, the APA guidelines for treatment of bulimia nervosa show the IOP as offering the structure for a patient at risk of relapse with adequate support. For these reasons, treatment at a less restrictive level of care such as weekly outpatient therapy would likely not have provided this patient with the guidance and support found in IOP during the period under review. Accordingly, the IOP services provided have been demonstrated to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested coverage for chiropractic/physical therapy treatments beyond the 38 treatments authorized and prospective coverage for continued chiropractic/physical therapy treatment (20 sessions).  The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees moderate to severe right upper back and bilateral lower neck pain.  Findings:  The physician reviewer found that the patient has undergone extensive therapies since her 2009 injury, including various passive palliative interventions for pain relief.  No significant, sustained benefit would be anticipated with further passive treatment such as chiropractic manipulation at this time.  The requested chiropractic therapy is not medically necessary, as there is no proven benefit of long-term chiropractic manipulation treatments on health or functional outcomes in the setting of chronic spinal pain, thoracic outlet syndrome or other musculoskeletal conditions.  Bronfort concluded that the evidence is not conclusive for the long-term efficacy of spinal manipulation for any type of low back pain.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  With respect to thoracic outlet syndrome management, the key to management is an accurate diagnosis.  Once the lesion is precisely identified, surgery may be needed to decompress the affected neurological or vascular structure.  There is no proven role, however, of chiropractic manipulation for this condition.In this patients case, the records do not establish any objective benefit that can be clearly attributed to the chiropractic manipulation that has been provided to date and was not a function of the natural history of symptoms in the course of a case of chronic pain.  Overall, no significant benefit would be expected with long-term chiropractic manipulation for this patient over an independent exercise program, relative rest and self-applied palliative modalities.  All told, prior chiropractic/physical therapy treatments beyond the 38 treatments authorized and continued chiropractic/physical therapy treatments (20 sessions) were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested coverage for flexion and/or extension DynaSplint low load prolonged duration stretch (LLPS) devices. The Health Plan has denied this request indicating that the device at issue was and is considered investigational for treatment of the enrollees hallux valgus deformity.  Findings:  Two physician reviewers found that The patient underwent a bunionectomy with screw fixation and subsequently underwent the removal of painful hardware. Following removal of the hardware, the patient had painful and limited range of motion (ROM) and home physical therapy (PT) as well as traditional office based PT, was provided. At 8 week follow-up, the patient presented with continuous pain and lack of appropriate mobility. A DynaSplint was prescribed. The patient has used the device with further improvement. The patients request for coverage for the DynaSplint was denied by the Health Plan as investigational for treatment of the patients medical condition. The literature shows that the use of DynaSplint at multiple different joint structures is highly effective, however its use has not been thoroughly established for the foot. There are limited case series and reports demonstrating that DynaSplint does provide improved ROM when used for the foot (Curran and Willis). It is thus reasonable and prudent to expect that the DynaSplint can materially aid this patient in her return to normal function and should therefore be approved (McClure, et al).
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 speech and language delay is an indicator of a childs overall developmental trajectory and may result in substantial long-term consequences (Law, et al.). According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Bernhardt and Major). These reviewers concluded that the meta-analysis showed that there is a positive overall effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient is a young male with severe receptive and expressive language deficits which negatively impact his ability to achieve age appropriate functional communication skills. While he has shown some improvement since initiation of therapeutic intervention earlier this year, continued speech therapy is appropriate at this time given the nature of the patients documented deficits. Studies have shown that speech therapy can result in significant improvement in this patient population. It is therefore medically appropriate and necessary to provide speech therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested authorization and coverage for Lyrica.  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees pain.  Findings:  Three physician reviewers found that the patient has a history of multiple back surgeries. He is status post lumbar fusion.  He now has recurrent pain.  Neurontin, Vicodin and oral steroids have not resulted in pain relief.  The patient has requested coverage for Lyrica.  The Health Plan has denied this request.  Per the Health Plan, Lyrica is investigational for the treatment of this patient.  The patient is appealing this denial.  The use of Lyrica is exceedingly common for neuropathies of all etiologies.  Lyrica is a first-line agent in the treatment of refractory neuropathy along with gabapentin and tricyclic antidepressants.  This patient has failed to obtain relief on Neurontin.  In this patients case, two surgical corrections have been attempted, and the patient has not responded to gabapentin, NSAIDs, low-dose narcotics, or steroids. The alternatives to Lyrica include interventional procedures, spinal cord stimulation, re-operation or higher dose narcotics, all of which involve a higher likelihood of morbidity.  The patient has done well with low-dose Lyrica, with little to no adverse effects.  Therefore, in this clinical situation, Lyrica is likely to be more effective than other treatment modalities.
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 moderate deficits in receptive and expressive language skills.  Findings:  The physician reviewer found that the current medical evidence supports the medical necessity of the requested speech therapy in this patients case.  Per 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 noted 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 reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  This patient has moderate receptive and expressive language delay. These deficits are significantly impairing his ability to communicate effectively and function socially. All told, the requested speech therapy is medically indicated in this patients case.