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

The parent of a two-year-old female enrollee has requested  individual speech and language therapy at a frequency of two hours per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in this patients case, the requested individual speech and language therapy at a frequency of two hours per week is medically necessary.  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 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.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.   The authors concluded that 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 some children with a history of severe phonological impairment.  This patient has receptive and expressive language deficits and articulation deficits that negatively impact her ability to achieve age-appropriate functional speech and language skills. Studies have shown that speech and language therapy can result in significant improvement in such children. While she has made some improvement with weekly therapy, individual speech and language therapy at a frequency of two hours per week is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested psychiatric residential treatment center (RTC) services for treatment of the enrollees behavioral health issues.   Findings:  The physician reviewer found that based on review of the available records, this patient has a several-year history of outpatient treatment with unsuccessful medication trials. Her history also indicates deterioration in functioning with serious functional impairment characterized by significant difficulty with impulsive behavior, vegetative symptoms such as sleep disturbance and appetite changes. She presented with a history of substance use, conflictual family relationships, and a suicide attempt leading to acute hospitalization prior to her admission to the RTC. Applying the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) Child and Adolescent Level of Care Utilization System (CALOCUS), a rating of serious functional impairment requires care at a level 5. Independent of other dimensions, level 5 is described as 24-hour services with psychiatric monitoring consistent with RTC level of care. Factors supporting RTC level of care include the presence of major co-morbidity, disruption in family relationships and a significant risk of harm. On admission to RTC the patient was considering going away without leave (AWOL) which is another factor indicating the patient would not be a good candidate for partial hospitalization program (PHP). The need for continued 24-hour staff monitoring and support is reflected in the progress notes from the provider describing an increase in self injury type behavior. In addition, the notes on the said date indicate that the patient was anxious, fearful and had been screaming and vomiting after hearing that a peer was going to be discharged. For these reasons, the RTC level of care provided this patient from the date in question forward has been established as medically necessary and consistent with AACAP practice parameters and CALOCUS criteria and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested anesthesia for treatment of her history of gastroesophageal reflux disease and Schatzkis ring status post dilatation.  Findings:  The physician reviewer found that monitored anesthesia care is directly administered by anesthesia personnel. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity and history of anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients age 70 or older, patients who are pregnant, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.  The medical documentation indicates that the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the upper endoscopy performed on the said date. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist. All told, anesthesia provided on the date in question was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested transcranial magnetic stimulation (TMS) treatments for treatment of his major depression.  Findings:  Three physician reviewers found that transcranial magnetic stimulation (TMS) was first introduced in 1985 as a novel method of non-invasive stimulation of the brain. The peer reviewed medical literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term and potential side effect profile along with patient selection, for benefit of repetitive TMS. In 2007, Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results suggest that TMS has significant antidepressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous, but continued trials are required to advance this treatment from the experimental phase into standard therapy. In Lam and colleagues, the authors concluded that for patients with treatment resistant depression, TMS 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 TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Further, Gershon and colleagues also reported positive responses of TMS as an antidepressant treatment, but cautioned that the need for verification and standardization of best practices and patient selection are still uncertain. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. However, the technical parameters possibly affecting treatment success including intensity and duration of treatment requires ongoing systematic testing of this modality.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested 35 transcranial magnetic stimulation (TMS) treatments for treatment of his major depression. Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for his depression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male enrollee has requested Daytrana 15 mg/9 hours daily patch for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that this patient has a documented diagnosis of ADHD and has been treated with multiple medications in the past. He has been tried on oral stimulants based upon amphetamines, oral stimulants based upon methylphenidate and the non-stimulant Strattera. He has had difficulties with side effects with insomnia, nausea, abdominal discomfort, and severe appetite disturbance. However, he has been treated for a month with a Daytrana 15 mg patch with improvement in academic performance and behavior. Clearly there is a marked difference in the metabolism of Daytrana that avoids many side effects for this patient. Perhaps it is the avoidance of irritation on the gastrointestinal (GI) system with the transdermal administration or perhaps it is the lower dosage required since the first pass is avoided. Ultimately, the transdermal administration of Daytrana changes the metabolism of this medication completely compared to its oral counterparts, in ways that make it tolerable for this patient. For these reasons, an oral methylphenidate is not an appropriate substitution for this patient and the requested Daytrana patch has been established as medically necessary for treatment of this patients ADHD and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested Suboxone for 1 year for treatment of his opiate dependency.  Findings:  The physician reviewer found that based on review of the available records, this patient has a severe addiction and co-morbid pain problem. Given his previous relapses with attempts to taper off Suboxone, this therapy remains the most prudent and safe medical treatment intervention for his medical problems. With Suboxone, the patient has the advantage of partial opioid agonist for his pain and the partial antagonist action for prevention of opioid use. His provider clearly supports this monitored use of Suboxone and reports that it has helped the patients pain and addiction issues. For these reasons, the requested one year of Suboxone therapy has been established as medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy services, at a frequency of one time per week for one hour, occupational therapy services, at a frequency of one time per week for one hour, and physical therapy services, at a frequency of one time per week for one hour for treatment of the enrollees lissencephaly, global developmental delay, seizure disorder, esotropia and cortical visual impairment.  Findings:  The physician reviewer found that speech therapy services, at a frequency of one time per week for one hour, are medically necessary for the treatment of this patient.  He has significant neurological abnormalities, including lissencephaly, seizure disorder, cortical visual impairment, and sensorineural hearing loss, resulting in delay in acquisition of appropriate communication skills. Communication skills are essential to help this patient express his needs. The medical evidence supports speech therapy services in this clinical situation.  Occupational therapy services, at a frequency of one time per week for one hour, are medically necessary in this patients case.  He has delays in fine motor skills, self-help skills, and feeding skills. Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patient.  Physical therapy services, at a frequency of one time per week for one hour, are medically indicated for the treatment of this patient.  As a result of structural abnormalities (rocker bottom feet) and global hypotonia, this patient has significant gross motor deficits impacting acquisition of stationary and locomotion skills.  Physical therapy is ideally suited to optimize this patients gross motor skills, including balance, standing, strength, and ambulation. All told, the requested services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his rectal cancer. Findings:  Two physician reviewers found that in this patients case, 3D conformal radiation therapy is the currently accepted standard of care.  Given the relatively low dose of radiation in a preoperative setting, and given that this dose is well within the dose constraints of normal surrounding tissue, intensity modulated radiation therapy is not indicated.  The National Comprehensive Cancer Network guidelines do not support intensity modulated radiation therapy in this patients case.  The superior efficacy of intensity modulated radiation therapy in this clinical setting has not been established. All told, intensity modulated radiation therapy is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested psychotherapy treatments at a frequency of 1-2 times per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that a review of the literature including the practice guidelines from the American Psychiatric Association (APA) suggest the use of supportive psychotherapy to decrease in frequency as treatment continues. This patient is currently in the maintenance phase of treatment and to be seen twice weekly appears to be more detrimental to this patient in terms of fostering dependency. As such, this patient does not require therapy at the frequency of 1-2 times per week, and should be seen on a less frequent basis of every other week to adequately and safely address his medical condition. For these reasons, the medical necessity of psychotherapy visits has been established at the frequency of twice per month.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested low back fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that although fusion in the lumbar spine is frequently performed, the indications are controversial.  Generally accepted indications include instability from trauma, tumor, or infection, iatrogenic instability, and abnormal motion demonstrated on studies. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disc degeneration. Improvement can be expected after fusion when an established indication exists, but less so in patients with chronic low back pain.  The careful selection of patients after conservative measures have been exhausted, and in the presence of a radiographic abnormality at the symptomatic level, is the key to favorable outcomes. For non-radicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation. Low back pain without a pathomorphological correlation is not an indication for fusion.  In this case, there is a lack of documentation of instability or stenosis.  All told, the requested low back fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 10-month-old female enrollee has requested speech therapy twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient is intellectually normal yet her expressive speech has shown no significant development. She is now nearly 2 years of age and should have a vocabulary of at least 50 words and should be initiating 2-word phrases. Both speech pathologists reported that the patient could not imitate or produce sounds. Overall, the formal testing has clearly demonstrated language delay in this patient. She is functioning at a severe to profound delay in her speech development but her language delay does not seem to be related to an underlying cognitive dysfunction. The delay is directly related to failure of normal brain maturation and is a congenital defect. In the medical literature, Law and colleagues reported that children with speech delay can be readily treated while Prelock and colleagues discussed the evaluation and successful therapies of speech delayed children. These findings were confirmed in the meta-analysis of multiple medical journal articles from Goorhuis-Brouwer and Kniff who specifically addressed the needs of speech-delayed children. The authors concluded that young, cognitively normal patients, are ideal candidates for successful speech therapy. Consistent with these recommendations for intervention the requested speech therapy is medically indicated for this patient. The medical community standard for a two year-old non-speaking child is speech therapy. The recommendation is for two hours per week for six months followed by speech re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued for another six months.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested Mepron for treatment of his Babesiosis. Findings:  Two physician reviewers found that the evidence indicating that this patient has Babesiosis is very limited. The disease is usually diagnosed by examination of blood smears and by a polymerase chain reaction (PCR) test. In this case, the patient did not present with the usual symptoms of this disease and he had an IgM antibody titer at a level of unclear significance as an antibody titer of less than 1:20 is reported as normal. Even if the test was repeated to confirm this level, alone it is not adequate evidence to make a diagnosis of Babesiosis. The treatment for this disease is usually Atovaquone and azithromycin, which is the regimen that the provider had planned to use. However, the Centers for Disease Control (CDC) recommendations suggest therapy for at least 7-10 days and do not recommend extending treatment beyond this period. All told, there is inadequate evidence in the peer reviewed medical literature showing that extending this period of treatment is necessary or appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Crestor 20mg for treatment of his hyperlipidemia and peripheral vascular disease.  Findings:  The physician reviewer found that based on the records provided, the patient has hyperlipidemia that is not effectively controlled with simvastatin 40mg daily.  The recent data from Armitage and colleagues indicated a significantly higher incidence of myopathy (0.9%) in the group that received 80mg daily of simvastatin compared to the group that received only 20mg daily (0.02%).  This has led the Food and Drug Administration to issue a warning regarding prescribing the higher dose simvastatin to patients who have not previously taken the higher dose for at least 12 months without signs of myopathy.  However, there is no report of increased risk of myopathy using high dose (80mg) pravastatin or high dose (80mg) lovastatin.  Per the submitted documentation, there has not been a treatment failure or intolerance to either pravastatin 80mg or lovastatin 80mg, both of which may result in more potent low-density lipoprotein (LDL) reduction compared to the lower dose (40mg) simvastatin the patient has been prescribed.  All told, the requested Crestor 20mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a silicone glove for the treatment of his status post right upper extremity above-elbow amputation.  Findings:  The physician reviewer found that the requested equipment is not medically necessary in this patients case. Upper limb prostheses have improved over the years, but still are generally considered poor replications of the biological hand.  Two of the primary issues are the lack of natural control of more than two degrees of freedom and the lack of sensory/haptic feedback.  Additions such as a custom silicone hand covering add a lifelike appearance, but these coverings are fragile and subject to damage, particularly due to the lack of sensory feedback.  These coverings, moreover, do not provide a functional need with respect to the patients activities of daily living that would not be provided by conventional plastic covers.  All told, the requested silicone glove is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested lumbar artificial discectomy for treatment of his back pain.  Findings:  Three physician reviewers found that this patient has back pain and has been diagnosed with degenerative changes of the lumbar spine. He is status post L4-S1 spinal fusion and instrumentation.  In this patients case, the requested procedure is not likely to be of greater benefit as compared to other available treatment options.  Lumbar disc replacement adjacent to fused segment has not been studied for safety and efficacy. Even though there are short-term and long-term studies involving lumbar arthroplasty, these studies do not support its use in this clinical scenario.  The current medical evidence has not demonstrated that the requested procedure is likely to be more effective than other treatment options.  Therefore, the requested lumbar artificial discectomy is not likely to be more beneficial for the treatment of the patients medical condition than other treatment alternatives.