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

A 53-year-old female enrollee has requested coverage for past facet joint injections for treatment of her osteopenia and diffuse connective tissue disease.  Findings:  The physician reviewer found that although more specific diagnostic codes involving lumbar facet dysfunction, such as spondylosis and enthesiopathy would be helpful, the provider clearly delineates suspected facetogenic pain in the lumbar spine from the L4-5 level. The patient has a complicated polyarthralgia with gluten enteropathy and immune system dysfunction causing connective tissue disease, which can affect the facet joints. According to the patients provider, magnetic resonance imaging (MRI) showed arthropathy, examination showed tenderness over this level, and the patient has been refractory to topical and systemic medications, lifestyle modifications and dietary changes. Therefore, an image guided injection is both diagnostic and therapeutic and was clinically indicated when performed. Although more conventionally done with x-ray and computed tomography (CT) scanning technology, ultrasound is a safe emerging alternative that allows direct joint visualization and proper observation of medication placement intra-articularly without exposing the patient to radiation. Consistent with these findings, the bilateral facet joint injections at L4-5 provided this patient were medically necessary and should therefore be a covered therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested for occupational therapy for treatment of the enrollees fine motor delay.  Findings:  The physician reviewer found that to support the need for occupational therapy, studies have shown benefits that prevent a deterioration or reversal of function and a significant improvement in activities of daily living. Feldman and colleagues concluded that reducing waiting times for rehabilitation services may allow rehabilitation specialists to better address psychosocial problems for these children. A study by Tang and colleagues showed children who received only institutional-based therapy (IT) improved in developmental level by 2.11 months compared with 3.11 months for those who received a combination of IT and home activity program (HAP). Consistent with these findings, the authors concluded that home therapy alone is not as effective as a combined program. Nearly 60% of the studies reported statistically significant improvements at follow-up as reported by Riethmuller and colleagues. For these reasons, the requested occupational therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested coverage for past substance abuse sub-acute rehabilitation provided for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of substance abuse sub-acute rehabilitation provided during the time period at issue.  There was no evidence of physician involvement in the patients treatment, and only minimal notes from a nurse practitioner during the dates of service at issue.  The patient showed no evidence of risk to self or others.  At the time of admission, the patient was already involved in an intensive treatment program and had achieved sobriety for 30 days. His parents were supportive of recovery, and there is no indication of any significant medical comorbidity. Per American Psychiatric Association guidelines, the patient could have been safely and effectively managed in the context of a less intensive treatment setting.  The services at issue were not clinically compatible with current evidence-based practice standards and expert consensus as set forth by the American Psychiatric Association and American Society of Addiction Medicine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested coverage for Dry Eye Light Intense Therapy for treatment of  her chronic severe dry eyes.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case.  There is a lack of medical evidence demonstrating the safety and efficacy of the requested treatment for this patients medical condition.  In this case, the patient has history of severe dry eyes and meibomian gland dysfunction.  Prior treatment has included topical medications, punctual plugs and environmental/dietary adjustments.  Intense pulsed light therapy was prescribed for additional treatment.  In the medical literature, there is a lack of controlled studies of intense pulsed light treatment for dry eyes or meibomian gland dysfunction.  There are a number of well-established and available treatments for dry eyes beyond the patients current therapies, such as systemic anti-inflammatory, or other local agents.  All told, the requested Dry Eye Light Intense Therapy treatments are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested coverage for a dynamic adjustable ankle extension/flexion device (Dynasplint for treatment of his Achilles tendon contracture.)  Findings:  Two physician reviewers found that the patient presented to orthopedics with a complaint of bilateral foot pain. He was diagnosed with pes planus and prescribed physical therapy and cast immobilization. He developed a rash from the casting and found the physical therapy to be ineffective. The patient has also been assessed with Achilles tendon contracture. An MRI was suspicious for a left second metatarsal fracture. The orthopedic provider recommended a Dynasplint for passive stretching.  The Dynasplint is not likely to be more beneficial for this patient than conservative physical therapy care consisting of manual stretching and heating.  There is no evidence in the peer-reviewed literature that Dynasplint offers a better functional outcome as compared to standard modalities. Additionally, the documentation shows that the patient demonstrated normal ankle range of motion (ROM) when examined and subsequent exams by additional providers revealed active ROM of the patients ankles of neutral and passive ROM of -10 through 20 degrees. Based upon the evidence provided, there is an absence of evidence of significant contracture that would require treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested authorization and coverage for a referral to an orthopedic doctor.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The initial treatment for bunions and similar problems is non-surgical, including the use of shoe modifications, inserts, and pads. Surgical consultation is indicated when these measures fail and there is continued pain and functional limitation.  Although there are a large number of different procedures available, the decision for surgery should follow the failure of non-surgical techniques.  In this case, there is no documentation of the presence of a skeletal abnormality on x-ray, and there is no documentation of efforts at non-surgical management. The current medical evidence does not support the requested services in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female has requested coverage for any or all of the services/CPT codes proposed by her dental provider for treatment of her deviating jaw shift and masticatory dysfunction.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with TMJ and myofascial pain disorder. Splint therapy has been shown to be beneficial in the treatment of patients with myofascial pain disorder. The relevant scientific literature indicates that a positive response to splint therapy is reported in 70% to 90% of patients.  There are various types of splints used to treat myofascial pain. While both maxillary and mandibular splints have been recommended for this patient, a single maxillary or mandibular splint is a well-accepted method for treating such patients. As such, a single maxillary or mandibular splint is medically appropriate and necessary for treatment of this patients myofascial pain disorder. The other services identified in the treatment plan are for purposes of the patients dental treatment and are not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male has requested coverage for blepharoplasty, upper eyelid (CPT 15823) and canthoplasty (CPT 67950) for treatment of his visual field loss secondary to eyelid droop.  Findings:  The physician reviewer found that based on the records provided for review, this patients eyelids constitute an abnormal structure of the body. Specifically, there is dermatochalasia and upper eyelid ptosis of both upper eyelids as documented in the providers notes and confirmed with photographs. These are developmental abnormalities in this patients case as he has developed functional loss of vision as a result of the excess skin of the upper eyelids and of the structures that keep the eyelid at a normal level. These anatomic structures are considered two separate conditions that require different treatments (Older). As noted by Nahai and Behr, upper lid ptosis should always be recorded. If present, it is pointed out to the patient and plans are discussed to correct it at the time of blepharoplasty.  As such, lid ptosis and redundant eyelid tissue can both cause functional problems that are addressed with different procedures. The medical documentation support that this patient has a combination of the two factors: redundant skin of the upper eyelid; and ptosis of the eyelid. The procedures for these two conditions are distinct and each is a separate attempt to improve the patients functional visual field. For these reasons, the requested surgery is reconstructive as it was primarily recommended to improve function and will create a normal appearance to the extent possible as a secondary result.  In summary, the blepharoplasty and ptosis codes should be approved as separate procedures as each is reconstructive in nature and therefore medically necessary. However, there is inadequate support for the canthoplasty, which is generally associated with the lower eyelids and not reconstructive or medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery at L4-5 with intervertebral device for treatment of the enrollees spinal stenosis.  Findings:  The physician reviewer found that based on review of the records provided, it is not medically necessary for this patient to undergo an anterior to posterior L4-5 fusion with intervertebral device combined with lumbar laminectomy and discectomy. A limited surgical approach is more likely to relieve the patients central spinal stenosis without the necessity for fusion. Instrumented fusion is most efficacious for documented instability either post fracture or acquired through degenerative or congenital spondylolisthesis. However, none of these diagnoses are reported in this patient. The presence of predominantly central spinal stenosis is likely to lend itself to a limited laminectomy and partial medial facetectomy without introducing instability. In the medical literature, Atlas and colleagues have documented, in a 10-year prospective observational cohort study of lumbar spinal stenosis, that patients initially treated with surgery had less severe leg pain symptoms and greater improvement in back specific functional status than non-surgically treated patients. This patient meets the criteria of severe spinal stenosis and the laminectomy approved by the Health Plan is medically appropriate and consistent with the standard of care in this setting. The issue of complex anterior to posterior fusion, as has been proposed in this case, is addressed by Deyo and colleagues in their recent publication. A retrospective cohort study of patients was performed on 31,543 patients who underwent surgery for spinal stenosis in 2004 with follow-up through 2008. Complex fusion combined with decompression had a higher re-operation rate at four years than other procedures. Consistent with these findings, the requested surgery has not been established as medically necessary for treatment of the patients spinal stenosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 10-month-old female enrollee has requested for speech therapy for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones. Speech and language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective. Therapy is tailored to the individual patient and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and some make more progress than others. Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Consistent with these findings, the requested speech therapy is medically necessary and should be provided to this patient to address her speech and language delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested coverage for 12 additional physical therapy (PT) visits for treatment of her lumbago and post-laminectomy syndrome.  Findings:  The physician reviewer found that this patients back condition has persisted despite surgery at the L4-5 lumbar spine such that she was diagnosed with post-laminectomy syndrome. The patient continues to experience back pain despite 12 sessions of PT. Based on the time course of the patients back pain (greater than 6 months of continuous pain), it is deemed that patient has chronic low back pain. Managing chronic low back pain requires a multidisciplinary approach involving medical management and PT. This patient has already been referred to a pain specialist by her primary care physician and undergone a course of PT. Currently, both patient and her physical therapist have indicated that the patient needs more PT sessions to manage her chronic low back pain. Based on medical literature, the patients request for 12 more sessions of physical therapy is appropriate and medically necessary. In a controlled investigation in 1988-1991, Manniche and colleagues showed that intensive back exercises, consisting of 30 sessions distributed during a period of three months significantly reduced low back pain in chronic patients and concluded that an intensive exercise protocol over a prolonged period is crucial for a satisfactory treatment outcome. Similarly, Kankaanpaa and colleagues found that an active rehabilitation program which included 24 exercise sessions during 12 weeks in an outpatient clinic was more successful in reducing pain and self-experienced disability and also in improving lumbar endurance than was the passive control treatment. As this patient has chronic low back pain that has persisted for over three years, the scientific data supports the medical necessity of the requested 12 additional PT sessions in order to manage her chronic low back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the medical literature, one study from Schirmer and colleagues concluded that, Children born prematurely with low birth weight had an increased risk of language acquisition delay, and also had lower cognitive and behavior scores. As noted by Luu and colleagues, preterm infants showed catch-up gains in speech and language using the Peabody Picture Vocabulary Test-Revised. Given the support for the efficacy of speech therapy for young patients with language delays, this patient will most likely develop normal expressive language skills with speech and language therapy. Therefore, the requested speech therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female coverage for lumbar spinal fusion surgery at 2 levels, or 1 level in the alternative for treatment of her grade 5 tears of the L3-4 and L4-5 discs.   Findings:  The physician reviewer found that based on review of the available records, this patient has chronic low back pain and has developed an L5 radiculopathy as well as progressive symptoms with weakness and decreased sensation as documented by the provider. The patients discography is not conclusive or helpful given her pain response at all three levels. In fact, the discographer even noted that he did not have an adequate control level. Thus, the data with low recorded pressures is considered less reliable. Since this patient has no evidence of instability, spondylolisthesis, angulation, fracture, tumor or infection, she does not meet criteria for fusion according to Bambakidis and colleagues or the Milliman Care Guidelines. Since she has left L5 radiculopathy due to lateral recess stenosis and disc protrusion/herniation the requested decompression is medically necessary for management of her condition. However, the patient does not meet the criteria for fusion as noted by Bambakidis and colleagues. Therefore, the requested fusion has not been shown to be medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested coverage for LAP Band surgery for treatment of her obesity and obesity related medical conditions.  Findings:  The physician reviewer found that the patient reportedly has a BMI of 34. Although the LAP Band adjustable gastric banding (LAGB) system is now no longer off label for use in low BMI patients, general guidelines including the National Institutes for Health (NIH) Consensus Guidelines do not currently recommend bariatric surgery for individuals with a low BMI (less than 35).  With a BMI less than 35, this patient does not meet generally accepted criteria for morbid or clinically severe obesity at this time. Low BMI bariatric surgery is still undergoing clinical trials. While studies involving small numbers of patients have been performed, no society or governmental guidelines are currently available for the use of bariatric surgery in patients with a BMI less than 35. All told, there is a paucity of medical literature indicating the requested procedure is safe and efficacious in this patient population. Therefore, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested  coverage for speech therapy twice per week for treatment of his speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. 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. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient at the requested frequency of two, one-hour sessions per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male has requested 12 occupational therapy sessions for treatment of his autism.  Findings:  The physician reviewer found that the patients self-help skills and fine motor abilities are significantly impaired, when compared with his same age peers. Although his progress during weekly occupational therapy sessions has been slow, gradual improvements have been documented. Thus, the patients self-help and fine motor abilities have not plateaued. There is substantial peer reviewed medical literature indicating that occupational therapy is a necessary component of the various therapeutic treatments included in the treatment plan for a patient diagnosed with autism (Myers, et al. and Case-Smith and Arbesman). Occupational therapy has been proven to improve motor function in autistic children (Dawson and Watling). In a study examining the long-term effects of occupational and physical therapies in children with autism, the authors found that over a seven year period the group treated with therapy demonstrated far greater improvements in motor skills, adaptive skills and social skills than the untreated group (Turner, et al.). In sum, it is medically appropriate and necessary for this patient to receive the requested 12 sessions of occupational therapy.