Persius/hicric huggingface dataset:
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 the enrollees expressive language delay.  Findings:  The physician reviewer found that 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.   Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient has significant expressive language delay.  These deficits negatively impact his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in this clinical scenario. All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested a magnetic resonance (MR) neurography for evaluation of her sciatica, buttock and leg pain.  Findings:  Two physician reviewers found that a literature search revealed a paucity of data establishing the sensitivity and specificity of MR neurography as a diagnostic test for piriformis syndrome. Filler and colleagues reported that in 239 patients with sciatica in whom standard diagnosis and treatment failed to provide improvement, MR neurography and interventional MR imaging led to the re-diagnoses. In their conclusion, the authors stated that MR neurography has 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without. In a critique of this paper, Tiel and Kline pointed out that sensitivity and specificity are used in clinical studies to evaluate new methods in reference to a recognized gold standard. Piriformis syndrome has not been submitted to this standard, and the data that the authors present are misleading. Comparing the two chosen groups may be interesting and illustrative, but in no recognized way does such a comparison generate a valid sensitivity or specificity. In a separate critique, Tiel stated that, MR neurography as practiced by Filler (and colleagues) needs histologic and physiologic confirmation to support his findings concerning the diagnosis of entrapment of the sciatic nerve by the piriformis muscle. Based on the lack of evidence for the true sensitivity and specificity of MR neurography for the diagnosis of piriformis syndrome, MR neurography was not likely to be more beneficial for evaluation of this patients medical condition than any available conventional modality when performed on the date in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested speech therapy services for treatment of the enrollees delays in receptive and expressive language development.  Findings:  The physician reviewer found that in this patients case, the requested speech therapy services are medically necessary for treatment of his receptive and expressive language delay. 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.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children with difficulties that persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient has severe receptive and expressive language delay, and this is negatively impacting his ability to communicate in an age-appropriate manner. Studies have shown that speech and language therapy can result in significant improvement in this clinical situation. All told, the requested speech therapy services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested outpatient psychotherapy visits once per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that according to available medical records of the patients therapy, there is no support that a significant likelihood of deterioration will occur with a reduction from weekly to twice monthly psychotherapeutic sessions. In addition, there is inadequate medical literature suggesting that the current weekly therapy is medically necessary to prevent an acute deterioration of his disorder. Further, there is no evidence of any clinical concerns supporting the conclusion that the patient could not be safely treated with twice monthly therapy. For these reasons, the patient should continue to benefit towards his recovery with psychotherapy sessions twice per month as the medical necessity of more frequent sessions has not been established in this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested therapy at a frequency of one or two times per week for treatment of her major depressive disorder. Findings:  The physician reviewer found that the medical necessity for therapy at a frequency of one to two times per week has not been established. This patient has participated in therapy for many years.  However, her GAF score has remained consistent. She has never been hospitalized, and there is no history to indicate that she has ever presented a serious risk to self or others. There is no indication of progress towards a defined set of treatment goals. There is no indication that the therapist has made or is making attempts to decrease the frequency of visits or foster involvement in community resources. The data reviewed do not indicate that a decrease in frequency will likely be detrimental to the patient or result in her requiring a higher level of care. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective.  There is no evidence that the patients safety would be compromised by decreasing the frequency of visits to once every two weeks. In this patients case, outpatient treatment at a frequency of once every other week was and is medically appropriate.  All told, therapy at a frequency of one or two times per week was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, nine-month-old male enrollee has requested speech therapy for treatment of the enrollees 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. Specifically, the patient should receive five hours of speech therapy per week. In addition, a complete and detailed speech and language evaluation should be performed by an independent therapist for an accurate diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for Orthovisc injections for treatment of her left knee arthritis. Findings:  The physician reviewer found that the evidence supporting viscosupplementation in osteoarthritis is limited at best. A recent Agency for Healthcare Research and Quality (AHRQ) guideline does not support this treatment. There is a lack of evidence in the peer-reviewed medical literature, supporting multiple series of injections as therapeutics. There are other effective treatments for relatively young patients with knee arthritis. They include osteoectomy, partial joint replacement, and cortisone injections. These options have been proven to be more effective in the available peer-reviewed medical literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that 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.
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 childhood apraxia of speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25%. An extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Childhood apraxia of speech is a condition in which children have difficulty with the controlled production of speech sounds. The etiology is thought to be neurologic in origin. Affected children make errors in producing vowels and consonants, and show enormous variability in terms of phonemes, loudness, and related features. This inconsistency in their production makes interpretation of their speech very challenging. Intensive levels of treatment are needed to help children with childhood apraxia of speech. Research suggests that these children require intensive therapy and a large number of sessions to move from 50% of their speech being understood by unfamiliar listeners to 75% of their speech being understood (Campbell, T.F.). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested a viral load test for evaluation of her hepatitis C.  Findings:  The physician reviewer found that there is documentation of the patient having the hepatitis C virus by a polymerase chain reaction (PCR) assay in the past and therefore the diagnosis of hepatitis C is not in question. The patient has minimal liver disease and prohibitive contraindications to therapy at this time. The only reason to repeat a hepatitis C viral load at some point in the future would be if she became a candidate for treatment. The absolute viral level has little prognostic value concerning progression of her liver disease. As noted by the patients provider, the most immediate concern is that the patient complete the chemical dependency program so that she can pursue treatment of her hepatitis C. The medical necessity of a viral load test has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested an MRI of the left knee for evaluation of the enrollees left knee arthritis.  Findings:  The physician reviewer found that in a recent case presentation at the American Academy of Orthopaedic Surgeons Annual Meeting, Khanuja stated that more than half of patients who underwent MRI did not require this imaging modality for the diagnosis and treatment of their knee osteoarthritis. Although some providers sometimes utilize MRI either with or instead of weight bearing x-rays for diagnosis, weight bearing x-rays are sufficient to diagnose osteoarthritis of the knee. This patient received an x-ray and underwent examination by an orthopedist. The specialists assessment based on physical examination and interpretation of the x-ray was osteoarthritis  left knee greater than right knee. Based on the medical records provided, an MRI is not medically necessary for evaluation of the patients condition. Given the available peer reviewed medical literature and the medical records, the Health Plans denial is appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested lymph node transplant (lymphatic microsurgery) for treatment of her lymphedema secondary to breast cancer treatment.  Findings:  The physician reviewer found that in the medical literature, the proposed surgical treatment is not the standard of care in routine cases of lymphedema and should only be considered once failure of non-operative therapy has been firmly established. The above references document some promise in microsurgical treatment of lymphedema and Chang concluded that, Lymphaticovenular bypass may effectively reduce the severity of lymphedema in breast cancer patients. This patient was referred to a plastic surgeon who found the patient to be a good candidate for lymphedema free flap surgery to relieve some of her symptoms. In addition, the provider reports that the patient has functional pain and decreased hand function that has failed conservative management. For these reasons, the requested surgery should be considered medically necessary and approved for this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for residential treatment services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the peer reviewed medical literature regarding residential treatment options for patients with anorexia nervosa and bulimia nervosa note that such programs are becoming increasingly more common. The studies also reveal that a wide variety of techniques and methods are employed in the treatment of patients with eating disorders within such residential treatment programs. The American Psychiatric Association (APA) has provided level of care guidelines for patients with eating disorders. These guidelines take into consideration 10 separate factors affecting eating disordered patients and cross reference these with a 5 level system to assist practitioners with assessment, recommendations, and planning in determining the clinically appropriate levels of care. All told, the medical necessity is currently supported for the RTC services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested participation in the autologous stem cell transplant randomized SCOT clinical trial for treatment of her systemic sclerosis.  Findings:  Two physician reviewers found that this patient has debilitating and progressive scleroderma that is recalcitrant to basic approved therapies. She has been on immunosuppressives such as azathioprine, methotrexate and steroids, although her disease has been progressive, and she has not tolerated these therapies very well.  High-dose chemotherapy with autologous stem cell transplant has been tried in scleroderma patients with some success.  This patient has a terminally progressive disease. The patient has requested coverage for enrollment in a clinical trial testing autologous hematopoietic stem cell transplant versus pulse dose cyclophosphamide for her disease. Both arms of the randomized clinical trial are supported by the medical literature as being efficacious.  All told, the requested services are likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested treatment at an acute rehabilitation center for treatment of her traumatic brain injury.  Findings:  The physician reviewer found that the medical literature indicates that efforts at rehabilitation are most effective early after an injury (Turner-Stokes, et al). This level of care was provided to this patient in the sub-acute rehabilitation facility. All told, she will likely continue to make progress but her pattern indicates that it will be gradual and may take years. Her rate of brain recovery will prevent her from making substantial gains with an inpatient rehabilitation program. Her rate of progress will be at least as good if not better at home with community based programs. Rehabilitation allows a person to maximize the gains available but does not increase the rate of brain healing. Overall, it is the severity of the injury not the site of the patients care that is predictive of outcome (Anderson, et al). As such, specialty care for general rehabilitation goals has not been shown to substantially improve patient recovery in this clinical circumstance. For these reasons, the medical necessity of the requested services has not been established in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested a left foot bunionectomy for treatment of her hallux valgus deformity.  Findings:  The physician reviewer found that a bunion deformity is a biomechanical deviation in which the great toe moves laterally towards the second toe. This creates a deviated and sometimes dislocated joint with a prominence of bone to the medial aspect of the first metatarsal head.  This bump of bone can be very painful and can inhibit normal comfortable ambulation in shoes. According to this patient, there are times when she cannot walk or wear shoes, and she has excruciating pain. The only way to correct a bunion deformity is to surgically remove the bump of bone and at times create an osteotomy to realign the first ray. In this case, surgical correction of this patients bunion is medically necessary to treat her painful foot.  Without surgical correction, the deformity may progress and worsen. All told, the requested left foot bunionectomy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested residential level of care or partial hospitalization program level of care for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the data reviewed do not support the medical necessity for residential level of care or partial hospitalization program level of care.  Per the submitted documentation, the patient has continued to gain weight and shows no additional comorbidity.  Recent laboratory values show no significant abnormalities, and her vital signs are within normal limits. On the said date, the patients weight was greater than 80% of ideal body weight. The patient has been participating regularly in the program, and she shows no indication of suicidal or homicidal ideation. She does not appear to need daily medical monitoring. In this patients case, the requested services are not medically necessary per current evidence-based standard practices and expert consensus as set forth in American Psychiatric Association guidelines. All told, the requested resumption of residential level of care or partial hospitalization program level of care is not medically necessary for the treatment of this patient.