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

The parent of a nine-year-old male has requested speech therapy with ongoing speech evaluation and occupational therapy for treatment of his autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. The medical literature supports both occupational therapy and speech therapy in the autistic population. Occupational therapy utilizing sensory integration techniques is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children and concluded that sensory integration was effective. All told, there is ample literature support for the use of occupational therapy in the treatment of children with autism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested coverage for Egrifta for treatment of his HIV associated lipodystrophy.  Findings:  The physician reviewer found that management of lipodystrophy in HIV patients may be indicated for a number of reasons.  This condition may be associated with significant impairment of truncal movement when abdominal fat accumulations are extreme.  In other situations, it may be argued that lipid abnormalities associated with lipodystrophy lead to atherosclerosis and therefore need to be managed. However, there are no indications in the records provided that this patient has experienced any of these complications as a result of his lipodystrophy. The literature also indicates adjustments in highly active antiretroviral therapy (HAART) drugs and exercise may be beneficial for treatment of lipodystrophy in HIV positive patients. There is no uniformly agreed indication for use of tesamorelin (Egrifta) in HIV infected patients. In this patients case, there is no objective documentation that his lipodystrophy is causing any functional problems. Therefore, the requested medication is not medically necessary. With regard to whether the use of Egrifta in this setting is considered reconstructive in nature, the available records do not document that this patients lipodystrophy is sufficiently severe to be considered an abnormal structure of the body. Based on the description of the lipodystrophic changes noted during the patients physical examination, they do not appear to rise to the level of an abnormal structure. Therefore, based upon the documentation provided, the use of Egrifta in this setting does not meet the definition of reconstructive services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested past and future coverage for transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of major depressive disorder. She had been tried on several different pharmacologic agents including Cymbalta, Lexapro, Prozac, Effexor, Remeron, Pamelor, Zoloft, Trazodone, Abilify, Celexa, Paxil, Wellbutrin and Pristiq. The patient has continued to have symptoms of anhedonia, decreased energy, cognitive impairment, interpersonal withdrawal, trouble sleeping, irritability, weight change, fatigue and suicidal ideation. This patient has been diagnosed with major depressive disorder and her condition has been refractory to numerous medication trials. Given her failure to respond to various medications, her provider recommended TMS as approved by the US Food and Drug Administration (FDA). In addition, this patient has not responded to conventional medications or therapies for the treatment of her sustained depression. It is thus reasonable that she receive TMS therapy for her diagnosis of major depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested biofeedback for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that early research showed promise with the utilization of neurofeedback in the treatment of ADHD. A paper by Linden published in 1996 studied 9 children who received EEG neurofeedback and 9 children who did not receive EEG neurofeedback. None of the children studied were receiving medication. The author reported improvement in IQ and attention in the treated group.  Subsequent studies have been mixed. A recent study by Wangler and colleagues found that EEG neurofeedback reduced ADHD symptoms in a controlled randomized trial.  However, another recent study by Logemann and colleagues noted no improvement in a sham neurofeedback controlled study. Based upon the conflicting results in recent studies, further research is needed before the beneficial effects of neurofeedback in this setting can be confirmed. Given theinconsistencies in the available peer reviewed medical literature, neurofeedback remains an unproven modality for the treatment of ADHD at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested coverage for Provigil 200mg for treatment of his schizoaffective disorder, bipolar type.  Findings:  The physician reviewer found that the requested medication is not medically indicated for the treatment of this patient.  The risk-benefit ratio is questionable, as this medication can trigger a manic episode.  Additionally, this patient has a history of stimulant abuse. American Psychiatric Association guidelines for bipolar disorder and schizophrenia do not indicate adjunctive use of stimulants. The current medical evidence does not support the requested medication in this patients case.  In sum, the data reviewed fails to support the use of Provigil in this clinical situation.  Current evidence-based standards of medical practice and expert consensus do not support the use of Provigil in this case.  All told, Provigil 200mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested coverage for partial hospitalization program services for treatment of her  alcohol dependency.  Findings:  The physician reviewer found that based on review of the available records, the patient was authorized for PHP care through a specific date, by which time she was medically stable, cooperative with the treatment and her clinical institute withdrawal assessment (CIWA) was zero. Patients with her low degree of severity and vast experience with sobriety and recovery can be safely and effectively managed on an outpatient basis, typically in an intensive outpatient program (IOP). Applying the treatment guidelines from the American Psychiatric Association (APA), PHP or residential care is generally reserved for patients who require a significant degree of medical or psychiatric monitoring or supervision and consultation, which was not demonstrated in this case. Therefore, the additional PHP services provided this patient were not medically necessary for management of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for Tysabri for treatment of multiple sclerosis. Findings:  The physician reviewer found that this patient has MS with noted weakness, imbalance, stiffness and spasticity. The detailed consult note from the patients treating neurologist states that the patient has a primarily relapsing physiology in regards to her MS. The patient has failed treatment with prednisone and Cellcept. The Health Plan has denied treatment with Tysabi because the patient has not attempted trials with interferon or Copaxone. The available medical literature indicates that Tysabri is as effective for the treatment of MS as interferon or Copaxone. Additionally, the prescribing information indicates that treatment with Tysabri carries a lower risk of heart related complications than the other suggested medications. In sum, the medication Tysabri is appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested coverage for past outpatient mental health treatments (at a frequency greater than the authorized one time per week) and coverage for future outpatient mental health treatments at a frequency of two to three times per week for treatment of her multiple mental health conditions.  Findings:  The physician reviewer found that dissociative identity disorder has been described since well before the modern medical era. However, up until 30 years ago, there were few, if any, well-designed, empirical studies of this condition. The increased attention in the literature community the past few decades has led to more cases being discovered of this complicated and controversial diagnosis. Despite its controversy, this condition can be found in the Diagnostic Statistical Manual (DSM). According to Sadock and Sadock and the International Society for the Study of Trauma and Dissociation, psychotherapy is the primary vehicle for recovery in this setting and the most efficacious modality. The treatment team must carefully defend against regression. With the assistance of a multidisciplinary treatment plan that clearly defines boundaries, goals and objectives, it is not uncommon to treat individuals with dissociative identity disorder at the rate of two therapy sessions per week. In keeping with an overarching goal of utilizing the least restrictive treatment setting (American Psychiatric Association), it is medically reasonable and appropriate to treat this condition with two outpatient mental health sessions per week. Accordingly, the treatments at issue were and are medically necessary for treatment of the patients medical condition at a frequency of two times per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that 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. This patients evaluation revealed a severe language expression delay that needs to be treated with the recommended speech and language therapy. 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

A 19-year-old male enrollee has requested reimbursement for inpatient treatment services for treatment of the enrollees depressive disorder.  Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of serious psychiatric symptomatologies. In the case of this patient, he was a distressed adolescent at risk of not only harming his father, but harming himself as well when one considers his past history and medical condition (Brent, et al.). The submitted documentation clearly demonstrates that this high-risk case represented a psychiatric emergency. There is no available data supporting a consistent length of inpatient hospitalization in cases such as this. In such cases, physician-led, multidisciplinary teams are tasked with performing serial, systematic evaluations throughout a hospitalization to determine the necessity of continued inpatient care.  On-going evaluation, combined with effective therapies, family involvement, case management services and discharge planning constitutes at least part of the duties of an inpatient staff.  It appears the staff worked these issues diligently and logically during the admission with the goal of a seamless transition back to the community, with a mitigated risk for readmission. The decision regarding a patients level of care should depend primarily on the patients level of function and safety to self and others, as determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment (Birmaher, et al.).  In this patients case, discharge on the first day that care was provided would have been premature. That day, the attending psychiatrist described the patient as depressed, with persistent homicidal ideation who was angry, isolative, withdrawn, and tearful. Two days later, the physician documented that the patient remained homicidal and depressed with poor activities of daily living, mood lability and continued self-isolation. The note from the fifth day in treatment describes a much-improved patient ready for discharge the following day.  All told, this was an appropriate admission of a high-risk patient. The services at issue were consistent with standards of good medical practice in the psychiatric community and were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested for speech therapy for treatment of the enrollees severe receptive and expressive language delays. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers 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.  The current medical evidence supports the requested therapy in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested reimbursement for a magnetic resonance (MR) neurography. Findings:  The physician reviewer found that the available peer reviewed medical literature does not provide sufficient evidence regarding the sensitivity and specificity of MR neurography, as a diagnostic test. Filler, et al. reported that in patients with sciatica in whom standard diagnosis and treatment failed to effect improvement, MR neurography and interventional MRI led to re-diagnosis. The authors also indicated that MR neurography had a 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without piriformis syndrome who had similar symptoms (Filler, et al). In a critique of this paper, Tiel and Kline (2006) indicated that sensitivity and specificity are used in clinical studies to evaluate new methods in reference to a recognized gold standard. However, piriformis syndrome has not been submitted to this standard and the data presented by Filler, et al. may be misleading. In a 2008 paper by Tiel, the author stated that histological and physiologic confirmation is needed to support the findings by Filler and colleagues concerning the diagnosis of entrapment of the sciatic nerve by the piriformis muscle. There are no other available studies in the peer reviewed medical literature demonstrating the efficacy of MR neurography in the diagnosis of piriformis syndrome. Based on the paucity of evidence demonstrating the true sensitivity and specificity of MR neurography in the diagnosis of piriformis syndrome, MR neurography was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Enbrel 50mg/ml (twice per week) for treatment of his palmar/plantar psoriasis.  Findings:  The physician reviewer found that in this patients case, his prior treatment for recalcitrant palmar/plantar psoriasis has included Enbrel, acitretin, and UVA phototherapy with psoralen (PUVA).  He continues to have painful flares of his psoriasis.  The patients provider reported that the patient experienced flares when he was tapered to once weekly dosing of Enbrel 50mg/ml.  The submitted documentation fails to demonstrate the extent or severity of these flares while on the lower dose of medication.  The provider noted that methotrexate is not a viable option due to his current medication (simvastatin).  However, there is no documentation of transaminitis or other medical data to support precluding this medication.  The submitted documentation fails to establish the medical necessity of Enbrel 50mg/ml (twice per week).  All told, Enbrel 50mg/ml (twice per week) was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested for residential eating disorder program for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient does not appear to meet the American Psychiatric Association (APA) treatment guidelines for the residential treatment facility. It is noted that this patient does not show deterioration of psychosocial function to put her at risk of relapse without 24-hour supervision and care. She is not reportedly experiencing a disturbance in mood, affect or cognition such that she cannot be safely managed in a less restrictive environment. The records suggest that this patient was more stabilized and could have been safely and adequately care for in a less restrictive treatment environment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested cervical discography for evaluation of his pain.   Findings:  The physician reviewer found that cervical discography is medically necessary for evaluation of this patients pain.  The patient had multiple cervical spine surgeries that moderately controlled his pain until his recent motor vehicle accident. Additionally, the MRI and CT scan of the cervical spine are significant for multilevel disease, making it difficult to determine the true pathological cause of his pain. Trigger point and epidural steroid injections only provided temporary relief of pain. The patient is in need of a more definitive intervention in order to treat his symptoms. Cervical discography would guide the provider in choosing the best intervention to appropriately treat the patients medical condition.Manchikanti and colleagues performed a systematic review of the medical literature on cervical discography to evaluate the validity of cervical provocation discography in managing and diagnosing discogenic pain. They concluded that cervical discography performed according to the International Association for the Study of Pain criteria may be a useful tool for evaluating chronic cervical pain.   Zheng and colleagues performed a retrospective study to compare the value of cervical MRI versus discography in selecting the level for discectomy and fusion and to evaluate surgical outcome. They concluded that MRI has relatively high false-negative and false-positive rates. Discography can prevent the levels from being unnecessarily fused.  The combination of clinical symptoms, MRI and discography provides the most information for decision making and can improve the management of cervical discogenic pain.  All told, the requested cervical discography is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested reimbursement for cryosurgical ablation therapy for treatment of the enrollees renal mass.  Findings:  Three physician reviewers found that the patient was found to have a renal mass during imaging for an unrelated urologic complaint. As a result of a high suspicion of malignancy based on the radiographic interpretation, he underwent needle biopsy which revealed renal cell carcinoma (RCC). He was treated with cryoablation of the mass and has requested coverage for this therapy. The patients Health Plan has denied reimbursement as they consider cryoablation to be investigational for treatment of RCC. There is a paucity of scientific data demonstrating that cryotherapy is the treatment of choice in an otherwise healthy patient when there is no evidence of extenuating circumstances such as diminished renal reserve or marginal health which would make surgery unusually risky. Current data suggest that partial nephrectomy offers greater local control of RCC (Rodriguez, et al). Consistent with these findings, partial nephrectomy remains the option supported as safe and effective in the long-term, and the cryoablation performed in this patients care was not likely to be more beneficial than the standard modality.