Persius/hicric huggingface dataset:
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 speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including the meta-analysis by Law, et al. noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period, when compared to no intervention or nursery-based intervention (Gallagher, et al). Speech therapy in this patients case is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees developmental language and speech delay.  Findings:  The physician reviewer found that children with speech delays can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefitted from speech therapy (Emanuel, et al; Buschman, et al).   Speech therapy is medically indicated in this child.  The medical community standard for a three-year-old verbally delayed child, such as this patient, is to continue speech therapy.  The requested speech therapy is medically necessary for six months, followed by a speech re-evaluation.  If the patient demonstrates improvement, but still has significant delay in both expressive and receptive speech, therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for mental health outpatient group treatments for treatment of the enrollees attention deficit/hyperactivity disorder, obsessive-compulsive disorder and generalized anxiety disorder. Findings:  The physician reviewer found that the current medical literature, there are no absolute clinical guidelines as to duration and frequency of treatment for obsessive-compulsive disorder and generalized anxiety disorder.  However, there is strong evidence indicating that patients with attention deficit/hyperactivity disorder and comorbid disorders benefit from an adjunctive psychosocial intervention. In most trials of anxiety disorders, monotherapies are effective.  However, combination treatment is almost always superior.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees receptive and expressive language delays. 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 reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder.  This patient has severe expressive language delay, as well as delays in receptive language, play, and cognition. These deficits are significantly impairing his ability to communicate effectively and function socially. They may also be negatively impacting his self-care and feeding skills.  The current medical literature supports the requested therapy in this patients case.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested left foot hallux valgus/bunion surgery for treatment of her hallux valgus.  Findings:  The physician reviewer found that after careful review of the submitted information it is my opinion that the requested left bunionectomy is medically necessary for the treatment of the patients painful medical condition. The patients left foot pain has apparently been present for quite some time and has not responded to conservative care including padding and inserts. The patient indicates that her left foot pain is inhibiting her ambulation. In addition, the patients bunion deformity has been clinically diagnosed by x-ray. As noted in numerous medical studies, bunionectomies are very successful surgical procedures performed to correct a malpositioned toe or bunion deformity. For these reasons, the requested surgery meets the criteria for medical necessity since it is required to treat a malformed body part which is causing the patient pain. Furthermore, a bunionectomy is in accordance with generally accepted standards of medical practice, and not being performed for the convenience or cosmetic purposes. Accordingly, the requested surgery has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a sacral nerve stimulator for treatment of her overactive bladder.  Findings:  Three physician reviewers found that the relevant peer reviewed medical literature does not support the use of sacral nerve stimulation as a first-line treatment in urinary symptoms of frequency and nocturia. While InterStim may be effective, there is a paucity of documentation that the device is equivalent or superior to conventional medical therapy. Apostolidis reported that although technical advances have significantly improved patient selection and outcomes, as well complication rates, but revision rates still remain high. The authors further concluded that, further research is needed to improve patient selection, identify prognostic factors, clarify the mechanism of action and reduce complications and revision rates. Given the standard medications available to this patient for treatment of her urinary symptoms, the requested sacral nerve stimulator is not likely to be more beneficial than standard modalities for her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested radiofrequency neurolysis of the sacroiliac joint (CPT 64623) for treatment of his chronic back pain.   Findings:  Three physician reviewers found that the majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology, as long as the patients are appropriately selected.  This patient had a spinal fusion in the area to be treated with radiofrequency ablation. The medical literature does not support the efficacy of radiofrequency ablation at levels in which the medial/lateral branches are already disrupted, which may occur in spinal fusions.  Cohen and colleagues proposed that cervical facet denervation was less likely to be beneficial due to poor selection criteria. This study may also be applied in the patients case, as he is a poor candidate for radiofrequency neurolysis due to his history of spinal fusion. Dreyfuss and colleagues performed a prospective audit to establish the efficacy of lumbar medial branch neurotomy under optimal conditions. They determined that lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. They also determined that adequate coagulation of the target nerves could be achieved by carefully placing the electrode in correct position as judged radiologically. If the anatomy were disrupted, as possible in spinal fusion, it would be difficult to adequately coagulate targeted nerves if they are still present.  Therefore, the requested radiofrequency neurolysis of the sacroiliac joint is not likely to be more beneficial than other available methods of treating this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested reimbursement for emergency services he received.  Findings:  The patient presented to the emergency department (ED) with a chief complaint of an increasingly severe sore throat with fever for the previous five days that had not been responsive to antibiotic therapy. The ED provider noted that it is very painful to swallow but the numerical level of pain was not recorded and the patient was not febrile. The patient reported that he was spitting in a cup because it was just too painful to swallow.  The physical examination revealed a red and edematous throat, more prominent on the right side. The patient was assessed with likely cellulitis without obvious abscess formation. The patient was given augmentin and prednisone in the ED and discharged with prescriptions for the same. He was instructed to follow-up with an otolaryngologist in two days.At issue in this case is whether a prudent layperson would have sought immediate medical attention in this case. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Cellulitis of the upper airway constitutes an emergency medical condition that requires immediate intervention with appropriate medications and timely referral to an otolaryngologist. The patients pain level and history of fever would have prompted a prudent layperson to seek care emergently. The patients decision to seek immediate medical attention is supported by the ED diagnosis, treatment regimen and follow-up instructions and is consistent with the response a prudent layperson would have had in this situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that 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, receptive, 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. This patients evaluations document the presence of delayed receptive and expressive language. For these reasons, the requested speech and language therapy has been shown to be medically necessary for treatment of the patients speech delay for one hour sessions, twice weekly.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy.   The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of gastrointestinal bleeding.  Findings:  Three physician reviewers found that the patient has required blood transfusions because of recurrent gastrointestinal hemorrhage. Colonoscopy and upper gastrointestinal endoscopy have been non-diagnostic.  A bleeding jejunal arteriovenous malformation was identified during upper endoscopy and was ablated.  No other candidate bleeding lesion has been found.  The gastrointestinal hemorrhage has been sufficiently severe to result in cardiac complications for which she may require systemic anticoagulation with warfarin.  Wireless capsule endoscopy has been requested to further evaluate the small intestine for additional potential sources of gastrointestinal hemorrhage. The Health Plan has denied coverage for gastrointestinal tract capsule endoscopy and reported that the requested services are investigational for the evaluation of this patient.  This patient has gastrointestinal bleeding of obscure origin that has been recurrent and has required transfusions. Upper endoscopy identified a bleeding jejunal arteriovenous malformation that was ablated, and colonoscopy was non-diagnostic.  Search for an additional small bowel source of recurrent gastrointestinal hemorrhage, in light of the potential need for systemic anticoagulation for cardiac reasons, has been appropriately considered.  The diagnostic test of choice to evaluate the small intestinal mucosa is wireless capsule endoscopy. The Health Plan has noted that small bowel radiography should be done prior to granting approval for the gastrointestinal tract capsule endoscopy.   However, small bowel radiography cannot identify a mucosal lesion such as a bleeding arteriovenous malformation or sometimes shallow ulcerations. Small bowel radiography can identify small bowel tumors and large polyps.  However, the likelihood that a small bowel tumor or large small bowel polyp is the reason for the patient's recurrent gastrointestinal hemorrhage is much less than the likelihood of an arteriovenous malformation. All told, the requested gastrointestinal tract capsule endoscopy is likely to be more efficacious than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested bilateral breast MRI for evaluation of her dense breast tissue. Findings:  Two physician reviewers found that per the American Cancer Society guidelines, annual screening MRI is indicated for patients with a lifetime risk for breast cancer of 20 to 25%.  The American Society of Breast Surgeons recommends breast MRI for patients with suspected or proven deleterious mutations of BRCA1 or BRCA2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of developing breast cancer of 18.7%.  There is no personal or family history of BRCA mutation. The patient does not have a history of radiation to the chest wall.  Therefore, in this patients case, the requested bilateral breast MRI is not likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25%. 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, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. According to the authors, approximately one-half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show greater improvement than those children who receive no treatment. Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. As such, speech therapy is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested speech therapy for one hour per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50% and speech therapy is indicated for any delay greater than 25%. An extensive review of the literature including meta-analysis by Law and colleagues demonstrates the positive effects of speech and language therapy interventions for children with expressive phonological and vocabulary difficulty. In addition, Volmar and Weisner indicate that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Further, approximately half of all children delayed at 2 years of age catch up to their peers by 3 years of age. All told, children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders and those who participate in speech therapy show better improvement than no treatment. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient has a history of extreme prematurity and speech delay. Consistent with the medical literature, ongoing treatment including speech therapy is crucial to help minimize his neurodevelopmental disabilities. For this reason, speech therapy is medically necessary for treatment of this patients expressive and receptive speech delays and should be approved at the requested frequency of one hour once per week.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested 35 treatments of transcranial magnetic stimulation (TMS) for treatment of the stated condition of major depressive disorder.  Findings:  Two physician reviewers found that despite the supplemental information provided, it is still the case that the patient has a history of manic episodes particular to bipolar disorder, rather than to unipolar depression. At this time, there remains a lack of large scale, randomized studies supporting the efficacy of TMS in the treatment of bipolar disorder. Moreover, there is no evidence of a trial of electroconvulsive therapy by this patient, which is an efficacious therapy in this setting. As previously noted, there is insufficient evidence that TMS is more effective than ECT for treatment resistant bipolar disorder. In sum, TMS therapy is not likely to be more effective for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for cataract revision surgery for treatment of her post status cataract surgery. Findings:  The physician reviewer found that the medical records do not indicate a disease or deformity that would necessitate surgery.  All told, the submitted medical records fail to establish the medical necessity of the requested cataract revision surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested SymlinPen for treatment of her diabetes mellitus. Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the requested SymlinPen.  Symlin is indicated when hemoglobin A1C is less than or equal to 9 to help optimize blood glucose control.  This patients hemoglobin A1C was higher on two occasions.  Symlin is used to supplement mealtime insulin, and not take its place. In this clinical situation, considering the patients hemoglobin A1C levels, there may be an issue regarding the insulin dosage.  The current medical evidence does not support the requested medication in this patients case.  All told, the requested SymlinPen is not medically indicated for the treatment of this patient.