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

The parent of a 17-year-old female enrollee has requested reimbursement for residential care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient was admitted with a high risk of recurrence of self-harm behavior. She had already made one suicide attempt by overdose, and even after treatment for one week in acute hospitalization, she became frustrated and made a second very serious attempt to slash her own throat. She also had a long history of severely cutting herself at times despite interventions from various providers. Given her history of repeated attempts to harm herself in spite of multiple interventions, requires that she achieve stability before being discharged home to the same type of environment as before. Overall, the monthly summaries indicate disturbing symptoms including distortion of reality and poor coping skills until improvement was noted in the records approximately five moments after admittance. At that point, the patient showed enough improvement in dealing with her own emotions that she would have been safe to be discharged to a lower level of care without a deep concern that she would relapse. Before this date, however, the concern that she would relapse if discharged to a lower level of care indicates that she met the criteria for continued stay in an RTC facility. Prior to improvement noted after five months, the patients poor reality testing prevented her from being manageable at an available lower level of care. However, each summary demonstrates that she continued to make progress, developed insight, and was able to leave on passes with her family and have a successful time when doing so. For these reasons, the RTC services provided to this patient from admittance until the date on which she was noted to have improved were medically necessary, but services after that date were not medically necessary for management of the patients medical condition.
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% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and 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. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement for anesthesia services.  Findings:  The physician reviewer found that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation. Monitored anesthesia care is directly provided by anesthesia personnel. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Society 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 notes 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. These 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 who are 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this case, the medical documentation indicates the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective procedures. The patient was an appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested reimbursement for residential level of care services and partial hospitalization program (PHP) level of care services for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient is a small statured woman who was at her highest weight at 100% of her ideal body weight (IBW) on admission. The patient indicated that she was to menstruate and did not use laxatives or purgatives or over exercise. Her mood symptoms tested out at minimal levels and her predominant concerning behavior was her self-cutting. Applying the practice guidelines from the American Psychiatric Association (APA), the RTC services were not medically necessary as the patients records do not document any medical instability, controlled psychiatric co-morbid conditions, or imminent weight loss that will predictably lead to medical instability. Similarly, the patient did not have the severity of symptoms recommended for treatment in a PHP level of care without evidence of significant restricting. Moreover, the patients treatment goals did not include re-feeding and weight restoration, and focused predominantly on behavioral issues and family conflict that could have been safely and adequately managed through a conventional outpatient mental health intervention. Accordingly, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old male enrollee has requested individual speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. 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 continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female has requested applied behavioral analysis (ABA) therapy at a frequency of 6 hours per week for treatment of her autism.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has significant behavioral and mental dysfunction. Her most serious dysfunction seems to be her obsessive activity, which freezes her into inactivity. ABA techniques have a well-documented history of effectively altering maladaptive behaviors. The medical literature strongly supports the treatment of autism with ABA therapy. The effectiveness of ABA based intervention in autism has been well documented through five decades of research. (Myers, et al.) The efficacy of ABA therapy has been proven in multiple controlled studies (Sallows and Graupner; and Remington, et al.). This patient has been diagnosed with autism and ABA therapy is the documented therapy of choice. There is limited data available regarding what age ABA techniques should be terminated. Therefore, ABA therapy should be continued through the date in question, at which time the patient should be reassessed to determine whether her obsessive behaviors have improved. If no improvement is noted, psychiatric assessment would be appropriate at that time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that The medical literature strongly supports speech therapy for treatment of this patients speech and language delays. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. Further, Goorhuis-Brouwer and Kniff concluded that normal and developmentally delayed children with speech delay are candidates for successful speech therapy. Moreover, Emanuel and colleagues noted that in prospective studies on patients in the 2-year-old population, who tested below the 10th percentile for age, benefit from speech therapy. Therefore, speech therapy for individual speech therapy sessions for 1 year with reassessments at 6 and 12 months has been established as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical records indicates that the patients symptoms improved while participating in the ECPHP. The weekly progress note on the date specified indicates that the patient participated in social recreation with good attention and compliance and also notes that the patient had good interest in a new classroom peer, displayed good response to limits and displayed safe behavior. Other progress notes indicated there were no tantrum behaviors from the time period specified. A progress note indicates the patients performance in structured activity was fair to good and her ability to initiate contact with peers and adults was described as good. An additional progress note described that the patients anxious behavior was responsive to positive reinforcement and redirection and her engagement in unsafe behavior was noted to be at 30%. The medical records also indicate the patient displayed safe behavior and that her anxiety and social interactions were improved overall. In sum, the patients behaviors had improved throughout the course of her treatment in the ECPHP program and she could have been transitioned to a lower level of care from the date indicated and forward. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  speech therapy for treatment of his autism and verbal apraxia. Findings:  The physician reviewer found that patients 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 sills, 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.).  A controlled study comparing autistic children who did and did not receive speech therapy demonstrated that children who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy and that age, either early or late in life, is not a barrier to speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for a custom anterior cruciate ligament (ACL) brace  for treatment of the enrollees medical condition status post ACL repair.  Findings:  The physician reviewer found that knee braces have been used for some time following ACL reconstructive surgery, there is little evidence to support the practice (Wright, et al). In addition, there is a paucity of scientific data demonstrating that the use of braces prophylactically to reduce injuries to knee ligaments is effective (Garrick and Requa). No significant protection could be identified, and there may be negative effects associated with brace use (Najibi and Albright). This lack of evidence of benefit has been reported for other contact sports, such as football, and hockey (Tegner and Lorentzon).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested reimbursement for acute inpatient psychiatric level of care services.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  At the time of admission, the patient was chronically depressed, and he engaged in alcohol and drug use. There is no evidence in the clinical notes indicating that the patient was acutely ill.  Passive suicidal thoughts, without active plan or intent, were identified.  The services and evaluation provided did not clearly address the patients clinical needs or provide a treatment plan that could be considered effective for the patients condition.  The medical notes do not demonstrate that the patient had failed structured outpatient treatment.  Additionally, the documentation does not demonstrate that less restrictive settings, such as intensive outpatient program services, had been considered.  In this patients case, intensive outpatient program services would have been medically necessary during the dates of service at issue. All told, acute inpatient psychiatric level of care treatment provided on the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested authorization and coverage for cataract surgery.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient reported that his vision impacts daily activities.  He reported difficulty driving at night and reading text on the television.  Although this patient exhibits cataract on examination, the records show that the patients vision loss is primarily related to an uncorrected refractive error.  The patients symptoms are likely correctable with glasses.  Refractive lens exchange was offered as a means to reduce the patients need for glasses.  The medical records do not demonstrate that the patients cataract is causing the patients symptoms.  All told, the requested cataract 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 two-year-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested  speech therapy services for treatment of his autism. Findings:  The physician reviewer found that the medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism spectrum disorders. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested speech therapy services for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Review of the available peer-reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism spectrum disorders.
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 for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient has a significant expressive speech delay with a mild mixed receptive component. The receptive component may be due to the home language being non-English. The patient is intellectually normal but cannot generate adequate speech for his age. With one hour of weekly speech therapy, his expressive language increased in a 5 month period from 12 months to 15-16 months of age equivalent speech. The standard of care within the medical community for a young patient of normal intelligence with these language delays is speech therapy. There is strong evidence in the medical literature that confirms the validity and effectiveness of speech therapy. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a summary of multiple medical journal articles. Further, Goorhuis-Brouwer and Kniff evaluated speech-delayed cognitively normal and abnormal children, and emphasized that intellectually normal children, such as this patient, are ideal candidates for successful speech therapy. Consistent with these data, the requested speech therapy is medically necessary for this patient. He should receive individual speech therapy for a minimum of one hour weekly for six months with reassessment at the six month interval. The speech therapist should be fluent in both English and the non-English language spoken at the enrollee's home to assist in parental education.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested authorization and coverage for a tonsillectomy for treatment of the enrollees tonsillitis.  Findings:  The physician reviewer found that based on review of the available records, this patient had only a few episodes of sore throat and hoarseness. There is no indication in the literature that bacterial tonsillitis can cause hoarseness. Hoarseness which occurs with sore throat is generally caused by a viral infection (Mau). In the medical literature, the indications for tonsillectomy do not include treatment of recurrent hoarseness (Clayburgh, et al). Therefore, in the absence of a diagnosis which is likely to be improved or relieved with surgical intervention, the requested tonsillectomy is not clinically indicated or medically necessary for treatment of this patients condition.