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

The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing the medical literature, there are numerous studies addressing the functional benefits of ABA therapy. When ABA therapy was first initiated, some providers recommended that 40 hours per week was indicated but this was later reduced to 20 hours per week as a result of the burden of the intensity that the therapy puts on families and service providers. Since that time, additional studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (more than 20 hours per week) to further assess the outcome relative to additional hours of treatment. In addition, studies have been conducted to address the need for intensive behavior therapy versus standardized care. Overall, the scientific data is supportive of the utility of behavioral therapy and suggest that patients who receive this treatment show a statistical improvement in cognitive, language and adaptive behavior skills when compared to patients who were untreated. However, Spreckley and Boyds meta analysis of the literature found that appropriately powered clinical trials with broader outcomes are still needed to fully establish the role of ABA in managing young patients with ASD. The authors cited a study by Roberts, et al. which determined that for best results, a minimum of 20 hours per week of intervention over 2 years, taking into account of each patients strengths and weaknesses and family circumstances, is essential for young patients with ASD to make gainsWhile there is no literature specifically addressing the utility of 25 hours per week of ABA therapy, there is support for high intensity therapy of at least 20 hours per week. Therefore, based on the clinical documentation provided as well as review of the relevant scientific evidence, there is adequate support for 20 hours of ABA therapy per week for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for a bilateral breast magnetic resonance imaging (MRI) scan for evaluation of her medical condition. Findings:  The physician reviewer found that she has extremely dense breast tissue on mammography, which markedly limits the usefulness of this technique in her case. Recommendations for short term follow-up MRIs, based upon imaging findings which are probably benign, are very common in breast imaging and this is the case in this individual. The abnormal finding has only been visible on MRI; therefore, it stands to reason this technique will be the exam that needs to be repeated in order to assess stability. Since the area in question has only been visible on MRI, a biopsy in lieu of repeating the exam would be out of the question as a surgeon would need to identify the area in question to biopsy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  for Somatropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that this patient does not have data supporting an abnormally poor height velocity based on measurements obtained over 1 year of time. Further, it is difficult to ascertain the accuracy of his height prediction but it does not appear to be less than 63 inches and is not evidenced with a complete growth chart, concomitant bone age radiographs, and height measurements. For these reasons, the medical necessity of the requested GH therapy has not been established in the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested 2 hours per week of occupational therapy for treatment of the enrollees autism.   Findings:  The physician reviewer found that the scientific literature is replete with studies supporting the use of occupational therapy (OT) to improve function in autistic patients. Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and found that across all domains studied, OT considerably helped the patient. The authors further noted that OT usually addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children with autism.  Moreover, the American Academy of Neurology (AAN) guidelines for autism developed in 2000 states, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Based on the data available, the standard of care for this patient is to provide the requested OT services as OT is an appropriate modality in this setting and therefore clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old female enrollee has requested for Alimentum ready to feed (RTF) formula for treatment of the enrollees food allergies.   Findings:  The physician reviewer found that symptoms such as abdominal pain, constipation, and regurgitation are relatively common in children. In the medical literature, Heine found that, Gastroesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. GI food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. For these reasons, the authors suggest that early recognition is essential for the optimal management to prevent nutritional deficiencies and aversive feeding behaviors. Further, Sicherer concluded that, A central aspect of management is periodic reevaluation (oral food challenge) for determination of tolerance, a procedure that often requires the specific expertise of an allergist or gastroenterologist if acute or severe reactions are possible. This patient is a young child with multiple symptoms since early infancy that are highly suggestive of food allergy. As recommended by her provider, appropriate management includes diagnostic studies as determined by a pediatric gastroenterologist and the use of a hypoallergenic formula.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity.  Findings:  The physician reviewer found that this patient has a BMI of 35 with hypertension and history of a cerebral vascular accident (stroke) related to hypertension. As such, she meets National Institutes of Health Consensus Guidelines criteria for clinically severe obesity and is an appropriate candidate for bariatric surgery. Laparoscopic sleeve gastrectomy is a well-accepted weight loss procedure with proven results for patients with clinically severe obesity. Therefore, the proposed procedure is medically necessary for this patient. As with any weight loss procedure, the patient should undergo appropriate dietary and psychological evaluations prior to surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested for a laparoscopic adjustable gastric band procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is morbidly obese, has failed prior dietary efforts and does not have any obvious metabolic, dietary, behavioral or medical barriers to surgery. She meets all generally accepted criteria for bariatric surgery, including published Betsy Lehman Best Practice Guidelines and National Institutes of Health Consensus Guidelines. The lap-band is a well-accepted weight loss procedure with proven results. With a BMI of 42.6, this patient is not likely to achieve adequate weight loss results without surgical intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for intravenous gamma globulin therapy for treatment of his idiopathic polyneuropathy.  Findings:  Two physician reviewers found that as reported by Dyck and colleagues, IVIG has been shown to be effective in the treatment of chronic inflammatory demyelinating polyneuropathy. However this patient does not meet the clinical criteria for that diagnosis based on the guidelines provided by the American Academy of Neurology (AAN). In addition, there is a paucity of medical literature or supporting the use of IVIG for idiopathic neuropathy. Accordingly, the effectiveness and safety of IVIG for treatment of this patients idiopathic polyneuropathy remains investigational and unproven in the scientific data.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that an overall evaluation of the scientific data, including positive analysis by Myers and colleagues, is supportive of the utility of speech and language therapy for patients with ASD. Consistent with the relevant medical literature, this patients clinical situation does not hinge on the existence of any laryngeal or oropharyngeal anatomical abnormalities since deficient language development and motor behaviors are seen in children with ASD without regard for these pathological anomalies. Further, the published studies suggest that young patients with ASD continue to be receptive due to the plasticity of the brain. Thus, specialists trained to work with these young patients can utilize the malleability of the developing brain to improve the patients overall neurologic health. Thus, specific treatment including speech and language 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 ASD and their co-morbidities including, but not limited to speech delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for portable oxygen for home use for treatment of her headaches.  Findings:  The physician reviewer found that there is limited evidence sustaining the positive impacts of oxygen for the treatment of migraine. To date, there are inadequate scientific data in terms of large, randomized clinical trials with long-term follow-up that demonstrate the effectiveness of oxygen in improved health benefits in patients with migraine. In addition, this patients records do not document that she has exhausted standard therapies including beta blockers, calcium channel blockers, and antidepressant medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 4-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted clinical information does not establish the need for 30 hours per week of ABA therapy. Based on the patients documented deficits and current level of functioning, the Easter Seals plan for 15 hours of ABA per week is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 4-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.   Findings:  The physician reviewer found that the submitted clinical information does not support the need for 30 hours per week of ABA therapy. Based on the patients current deficits and level of functioning, the Easter Seals plan for 15 hours of ABA per week is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of his obesity.  Findings:  The physician reviewer found that this patient has a BMI less than 35. In addition, there is no indication of any supervised weight loss attempts of any kind within the past two years. Given a current BMI of less than 35, the lack of a multidisciplinary evaluation, and the absence of medical record documentation of prior failed weight loss attempts (within the last two years), this patient does not meet nationally accepted criteria for weight loss surgery at this time. According to the National Institutes of Health Consensus Guidelines for weight loss surgery, patients must have a BMI of at least 35 and the presence of a significant co-morbid condition to meet indications for weight loss surgery.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for emergency services were not required on an emergent basis. Findings:  The physician reviewer found that patient had been suffering from a cough for several days. She denied any pain at the time of her visit. She denied shortness of breath or vomiting. Her symptoms had not suddenly changed or worsened. The records document that the patient was well-appearing and in no distress. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested for continued use of Velcade treatment regimen for treatment of his multiple myeloma. Findings:  Three physician reviewers found that Velcade (bortezomib) is an important drug for myeloma.  It is usually used up front in newly diagnosed patients and in those patients with relapsed disease.  Despite high response rates from bortezomib and other new agents such as thalidomide and lenalidomide, myeloma remains incurable. Thus, maintenance therapy has been considered to keep patients in remission. Interferon alpha, thalidomide and glucocorticoids have been studied in this setting, as noted by Engelhardt and colleagues.  Interferon has shown mixed results.  Thalidomide and prednisone has shown improved overall survival in at least one study, as noted by Berenson and colleagues.  This patient was enrolled in a clinical trial with a maintenance phase of Velcade. His disease has remained stable on this maintenance therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for extreme lateral interbody fusion (XLIF) at the L3-4 spinal level for treatment of his degenerative disc disease. Findings:  The physician reviewer found that there is inadequate medical documentation submitted to substantiate the presence of spinal instability above the levels of this patients prior L4 to S1 fusion. Supine radiographs fail to reveal spondylolisthesis in 20% of patients. Flexion- extension views may reveal subtle or unstable slips accentuated by flexion and reduced in extension. If instability is present and is indeed documented in lateral flexion-extension views, then there would potentially be a rationale for extending this patients fusion more proximally. However, without demonstration of specific mechanical instability and with this patients multiple comorbidities, it is not medically necessary for this patient to proceed with an extreme lateral interbody fusion of the lumbar spine (XLIF) at the L3-4 level.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 20-year-old male enrollee has requested for care for treatment of the enrollees parent-child relational problem, bereavement and conduct disorder, adolescent-onset type. Findings:  The physician reviewer found that the submitted documentation does not demonstrate that the patient required the intensity of services of the disputed level of care at any time during his stay. Furthermore, a GAF of 60 was listed. A GAF of 60 indicates moderate functional impairment, not severe impairment. Nor is there is no evidence of comorbid psychological or medical issues that would have warranted the level of care provided.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for an EML4-ALK Rt PCR Pathology Test for evaluation of her lung cancer. Findings:  Two physician reviewers found that the EML4-ALK fusion oncogene defines a new molecular subset of non-small cell lung cancer with distinct clinical and pathologic features. The patients who are most likely to harbor EML4-ALK are relatively young, and never have been or are light smokers with adenocarcinoma. These same features are associated with epidermal growth factor receptor mutation; thus it is essential to screen patients by genetic testing and not rely solely on the presence of clinical predictors. The results of genetic screening can then be used to choose the appropriate molecularly targeted therapy. Pre-clinical studies showed that the presence of EML4-ALK confers sensitivity to ALK inhibitors both in vitro and in vivo, and suggest that patients with this gene rearrangement may derive clinical benefit from specific ALK inhibition. Preliminary results from a phase I/II study demonstrate that the ALK inhibitor crizotinib is active in patients whose tumors harbor the EML4-ALK fusion gene.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested for allergen specific blood testing for evaluation of her medical condition.   Findings:  Two physician reviewers found that IgG food testing is considered to be experimental in large part because the significance of positive IgG tests to foods is not known. Standard evaluation for suspected food allergies would include skin testing to the suspect foods and/or IgE testing (as this is not considered experimental in nature) for foods, but not IgG testing. A review of the testing performed on this patient shows that she was tested for a large number of foods, and that the testing consisted of both IgE and IgG tests. However, the results did not distinguish between these two types of tests.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for emergency services were not required on an emergent basis. Findings:  The physician reviewer found that This patient had been suffering from a sore throat for four days and hoarse voice for three days. She denied vomiting. Her symptoms had not suddenly changed or worsened. The records document that the patient was well-appearing and in no distress. She required only oral ibuprofen in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested for a consultation with a specialist for occipital nerve decompression for treatment of his neuralgia. Findings:  Three physician reviewers found that this patient has chronic neck pain and numbness of his face and right upper extremity with a normal examination and normal MRI. The diagnoses of occipital neuralgia, migraine, and cervicogenic headache have not been proven. There is a lack of large, prospective, scientific, randomized studies proving the efficacy of surgical treatment of occipital neuralgia.  There is also a lack of any large, randomized studies showing its long-term effectiveness. The above cited studies have described retrospective, small number, non-randomized series reporting short-term effectiveness of surgical treatment. In this patients case, the requested services are not likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that despite the fact that Lyrica is not officially approved for the indication of trigeminal neuralgia by the Food and Drug Administration, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology. In addition, there is clinical experience supporting the use of Lyrica for this condition as a very effective medication. In this patients particular case, she has failed trials with previous medications and was started on treatment with Lyrica in a medically appropriate clinical decision, with the support of all of the patients prior clinical success in the management of her pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of the his behavioral health condition.   Findings:  Two physician reviewers found that current scientific data does not support the use of TMS therapy in this patients case. The medical literature indicates that there is insufficient evidence in support of its efficacy to warrant use in standard practice. Other studies have shown that patients with psychotic depression do not respond well to TMS, and hence it is likely to be less effective than ECT, which is the treatment of choice of the patients condition. Although the patient complains of memory loss, this effect is likely to be transient and can be mitigated by unilateral electrode placement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that many studies show that ABA therapy is effective in improving sensory issues and teaching new skills. In addition, many studies demonstrate that ABA is effective in reducing problem behavior (Horner, et al.). A number of studies also indicate that, when implemented intensively (more than 20 hours per week) and beginning prior to the age of 4 years of age, ABA may produce large gains in development. This patient exhibits high sensory needs which pose a challenge to his ability to self-regulate and control his impulses. He becomes easily frustrated with his communication delays and resorts to negative behaviors of tantrums and inappropriate sensory seeking behaviors. These deficits continue to limit his participation in less restrictive environments within his school and community settings. Further, his difficulties continue to cause significant safety concerns requiring very close supervision at all times.