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

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees delays in receptive and expressive language skills and social/pragmatic language skills. Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  There is evidence that early intervention can improve speech and language skills over short-term follow-up.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of speech and language delay, speech therapy is standard of care. There is adequate support in the medical literature for the efficacy of the requested services in this clinical situation.  All told, in this patients case, the requested speech therapy is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Neurostar transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder, single episode, severe.  Findings:  Three physician reviewers found that peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors concluded that although results are suggestive that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  All told, in this clinical scenario, the superior efficacy of the requested Neurostar transcranial magnetic stimulation therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested mental health outpatient therapy for treatment of her behavioral health issues. Findings:  The physician reviewer found that the outpatient psychotherapy services provided during the time period at issue are not supported as leading to demonstrable improvement in the patients functioning, despite significant frequency over a long period of time. Consistent with the Health Plans recommendation, the patient required a more intensive treatment program and therefore intensive outpatient program (IOP) or partial hospitalization program (PHP) services would have been considered medically necessary modalities for this patient. Given the lack of potential for benefit, the outpatient psychotherapy provided during the time period at issue was not medically necessary.  With regard to continuation of outpatient psychotherapy at this time, there is little evidence demonstrating that the requested twice weekly therapy without medication management will afford any better or even equal outcomes compared to the patients past regimen. The standard of care in this setting includes consideration of IOP treatment or dialectical behavioral therapy available in forums such as the PHP setting. Such programs offer medication management and monitoring to attenuate the patients symptoms of depression and anxiety. There is no peer reviewed data demonstrating that ongoing outpatient psychotherapy without concomitant medication management is likely to result in clinically significant improvement in daily function in this setting. As such, the requested twice weekly outpatient psychotherapy sessions are not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested a referral for acupuncture treatment for treatment of his carpal tunnel syndrome.  Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the requested service. The value of acupuncture therapy in the treatment of carpal tunnel syndrome has been the subject of study. Although some reports have been encouraging, most other reports have not. Significant benefit was not seen in studies, and other reviews have not suggested that this treatment is effective.  More recent trials have not established a therapeutic value for acupuncture in the treatment of carpal tunnel syndrome, and further trials were recommended by Sim and colleagues.  Other studies in progress have not yet published their results.  At this time, the current medical literature has not demonstrated the efficacy of the requested service in this clinical scenario.  All told, the requested referral for acupuncture treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old male enrollee has requested 52 weeks of occupational therapy at a frequency of 2 sessions per week at 1 hour per session (104 sessions) for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that review of the submitted evidence demonstrates this patient is significantly impaired, as he still is not toilet-trained and is only minimally effective in dressing and undressing skills. The record indicates that for the past 2 years he has been the recipient of extensive home and clinic occupational therapy.  Therapeutic gains have occurred through these occupational therapy interventions; however, they have been relatively minimal according to the records provided.An extensive meta-analysis of the literature indicates that occupational therapy is effective in reducing many of the sensory processing difficulties associated with autism (Pfeiffer, et al.).  May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that occupational therapy was effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects.  Since this patient has been receiving 2 hours of weekly occupational therapy for 2 years with limited effect, the requested duration of therapy is excessive. His last occupational therapy progress report dated the end of last year recommended 1 hour of occupational therapy weekly. Based on the documentation provided, the Health Plan has authorized 2 hours of weekly occupational therapy for a 12-week period. The services authorized by the Health Plan are medically reasonable and appropriate at this time. The patient should be re-evaluated at the end of the 12-week period to determine if there is a need for additional services based on continuing improvement and progress toward goals.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested skilled nursing facility (SNF) services or in the alternative, outpatient physical, occupational, and speech therapies for treatment of his medical condition status post multiple ischemic strokes. Findings:  The physician reviewer found that with regard to the skilled nursing visits from the date of service at issue onward, the patient did not have ongoing medical issues that required regular monitoring by skilled nursing professionals. The services provided during this period included assistance with nutrition and medications, bowel and bladder incontinence care, supervision due to impulsivity, and physical assistance for activities of daily living and basic mobility tasks. As noted above, these services are based on custodial needs. Thus, the patients care could have been safely provided in a custodial setting without scheduled nursing visits. Similarly, the evidence does not support continuation of skilled nursing visits at this time. Concerning the medical necessity of outpatient occupational therapy, speech therapy, and physical therapy, based on the patients documented deficits and level of functioning, each modality is medically necessary at a frequency of once a week. Such services are indicated to assess the patients function, adjust home programs as necessary, and make assessments and recommendations regarding appropriate supervision and assistance needs, as well as to train caregivers as needed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has clinically definite multiple sclerosis. She has highly active disease and requires treatment.  Gilenya is the only currently available FDA approved medication for multiple sclerosis that is oral.  Gilenya is approved for relapsing-remitting multiple sclerosis. This medication has shown a 52% reduction in annualized relapse rate, which is greater than that shown in the pivotal studies of injectable multiple sclerosis drugs.  In this patients case, given this patients highly active disease, the requested medication is medically indicated. All told, the submitted documentation has demonstrated the medical necessity of Gilenya.
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 receptive and expressive language delays.  Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life, and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits.  Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.   Efficacy research is difficult in this patient population because of the numerous deficits represented.  This patient has choreoathetoid cerebral palsy, global developmental delay, and expressive and receptive language delay, and his skills fall significantly below those of other children his age. These deficits negatively impact his ability to communicate effectively.  In this patients case, the requested speech therapy is standard of care.  The submitted documentation has established the medical necessity of the requested therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested intravitreal injections of Avastin for treatment of the enrollee, who has been diagnosed with severe central serous retinopathy. Findings:  Three physician reviewers found that this patient has a history of central serous retinopathy causing vision loss and scarring in the macula. The use of Avastin was based on progression of the disease and the suspicion of choroidal neovascularization.  It is well-established that Avastin is safe and effective for a number of diseases that are characterized by choroidal neovascularization.  The medical literature supports the use of Avastin in the treatment of other types of retinal diseases involving neovascularization. In this patients case, the physician recommended intravitreal Avastin injections primarily based on the suspicion of choroidal neovascularization. Alternative treatments, such as photodynamic or observation, would likely not be as beneficial for this patient.  Therefore, intravitreal injections of Avastin were and are likely to be superior over other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested cryosurgical ablation for treatment of her fibroadenoma. Findings:  Two physician reviewers found that standard treatment options for fibroadenomas include close observation or surgical excision. Cryoablation has been proposed as an alternative approach for patients who desire more than watchful waiting yet want to avoid an operation.  While the technique was approved by the FDA as being safe and effective therapy, the scientific literature lacks follow-up beyond four years.  Reports which include larger numbers of patients report satisfaction with short-term results, but advise that longer follow-up is needed to understand the time course for resolution of these lesions both physically and radiographically. There is also the possibility that some patients may still require excision if the lesion does not completely resolve.  Surgical excision remains the standard of care for symptomatic or enlarging fibroadenomas with minimal morbidity. The procedure can also be performed under local anesthesia and provides complete histologic evaluation of the lesion. In this patients case, the requested cryosurgical ablation is not likely to be of greater benefit than other available standard treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested physical therapy services for treatment of the enrollees abnormality of gait. Findings:  The physician reviewer found that this patient has been followed for an as-yet undiagnosed neurological condition and abnormal gait, including mild bilateral foot abnormalities and decreased lower extremity strength. While there are no specific studies documenting the utility of physical therapy in a child with this patients particular constellation of physical and functional findings, physical therapy is standard of care for well-defined groups of children exhibiting similar deficits in gait and ambulation. There is sufficient medical evidence supporting the services at issue in this clinical scenario. All told, the physical therapy services at issue were medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. A prudent layperson would reasonably believe that he or she was experiencing an emergent medical condition given the signs and symptoms (headache, numbness, visual changes) that this patient was experiencing.  It is well documented in the literature that headache, migraines, and stroke are inter-related. The patient was warned by her neurologist that she might be at risk for stroke given her history of migraine. She was suffering from increased frequency of headaches leading up to the Emergency Department visit. Given the occurrence of the patients visual and sensory neurologic deficits in association with her acute headache, it was reasonable for her to be concerned that she might be suffering from a stroke, an emergency medical condition.  As such, it was reasonable for the patient to seek emergency medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested an MRI of the right knee for evaluation of her knee pain. Findings:  The physician reviewer found that the indications for MRI of the knee have broadened over time. Initial indications for the test were to avoid unnecessary arthroscopic evaluation (Southgate and Thomas) and the avoidance of unneeded specialist evaluations (Solomon). However, the utilization of the MRI for the diagnosis of internal derangements of the knee, as opposed to clinical evaluation, has led to an increased dependence on this test, rather than the equally accurate evaluation by a skilled orthopedic surgeon (Kocabey). In this patients case, another orthopedic consultation has been authorized by the Health Plan. This consultation is an appropriate next step in this setting and is indicated prior to consideration of an MRI. At this time, there is no evidence that an MRI is medically necessary to evaluate this patients condition, thus the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested septoplasty nasal surgery and reduction of nasal turbinate for treatment of his breathing difficulties. Findings:  The physician reviewer found that this patient does not meet medical necessity criteria for consideration of the proposed surgical intervention. There is no documentation of an attempt at medical management or the results of failure of medical management. This criteria is consistent with the recommended guidelines by the American Academy of Otolaryngology-Head and Neck Surgery Foundation for the management of patients with nasal obstruction and anatomic documentation of nasal septal deviation or spur formation. The results of the clinical studies show that outcomes for surgical intervention are significantly improved following failure of adequate medical management. In the absence of documentation indicating that the patient has undergone adequate attempts at medical management without success, the surgical treatment requested is not medically necessary and thus the Health Plans denial was appropriate.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring immediate medical attention. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part.  Pain of 7/10 severity associated with a fever and visible signs of infection of the upper airway constitutes symptoms that a prudent layperson could reasonably interpret to be an emergency medical condition. The patient was also advised by a medical professional to seek emergency services. For these reasons, the patients decision to seek treatment in the Emergency Department was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested child/adolescent psychiatric residential treatment for treatment of his behavioral health problems. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity for child/adolescent psychiatric residential treatment during the time frame in question . While the patient did not progress satisfactorily in individual treatment, there was no indication that alternatives were considered, such as intensive outpatient treatment.  Additionally, it is not apparent that aggressive medication management was attempted. Furthermore, the records submitted from the facility did not indicate that the patient required or received timely services commensurate with those expected in a residential setting.  For example, the initial evaluation appeared to take place one month after the patient was admitted, and there is no additional evidence of intensive multidisciplinary team work with multiple hours of programming on a daily basis. American Psychiatric Association practice guidelines indicate that patients should be treated in the least intensive setting which is likely to be safe and effective. There is no indication in the record that the patient could not have been safely and effectively managed on an ambulatory basis.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested Synvisc injections for treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has been shown to be of value in the treatment of osteoarthritis. Viscosupplementation is most suitable for patients with mild to moderate arthritis, and in those patients for whom other modalities are contraindicated, or have failed, and as part of a comprehensive treatment strategy.  Additional study is needed to clarify uncertainties about the therapeutic effects of different products in various clinical situations, but management of osteoarthritis requires a combination of non-pharmacologic modalities, such as exercise and weight reduction, and pharmacologic modalities, including NSAID medications.  In this case, there is no documentation of any treatment other than the proposed viscosupplementation. There is no documentation of failure of other treatment, and no documentation of any contraindication, such as allergy. All told, in this patients case, the requested Synvisc injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees expressive language delay. Findings:  The physician reviewer found that the literature supports the use and medical necessity of intensive speech and language therapy for expressive language delay (Nelson, et al). This patient has expressive language delay with skills substantially below those of her peers. These deficits negatively impact her ability to communicate effectively with children her age and adults. Studies have shown that speech and language therapy can result in significant improvement in patients within this population. As such, it is medically necessary to provide speech and language therapy for this patient.