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

The parent of an 11-year-old male enrollee has requested speech therapy and continuation of speech therapy at a frequency of one time per week for treatment of the enrollees moderate articulation disorder and moderate expressive and receptive 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 noted 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. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  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. This patient demonstrates moderate to severe receptive and expressive language deficits, social pragmatic deficits, and moderate articulation deficits that negatively impact his ability to achieve age-appropriate functional communication skills.  Studies have shown that speech and language therapy can result in significant improvement in such children.  This patient is demonstrating consistent improvement with individual therapeutic intervention.  All told, all of the speech therapy provided from the said date forward was medically necessary for the treatment of this patient, and continuation of speech therapy at a frequency of one time per week is medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested coverage for radiofrequency ablation (radiofrequency neurolysis) of L5-S1 for treatment of her low back pain.  Findings:  Three physician reviewers found that the patient has chronic pain and is diagnosed with lumbar degenerative disc disease, a lumbar herniated disc and sacroiliitis. She has received a number of epidural steroid injections and sacroiliac joint injections with various results. Due to this patients sacroiliac pain, her provider wishes to perform radiofrequency ablation at L5-S1. This has been denied by the Health Plan as investigational, which is the subject of this review.This patient has a number of different diagnoses including sacroiliac pain. Although the patient has had some success with past spinal injections, the American Pain Societys clinical practice guidelines do not recommend radiofrequency ablation to treat sacroiliac pain (Chou, et al.). Additionally, there is a lack of peer-reviewed evidence supporting the safety and efficacy of radiofrequency ablation in the treatment of sacroiliac pain (Hansen, et al.). Thus, at this time, there is insufficient data from properly designed, randomized, double-blinded studies demonstrating that radiofrequency ablation is likely to be more efficacious in this setting than standard modalities. Therefore, the requested procedure is not likely to be more beneficial for treatment of this patients back pain than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for residential treatment center for treatment of her alcohol dependence and major depressive disorder with psychotic features. Findings:  The physician reviewer found that utilizing the American Society of Addiction Medicine criteria for a Level III treatment facility, this patient meets criteria for residential treatment. She was a severe withdrawal risk which requires management in a Level III treatment facility. The American Psychiatric Association practice guideline for substance abuse/alcohol dependence states that patients should be treated in the environment that would be the most conducive for their treatment. Based on documentation, this patient should continue treatment at a residential level of care, as she was unable to maintain sobriety in an IOP program. All told, this patient has failed treatment attempts in a less restrictive setting and continues to have suicidal thoughts; therefore, residential treatment center services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested coverage for selective internal radiation therapy (SIRT) radioembolization of metastatic liver tumors for treatment of his pancreatic adenocarcinoma with liver metastases.  Findings:  Two physician reviewers found that the patient has a past history of prostate cancer and was found to have multiple liver metastases several years ago. Biopsy demonstrated a signet ring adenocarcinoma with most likely a pancreatic primary. The patient was started on chemotherapy with Gemzar/Xeloda/Tarceva which was continued through three years when progression of disease was noted. He was then switched to Abraxane/Vandetanib and subsequently to FOLFOX with progression of disease. Most recently, the patient had re-staging of disease, with further evidence of progression. Pathology review found either stomach, pancreatic or biliary duct primary. The patient was not noted to be a candidate for a clinical trial but has been recommended for treatment with selective internal radiation therapy (SIRT) with Y-90 microspheres. Selective internal radiation therapy (SIRT) is the use of hepatic arterial embolization with microspheres loaded with radioactive Yttrium-90. The current data on the use of this therapy is limited. In 2008, Sato and colleagues reviewed their experience with SIRT in a wide variety of cancer types and concluded that although there appeared to be a significant response rate, in the absence of any controlled analysis it was not possible to determine the contribution of the treatment to patient outcomes. Townsend and colleagues concluded that of the available studies, phase III randomized, controlled trials were still needed to fully evaluate this modality. Thus, despite encouraging results from Kucuk and colleagues reporting that SIRT is a useful treatment in a number of patients with liver metastases, there is limited information as to tumor types and prior therapy. All told, this patient with presumed pancreatic primary disease and significant previous chemotherapy is not likely to experience an improved health outcome with SIRT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested coverage for L4-L5 lumbar spinal fusion (CPT 20930, 22612 and 22840) and laminectomy for treatment of his spondylolysis and severe facet disease at L4-L5.  Findings:  The physician reviewer found that while fusion of the lumbar spine is frequently performed, the indications for this procedure are not clearly defined (Sonntag and Carciano). Fusion may be indicated in specific pathologies, such as mechanical instability associated with localized destruction from tumor, trauma, or infection, but low back pain without an explainable pathomorphologic correlation or functional deficit is not an indication for fusion (Aebi). There must be evidence of instability with progressing neurological impairment in order for fusion to be considered medically necessary. In this case, evidence of instability is not well documented. Although the provider describes a 4mm movement in the study, no listhesis is described by the radiologist in the radiology report of the same study. All told, there is inadequate objective evidence provided of spinal instability in this patient and therefore the medical necessity of L4-L5 lumbar spinal fusion in addition to laminectomy is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested coverage for speech therapy for treatment of his developmental delay not otherwise specified and speech delay.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability (Nelson, et al.). According to a Cochrane Database meta-analysis, speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties typically produce positive outcomes. Early intervention can promote normalization of speech development and normal acquisition of skills for some children (Bernhardt and Major). Further, in a recent review of therapeutic intervention for children with speech and language delay, McLaughlin concluded that there is good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. This patient is a two-year-old with a moderate expressive language delay, as well as delays in other areas of development. His language delay significantly impairs his ability to communicate effectively and function socially. In accordance with the peer-reviewed medical literature, the requested speech therapy is medically necessary and appropriate for this patient.
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 severe expressive language delay and articulation delay.  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 noted 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.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that while most childrens difficulties resolve, 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 and language therapy, particularly for children with primary expressive language disorder.  This patient demonstrates delays in both receptive and expressive language that negatively impact her ability to communicate effectively.  Studies have shown that speech and language therapy can result in significant improvement in such children.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for lumbar spinal fusion at L5-S1 for treatment of her back and leg pain.  Findings:  The physician reviewer found that there has not been any defined lumbar radiculopathy, or sciatic localizing symptoms or signs. Nor has there been any substantiating medical data implicating or conclusively showing that the L5-S1 level is his pain generator. In addition, there is no documentation of any instability, angulation, tumor, or infection. Thus, the indications for fusion as published by Bambakidis and colleagues and the Milliman Criteria for lumbar fusion have not been satisfied in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested for plasma transfusion for treatment of the enrollees atypical hemolytic uremic syndrome related to factor H deficiency. Findings:  The physician reviewer found that this patient has suffered multiple complications as a result of atypical hemolytic uremic syndrome and has been severely ill as a result.  Although the exact etiology of his disease is not known, there is some thought that the relapses have been due to infectious exposure.Given the potential risk for relapse from infectious exposure and negative impact on his quality of life, the requested services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  coverage for speech therapy at a frequency of 2 sessions per week for 30 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that this eight-year-old autistic patient has a severe language delay. Speech therapy has been successful, but progress has been slow due to his inability to focus and concentrate, his cognitive impairments, and his tantrum behavior. While the patients progress has been slow, there is a large body of medical literature supporting speech therapy in autistic children.  As noted by Myers and colleagues, People with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. In a controlled study comparing autistic children who did and did not receive speech therapy, it was noted that those who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that all autistic children can benefit from speech therapy and emphasizes that age, either early or late in life, is not a barrier to speech therapy. Additionally, the common practice within the medical community would be to continue individual speech therapy for this patient. Therefore, the requested speech therapy at a frequency of 2 sessions per week for 30 minutes per session is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested bariatric surgery (Lap-Band for treatment of her obesity.  Findings:  Three physician reviewers found that the patient has a medical history of hypertension, type 2 diabetes, hyperlipidemia, and nonalcoholic steatohepatitis (NASH).  The patient reports that her body mass index has fluctuated between 30 and 34.  The patient is 57.5 and weighed 203 pounds on a recent weigh-in, resulting in body mass index of 31.32.  She has attempted a variety of self-directed interventions to facilitate weight loss, and she has not been successful at long-term weight reduction.  The patient was entered into a clinical trial for two years.  This was an observational study of etiologies related to NASH development and included dietary counseling, exercise diaries and medical review.  The documentation does not indicate that this included dietary or exercise interventions.  The patients provider has recommended bariatric surgery (Lap-Band).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  In this patients case, the requested procedure is not likely to be more effective than other methods of treatment.  She does not meet the National Institutes of Health criteria for bariatric surgery for the treatment of her obesity.  Although the patient reported a variety of attempts at weight loss, the documentation does not demonstrate that these attempts at weight loss have been medically directed.  Thus, the patient has not failed non-surgical attempts at weight loss.  All told, the requested bariatric surgery (Lap-Band) is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested coverage for Viagra 100mg for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication in this patients case. As noted on an authorization request form, the patient has tried Levitra.  The patients provider has reported that Levitra has been ineffective.  However, details regarding the initiation of this medication, its impact, and duration of use were not provided.  The submitted medical records fail to establish an organic cause for the patients erectile dysfunction. In this patients case, the documentation does not demonstrate a workup of hormonal status.  The current medical evidence does not support the requested medication in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested authorization and coverage for a computed tomography angiography (CTA).  Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk, but with no documentation of symptoms that are suspicious for coronary ischemia and no documented suspicion of anomalous coronary artery disease. In this circumstance, screening CTA scanning to assess for coronary artery disease is not medically necessary and not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations do not consider the use of CTA scanning for the assessment of coronary anatomy appropriate as a screening tool in asymptomatic patients. There are no documented accepted indications for CTA scanning in the records provided, such as suspicion of coronary anomaly, symptoms suspicious of coronary artery disease with equivocal stress test results, or concern for other forms of congenital heart disease. Therefore, the requested CTA is not medically necessary for evaluation of the patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested authorization and coverage for an endoscopic maze procedure for treatment of the enrollees uncontrolled atrial fibrillation.  Findings:  Three physician reviewers found that the patient has an approximate 5 year history of diagnosed atrial fibrillation. The patient has a history of multiple cardioversions, multiple ablations, and medical management of his uncontrolled paroxysmal atrial fibrillation. The patient reports he is currently symptomatic. The patients provider has recommended the patient undergo an endoscopic maze procedure for treatment of his atrial fibrillation. The Health Plan has denied authorization for the proposed procedure, citing a lack of peer-reviewed data supporting its efficacy.  Review of the submitted documentation demonstrates that the patient is an appropriate candidate for a maze procedure, as the patient has uncontrolled atrial fibrillation that has been refractory to several other procedures. Based upon the available scientific data there is sufficient evidence to support the likelihood that the maze procedure will eradicate this patients atrial fibrillation. The maze procedure is  a well-accepted surgical option and there are CPT codes and DRG codes for this procedure. An endoscopic approach versus an open surgical procedure is a medically reasonable and appropriate option for this patient.  Although controlled, prospective, randomized trials for this therapy are lacking, recent studies demonstrate that this patient may very well benefit from this procedure. Given that the patients atrial fibrillation has failed to respond to several other treatment attempts, the requested procedure is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees migraine headaches.  Findings:  Two physician reviewers found that the patient has a reported history of migraines.  Her provider noted that the patient has chronic migraines which had been more aggressive and frequent in the prior three to four months.  The medical records reflect that she has history of three to four headaches per week, and each may last three to five hours. She reportedly has had migraines since age 12, and she experiences incapacity, severe nausea, headache, numbness and light and noise sensitivity. She reportedly has been treated with oxycodone, Norco, ibuprofen and Imitrex. The patient has requested authorization and coverage for Botox injections.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  The patient has appealed this denial.  Botox has been demonstrated to be safe and effective for the management of chronic migraine. While it is typical clinical care to begin with more simple preventive management prior to transition to other therapies, the Food and Drug Administration approval was not contingent on failure of other preventives.  The medical records indicate that prior Botox injections were beneficial in this patients case.  The current medical evidence supports the requested services in this clinical scenario.  All told, the requested Botox injections are likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested for inpatient mental health services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient was noted to show some thought disorder with psychosis such that the treating psychiatrist recommended treatment on an acute inpatient unit for safety purposes. This conclusion is consistent with the American Psychiatric Association (APA) treatment guidelines, which advocate in favor of therapy at the least restrictive level possible. Further, the appropriate treatment setting should provide the patient with the necessary support and supervision required for the patient to progress in functioning. The requested inpatient mental health treatment has been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-11-month-old female enrollee has requested  for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the common practice of the medical community is to refer a speech-delayed child to a speech therapist to develop speech. There is a robust medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). Thus, it is medically necessary for this patient to receive individual speech therapy.