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

A 23-year-old female enrollee has requested an upper extremity externally powered prosthetic arm for treatment of her congenitally involved left transradial amputee.  Findings:  The physician reviewer found that successful upper limb prosthetic care requires multidisciplinary care and cooperation between the person with an amputation and the various members of the rehabilitation team.  In this case, there is no documentation of a recent physicians assessment of the patient, including physical examination by a physician familiar with prosthetics.  Information regarding this patients range of motion at the shoulder and elbow, the strength at these joints, the length of the residual forearm, and the integrity of the skin at the residual limb are lacking.  There is also no documentation of an assessment by an independent occupational therapist (i.e., not associated with the prosthetics vendor) familiar with upper limb prosthetics.  The submitted documentation does not demonstrate that the patient reliably produced electromyographic signals that were detected by the sensors of a myoelectric prosthesis at the required number of sites.  Follow-up with the prosthetics vendor was not apparently to be scheduled until after approval of the requested myoelectric limb.  There is a lack of published, high-grade, disinterested clinical literature that supports that the requested myoelectric electrical prosthesis with an i-LIMB terminal device confers significant, marginal functional benefit in the setting of unilateral upper limb amputation in comparison to a conventional myoelectrical prosthesis or a non-myoelectrical prosthesis with respect to activities of daily living.  There is also a lack of high-grade published data regarding long-term usage patterns.  Notably, prosthesis rejection rates for congenital amputees who receive prostheses later in life are known to be high, as noted by Biddiss and Chau. Overall, the medical necessity of the requested upper extremity externally powered prosthetic arm has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a brow lift for treatment of her brow ptosis. Findings:  The physician reviewer found that no fully automated peripheral field studies (with eyelids taped and with eyelids untaped) have been provided for review. Given the lack of testing performed to determine whether the patients issue is eyelid ptosis, brow ptosis or another condition, her diagnosis is unclear. The Health Plan states the patients excess skin laterally is outside the eyelid boundary and would not cause visual encroachment. Visual field studies could determine whether or not this is the case. Lacking these diagnostic studies, a brow lift is not medically necessary. Additionally, based on the photographic evidence provided, the patients condition appears to be consistent with the natural aging process and does not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested gastric bypass revision to remove an additional 100 cm from the common channel for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is status post Roux-en-Y gastric bypass (RYGBP) surgery in 2001 with maintenance of weight loss of nearly 200 pounds, despite a regain of 45 pounds. The patient started out with a body mass index (BMI) of 82, which is most recently reported at 47. The patient is a statistical success with well over 50% estimated weight loss (EWL) despite the continued presence of morbid obesity. At this time, the scientific data on conversion to distal RYGBP does offer some preliminary findings of short-term weight loss. However, there are significant potential risks including protein malnutrition, need for reversal, and significant morbidity. At this time, the patients records do not suggest the presence of a failure of the earlier surgical procedure. As such, the requested surgical intervention should not be considered except as part of an Institutional Review Board (IRB) approved clinical trial. For these reasons, the requested surgery is not medically necessary in the management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested Xolair for treatment of her asthma. Findings:  Two physician reviewers found that this patient has moderate to severe persistent allergic asthma, and she has been optimally treated based upon current medical guidelines.  However, her disease appears to remain largely uncontrolled.  She has had a positive response to Xolair, with no notable side effects.  A review of the medical literature shows that there may not be explicit clinical rationale to prohibit the use of Xolair for patients with IgE level greater than 700.  In this patients case, Xolair was and is likely to be of greater benefit than other available treatment alternatives.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a then 13-year-old female enrollee has requested emergency surgical services the enrollee received out of the country for treatment of the enrollee's scoliosis. Findings:  The physician reviewer found that the disputed services meet prudent layperson criteria for emergency care given the totality of the patients circumstances. According to the patients parents, they were informed by the patients surgeon that it was not safe for the patient to travel back to the United States and therefore emergent surgery was required. This is consistent with a written statement from the treating surgeon in which he indicates that surgery could not be delayed until the patient returned home. In light of this evidence, the parents decision to pursue surgical intervention out of the country was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested a standing frame device for treatment of his paraplegia. Findings:  Two physician reviewers found that a standing frame was prescribed to promote skin integrity, build cardiovascular endurance, reduce lower extremity edema, increase range of motion and improve weight-bearing to prevent osteoporosis. The current medical evidence has not established that the requested equipment is likely to be of greater benefit than other treatment options in this patients case. A review of medical literature shows a lack of quality studies that demonstrate the benefits of supported standing with a standing frame.  Specifically, the scientific data does not support that standing frame use decreases contracture, spasticity or osteoporosis. Further, passive standing has also not been demonstrated to offer adequate cardiovascular benefits. Moreover, there are inadequate well-researched studies supporting the benefits of the device for respiratory, urinary and bowel function. At this time, there is insufficient evidence to support its use in this clinical situation.  Therefore, the requested standing frame device is not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that language deficits are one of the core aspects of autism, and speech therapy provides professional help and guidance on communication development for individuals with autism (Rogers). Stone et al. evaluated 34 children with autism at 2 years of age and re-evaluated them 2 years later to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The individuals with significant speech and language intervention improved in their language development. Goldstein also reviewed communication intervention for autism. This was done in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions exist to teach communication skills to children with autism.  Language skills make a significant difference in the ability of children to control their environment and have been found to be an adaptive alternative to highly disrupted behaviors as noted in this patient. Ongoing speech therapy is a medically necessary component of the treatment plan. Speech therapy is medically necessary for this patient with Autism Spectrum Disorder and severe expressive and receptive language delays with socialization deficits. The patient should receive 2 hours of speech therapy/week of an intensive and direct language program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested ongoing transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar type 2, major episode severe, with a history of psychotic symptoms. Findings:  Two physician reviewers found that the 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 TMS therapy. There is a provided meta-analysis of studies related to this treatment modality (Gross and colleagues).  Their conclusions report that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. It was concluded that for patients with treatment-resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies (Lam and colleagues). 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 this therapy can be considered as a first-line monotherapy treatment for treatment-resistant depression. There were reported positive responses of repetitive TMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit (Gershon and colleagues). Therefore, in this patients case, the superior efficacy of the requested TMS therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-month-old male enrollee has requested speech and language therapy one hour per week for treatment of his language 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. 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. Left untreated speech and language delay in preschool children has shown variable persistence rates. Language delayed children have also shown more behavior problems and impaired psychosocial adjustment. (Nelson, et al) From this detailed account, the long-term consequences of speech and language delay may be substantial. According to a Cochrane Database meta-analysis of 25 studies, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. (Law, et al) In addition, Bernhardt and Major concluded the results of their study suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. In this case, the patient is a young child with significant speech and language delay, particularly in the area of language expression. The etiology of his delays is not completely clear, but may be related to the prenatal complications, intrauterine growth retardation, and severe anemia. Regardless of the etiology, his speech and language deficits negatively impact his ability to interact with others and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such patients. It is therefore medically necessary to provide speech and language therapy 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, twice per week for one hour per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the clinical literature, Shevell evaluated patients under five years of age who were referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Of these patients, 99 were found to have global developmental delay with 96% showing evidence of a mild or moderate delay. An etiologic diagnosis was determined in 44 patients and the authors concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. The patient in this case does not have any evidence of autism. However, the In-Plan provider did not attempt to look for an etiology of this patients speech delay. Similarly, the American Academy of Neurology (AAN) practice parameters recommend evaluation of a patient with non-progressive global delay as a specific etiology can be determined in the majority of these children. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed, which were not conducted in this patients evaluation. The goal of the evaluation is to assess the patients speech and language function relative to age and developmental expectations. When therapy is recommended, the primary goal is to give the patient a reliable way to exchange ideas and information in his daily social and educational environment. Treatment is tailored to the specific communication needs of each child, which vary with disorder type and severity, the patients age, and the etiology of the problem. Any speech or language intervention requires that the patients family and educators be involved to provide ongoing support for the patient outside of the clinical setting. Thus, speech therapy is within the standard of care for patients with speech delay of unknown etiology. Given this patients deficits, it is medically necessary for this patient to receive the requested speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her anorexia nervosa and depression.  Findings:  The physician reviewer found that review of the medical records shows that at the time of admittance to the RTC, the patients weight was increasing and she was cooperating with therapy with good participation in group therapy. In addition, her vital signs and lab tests continued to be normal, and her mood and anxiety were reported to be at the low to moderate level.  Suicidal ideation was not evident and no self injurious behaviors were noted. Moreover, her family was reported to be supportive. Given these findings, the patient no longer required the intensity of service of a residential treatment level of care as of the date in question.In sum, residential treatment services during the time at issue were not medically necessary for treatment of the patients medical and mental health conditions. This finding is made in consideration of the patients history, clinical course during treatment, physical condition and overall clinical and psychological status. Partial Hospitalization (Full-Day Out-Patient Care) would have been the appropriate level of care and was medically necessary for treatment of the patients condition as of the original date.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested spine surgery including CPT codes 63047 (removal of spinal lamina), 22842 (insertion of spinal fixation device) for bilateral lumbar L4-S1 laminectomies, medial laminectomies and right diskectomies as well as L4-5 and possibly L5-S1 fusion with instrumentation for treatment of his L4-5 stenosis with claudication and kyphosis, and right L5-S1 intervertebral disc herniation with polyradiculitis.  Findings:  The physician reviewer found that this patient has back and right lower extremity pain for an unknown period of time. He was seen and had an MRI scan last year. He does not have symptoms of a defined radiculopathy (Tarulli and Raynor). In addition, the records do not provide evidence of severe stenosis, neurogenic claudication, spondylolysis, spondylolisthesis, instability, infection, or significant scoliosis, any of which may be indications for lumbar laminectomy and spinal fusion. The patients sensory loss does not match a radicular/dermatomal distribution. He has no weakness, negative straight leg raise, and reflexes are documented to be within normal limits. There has been no mention of what conservative measures he has undergone and failed, if any. His symptoms do not correlate with the MRI scan. As stated by Bambakidis and colleagues, Lumbar fusion is rarely indicated for routine discectomy. In patients with mechanical back or neck pain, surgery should only be considered after conservative measures have been exhausted and a radiographic abnormality is present at the symptomatic level, perhaps with pain concordant with discographic findings. As such, the proposed surgery is not medically necessary or appropriate for treatment of this patients back and right lower extremity pain and the Health Plans denial was therefore appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested physical therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has significant documentation of signs and symptoms consistent with ASD since of 18 months of age. Repeated evaluations by both physical and occupational therapists have revealed significant developmental delays in fine motor skills, sensory modulation defects, and activities of daily living. In the medical literature, the article from Myers and colleagues recommended OT based on community practice, although the authors noted there were limited literature studies of this modality. However, subsequent to their report, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of OT in the young autistic population. Similarly, Dawson and Watling reported on the value of OT in the motor treatment of autistic children discussing positive studies facilitating improvement in motor skills utilizing OT therapies. In addition, Turner and colleagues conducted a long-term, controlled study of both OT and PT services in children with ASD and found that the treated group had far greater improvement in motor, adaptive, and social skills than the untreated group. Thus, PT is also an accepted modality in this setting and is often included as part of a coordinated, multi-disciplinary approach. All told, it is medically necessary for this patient to receive both OT and PT services for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her medical condition.  Findings:  The physician reviewer found that this patient was admitted to the residential treatment center (RTC) care with a history of a mood disorder and borderline personality disorder. She also presented with a history of substance abuse and an eating disorder however during the admissions at issue she did not require the intensity of services provided in a 24-hour facility. At the time of admission on the date in question, she was not showing any severe mood symptoms. Throughout this course of treatment, she was not showing any suicidal or homicidal thoughts, plans or intent. For these reasons, the services provided during the timeframe at issue have not been established as medically necessary for management of this patients condition as she was a candidate for evaluation for treatment at a lower level of care at the time of admission.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested 36 treatments of transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that to date, TMS as a therapeutic device for neuropsychiatric disorders, including depression, remains uncertain in terms of efficacy and safety. Specifically, there is limited evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of psychiatric disorders. Most of the studies that have been published were not truly double blind and were only based on small samples over short periods of time ranging from one to two weeks. At this time, further research is needed to support the use of TMS in terms of improved health outcomes and long-term safety and efficacy when used in the treatment of depression and other psychiatric disorders. In this patients case, he has a chronic course of depression with previous treatments including many medications and prior courses of TMS. However, the current information does not support TMS as likely to provide superior health benefits compared to further conventional treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Supartz injections for treatment of her knee pain.  Findings:  The physician reviewer found that this patient has a history of bilateral knee pain and has been diagnosed with osteoarthritis. She has received repeated Supartz injections. Viscosupplementation has been accepted for many years in the treatment of mild to moderate osteoarthritis of the knee.  At this time, no superiority has been identified among the various hyaluronic acid products.  In this patients case, the use of the Health Plan alternatives Euflexxa or Orthovisc would have been medically appropriate.  Although there is documentation of the presence of mild to moderate osteoarthritis in the knees, there is no documentation of prior intolerance to these other agents. All told, Supartz injections provided during the time frame at issue were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male has requested residential treatment center (RTC) care services for treatment of his behavioral health issues. Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) criteria for 24-hour medical and nursing care, there must be evidence of moderate to severe levels of dangerousness or lethality; moderate to severe interference with addiction recovery; severe social functioning impairments; and the course of illness is described as moderate to severe. None of these findings were reported by this patients providers. Moreover, there was little reasonable expectation that the patient would have improved with short-term subacute RTC or that this level of care would benefit his behaviors and symptoms to enable him to return to outpatient treatment. For these reasons, the patient does not meet the criteria for a 24-hour residential care and the medical necessity of the RTC services provided has not been established in this case.