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

The parent of a four-month-old male enrollee has requested palivizumab (Synagis) injections for treatment of the enrollee, who was born at 32 weeks gestation. Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from respiratory syncytial virus (RSV) in infants born at 32 to 35 weeks gestation. The most striking of these is a birth weight less than 2500 grams.  An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams.  Simoes and colleagues have developed a model based on seven risk factors to predict which infants born between 32 and 35 weeks are at highest risk of severe RSV disease. This patients risk factors include gestational age and birth weight less than 2500 grams, placing him at risk for significant morbidity from RSV disease.  The Impact-RSV Study Group examined the effect of palivizumab prophylaxis on severity of illness in premature infants.  The study demonstrated a significant decrease in hospitalization rate for all infants. For infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness.  All told, palivizumab (Synagis) injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 1-year, 11-month-old female has requested  coverage for 6 doses of Synagis injections for treatment of her asthma.  Findings:  The physician reviewer found that based on review of the available records, Synagis administration is not indicated for this young patient. There are a number of risk factors that increase the chance of morbidity from RSV disease in infants born prematurely, up to 12 months of age. The most striking of these factors is a birth weight less than 2500 grams (Holman, et al). Older infants who are still less than 24 months of age are considered high-risk if they carry a diagnosis of chronic lung disease or hemodynamically significant heart disease. While this ex-premature female infant may have been an appropriate candidate for Synagis administration in the past, she currently does not meet the published criteria or fall within a high-risk population based on the relevant medical literature. For these reasons, the requested administration of Synagis for RSV prophylaxis is thus not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  coverage for speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that it is within the standard of care in the medical community to continue to provide this patient speech therapy as recommended by his provider. There is strong evidence in the peer-reviewed medical literature supporting speech therapy in similar speech-delayed patients. Law and colleagues meta-analysis concluded that, overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Similarly, Buschmann and colleagues reported that the 2-year-old population with language delay benefitted from speech therapy. Goorhuis-Brouwer and Kniff demonstrated that cognitively intact patients are ideal candidates for successful speech therapy. This patient is developmentally and intellectually normal except for his significant delay in expressive speech. As measured by his performance on the RITLS, his expressive speech improved from a 6-month level to a 12-month level since he started speech therapy. For these reasons, it is medically necessary that this patient receive individual speech therapy sessions twice weekly as recommended by his provider.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested coverage for past and future skilled nursing services and/or skilled nursing facility (SNF) rehabilitation services for treatment of her medical condition status post right front parietal stroke.   Findings:  The physician reviewer found that the patients records indicate that by the date under review, she required stand by assistance for ambulation and ambulating 100 feet with a walker. The progress notes do not document that she progressed beyond this level with continued therapy and actually showed evidence of some regression. Consistent with the medical literature the skilled services provided from the date under review and forward are not medically necessary to establish a maintenance program or to prevent deterioration of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested coverage for past and future speech therapy at a frequency of two sessions per week, for one hour per session, for ongoing therapyfor treatment of her language delay.  Findings:  The physician reviewer found that this patient has severe developmental delays, cerebral palsy, moderate deafness and severe visual impairments. The records indicate that the speech therapy provided was effective in moving the patient from being non-verbal to a state of speech imitation and the ability to sign. Given this patients complex clinical presentation, she cannot be effectively treated by her parents with a home program. This patient clearly requires continued professional speech therapy intervention. The medical communitys standard of care would be to offer the patient continued individual speech therapy. Children with speech delays can be readily treated (Law, et al.) and even patients with cognitive deficits are candidates for successful speech therapy (Goorhuis-Brower and Kniff). In sum, the speech therapy provided was medically necessary and ongoing speech therapy at a frequency of two hours per week is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested coverage for a consultation with a neurologist for treatment of her leg weakness, dystonia and stiff-person syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  This patient has had a progressive neurologic condition, with a variety of diagnoses entertained by different consultants.   There have been conflicting features, but significant evidence of autoimmunity.  She has been evaluated and treated at tertiary care centers, and she has requested an additional opinion by a community neurologist.  There is no evidence that a seventh opinion is needed. In this patients case, the clinical picture of autoimmunity with anti-GAD antibodies may still represent stiff-person syndrome. In this clinical situation, follow-up with one of the prior neurology consultants for re-evaluation is medically appropriate.  All told, the requested coverage for a consultation with a neurologist is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female has requested coverage for spinal fusion surgery at L1-2 and a planned 3-day hospital stay for treatment of her lumbosacral neuritis.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of chronic low back pain. She has not had any localizing pain referable to the L1-2 segment. She has abnormalities at the L1-2 segment and at T12-L1, but there is also a disc bulge at L2-3 with facet arthropathy at that level as well as at L3-4, and a broad-based disc bulge at L5-S1. With regard to the requested surgery, the patient does not have any defined L1-2 radiculopathy (Tarulli and Raynor). In addition, she has not had L1-2 identified as her defined pain generator. For these reasons, she does not meet the Milliman criteria or recommendations from Bambakidis and colleagues for a lumbar fusion.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  California law defines an emergency medical condition as 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 to bodily functions; (3) Serious dysfunction of any bodily organ or part.Chalazions are not acute medical emergencies. They are typically managed with warm compresses and antibiotic ointment with referral to an ophthalmologist when that fails.  In this case, the patient reports he experienced a significant worsening of pain and swelling and that his vision was blurry. The emergency physician record indicates that the patients pain in the emergency room was 2-3 out of 10 and his visual acuity was 20/20. The patient did not require narcotic analgesia. He received Motrin for pain. All told, the objective medical record documentation does not support the contention that the patient experienced a significant worsening of pain, swelling and vision problems at the time he sought emergency services. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and thus would not have sought immediate medical attention for the patients complaints.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested coverage for Bioness H200 Hand Rehabilitation System (for left hand) and the necessary supplies for its operation for treatment of his status post large right middle cerebral artery stroke secondary to right carotid artery dissection.  Findings:  Two physician reviewers found that the submitted documentation indicates that the patient has had stiffness, swelling and pain following the stroke.  In this patients case, the superior efficacy of the requested equipment has not been demonstrated.   There is no record of use of anti-spasticity treatments, such as baclofen or Botox.  Botox is an established treatment for the management of upper limb spasticity.  Tarkka and colleagues conducted a study of adult stroke survivors.  The authors noted that functional exercise augmented with individualized electrical therapy may enhance neuroplasticity, observed as corticospinal facilitation along with moderate improvements in the voluntary motor control of the affected limb.  Constraint induced therapy has been shown to be beneficial in recovery from upper limb spastic hemiplegia. The current medical evidence does not demonstrate that functional electrical stimulation is superior over constraint induced therapy, Botox, or physical therapy measures.  Therefore, the requested Bioness H200 Hand Rehabilitation System (for left hand) and the necessary supplies for its operation are not likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested coverage for arthroscopic superior labrum anterior to posterior (SLAP) tear repair for treatment of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  The surgical treatment of rotator cuff tears is generally accepted by orthopedic surgeons for patients whose symptoms are not relieved by adequate conservative measures, or for those whose tear is complete. There is evidence of efficacy on long-term study.   However, there remains much variation among surgeons as to the indications for surgery.  With regard to the question of a superior labrum anterior to posterior (SLAP) tear, the Milliman Care Guidelines do indicate the need for magnetic resonance arthrographic or other imaging confirmation of the presence of the SLAP tear.   In this case, there is no documentation of the presence of a SLAP tear on imaging. In addition, there is a lack of documentation of conservative management, other than the injections noted and pendulum exercises. All told, the requested arthroscopic superior labrum anterior to posterior (SLAP) tear repair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested for speech therapy for treatment of the enrollees delays in expressive language skills.  Findings:  The physician reviewer found that 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 a meta-analysis by 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.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. Based upon the medical literature, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested  coverage for speech therapy at a frequency of two sessions per week for one hour per session for treatment of his speech delay.  Findings:  The physician reviewer found that this nearly three-year-old patient has no speech. The available studies indicate that the patient is functioning in a moderate developmental delay category (scores ranged from the 9th to the 45th percentile for age in various developmental categories.) The common practice of the medical community, for a non-verbal child who does have the potential for speech development, would be to prescribe speech therapy. There is a robust body of medical literature supporting the need for speech therapy in this speech delayed population. A paper by Law et al. reports that children with speech delay can be readily treated, as confirmed by a meta-analysis of multiple medical journal articles. Goorhuis-Brouwer, et al. specifically examined speech-delayed normal and abnormal intellect children and found that both groups are candidates for successful speech therapy. Reports by Emmanues and Buschman describe two-year-olds who tested below the 10th percentile for age in both receptive and expressive language and benefitted from speech therapy in prospective studies. Thus, the literature is replete with support for the use of speech therapy in the speech delayed two-year-old population. While speech therapy is a medically necessary modality for this patient, the submitted documentation does not support two hourly sessions of speech therapy per week at this time. The patient should receive one hour weekly of individual speech therapy. The patients progress toward goals should be documented and he should be reassessed in six months to determine the need for continued therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male has requested coverage for Provigil or Nuvigil for treatment of his narcolepsy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medications in this clinical situation.  The documentation noted that Adderall has been discontinued.  However, details regarding possible side effects with this treatment were not provided. Additionally, there is no evidence that therapeutic alternatives, such as Ritalin or Dexedrine, were considered.  Furthermore, the medical records do not demonstrate that this patient has been evaluated by a pediatric sleep specialist.  The medical records do not show that this patient has been treated with alternatives to Adderall which are approved for children under the age of 17.  The current medical evidence does not support the requested medications in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 18-year-old female has requested coverage for Humira for treatment of her orbital myositis.  Findings:  Three physician reviewers found that the patient has a complex medical history. The issue at hand is the patients history of orbital myositis and the treatment options available to her. She has had serious side effects from systemic corticosteroid use, including osteopenia. She was treated with methotrexate and CellCept, neither of which was effective. She also has received external beam irradiation and now her providers are requesting Humira as a treatment option. Orbital myositis, or orbital inflammatory syndrome, is an orbital inflammatory process which can be difficult to treat. The standard first-line treatment has been systemic corticosteroids. A biopsy is usually warranted if a typical response to corticosteroids is not evident, or if more aggressive chemotherapy is pursued. This patient is presently in a difficult situation as further corticosteroids will cause more serious systemic side effects, and all other chemotherapeutic agents have been ineffective or poorly tolerated. Any benefit from external beam irradiation would at this point be manifested, however the patients inflammation persists, therefore the use of Humira is clinically reasonable. There is literature describing the safety and effectiveness of Humira in idiopathic orbital inflammation, and a trial to assess its efficacy is warranted in this situation where no other options are presently available. Humira has been utilized for other chronic idiopathic inflammatory conditions such as rheumatoid arthritis and Crohns disease, so the peer reviewed medical literature supports its use in this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 70-year-old female has requested coverage for past tomographic genotyping provided for evaluation of her pancreatic cysts.  Findings:  Two physician reviewers found that the patient has a history of pancreatic cysts. The patient underwent evaluation with endoscopic ultrasound with fine needle aspiration biopsies of the cysts in the pancreas. The tissue was submitted for DNA analysis with the PathFinderTG. The PathFinder test is an analysis of the DNA of mutations and of the DNA in a cellular population. The PathFinder has been used in patients with cancer of an unknown primary, to identify the tissue of origin of the cancer. In such clinical situations, its use remains controversial, yet has been shown to provide substantial benefit in a limited number of patients. Another use for the PathFinder test is in the analysis of pancreatic cysts, as in this patients case. The PathFinder analysis attempts to determine if the cysts are truly benign or whether they contain elements that more closely resemble a malignant expression. As noted in the peer reviewed medical literature submitted with the appeal, the PathFinder test is considered useful in the analysis of pancreatic cysts for this purpose. For these reasons, the PathFinderTG was likely to be more beneficial for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  coverage for speech therapy at a frequency of one and a half hours per session for two sessions per week for treatment of  his speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in his receptive language skills of approximately 33% and of greater than 50% in expressive language skills.  Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature, including the meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. In sum, speech therapy at the requested frequency of one and a half hours per session for two sessions per week is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female has requested coverage for a speech therapy evaluation by a provider experienced in swallowing disorders to assess her history of hoarseness.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services at this time.  Per the medical records, the patient is suffering from hoarseness.  She reported an eight-month history of being hoarse in the morning. Based upon the submitted documentation, the patients provider has not performed a laryngoscopy to assess the cause of the hoarseness.  An evaluation of the larynx is necessary in order to establish the medical necessity of the requested speech therapy evaluation.  Per the records, there is no documentation of a laryngeal examination.  The current medical evidence does not support the requested services at this time.  All told, the requested speech therapy evaluation by a provider experienced in swallowing disorders is not medically indicated for the treatment of this patient at this time.