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

The parent of a 6-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for 12 months for treatment of the enrollees autism and global developmental delay. Findings:  The physician reviewer found that ABA therapy has been in existence for at least 30 years and has been widely used in the therapeutic intervention in autistic children. In clinical trials, Dawson and colleagues conducted the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of the ASD diagnosis. Further, when comparing patients treated with ABA therapy versus those who received standardized therapy, ABA is noted to provide a statistical improvement in cognitive, language, and adaptive behavior skills. Eikeseth stated that children who received ABA therapy made significant gains compared to those in special education. On average, the children who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, without further gains. On review of the new information provided in this patients case, she has not received three years of therapy as previously indicated by the Health Plan. In fact, she has only been participating in 30 hours per week of ABA therapy since said date. As reported by Lovaas in the peer reviewed medical literature, the requested 30 hours per week of intensive ABA therapy is required for at least one year in order for the patient to yield the maximum benefits from treatment. Thus, based on the recent progress report of said date, the ABA therapy at issue should be approved for this patient as medically necessary from said date and forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested one hour per week of speech therapy for treatment of the enrollees speech and language delay. Findings:  The physician reviewer found that speech therapy is medically necessary for treatment of this patients expressive language delay at a frequency of one hour per week. 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. Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has significant speech and language delay, particularly in the area of language expression. Her speech and language delays negatively impact her ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested one hour per week of speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depression. Findings:  Two physician reviewers found that this patient has been treated with several different antidepressants and they were not satisfactory to her.  Additionally, she has already been treated with ECT, with a poor response as well as significant side effects.  In this clinical scenario, the requested transcranial magnetic stimulation therapy is likely to be more efficacious than other available treatment alternatives.  The medical literature supports the use of transcranial magnetic stimulation in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder. Findings:  Two physician reviewers found that the patients history of treatment for major depressive disorder shows the patient failed to receive adequate relief of symptoms from trials of multiple psychopharmacologic agents.  Despite his prior treatments with psychotherapy and antidepressant medication of different classes, the patient continued to experience significant levels of depression. Thus, TMS treatment was a scientifically established treatment for this patients depressive disorder at the time of service and was likely to result in greater benefit to the patient than further trials of pharmacologic agents, as multiple agents (as well as psychotherapy) had already been tried without adequate improvement. In consideration of the above, the use of TMS therapy was medically reasonable and consistent with the standard of care for the treatment of this patients illness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient with autism will continue to benefit from intensive ABA therapy and has shown impressive gains in all domains since the start of treatment. The American Academy of Pediatrics (AAP) recommends a minimum of 25 hours per week of ABA therapy per week for children with autism. As this is the standard of care for patients with autism, 25 hours per week of ABA therapy is medically necessary for the management of this patients behavioral issues associated with autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested surgical correction of diastasis recti for treatment of her medical condition.  Findings:  The physician reviewer found that the patients records describe the patient to have abdominal pain, which may constitute an abnormal state from some structure or disease process that has not yet been fully diagnosed. Umbilical hernias can cause abdominal pain as suggested by the patients primary care physician but a thorough abdominal examination has not been well documented. The patients weight and height could be considered an overweight condition. Thus, there could be an abdominal pannus contributing to the patients pain and referral to a plastic surgeon may help diagnose this patients condition. As discussed by Toranto in the medical literature, there is some evidence low back pain may be treated with plication of the anterior abdominal wall, which is the primary treatment of diastasis recti. As this patients general surgeon noted the presence of painful diastasis recti, and a plastic surgeon may perform the procedure, an evaluation by a plastic surgeon is indicated (Oneal, et al). However, diastasis recti are not typically associated with pain, which further suggests that this patients condition needs to be further investigated. In summary, a thorough evaluation by a plastic surgeon should be performed to evaluate the patients abdominal pain, which is the functional issue in this case. However, there is a lack of evidence in the records presented for review to establish the requested surgical intervention as medically necessary or reconstructive in nature at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment facility (RTC) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that during the period at issue, the patients pulse and blood pressure remained within the normal range. Her weight was stable and consistent, with a BMI of about 20. The group therapy notes continued to document her active and appropriate participation. The progress notes also indicated her bright mood, active participation, compliance with her meal plan, and good progress. Further, her family was very supportive and cooperative. She had demonstrated that she was using her coping skills to address her anxiety about weight gain. As such, the medical necessity of the RTC services at issue has not been established in this patients care.
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 autism. Findings:  The physician reviewer found that language deficits are one of the core aspects of autism for which speech therapy provides professional help and guidance in development of communication (Law, et al). In the clinical studies, Stone and Yoder evaluated 34 children with autism at 2-years of age with re-evaluation 2 years later to assess the factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, the patients with significant speech and language intervention improved in their language development. This patients language evaluation demonstrates qualitative impairments in social interactions, understanding complex speech and pragmatic language deficits. Given the scientific data establishing the role of speech therapy in helping patients with autism to improve their independence and ability to interact with their environment, the requested therapy is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his comorbid anorexia nervosa, binge/purge type, obsessive compulsive disorder and polysubstance abuse. Findings:  The physician reviewer found that the submitted medical records demonstrates this patient was a very emaciated young man. He was admitted to the RTC facility at less than 80% of his ideal body weight. He also abused substances. He was admitted to re-feed and to stabilize his behaviors. As late as the last day of his stay, the only unauthorized day, this patient remained a significant risk for relapse and for returning to self harming food restriction behaviors. According to American Psychiatric Association guidelines for treatment of patients with eating disorders, the last day of this patients stay at the RTC facility was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested an off-the-shelf functional anterior cruciate ligament (ACL) knee brace (L1845)for treatment of her post ACL reconstruction and partial lateral meniscectomy on the left knee.  Findings:  The physician reviewer found that  in the article published by McDevitt and colleagues involving 100 volunteers randomized into braced and un-braced group, the authors found  no difference in clinical outcomes. However, patients with chondral injuries or significant meniscal tears were excluded from this study. This specific patient had a complex tear of the lateral meniscus and chondromalacic changes in the lateral compartment of the knee. The study by Sterett and colleagues indicates that functional bracing is likely to be beneficial for this patient.. This study followed 820 skiers who had experienced anterior cruciate ligament injuries and reconstruction. In this study, 257 of the skiers used functional bracing during skiing, and 563 skiers did not. There was a demonstrated statistically significant increase in incidence of subsequent knee injury in non-braced skiers. Sterett and colleagues additionally recommended functional bracing for individuals with anterior ligament reconstruction. Given the presence of complex lateral meniscal tear and chondral changes which are likely to benefit from further protection, the requested off-the-shelf functional anterior cruciate ligament (ACL) knee brace (L1845) is medically indicated for this patient. The presence of a medial collateral ligament tear and 3+ Lachmans test at surgery further contribute to the indications for postoperative functional bracing during rehabilitation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

59-year-old female enrollee has requested a contrast-enhanced computed tomography of the chest for evaluation of the her chest pain.  Findings:  Three physician reviewers found that while it appears a coronary CT angiography was initially ordered by the provider, review of the procedure report from said date reveals no mention of the coronary arteries in the report or of the CT scan having been performed as a coronary CT angiography. The procedure actually performed was a CT scan of the chest, which is a routine diagnostic procedure that is not considered experimental or investigational for the evaluation of chest pain. There is ample data to support the role of CT scan of the chest in the evaluation and treatment of patients with chest pain, as was the case with this patient. As such, the Health Plans denial of this service should be overturned.
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 lymphangioma and speech delay. Findings:  The physician reviewer found that the Rosssetti Infant-Toddler Language Scale administered to this patient at 15 months and 24 months of age indicates that the patient has made no improvement in her language skills over a 9-month period.  Her language development reached a plateau during this period. Speech therapy has been denied based on the lack of diagnosable structural abnormalities in this patients oral pharynx. A review of the records provided indicates that this patient has a congenital dysfunction in the cerebral cortex connecting the frontal and temporal lobes for the generation of speech. Emmanues, et al. states that the clinical decision to provide speech therapy to impaired patients in this patients age group is usually of extreme benefit. A study by Landa indicates that the earlier a patient begins speech therapy, the more likely he or she is to meet developmental milestones. The available peer-reviewed medical literature indicates that speech therapy for children with delays in their language development is beneficial. Given this patients documented deficits coupled with the evidence for the success of speech therapy in this patient population, it is medically necessary that this patient receive individual speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for Synvisc injections for treatment of his osteoarthritis of the right hip. Findings:  Two physician reviewers found that the current medical evidence does not support Synvisc injections in this clinical scenario. There is a lack of long-term, controlled, double-blinded studies validating viscosupplementation injections into the hip.  This patient appears to have end-stage osteoarthritis of the right hip. Although concerns have been expressed with proceeding with surgery in light of the patients need for immunosuppressive medications, the use of Synvisc in this setting is not likely to be an effective therapeutic intervention. Currently, the relatively low evidence level limits recommendation of viscosupplementation as a therapy for hip osteoarthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for inpatient detoxification for treatment of her Soma dependence. Findings:  The physician reviewer found that an attempted inpatient detoxification via Emergency Room intake, the patient decided to leave and have further discussion with her outpatient provider.  Intensive outpatient program services have been recommended to manage this patients anxiety, and these recommendations were not followed.  At this time, inpatient detoxification is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for steroid injections for treatment of her moderate to severe spinal stenosis.  Findings:  The physician reviewer found that the medical literature relevant to this determination includes a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy (Vad, et al). The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the non-surgical management of patients with lumbosacral radiculopathy secondary to a herniated nucleus pulposus. With regard to the frequency and timing of treatment, Novak and Nemeth performed a literature review of the current evidence-based guidelines. The researchers concluded that there does not appear to be any evidence to support the current common practice of a series of injections. However, it is appropriate to perform no more than four epidural steroid injections in one year, at least six weeks apart, if the first injection provides adequate pain relief. In addition, Arden and colleagues WEST Study consisted of a multicentre randomized controlled trial of epidural steroid injections for treatment of sciatica in terms of effectiveness and predictors of response. The authors found that epidural steroid injections offered transient benefits in symptoms at three-weeks in patients with sciatica, but no sustained benefits in terms of pain, function, or need for surgery, were reported.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-month-old male enrollee has requested authorization and coverage for in-home physical therapy for treatment of the enrollees Hirschsprungs disease and intracranial hemorrhage.  Findings:  The physician reviewer found that in an effort to reduce neurological dysfunction, it is clear from the scientific data that PT is instrumental following an acquired brain injury (ABI) and remains essential for a patient to achieve full rehabilitation potential. In summary, PT is essential to promote recovery to the greatest degree possible in patients with ABI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a cardiac computed tomography (CT) for evaluation of her chest pain. Findings:  The physician reviewer found that in this patients case, the currently accepted criteria for coronary CT angiography have not been met since the test was not used in lieu of an imaging stress test, the test did not demonstrate equivocal or discordant results by report, and there is no suspicion of congenital coronary anomalies. Applying the expert consensus guidelines endorsed by the American College of Cardiology Foundation Task Force on Expert Consensus Documents, coronary CT angiography is not clinically indicated in the setting of stress testing without equivocal or discordant stress test results. As such, the diagnostic procedure at issue was not medically necessary in the evaluation and treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient is nearly two-years of age but has not developed the ability to orally communicate. Although this patient does not have a diagnosis of autism, without professional intervention, he may not develop any understandable speech for many years. In the medical literature, Norbury and colleagues reported that the parental checklist is an extremely reliable diagnostic tool in toddlers with speech delay, thus, the patients failure to communicate should be accurately described. In addition, Emmanuel and colleagues concluded that a therapists initial impression of a patient tends to be remarkably accurate in long-term follow-up of very young children with speech delay. With regard to treatment, Landa found that the earlier intervention is initiated for speech delay, the better a patients prognosis. This patients problem is organic, as it is the failure of the normal axonal frontal-temporal-brainstem cerebral pathways to develop. Consistent with the recommendations in the clinical studies, it is medically indicated that this patient receive 1 to1 speech therapy to address his speech and language delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested more than 4 hours per day of shift nursing care services and 8 hours per day of skilled nursing care for treatment of the enrollees myasthenia gravis. Findings:  The physician reviewer found that this patient has congenital myasthenia gravis (MG) with clinical symptoms significant enough to warrant the type of nursing care defined as skilled. Although the patients needs may not require acute or intensive care at this time, the concept behind skilled home nursing care is to prevent regression of his condition to the point where hospitalization is needed. This translates into best medical practice and the standard of care indicated for this patient is skilled nursing care from the said date and forward. The patients records clearly document the need for skilled nursing care in order to maintain a severely compromised airway. As noted by Hardy and Rittenberry of caring for patients with MG, Nursing care is complex and involves patient education about drug therapy and treatment options as well as caring for the numerous problems that arise from varying degrees of muscle weakness. The authors also found that, Skilled nursing assessment and intervention can help protect the myasthenic patient from the life-threatening complications of respiratory compromise. Thus, based on review of the literature and the details of this case, skilled nursing care was and is indeed medically necessary for this patient with congenital MG. The requested 8 hours of skilled nursing care per day have been shown to be medically necessary for this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested home infusion of intravenous immune globulin (IVIG) therapy for treatment of his idiopathic thrombocytopenic purpura ITP). Findings:  The physician reviewer found that although there are other treatments for ITP, including RhIg and thrombopoietic agents, IVIG has been effective in managing this patients symptoms to date. The record also indicates that a splenectomy is being considered. While it is medically appropriate for the patient to continue IVIG therapy, there is no indication for an ambulatory patient to receive home based infusions of IVIG for treatment of ITP. There is no medical advantage to doing so. Such home treatment is not recommended by any guideline or specialty group. There is no clinical justification for home based IVIG treatment for patients who are not homebound. Thus, home based IVIG therapy, while desired by the patient, is not necessary from a medical standpoint.