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

The parent of a 2-year-old female enrollee has requested authorization and coverage for speech therapy at a frequency of 1.5 hours per week.  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. In addition, 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. As adults, children with phonological difficulties may hold lower-skilled jobs, and show more behavior problems and impaired psychosocial adjustment than their non-impaired peers (Nelson, et al). From this detailed account, speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial.  According to a meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Law, et al). The authors noted that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy; socialization; behaviour and school attainment. These reviewers concluded that, overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the authors found that, there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin). This patient presents with expressive language delay that significantly impairs her ability to communicate effectively and function socially. Consistent with the support of the efficacy of speech and language therapy in this patient population, the requested speech therapy for 1.5 hours per week is medically necessary and appropriate for this patient to address her speech and language delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees significant delays in expressive language and speech skills. Findings:  The physician reviewer found that per 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 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.  McLaughlin noted that there is good data available to support the effectiveness of speech and language therapy for children with primary expressive language disorder.  Based on the literature, speech and language therapy is medically necessary to address this patients speech and language challenges.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested bariatric surgery, specifically, a Lap Band procedure for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient meets the generally accepted criteria for bariatric surgery, including those criteria listed by the National Institutes of Health (NIH) Consensus Guidelines. The patient has clinically severe obesity with a BMI of greater than 38 and hypertension being treated with medication. She has failed supervised dietary efforts and has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery. Medical clearance is documented for the requested procedure and there is no documented evidence of any treatable metabolic causes of obesity in this patient. All told, the requested Lap Band procedure is medically necessary for treatment of the patients obesity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 24-year-old female enrollee has requested for deep brain stimulation and stem cell implant for treatment of the enrollees traumatic brain injury. Findings:  Three physician reviewers found that review of the literature indicates there have been case reports in which deep brain stimulation increased arousal and sustained eye-opening, as well as rapid bilateral head-turning to voice, and initiation of speech in a patient with diminished consciousness. While some promising results have been noted in the literature, there is currently a lack of randomized, controlled studies involving sufficient numbers of patients to be able to accurately assess the potential efficacy of this therapy. With regard to stem cell implantation, there is no evidence-basis for the use of stem cell implant in the treatment of coma or vegetative state. The use of this technology in this setting has not been the subject of rigorous study, and as such, there is no data in the current peer-reviewed literature to support the use of stem cells in the treatment of coma or vegetative state.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 24-year-old female enrollee has requested a neuro-rehabilitation program and a cerebral angiography for treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patient has had a severe traumatic brain injury with persistent neurologic impairments, diagnosed as vegetative state. As noted in the relevant literature, accepted treatment for vegetative state is supportive care. Rehabilitation efforts and stimulation may be utilized to attempt to improve recovery. However, there is no evidence that any particular rehabilitation strategies change outcomes. A prospective study by Lippert-Gruner, et al. conducted to assess the one-year outcome of comatose patients after severe traumatic brain injury showed Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity. Thus, while continued efforts at support and stimulation are potentially helpful, there is no evidence that a neuro-cognitive rehabilitation program will result in an improved outcome for this patient. As such, the proposed rehabilitation program is not medically necessary for treatment of the patients condition.Regarding the request for cerebral angiography, there is no data included in the submitted records to suggest an undiagnosed cerebral vascular abnormality. Angiograms are invasive, and there is no evidence of the potential benefit of angiogram in this setting which would offset the risks associated with this procedure. Thus, there is no medically necessary indication for a cerebral angiography for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested for speech therapy for treatment of the enrollees severe receptive and expressive language delays and articulation 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.  Per the authors, 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.  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.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested social skills group therapy for treatment of his autistic disorder. Findings:  The physician reviewer found that social skills group therapy is to help facilitate social and play skills in a functional and naturalistic setting. It fosters the development of social skills such as making friends, reciprocal communication, joining groups and using verbal and non-verbal communication. Participants learn these new social skills concepts in a clinical setting and are encouraged to carry the information with them for use at outings in various sites within the community.  Therefore, this treatment is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of 3-year-11-month-old male enrollee has requested reimbursement and continued authorization and coverage for speech therapy services provided from a specific date and forward.  Findings:  The physician reviewer found that Childhood apraxia of speech (CAS) is a serious childhood speech deficiency.  Lewis, et al. studied 10 children with CAS who were diagnosed at age 4 and reassessed at age 10.  At age 10, their improvement was limited compared to children with other speech disorders; additionally they demonstrated serious deficiencies in reading and spelling.  The authors recommended intensive speech therapy for patients diagnosed with CAS.  Additionally, there is a significant medical literature supporting speech therapy in the three plus age group. Speech therapy is considered necessary and efficacious in children over the age of three with articulation and speech dysfunction (Tyler; and Sharp and Hillenbrand).  In the case of this patient, a repeat speech evaluation is not necessary, as he underwent an extensive evaluation approximately six months ago.  It is common in the medical community to refer a child with CAS for speech therapy, especially when there is literature supporting that these children have a high probability of retaining CAS for many years.  In sum, the submitted documentation supports the medical necessity of two hours weekly of individual speech therapy, starting from the date in question and forward.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old male paraplegic has requested authorization and coverage for an Easy Stand Glider.  Findings:  Two physician reviewers found that the Easy Stand Glider shows considerable promise in that it may well improve upper body strength, lower extremity circulation and decrease the chance of pressure ulcers. Based on the current peer-reviewed medical literature, there is some evidence which suggests that the Easy Stand Glider may improve activity and function. However, there is not yet sufficient scientific evidence to demonstrate that the Easy Stand Glider is superior to available standard wheelchairs.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested authorization and coverage for laser treatment for treatment of the enrollees vitiligo.  Findings:  Two physician reviewers found that the patient has vitiligo of the face and scalp.  He has been treated with excimer laser and Protopic, with improvement.  The patients parent has requested authorization and coverage for laser treatment.  The Health Plan has denied this request and reported that laser treatment is investigational for the treatment of this patient.  The patients parent has appealed this denial.  There are multiple treatment options for vitiligo, each with varying degrees of success and side effects.  It is important to provide treatment for children with vitiligo.  In the article by Bilgic and colleagues, 41 children with vitiligo were compared to control patients.  Various methods were used to measure depression, anxiety and quality of life.  The authors concluded that there was a higher rate of depression in children with vitiligo, especially those with face, head or neck involvement.  Felsten and colleagues discussed repigmentation rates of more than 75% in 16% to 52% of patients treated with the excimer laser.  Response rates were as high as 95%.  Most cases were stable at one year of follow-up.  The article by Silverberg and Travis demonstrated that the excimer laser is more efficacious in patients with darker skin types with vitiligo of the head and neck.  The efficacy is enhanced with the combination of topical tacrolimus ointment.  The article by Mouzakis and colleagues also demonstrated efficacy of combination therapy of excimer laser with topical calcipotriene.  Felsten and colleagues discussed other traditional therapies for vitiligo.  Topical corticosteroids produce response rates varying from 49% to 64%.  Side effects include epidermal atrophy, telangiectasias, striae and folliculitis.  Topical calcineurin inhibitors showed repigmentation in 26% to 72%, but they were most effective when used in combination with other therapies, such as phototherapy.  Topical calcipotriene is inferior to topical corticosteroids when used alone, but may be beneficial as combination therapy.  UVB phototherapy, especially narrow band UVB, can show repigmentation rates of 40% to 100%.  However, this therapy requires exposure of normal skin to ultraviolet rays, while the excimer laser uses the same wavelength, but only exposes involved skin.  All told, in this patients case, the requested laser treatment is likely to be superior over other available treatment alternatives.
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 an extensive development assessment.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties.  These difficulties include nutrition and growth problems, cerebral palsy and other motor difficulties, neurodevelopmental disabilities, behavioral problems, and sensory impairments.  These individuals have more language delay, visual-perceptual problems, and problems with attention and behavior.  As noted by Merenstein and Gardner, parents of neonatal intensive care unit infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood.   Spittle and colleagues conducted a review of the effectiveness of early developmental intervention post discharge from hospital for preterm infants.  The authors concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short-term and medium-term. Early developmental follow-up is the standard of care in many centers.  In this patients case, the requested extensive development assessment is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-month-old female enrollee has requested authorization and coverage for an extensive development assessment.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties, including nutrition and growth problems, cerebral palsy and other motor difficulties, neurodevelopmental disabilities, behavioral problems, and sensory impairments.  These children have more language delay, visual-perceptual problems, and problems with attention and behavior.  As noted by Merenstein and Gardner, parents of neonatal intensive care unit infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood.  In their review of the effectiveness of early developmental intervention post discharge from hospital for preterm infants, Spittle and colleagues concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short-term and medium-term. In many centers, early developmental follow-up is the standard of care.  All told, the requested extensive development assessment is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year, 5-month-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that there is a robust medical literature advocating speech therapy for autistic children and the scientific literature strongly supports speech therapy. Goldsteins article discusses the multiple techniques that can be successful in teaching autistic children to communicate. The paper by Turner and colleagues is a controlled study comparing autistic children, who did and did not receive speech therapy. Patients that did receive therapy had far greater communication skills than those that did not benefit from speech therapy. In addition, the report of the Speech-Language Hearing Association states that all autistic children can benefit from speech therapy as age, either early or late in life, is not a barrier to speech therapy. It is a medical necessity for this patient to receive speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested coverage for total disc replacement surgery (with a Pro-Disc lumbar artificial disc) for treatment of her low back pain.  Findings:  Three physician reviewers found that at this time, the long-term safety and efficacy of the Pro-Disc lumbar artificial disc has not been established.  Early reports have been encouraging, but there have been more frequent reports of mechanical failure of the implant. The evidence of non-inferiority to fusion is low-quality and contradictory, and has led to recognition of the need for long-term follow-up outcome reports. The situation with regard to hybrid constructs of fusion and disc replacement is similar, with encouraging early reports, and calls for further evaluation.  All told, the current medical evidence has not demonstrated the superior efficacy of the requested total disc replacement surgery with a Pro-Disc lumbar artificial disc in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that speech therapy is a standard modality for patients with autism. The report by Myers, et al. states, that 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. Children with autism who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The American Speech and Language Association 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. There is strong literature support that speech therapy should not be completely discontinued in this setting.   In sum, speech therapy is medically indicated for this patient and would be considered the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested coverage for Orthovisc injections for treatment of the his anterolateral ankle pain after an inversion injury.  Findings:  Three physician reviewers found that the patient suffers from ongoing foot and ankle pain. He had a talonavicular fusion which is noted to have progressed to nonunion. The patients provider has recommended Orthovisc injections for ankle osteoarthritis (OA) as demonstrated on magnetic resonance imaging (MRI). The records indicate that he has also undergone a course of physical therapy and anti-inflammatory drugs. The peer reviewed medical literature including case series and clinical trials does not currently support the long-term safety and effectiveness of viscosupplementation for ankle OA. As concluded by Pleimann and colleagues, Anecdotal use in OA of the ankle has been encouraging, but larger scale, controlled studies need to be performed. In addition, long-term investigations will better define the duration of effectiveness that viscosupplementation provides. For these reasons, the requested therapy is not likely to be more beneficial than standard therapies for treatment of this patients ankle OA.