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

The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.  Findings:  The physician reviewer found that Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy. The patients intellectual disability is a frequent co-morbid diagnosis in autistic children. However, this condition does not preclude the patient from benefitting extensively from ABA therapy. ABA therapy is well-documented as the only consistently successful intervention for autistic children. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a documented 40-year track record of substantially improving motor, verbal, and socially interactive skills in autistic children. Myers and Johnson indicate that the effectiveness of ABA-based intervention in autism spectrum disorder has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Further, the authors report that, children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. This patient has been diagnosed as autistic, for which ABA therapy is the well-documented therapy of choice. There is consensus among clinical psychologists that ABA therapy should be intensively initiated as soon as a diagnosis of autism is established. With regard to the appropriate frequency of ABA therapy, at the requested 35 hours per week of ABA services, there would be inadequate time to develop group socialization or trials of mainstreaming the patient during school hours. A frequency of 20 hours of ABA therapy per week is more appropriate in this setting. All told, it is medically necessary that ABA therapy be continued for this patient. However, the recommendation is for 20 hours of ABA therapy per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested authorization and coverage for Lidoderm 5% patch (30 per month) for treatment of the enrollees cervicalgia, cervical degenerative disc disease, and myofascial pain syndrome.  Findings:  The physician reviewer found that the use of Lidoderm patches in myofascial pain syndrome is considered off-label use. However, the use of topical lidocaine and injectable lidocaine for trigger points and myofascial pain has been proven to be effective for isolated myofascial pain areas through both direct action and placebo effect. The patient in this case is on a very potent narcotic analgesic and addictive skeletal muscle relaxant, the addition of another sedative systemic analgesic or anti-neuropathic or myofascial pain agent is concerning for both dependence and adverse reactions. To avoid these risks, the use of topical lidocaine 5% (Lidoderm) patches poses little risk of dependence or systemic adverse reaction. This patient has reported relief with trigger point injections and the use of Lidoderm patches. In this case, its use is supported by randomized and placebo controlled clinical trials. Further, this is a well accepted and prescribed modality in chronic back and myofascial pain and it is reasonable to supplement the use of injections and potent narcotic analgesics to help control her chronic pain. Given this patients long standing history of pain and the use of schedule II narcotic analgesics, the supplemental use of Lidocaine patches is a medically necessary adjunct to help reduce her pain and narcotic use. The Lidoderm 5% patch should be approved as long as the patient continues to experience significant documented relief without adverse effects.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested reimbursement for residential treatment services provided on consecutive days and prospective authorization and coverage for resumption of residential treatment. Findings:  The physician reviewer found that based on review of the available records, the RTC level of care services provided on the dates in question were medically necessary. There is a family therapy note dated the day before that describes the patient as being very negative. He was noted to still exhibit impulsive behaviors and would run away when triggered. When his mother entered the session, he appeared to jump into his emotions and needed prompting to take some deep breaths. The records indicate the patient was still very labile at this session and not stable enough to ensure he would not relapse if discharged to a lower level of care. He expressed considerable hostility toward his father. The patient was not stable enough to maintain himself absent the structure of the RTC setting through the second date in question. Therefore, RTC services on the dates in question were medically necessary. Subsequently, the patient received services for approximately two weeks and was discharged in an improved condition. Based on the records provided for review, there is inadequate documentation to support re-referral to the RTC level of care. All told, the RTC services provided on the first two days were medically necessary but readmission to RTC is not medically necessary for treatment of the patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested authorization and coverage for acute inpatient mental health services provided at over five days for treatment of the enrollees major depressive disorder, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue.  This patient presented with acute intrapsychic discord with anxiety and depression after seeking treatment in a less restrictive setting.  She was suicidal with plan, and she had a history of prior suicide attempts.  Further, her diagnoses of post-traumatic stress disorder and major depressive disorder placed her at high risk for suicide.  The current medical evidence supports acute inpatient mental health services in this clinical setting.  Based upon the submitted medical records and current practice guidelines, acute hospitalization was indicated.  All told, acute inpatient mental health services provided on the dates in question were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested reimbursement for neuropsychological testing performed on two dates for evaluation of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the testing at issue in this patients case.  This patient was diagnosed with attention deficit/hyperactivity disorder.  The current medical evidence supports neuropsychological testing in selected patients.  As noted by Pritchard and colleagues, neuropsychological testing can provide information that can potentially reduce risks for poor outcomes and improve the quality of life for children with attention deficit/hyperactivity disorder.  However, in this patients case, there is no indication that the patient underwent initial evaluation by his pediatrician using preliminary screening tests which would have suggested the possibility of attention deficit/hyperactivity disorder.  In this clinical setting, given the absence of a preliminary evaluation by a medical or psychological care provider, the medical necessity of the testing at issue cannot be established.  All told, neuropsychological testing performed was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old female enrollee has requested authorization and coverage for breast reconstruction surgery (removal of supernumerary breast axilla) for treatment of the enrollee, who is status post bilateral breast reduction.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  The medical records document an illness or disease related to the excess left axillary tissue (cellulitis) for which medication was prescribed.  In this clinical setting, direct removal of the left axillary skin fold is medically indicated.  In this patients case, the axillary skin folds constitute an abnormal structure of the body.  This abnormal structure of the body has resulted in skin infections of the fold.  The requested surgery will be performed to improve function by removing the cause of the infection.  Additionally, the surgery will also provide improvement in the appearance of the patient by removing the axillary fold.  All told, the requested breast reconstruction surgery (removal of supernumerary breast axilla) is reconstructive in nature and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested authorization and coverage for an MRI for evaluation of the enrollees back pain. Findings:  The physician reviewer found that treatment of patients with uncomplicated low back pain is well-established in the medical literature.  A patient has uncomplicated low back pain when there is no history of cancer, no clinical concern of infection, no history of significant recent trauma, and no neurological deficits on clinical examination.  The American College of Radiology recommends a trial of conservative care for patients with uncomplicated back pain prior to advanced imaging, such as MRI.  Conservative care can include non-steroidal anti-inflammatory medications, physical therapy, and a home exercise program.  If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate.  In this patients case, there is no clinical concern of infection, and there is no history of significant recent trauma.  Per the submitted documentation, the patient has no neurological deficits and no history of cancer.  There is no documentation that the patient has failed a four-week to six-week trial of conservative therapy.  In this case, there is insufficient clinical evidence to support the requested MRI.  All told, the requested MRI is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male has requested an for evaluation of his right shoulder strain.  Findings:  The physician reviewer found that this patient presents with a history of right clavicle pain.  He has no history of recent trauma but does have a prior right clavicle fracture that radiographically is well healed.  Clinically, there is no evidence of infection or occult fracture.  The patient has been diagnosed with shoulder strain.  In this clinical setting, a trial of conservative therapy, including 4 to 6 weeks of non-steroidal anti-inflammatory medications (NSAIDs) and activity modification, which can include physical therapy or a home exercise program, is medically appropriate.  An MRI of the shoulder is medically appropriate if there is clinical concern of a rotator cuff tear, impingement syndrome, or a labral abnormality, per American College of Radiology guidelines.  In this patients case, there is no clinical evidence of a suspected rotator cuff tear, impingement syndrome, or labral abnormality.  All told, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female has requested a power operated wheelchair for treatment of her tetraplegia.  Findings:  The physician reviewer found that based on review of the available records, the documentation supports the medical necessity of a power wheelchair for this patient. She is non-ambulatory and her upper extremity impairments significantly limit her ability to self-propel a manual wheelchair. A power wheelchair will significantly enhance her ability to perform mobility related ADLs. In addition, her home will accommodate a power wheelchair, and she should be able to effectively and safely use such a device. Her weight does not appear to be a limiting factor. Her ability to safely transfer in and out of a wheelchair under certain situations and stand with the use of a walker does not lessen the patients need for the device. All told, a power wheelchair is medically necessary given the patients impairments and disabilities
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male has requested an orthotic brace (customized chest wall brace) for treatment of his pectus carinatum.  Findings:  Three physician reviewers found that the patient has a history of pectus carinatum first diagnosed three years ago and managed non-operatively with an orthotic brace. According to the records clinical response has been good. The treating physician, noting that they have had excellent results in general with bracing of pectus carinatum deformity, has recommended a replacement brace for the enrollee since he has outgrown his current brace. The available medical studies support the benefit of orthotic bracing for the initial management of patients with pectus carinatum. The records indicate that the patient has benefited from use of the orthosis for the past three years and requires a replacement since he has outgrown his current brace. A replacement orthotic brace is therefore likely to continue to be beneficial for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male has requested the ProDisc-L procedure (artificial disc replacement L3-4) for treatment of his low back pain.  Findings:  Three physician reviewers found that the patient has a history of low back pain.  A three-level discogram noted slight to moderate concordant pain at the L3-4 level, slight to moderate concordant pain at the L4-5 level, and no pain at the L5-S1 level. An MRI of the lumbar spine was performed, with comparison to imaging.  The report noted no interval change, with no evidence of neural impingement at any lumbar level.  Physical examination revealed 4+/5 weakness in the left quadriceps and buttock pain that was elicited with forward flexion as well as extension.  In this patients case, the requested procedure is not likely to be of greater benefit than other treatment options.  This patient has chronic low back pain.  The current medical evidence has not established the support efficacy of the requested procedure in this clinical setting.  The medical literature has not established the long-term safety and efficacy of the requested ProDisc-L procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested speech therapy, 30 minute sessions, twice per week for treatment of her mild to moderate receptive language impairment and severe expressive language impairment.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  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.  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.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she demonstrates speech and language deficits which are most prominent in her expressive language skills.  These deficits are impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested reimbursement for collagen cross links/bone turnover markers testing for evaluation of the enrollees osteoporosis.  Findings:  Three physician reviewers found that the patient has a history of low bone mineral density.  The medical records noted that the patient had been menopausal for 10 years.  The patient did not have a history of bone fracture or kidney stones.  The providers assessment was osteoporosis.  She has requested reimbursement for collagen cross links/bone turnover markers testing.  In this patients case, the testing at issue was not likely to be of greater benefit than other methods of evaluation.  She had an established diagnosis of osteoporosis per a bone density study.  Bone turnover markers testing was not likely to be of benefit in this clinical setting.  At this time, there is no consensus on whether there is a role for the testing at issue in determining candidates for osteoporosis therapy.  The decision regarding the appropriate candidates for osteoporosis therapy should be based upon fracture risk assessment using bone mineral density and clinical risk factors.  Thus, the superior efficacy of collagen cross links/bone turnover markers testing has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested reimbursement for Lexapro for treatment of the enrollees depression. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue in this patients case.  The Health Plan has offered formulary alternatives, including citalopram, fluoxetine, paroxetine, and sertraline.  Lexapro tends to be a well-tolerated medication with good efficacy.  However, there is a lack of well-designed, controlled studies demonstrating its superiority to the four selective serotonin reuptake inhibitors offered by the Health Plan.  There is adequate medical evidence supporting the use of the alternative medications offered by the Health Plan in this patients case.  The submitted medical records do not demonstrate that the patient has tried and failed treatment with sertraline.  Sertraline is an accepted treatment alternative in this clinical setting.  All told, Lexapro was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested authorization and coverage for Cialis 5mg for treatment of the enrollees enlarged prostate and erectile dysfunction. Findings:  The physician reviewer found that the safety and efficacy of daily use Cialis has not been established as being superior in the treatment of obstructive uropathy or erectile dysfunction than the as needed dosing most commonly utilized. Cialis is not first-line therapy for the treatment of obstructive uropathy. While there appears to be some benefit in the alleviation of this condition, Cialis is not typically utilized for this condition considering the variety of other medications that can be prescribed as single agents or in combination. Daily Cialis is generally recommended as treatment for erectile dysfunction when the patient wants a threshold of medication to enable sexual relations on a random or spontaneous basis. However, there is scant validation to recommend daily low-dose Cialis to treat erectile dysfunction as being more efficacious than as needed dosing. Therefore, the Health Plans denial was appropriate and the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee has requested acute psychiatric care for treatment of his major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient had impaired functioning socially and occupationally with signs and symptoms noted throughout his admission. Despite intensive outpatient therapy, his symptoms had not improved. Further, the patients depressed mood, hopelessness, insomnia, lack of energy, anhedonia, and isolativeness persisted throughout the admission indicating the need for ongoing treatment. A discharge global assessment of functioning (GAF) score of 35 also supports the indication for acute psychiatric level of care treatment. Consistent with these findings, the acute inpatient hospitalization during the said timeframe was appropriate to treat the patients condition, consistent with standards of good medical practice, and could not have been provided safely in a less restrictive setting. As such, the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested authorization and coverage for Cialis 5mg, 1 per day. Findings:  The physician reviewer found that the safety and efficacy of daily use Cialis has not been established as being superior in the treatment of erectile dysfunction than the as needed dosing most commonly utilized. Additionally, Cialis is not first-line therapy for the treatment of benign prostatic hyperplasia (BPH). While there appears to be some benefit in the alleviation of obstructive uropathy, Cialis is not considered appropriate initial therapy for this condition considering the variety of other medications that can be utilized as single agents or in combination. Daily Cialis is generally recommended as treatment for erectile dysfunction when the patient wants a threshold of medication to enable sexual relations on a random or spontaneous basis. However, there is scant validation to recommend daily low-dose Cialis to treat erectile dysfunction as being more efficacious than as needed dosing. Therefore, the Health Plans denial was appropriate and the requested medication is not medically necessary for treatment of the patients medical condition.