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

A 56-year-old female enrollee has requested authorization and coverage for a power operated wheelchair for treatment of the enrollees ankle injury.  Findings:  The physician reviewer found that the documentation provided does not include a mobility evaluation. Accepted medical necessity criteria in this setting (Medicare guidelines) require that an individual undergo a mobility evaluation before the appropriateness of a power operated vehicle can be determined. Given the absence of a sufficient mobility evaluation, it is unclear whether the patient currently has mobility related activity of daily living (MRADL) deficits within the home. The presence and extent of such deficits must be documented in order to determine if a power wheelchair is necessary to ameliorate the patients mobility deficits within the home. Moreover, it is not clear that another assistive device would be insufficient to ameliorate any of the patients mobility deficits. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested Botox injections for treatment of her migraine headaches, low back pain and piriformis syndrome.    Findings:  Two physician reviewers found that the patient has a reported history of migraine headaches, low back pain and piriformis syndrome. Per a provider note, the patient previously had six months of benefit from Botox injections. The patient has had a variety of treatments for low back pain complaints including facet interventions and medication management. Prior to the visit on the date at issue, the patients listed diagnoses primarily pertained to low back pain issues and treatment was primarily focused on improving her low back symptoms. It is not clear that the patient has had treatment with a variety of medications that can help with migraine headaches. Botox is not indicated for low back pain complaints or a diagnosis of piriformis syndrome. There is no clear evidence that Botox would be more beneficial than available standard therapies for these diagnoses/conditions. Botox does have an indication for migraine headaches. However, it is not clear that the patient has attempted an adequate course of treatment with standard migraine preventative agents. Botox is generally not used as a first-line treatment for patients with migraine headaches and thus there must be documented evidence of trial and failure of standard agents before consideration of Botox is appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for occipital nerve stimulator trial for treatment of his occipital neuralgia.  Findings:  Two physician reviewers found that occipital nerve stimulation has promise as a future therapy for neck pain and occipital neuralgia, more studies are needed to determine its safety and efficacy in patients with cervical and occipital complaints. There is insufficient evidence validating its use over more standard therapies such as medication and nerve blocks.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that The issue in this case is whether the requested medication, Orthovisc, is medically necessary for the treatment of the patient. The use of hyaluronans such as Orthovisc in the treatment of osteoarthritis of the knee has been generally accepted (Bellamy, et al.), and is most suitable for patients with mild to moderate disease (Dagenais, et al.) with no or mild effusion (Gossec and Dougados). The available evidence of the effects of multiple courses of therapy on outcomes is not sufficient to reach firm conclusions (Espallargues and Pons). Although some studies have been encouraging (Raynauld, et al.), problems such as painful acute local reaction have been reported with repeated courses of treatment (Morton, et al.). Additional studies are in progress, but the results are not yet available. In the absence of adequate data supporting the safety and efficacy of repeated courses of intra-articular hyaluronan injections, the requested medication is not medically necessary for treatment of this patients condition. Therefore, the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested authorization and coverage for a computed tomography coronary angiography for evaluation of her heart abnormalities.  Findings:  Two physician reviewers found that coronary CTA is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of the CTA. In addition, CTA has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old female has requested speech therapy twice per week for 60 minute sessions for treatment of her speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient is globally delayed, both in motor and intellectual development. In addition, she clinically demonstrates hypotonia, which suggests that she has an organic cerebral basis to her developmental deficits. It is within the standard of care to prescribe speech therapy for a toddler with speech delay. The value of speech therapy, in a developmentally delayed child, is well documented in the peer-reviewed medical literature. The effectiveness of speech therapy in a young child is emphasized by Law and colleagues, who reported that children with speech delay can be readily treated. Further, Goorhuis-Brouwer and Kniff evaluated speech-delayed children, such as this cognitively delayed patient, and concluded that such children are candidates for successful speech therapy. Similarly, Prelock and colleagues discussed the evaluation and the value of treatment for speech delayed children. Consistent with these findings, it is medically necessary that this patient receive the recommended two hours weekly of individual speech therapy for six months. Following six months of therapy, the patient needs to be reassessed to determine the need to continue either one or two hours of speech therapy for the next six months.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has documented migraine headaches that occur approximately 12-15 times a month with duration of up to 112 days. In the past, the patient has had headaches while taking Adderall, Imitrex, and Norco. There is no documentation that the patient has tried or failed any preventative therapies including antidepressants, antihypertensive medications or antiepileptics. In the past, the patient has had a trial of Botox with reported relief of her symptoms. Her provider has requested the continued use of this therapy. The literature provided documents the utility of several of the migraine prevention therapies. Although Botox can be useful in migraine headaches, it should not be selected without a proper trial of more standard preventative therapies such as antidepressant, antihypertensive, or antiepileptic medications. There is no documentation that this patient has tried any of these standard headache medications. Without documented trial and failure of these potentially effective therapies, the continued use and exposure to Botox cannot be justified and would not be considered standard of care.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old male has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient presented to the emergency room complaining of left upper canine tooth pain for one week. The patient reported having bitten into a hard piece of bread one week prior and experienced pain in the canine tooth since that time. The patient denied any other trauma, fever, chills or facial swelling. His vital signs and physical examination were unremarkable. While in the emergency room, the patient received an injection of pain medication and was ultimately diagnosed with a possible dental fracture.  The patient was prescribed narcotic pain pills and was instructed to follow up with a dentist. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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.This case meets prudent layperson criteria for an emergency medical condition as the dental pain experienced by the patient was of sufficient severity, namely significant pain, such that an absence of immediate medical attention would likely result in continued uncontrolled pain and significant discomfort. A prudent layperson in this patients circumstances would have sought immediate medical attention for purposes of pain control. Therefore, it was medically reasonable and appropriate that the patient sought care for evaluation and treatment of his dental pain and possible dental fracture.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy, at a frequency of two times per week for treatment of the enrollees receptive and expressive language delay.  Findings:  The physician reviewer found that the current medical evidence supports the requested therapy in this patients case.  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.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported 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, he demonstrates receptive and expressive language delay that is negatively impacting his 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.  All told, speech therapy, at a frequency of two times per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for transcranial magnetic stimulation therapy for treatment of the her major depressive disorder. Findings:  The physician reviewer found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  There is sufficient evidence in peer-reviewed medical literature to support the use of transcranial magnetic stimulation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees stated condition of speech delay. Findings:  The physician reviewer found that the relevant scientific literature demonstrates that improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Speech therapy is indicated with any delay greater than 25% (Law, et al.). While speech therapy has been shown to be an effective modality for children with speech delay, based upon the documentation provided, this patient does not currently have any documented delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees stated condition of autism.  Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder (Dawson, et al.; Rogers, et al.; Warren, et al.; and Kelley, et al.). The scientific literature supports the use of ABA and guidelines recommend at least 25 hours per week for appropriate intervention (Rogers, et al. and Kelley, et al.). A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al.). Warren, et al. reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. More recently, a retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcomes when compared to typically developing peers and peers with high-functioning ASD. The results indicated that 62% of children in the optimal outcome group received intensive behavioral therapy, including greater than 20 hours per week of intervention therapy, whereas only 13% of the high-functioning group received this level of intervention. Therefore, data suggests that treatment intensity may play a role in optimal outcomes (Kelley, et al.). In conclusion, the request for ABA therapy at a frequency of 25 hours per week is medically appropriate and necessary for treatment of the patients medical condition and the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested authorization and coverage for a ProDisc C artificial disc replacement of the neck bone for treatment of the his neck and bilateral arm pain. Findings:  Three physician reviewers found that there are no large, multicenter double-blind studies examining the safety and effectiveness of total disc replacement utilizing the ProDisc C (Matz, et al.). When comparing decompression and fusion procedures to total disc arthroplasty, one study found that the arthroplasty group had superior outcomes (Mummaneni, et al.), while another found clinical improvement in both the arthroplasty group and the decompression and fusion group (Porchet and Metcalf). However, both studies precluded conclusions from being drawn, due to lack of blinding and randomization, as well as multiple confounding factors and lack of follow-up with patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested authorization and coverage for treatment of the enrollee diagnose with attention deficit/hyperactivity disorder and Tourettes syndrome. Findings:  The physician reviewer found that that treatment of comorbid attention deficit/hyperactivity disorder has been controversial due to reports that stimulants hasten the onset or increase the severity of tics in some patients. This is not necessarily a contraindication for stimulant treatment in patients with significant symptoms of attention deficit/hyperactivity disorder.  A stimulant in combination with either clonidine or guanfacine, or with a neuroleptic agent may be beneficial in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested authorization and coverage for occupational therapy visits for treatment of the enrollees difficulty feeding.  Findings:  The physician reviewer found that feeding difficulties are common with an estimated prevalence of 25%-45% in normally developing children and up to 80% in developmentally delayed children. The need for timely and effective treatment is essential to prevent failure to thrive and related complications. Successful treatment requires interdisciplinary approach involving several providers. There is evidence in the literature to support the need for occupational therapy in the treatment of feeding difficulties.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the patient has an identified delay in expressive speech of approximately 61% and in comprehension of 32%. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). 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 preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested reimbursement for a gastroenterologist consultation and a diagnostic CT enterography scan performed on different dates.  The Health Plan has denied this request indicating the services at issue were not required on an urgent basis. Findings:  The physician reviewer found that the patient underwent a gastrointestinal consultation and computed tomography (CT) enterography scan of the abdomen about a month later for the evaluation of abdominal pain while outside of her plans service area. The patient has a history of appendectomy with lysis of adhesions. The pain was described as a deep pain and had been present for several months prior to evaluation. During the exam, it was noted that the patient had a tender subcutaneous nodule in the right lower quadrant as well as diffuse mild tenderness of the whole right lower quadrant. The provider ordered a CT scan. The CT scan only showed post-operative changes. The patient has requested reimbursement for the services. The Health Plan has denied coverage for these services indicating that they were not urgent in nature.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the dates in question. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area.  The patients gastroenterologist noted that recurrent adhesions or even a mild flare of irritable bowel disease (IBD) was possible. The patient did not present with symptoms that would cause a reasonable layperson to believe that immediate medical attention was required. The patients symptoms were ongoing and had been present for several months prior to evaluation. The submitted evidence does not demonstrate that the patient was experiencing a complication of an existing condition for which treatment could not be delayed until she returned to the Plan's service area. A gastroenterology work-up could have been deferred until the patient returned to the Plans service area. All told, a prudent layperson in this situation would not have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested reimbursement for fentanyl lozenges for treatment of her pain. Findings:  The physician reviewer found that Fentanyl lozenges are presently indicated for breakthrough cancer pain in patients who are opioid tolerant or in patients with a limited life expectancy. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested authorization and coverage for platelet rich plasma injections for treatment of her lateral epicondylitis.  Findings:  Two physician reviewers found that the value of injections of platelet rich plasma (PRP) in the treatment of lateral epicondylitis of the elbow and other tendinopathies has been the subject of controversy for several years, with some encouraging reports, but with other studies not reporting significant differences in outcome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a powered wheelchair or scooter for treatment of her chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) criteria states that power wheelchairs are not medically necessary if the primary purpose of use is to assist patients with community mobility. In addition, the criteria stipulate that the primary intended use for power wheelchair should be to assist patients complete mobility related activities of daily living (MRADLs) within the home. There is no documentation of difficulties with MRADLs within the home, the requested power scooter or wheelchair is not medically necessary for treatment of this patients medical condition.