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

The parent of a five-year-old male enrollee has requested for  applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in the relevant scientific data, the article by Myers and colleagues is a seminal report developed by the Council on Children with Developmental Disabilities of the American Academy of Pediatrics. The report states that, The effectiveness of ABA-based intervention in ASDs 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. Moreover, numerous controlled studies demonstrate improved behavior, language, and educational achievement in patients treated in ABA programs when compared to untreated patients. One such study, reported by McEachin and colleagues, is a long-term follow-up of ABA treated patients and untreated controls. Another was conducted by Eikeseth and colleagues with a one year follow-up. Each of these studies report on the clinical value of ABA therapy. Thus, the utility of ABA therapy is well supported in the medical literature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox is not a first-line therapy for migraine or chronic headaches, there is medical literature supporting its use for chronic intractable headaches. The literature regarding Botox demonstrates that is well tolerated, generally without systemic side-effects. Adverse effects are generally mild to moderate in severity. The most recent and largest studies show the benefit of Botox use in patients with chronic headaches. Thus, there is adequate evidence that Botox can be useful in a subset of migraine patients who have tried and failed multiple standard preventive agents. In this patients particular case, she had tried (and failed) many first-line therapies to treat her migraine headaches. It is not likely that further treatment attempts with standard migraine preventive medications are likely to of benefit. Therefore, she is an appropriate candidate for treatment with a secondary agent, such as Botox.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested for mental health outpatient therapy for treatment of his behavioral health condition. Findings:  The physician reviewer found that Leichsenring and Rabung provide evidence that individuals with chronic and complex mental illnesses improve with long-term psychotherapy, and that a greater number of sessions is associated with better outcomes. Furthermore, Bolton and colleagues provide evidence that anxiety disorders (including PTSD) independently increase the risk for suicidal behavior. Although a medication adjustment could certainly be attempted and may indeed augment this patients psychotherapy, it is not an alternative, but a compliment to the therapy. All told, this patient is extremely ill and suffering from multiple psychiatric conditions. He requires an ongoing intensive multi-pronged approach including medication management, attending AA, and individual psychotherapy twice per week in order to improve his functioning and reduce his risk for suicide.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for a replacement feeding chair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that this replacement feeding chair will facilitate safe feeding, and promote easy access to this patient. This patient has spastic cerebral palsy, and in an episode of choking or aspiration, quick and easy access is imperative. In addition, this chair may prevent the need for gastric feeding tube (G-tube) placement, which is a concern in this patient population. All told, the requested equipment is necessary for the patients safety and well-being and is not a convenience item.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation as a component in the treatment of osteoarthritis of the knee has come to be an accepted procedure, especially in patients with mild to moderate arthritis, as noted by Dagenais. It is more efficacious in cases with minimal, or no, effusion, as noted by Gossec and Dougados.  Adverse reactions are usually infrequent and limited, and may be related to the injections. The use of viscosupplementation after the failure of exercise and other conservative measures or in situations of adverse events associated with medications has been recommended.  In this case, the patient has had recurrent effusion. There is no documentation of any employment of physical therapy, except for a self-exercise program, not otherwise defined.  There is no documentation of any adverse response to medications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested for SPECT scans for evaluation of his brain trauma, general anxiety disorder, attention deficit disorder, inattentive type, and mood disorder, not otherwise specified. Findings:  Three physician reviewers found that SPECT scans did not add any significance to the evaluation and did not direct treatment that would not already be indicated. Its approved usage involves evaluating and monitoring structural brains disorders such as stroke, seizures and dementia. SPECT scans are also approved for heart problems such as arterial blockage, and cancer evaluation, especially determining the extent of metastasis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested for speech therapy and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that OT combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone to enhance language development. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. Eikeseth concluded of his study that patients who received behavioral treatment gained an average of 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 with no additional improvements noted. Finally, the American Academy of Neurology (AAN) guidelines for autism developed in 2000 states, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested for acute inpatient hospital services for treatment of the enrollees left-sided weakness, left-sided numbness, difficulty walking and slurred speech. Findings:  The physician reviewer found that the literature is mixed regarding the need for acute inpatient admission for management and evaluation of suspected transient ischemic attack. The literature suggests that clinical risk factors may be used to predict the risk of recurrent stroke. These risks include age greater than 60, diabetes mellitus, symptoms lasting more than 10 minutes, speech impairment and weakness. In this patients case, he reported speech impairment, weakness and symptoms lasting more than 10 minutes. Based on the etiology, workup may include ECG, echocardiogram, carotid ultrasound, MRI/MRA and observation. As per standard management, aspirin was started on the first day of the admission and was then given daily. Based on the patients presentation with the normal physical examination that was consistent with a transient process (whether complicated migraine versus transient ischemic attack), acute inpatient care was not clinically necessary. There is a recognized risk of recurrent transient ischemic attack and stroke in patients presenting with a transient ischemic attack, which speaks to the importance of having rapid follow-up to complete the evaluation. The literature does not distinguish the importance of obtaining a CT versus MRI as the imaging modality of choice. Therefore, the delay between the days for testing was not clinically warranted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Three physician reviewers found that this patient meets criteria for weight loss surgery based on National Institutes of Health guidelines. While laparoscopic sleeve gastrectomy does not have as long of a track record as Roux-en-Y gastric bypass or adjustable gastric banding (Lap-band), five-year follow-up data is available and documents good results. Additionally, outcome studies of the Lap-band are starting to show poor results. Moreover, Roux-en-Y gastric bypass is associated with dumping syndrome whereas sleeve gastrectomy is not. As such, laparoscopic sleeve gastrectomy is a medically reasonable and appropriate option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  for continued social skills training group therapy for treatment of the enrollees Aspergers syndrome and obsessive compulsive disorder. Findings:  The physician reviewer found that the concept of social skills training group therapy is discussed in retrospective or case-controlled studies that are of small scale. At this time, is a notable lack of medical evidence-based peer review of the efficacy of social skills training in this setting. Reports of benefit stem primarily from descriptive and anecdotal literature, although the quantity and quality of research is increasing. Williams White, et al. concluded that the state of research about the effectiveness of social skills groups is still in its infancy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested for shower legs  and pool physical therapy for treatment of her medical condition. Findings:  The physician reviewer found that this patient has demonstrated a significant level of independence, given the complexity of her medical condition and multiple co-morbidities. Nevertheless, there is inadequate medical literature to support the notion that pool physical therapy is medically necessary over land-based therapy. In regard to the request for shower legs, there is no current peer-reviewed medical literature supporting the use of shower/waterproof types of prosthesis devices as being necessary for bathing. Due to safety reasons, standing inside a shower on a wet surface is contraindicated for patients who are status post bilateral amputation. Sitting in a shower chair or a tub bench and taking a bath or utilizing a hand held shower are more appropriate options for this patient population.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for a myelography, physician visit, and lumbar discography for evaluation of her Behcet syndrome for placement of an intrathecal catheter.  Findings:  The physician reviewer found that Behcets disease is essentially a chronic disturbance in the bodys immune system. In severe cases, the nervous system can be involved, (i.e. Neuro-Behcets) and occasionally patients with severe Behcets require large doses of pain medicine, usually given intravenously or through an intrathecal catheter. This patient had a permanent intrathecal catheter and pain pump inserted, which was noted to be reasonably effective. The anesthesiologist who performed the procedure also performed a lumbar discography and myelography as well. Considering the fact that misplacement of an intrathecal catheter is an undesirable result, it was reasonable for the provider to perform the imaging for achieve a functional outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for partial hospitalization for treatment of her bulimia nervosa. Findings:  The physician reviewer found that she continued to have significant symptoms, including anxiety and dysphoria.  This patient would most likely have deteriorated in mood, eating disorder symptoms, and anxiety symptoms without this continued level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for surgical repair of pectus carinatum for treatment of the enrollees pectus carinatum. Findings:  The physician reviewer found that the photographs show pectus carinatum, this condition was not so severe as to be considered an abnormal structure of the body. In this patients case, the requested surgery is not being performed to improve function or create a normal appearance from an abnormal appearance. There are no functional complaints. The proposed surgery offers only a minimal improvement in the appearance of the patient. All told, the submitted documentation does not demonstrate the medical necessity of the requested repair of pectus carinatum.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested  for Nutropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients height is 17 cm below the average height for his age, and he has consistently been below the 1st percentile on the growth curve. His predicted final adult height is 160 cm, which is well below the normal height for a male.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for referral to an orthopedic spine specialist for treatment of her medical condition status post motor vehicle accident.   Findings:  The physician reviewer found that it is well accepted that adequate attempts at conservative modalities (including physical therapy utilizing manipulation/mobilization techniques) are indicated before pursuing surgical intervention. In 2004, Gross and colleagues published a systematic review of randomized trials in which the authors assessed manipulation and mobilization techniques in terms of pain relief, improved function, patient satisfaction, and global perceived effect in adult patients with mechanical neck disorders. Of the 33 selected trials, 42% were high quality trials. The authors reported strong evidence of benefit favoring multimodal care including mobilization and/or manipulation plus exercise for treatment of chronic mechanical neck disorders (MND) with or without headache. In the case of this patient, while one of the patients providers states that the patient has undergone physical therapy, the submitted medical records do not include documentation of the duration and intensity of the patients course of therapy and the patients response. Objective documentation of an adequate course of physical therapy is required prior to an orthopedic evaluation for a surgical procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested a spinal cord stimulator for treatment of his pain. Findings:  Two physician reviewers found that spinal cord stimulation is a well-accepted modality of treatment for the management of several forms of chronic pain, including failed back surgery syndrome. Psychological evaluation is recommended, as this type of screening by a psychologist is helpful to rule out red flags such as untreated depression and other psychiatric comorbidities. None of these diagnoses were found in the patients evaluation. In this patients case, the patient would require an extensive surgery since his diagnostic discogram showed three positive discs (L1-2, L4-5 and L5-S1). The success rate of surgical fusion requiring more than two levels is low, especially if this patient may require fusion from L1 to S1.  In this patients case, the requested spinal cord stimulator is likely to be superior over other available treatment alternatives.
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 Mobius syndrome with right hemiparetic cerebral palsy.   Findings:  The physician reviewer found that Mobius syndrome is a rare disorder characterized by mask-like faces with 6th and 7th cranial nerve palsies. Neurodevelopmentally, these features may be due to hypoplasia of the corresponding brain stem nuclei, destructive degeneration of central brain nuclei, myopathy, or peripheral nerve involvement. Up to 30% of affected patients are cognitively delayed. Hearing loss, most frequently due to chronic otitis media, is common as is impaired speech in the majority of cases. Over time, the lack of facial expression can result in problems with social interaction and acceptance. According to the publication by Sjogreen and colleagues, Early intervention by a speech pathologist and a paediatric dentist should be undertaken to improve orofacial function and symptoms. This young patient with Mobius syndrome has anatomic and functional abnormalities resulting in difficulties with speech and language development. Thus, comprehensive speech evaluation and therapy are medically necessary and the standard of care within the community.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year, seven-month-old male enrollee has requested speech and language therapy for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that the patients medical records suggest that he has mild developmental delays. The patient began walking at 17 months, but was 4 weeks premature. The age-adjusted expectation for his development would place him walking at 16 months of age. This delay is still considered within normal limits for the onset of walking. Further, his communication skills appear to be relatively intact for his age. Based on the study by Coplan and Gleason, as well as other studies, it is likely that this young patient will progress in his language skills without intervention at this time. Thus, based on the clinical information provided, active speech and language therapy is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested intensive outpatient program for treatment of the enrollees substance use disorder.  Findings:  The physician reviewer found that the patients mental status examination (MSE) reveals no major mood disturbance, anxiety, suicidal ideation, or psychosis. The patients progress notes indicate he was having a good week in school and was following his home contract. The provider indicated the patient was doing well in school and attending meetings. It should be noted that his urine drug screens were negative. Based on the Child and Adolescent Level of Care Utilization system (CALOCUS) and the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines, this patient was a candidate for less restrictive level of care. Given that he was involved in his treatment and was at low risk for relapse, he was a candidate for community based services during the period at issue. For these reasons, the medical necessity for IOP has not been demonstrated based on the records provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested psychodynamic psychotherapy for treatment of his behavioral health condition. Findings:  The physician reviewer found that Leichsenring and Rabung provide evidence that individuals with chronic, complex mental illnesses seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions are associated with better outcomes. The article by Gabbard explains how this is particularly pertinent in individuals with cluster B personality disorder traits. This patient has chronic, complex mental illness, namely bipolar II disorder and personality disorder with cluster B traits. Psychodynamic psychotherapy is both appropriate and a standard form of treatment for his behavioral health condition. Psychodynamic psychotherapy is most effective when provided more frequently, up to three times per week, as appears to have been the case in this patients treatment. He should therefore continue psychodynamic psychotherapy at the proposed frequency of three times per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested an electric microprocessor knee-shin swing/stand prosthetic (Otto Bock C-Leg system) and related accessories for treatment of his left above knee amputation.  Findings:  The physician reviewer found that the literature supports the functional benefits of microprocessor-controlled prosthetic knees for active community ambulators with transfemoral amputations. Given the findings by Hadley and colleagues, this patient is an appropriate candidate for this type of prosthesis, given his age, functional status, and active lifestyle. His current prosthesis is in marked disrepair and requires replacement. Applying the conclusion published by Seymour and colleagues, replacement with a new prosthesis with a microprocessor-controlled prosthetic knee is consistent with current clinical standards of practice. Moreover, provision of the requested equipment should further enhance the patients gait, reduce his risk for falls, and decrease barriers to a more active overall lifestyle. Therefore, the requested equipment has been demonstrated to be medically necessary.
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 articulation disorder. Findings:  The physician reviewer found that this patient did not begin combining words until 28 months of age. He now speaks in short phrases and sentences. There is no documented neurological or developmental disorder as the cause for this patient's articulation disorder. However, this patient shows less than 50% intelligibility in an unknown context.  Roulstone and colleagues noted that children with an articulation disorder at this age are at risk for other learning disabilities later as a child.  They also documented that in this type of clinical scenario, improvement is not likely to occur without treatment regardless of other developmental delays.  In this patients case, the requested speech therapy is medically indicated for the treatment of his articulation disorder.