Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested emergency services for treatment of his peri-rectal abscess. Findings:  The physician reviewer found that the disputed services meet prudent layperson criteria for emergency care given the totality of the patients circumstances. The patient had a large peri-rectal abscess which was incised, drained of copious pus, and packed with gauze on the first visit to the emergency department. The patient returned 48 hours later and the wound was noted to have a small amount of persistent drainage and was re-packed with gauze.  The patient returned 48 hours later for packing removal.  Patients who have undergone minor surgical procedures such as abscess drainage are often followed by the service that performed the procedure. Since the patients wound had previously been packed/repacked twice, it is to be expected that the patient would return to the emergency department on the date of service at issue for packing removal. The patient reasonably sought care in the emergency department to undergo packing removal as his primary care provider was not able to see him and the wound needed to be evaluated and the packing removed. For these reasons, the patients decision to seek treatment in the emergency department for the wound check/packing removal was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy two times per week and sensory integration occupational therapy one time per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the need for speech therapy for this patient with autism is clearly illustrated in the records provided for this review. Speech and language therapy is an essential component in the treatment of young patients with autism. Specifically, speech therapy has been shown to be beneficial and necessary in improving communication in children with autism. According to Myers and colleagues, most children with ASDs can develop useful speech, however, traditional, low-intensity pull-out service delivery models are often ineffective, and speech-language pathologists are likely to be most effective when they train and work in close collaboration with teachers, support personnel, families, and the childs peers to promote functional communication in natural settings throughout the day. As such, this patient should continue to receive services through the school with additional individual speech therapy authorized by the Health Plan to allow for the inclusion of other caregivers and settings.With regard to the request for once weekly sensory integration occupational therapy, the submitted records currently do not document delays that are likely to be benefit from this therapy. The Health Plan recommended the patient undergo an evaluation for sensory integration occupational therapy to determine the medical necessity of these services. Given the lack of evidence demonstrating the need for sensory integration therapy at this time, the alternative service recommended by the Health Plan is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy twice per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that the American Academy of Neurology (AAN) and Child Neurology Society (CNS) evidence-based guidelines for autism recommend speech therapy for autistic children. Specifically, the guidelines state that 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 autism spectrum disorder. In the case of this patient, he has benefitted from speech therapy with weekly progress notes showing progress toward goals. In addition, new goals have been set for the patients ongoing deficits. Given that speech therapy is standard of care for patients with autism and in light of the patients documented deficits, speech therapy twice a week is medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested proton beam therapy consisting of 45 treatments for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the definitive treatment of prostate cancer is either surgery or radiation therapy. Surgery is defined as radical prostatectomy. Radiation can be delivered as either external beam or it the form of brachytherapy, which is seed implant. For modern radiation therapy, the standard of care is IMRT. Proton beam therapy is another form of radiation therapy using protons in lieu of photons. The medical literature shows no significant advantage in terms of a cure or side effects when these two modalities are compared. When proton therapy was compared with older 3-D conformal radiation, it did have fewer side effects. Thus, proton beam therapy may be appropriate, but has not clearly been shown to be superior in either outcomes or side effects for this particular cancer as compared to IMRT. In summary, the Health Plan is correct in offering IMRT as the state of the art in radiation therapy to patients who prefer radiation to surgery. In addition, there is inadequate medical justification for this patient to be treated at the requested facility with proton beam therapy. He can expect excellent results and low morbidity with IMRT.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested Supprelin LA implant for treatment of the enrollees diagnosis of precocious puberty.  Findings:  The physician reviewer found that Supprelin LA was approved by the Food and Drug Administration (FDA) in 2007 for treatment of central precocious puberty. Although this patient experienced onset of puberty at an age older than the cutoff of 8 years, her puberty is noted to be progressing at a rapid pace. With progression in skeletal maturation, she is expected to have a shorter and shorter predicted adult height over time. As she started out with short stature due to SGA and familial causes, further compromise in her adult height on the basis of her precocious puberty is apt to result in an even poorer predicted adult height. Her current predicted adult height falls between 54 to 56 inches, which is more than 3 standard deviations below normal for an adult female. Administration of Supprelin results in decreased levels of luteinizing hormone (LH) and FSH, thus suppressing puberty and further advancement in skeletal maturation. Treatment for precocious puberty is medically necessary both to prevent premature epiphyseal fusion and to prevent further progression in pubertal development, allowing time for GH to have an effect while her growth plates are still open. In addition, clinical data has demonstrated that the Supprelin implant consistently suppresses clinical and laboratory parameters of precocious puberty for at least one year while avoiding the pain and inconvenience of monthly injections. Thus, the requested Supprelin LA implant has been established as medically necessary for management of this patients precocious puberty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested outpatient psychotherapy twice per week for treatment of her anxiety disorder and depression. Findings:  The physician reviewer found that based on the records provided, the twice weekly treatment plan was not clinically indicated by the current American Psychiatric Association (APA) practice guidelines. As noted by the APA, the role of psychodynamic psychotherapy is limited and is recommended for about 12 weeks. In addition, the treatment of anxiety disorders has a wide array of pharmacotherapy options, which were not described in this patients records. Finally, this patients primary diagnosis is inconsistent as panic various diagnoses have been mentioned including disorder, generalized anxiety disorder, obsessive compulsive disorder, and major depression. Management of her complex condition would require different approaches and may lead to ambiguous therapeutic interventions. As this patient still has a litany of pharmacotherapeutic options available for management her condition, the medical necessity of the twice weekly psychotherapy sessions has not been established in this instance.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a toe extension Dynasplint system for treatment of his status post hemi-implant arthroplasty of the right metatarsophalangeal joint.  Findings:  Three physician reviewers found that treatment for hallux limitus or hallux rigidus in the medical literature includes options such as footwear modifications, non-steroidals and surgery.  There is a lack of published high-grade medical literature supporting the efficacy of dynamic splinting using devices such as the Dynasplint in the setting of hallux limitus or hallux rigidus, whether preoperatively or postoperatively.  There is only very limited medical literature that is anecdotal in nature, such as case reports.  These case reports, moreover, were written by authors affiliated with the device manufacturer.  In the present case, the records forwarded for review do not establish that the patient gained significant benefit specifically from the Dynasplint intervention.  His range of motion gains followed the surgical correction.  No benefit in range of motion can be specifically apportioned to the Dynasplint.  Therefore, the toe extension Dynasplint system was not and is not likely to of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested anterior and posterior L5-S1 fusion for treatment of her mild anterolisthesis at L5-S1.  Findings:  The physician reviewer found that at issue in this case is the medical necessity of an anterior and posterior fusion at L5-S1. In the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified. Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option 1 would argue against a fusion in this patient as she would be undergoing a primary disc excision at the L5-S1 level. Option 2 is also contraindicated as she does not have evidence of lumbar spinal instability at any level. Although she does have some mild anterolisthesis, there is no radiographic evidence such as a flexion-extension film that the spine is unstable. Option 3 does not apply to this patient as she does not have objective evidence of chronic axial low back pain. Finally, options 4 and 5 do not apply as she does not have evidence of a recurrent disc herniation at L5-S1. Thus, of the five treatment options detailed by Resnick and colleagues, none of them provide support for a lumbar fusion procedure in this patient. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested neuropsychological testing for evaluation of the enrollees hyperkinetic syndrome.  Findings:  The physician reviewer found that specific learning disability and attention-deficit hyperactivity disorder (ADHD) are two distinct neurobehavioral developmental disorders that commonly occur in children. About 20% of children with specific learning disability have associated ADHD and vice versa. Researchers are divided at to whether each of these disorders has an independent etiology or the frequent co-occurrence is the result of a generalized atypical brain development. In either event, both specific learning disability and ADHD are known to impair educational achievement and social functioning. In addition, patients with specific learning disability and ADHD tend to have more severe learning and attention problems than those with specific learning disability alone. Thus, a thorough evaluation for ADHD should include assessment for associated co-morbid conditions. For this reason, the neuropsychological testing and evaluation performed were medically necessary to assess this patients possible co-morbid conditions that may impact his future development. In fact the diagnostic testing indicated the patient is at risk for specific learning disorder, which will guide in the management of his deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested an abdominoplasty in conjunction with repair of incisional hernia for treatment of her excess skin.  Findings:  The physician reviewer found that the patients condition constitutes an abnormal structure of the body. Panniculectomy is a lesser procedure than abdominoplasty in that it only involves removal of the lower abdominal skin without muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty. It is medically necessary rather than cosmetic in nature when the removed skin has a history of recurrent infections, as in this patients case. The records provided for review demonstrate that this patient has been treated on numerous occasions for skin rash and irritation with topical creams and persistence of the condition despite treatment. Thus, the requested surgery is primarily being performed to stop recurrent skin infections and thereby improve the patients function. As such, even though the proposed surgery will improve appearance, this is not the primary purpose of the procedure and it is therefore medically necessary for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a full body positron emission tomography/computed tomography (PET/CT) scan for evaluation of her malignant neoplasm of the endocervix.  Findings:  Three physician reviewers found that to date, there is no other test to evaluate tumor reoccurrence in patients with cervical cancer aside from the requested PET/CT scan. The sensitivity and specificity of PET/CT to detect recurrence is superior to other standard imaging alternatives. Moreover, the peer reviewed medical literature supports the utility of the PET/CT scan as within the standard of care within the medical community in the evaluation and treatment of patients with cervical cancer (Mittra, et al). Thus, the requested diagnostic procedure should be approved as it is likely to provide novel data that will prove useful in this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested speech therapy two times per week for 36 weeks (30 minute sessions for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that there are many conditions in which the corpus callosum develops abnormally. These are typically diagnosed with neuroimaging and are often discovered when a child presents with a developmental delay. These conditions range from dysgenesis of the corpus callosum to hypoplasia of the corpus callosum to partial agenesis of the corpus callosum and complete agenesis of the corpus callosum.  The corpus callosum is a large connective pathway connecting the right and left cerebral hemispheres. Defects in the corpus callosum can lead to cognitive impairments as well as motor impairments. Children with disorders of the corpus callosum often have global developmental delays including speech and language delay.  The role of speech and language therapy in children with developmental disabilities is well-published in the medical literature.  Given this patients diagnosis of dysgenesis of the corpus callosum and global developmental delay, the requested speech therapy is medically indicated.  The current medical evidence supports speech therapy in this clinical scenario.  All told, the requested speech therapy, two times per week for 36 weeks (30 minute sessions), is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested intravenous immunoglobulin therapy for a period of two years for treatment of the enrollees hypogammaglobulinemia and antibody deficiency.  Findings:  The physician reviewer found that this patient has a documented immune deficiency disorder.  As noted by the patients provider, standard recommendations by leading experts recommend at least a two-year trial of immunoglobulin in this clinical scenario. This patient has received intravenous immunoglobulin therapy, with beneficial results reported. Subcutaneous infusion is considered standard of care for young children with this clinical presentation. Although the Health Plan has only authorized intravenous immunoglobulin therapy for a period of 26 weeks, the current medical evidence supports intravenous immunoglobulin therapy for a two-year period. All told, the requested intravenous immunoglobulin therapy for a period of two years is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested twice weekly outpatient psychotherapy treatments (rather than the approved once per week treatment) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient has been participating in outpatient psychotherapy and has achieved an important therapeutic goal of abstinence which maximizes her chances for recovery and minimizes suicidal risk. While she appeared to have some continued instability of mood, medication titration could have been performed in the context of less frequent visits. The submitted information fails to establish the medical necessity for twice weekly psychotherapy. The patients condition does warrant ongoing monitoring and intervention to promote further recovery and/or prevent worsening. However, the patient can be safely and effectively treated with psychotherapy at a frequency of once per week. All told, the requested twice weekly outpatient psychotherapy treatments during this time was not and is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is a medically necessary intervention for this patient with autism given his history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions for autism in peer-review research articles and found sufficient evidence supporting the effectiveness of interventions to teach communication skills to children with autism. Specifically, language skills make a significant difference in the ability of children to control their environment, especially with disruptive behaviors. As language deficits are one of the core aspects of autism for which speech therapy provides professional guidance on communication development, the requested two hours per week of speech therapy (past and future) has been shown to be medically necessary for treatment of this patients autism related delays. Concerning the requested occupational therapy, this modality is considered a standard treatment intervention for patients with autism. The submitted records indicate the patient has previously had documented delays in fine motor and gross motor abilities. Therefore, I find that the patients previous occupational therapy was medically indicated and necessary. With regard to the request for future occupational therapy service, the patients most recent occupational therapy on the date in question (by an in-plan provider) indicated the patient presented with no apparent occupational therapy problems. However, the patient was noted not to scribble spontaneously (this is typically developmentally noted at 18 months of age). Of further significance, this evaluation did not include a reliable testing measure to determine the extent of the patients fine motor and gross motor abilities. The Vineland Adaptive Behavior Scales-second edition (VABS) and Mullen Early Scales of Learning on the said date found deficits of up to 33% on fine motor abilities. Given the inconsistent results on previous evaluations, the patient should have an objective independent evaluation to determine his occupational therapy needs going forward.