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

The parent of a four-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism.   Findings:  The physician reviewer found that this patient has a diagnosis of autism with documented impairment in fine motor and self care tasks. He presents with cognitive/behavioral and sensory processing issues. The prevalence of impairments in fine/gross motor skills appears to be relatively high in autistic patients based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. Studies have shown that occupational therapy is beneficial in this setting in that it prevents deterioration and provides significant improvement in activities of daily living (Case-Smith and Arbesman, and Shoener, et al). As such, occupational therapy is within the standard of care for patients with autism and it is therefore medically necessary for this patient to receive the requested occupational therapy services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a standing x-ray for evaluation of her leg length discrepancy status post right total hip replacement surgery.  Findings:  The physician reviewer found that after total hip arthroplasty, a leg-length discrepancy can be a significant problem to the patient. Discrepancies of less than one centimeter are common, and usually well tolerated (Maloney and Keeney). Functional leg length discrepancy may be the result of tightness of the periarticular soft tissues, and many have resolution of symptoms by six months after surgery (Ranawat and Rodriguez). With time, most patients report good clinical outcomes (Sayed-Noor, et al). The methods used to measure leg length have been the object of much study. Although radiological measurement is the most reliable, tape measurement between fixed anatomical points is also a valid technique (Woerman, et al). The full length x-ray is a valuable procedure for initial evaluation, since there is less radiation exposure, but offers no greater accuracy than other more detailed radiologic studies (Sabharwal, et al). In this case, the patient has already undergone measurement by radiological and tape measurement, with both techniques resulting in comparable results. The addition of another study, specifically a standing x-ray, would require additional radiation exposure and would not offer any additional information of significance. The denial was therefore appropriate as the requested diagnostic procedure is not medically indicated for evaluation of this patients condition status post hip replacement surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested inpatient rehabilitation/detoxification for treatment of his substance use disorder.  Findings:  The physician reviewer found that the records indicate the patient had been tried on outpatient treatment with poor success due to noncompliance with attendants and following the treatment regimen. The patient was started in what appears to be intensive outpatient treatment (IOP), which he did not regularly attend and did not follow the prescribed recommended treatment options in that program. The American Society for Addiction Medicine (ASAM) criteria for acute inpatient hospitalization requires the patient to be a severe withdrawal risk. The patient must require constant supervision for withdrawal symptoms and may present with severe psychiatric symptoms which require 24-hour observation. The criteria suggest the patient may show difficulty with acceptance and treatment and may be in an environment that is dangerous or logistical concerns impede the patients treatment. Overall, the records do not indicate that he was showing any worsening of his psychiatric symptoms necessitating 24-hour supervision and care. Ultimately, the patient does not meet the criteria for an acute inpatient detoxification and CD treatment based on the ASAM criteria for that level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breast for treatment of her bilateral breast densities.  Findings:  Two physician reviewers found that the medical literature shows that a patient who has inherited a harmful mutation in BRCA1 or BRCA2 is about five times more likely to develop breast cancer than a patient without such mutation. Based on the information provided, this patients estimated risk for developing invasive breast cancer over her lifetime (to age 90) is 34.9% compared to 9.3% for a woman of the same age and ethnicity from the general population. In attempts at early diagnosis, studies support the high sensitivity of MRI, ranging from 71% to 100% versus 16% to 40% for mammography in high-risk populations. Further, the American College of Radiology (ACR) appropriateness criteria recommends MRI for evaluation of high risk patients given its increased sensitivity. Clearly, the increased sensitivity of MRI has been established in the screening of high risk patients. Given the recommendations from the ACR and the National Cancer Institute (NCI), this patient meets the criteria established for screening MRI of the breast.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested continued chiropractic visits for treatment of his low back pain.  Findings:  The physician reviewer found that systematic reviews of current literature suggest that spinal manipulative therapy is likely less effective than previously suggested. In addition, there is no scientific data supporting spinal manipulative therapy as superior to other therapies for treatment of back pain. While combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute low-back pain, current evidence neither supports nor refutes that such interventions provide a clinically meaningful difference for pain or disability in people with low-back pain when compared to other interventions.Per the documentation, the patient presented with low back pain and received chiropractic treatment including spinal manipulation during the time periods. The progress notes indicate that the patient had some improvement with these therapies. However, there is no specific documentation describing the patients range of motion, strength or pain scale. Further, the patient has already been instructed in a HEP, which should adequately address her chronic condition. For these reasons, the requested chiropractic treatment has not been established as medically necessary for treatment of this patients back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that although this patient required ongoing intense treatment, the submitted documentation does not demonstrate the medical necessity of residential treatment provided from on the dates in question. During the dates of service at issue, partial hospitalization level of care was medically indicated. Per American Psychiatric Association guidelines, the patient could have been safely and effectively treated at the partial hospitalization level of care. All told, residential treatment provided on the said dates was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech and language delay.  Findings:  The physician reviewer found that formal testing has demonstrated language delay in this child.  She has demonstrated a significant delay in her speech development.  Evaluation revealed a 54 to 65% deficit in receptive language skills and 65 to 77% deficit in expressive language skills. The patients language delay is directly related to failure of normal brain maturation and is a congenital defect.  The current medical literature supports speech therapy in this clinical scenario.  Goorhuis-Brouwer and colleagues evaluated speech-delayed children, such as this patient, and reported that such children are ideal candidates for successful speech therapy.  The article by Law and colleagues also supports speech therapy in this clinical situation.  All told, the requested speech therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees MECP2 duplication syndrome.   Findings:  The physician reviewer found that MECP2 duplication syndrome is a severe neurodevelopmental disorder occurring almost exclusively in males. Clinical features include severe to profound mental retardation, limited or absent speech, early-onset hypotonia with slow motor development, progressive spasticity especially of the lower extremities, and predisposition to infections, epileptic seizures, and features of autistic spectrum disorder. Specific treatments focus on manifestations, such as speech therapy and developmental stimulation, anti-epileptic medications, with aggressive treatment of respiratory infections. General guidelines are a good resource for treatment of other associated conditions, such as therapy for spasticity, medical and rehabilitation therapy for feeding problems and gastroesophageal reflux. Physical therapy is also important to maintain joint range of motion and prevent contractures. Given this patients deficits, it is medically necessary and essential for him to receive speech therapy services given the association of his condition with limited speech and the need to communicate. In fact, speech therapy will be helpful with the patients development of words or use of alternative augmentative communication devices. This is particularly important because of the high association of MECP2 duplication syndrome with autism spectrum disorder, and the communication deficits known to be associated with that diagnosis. With regard to occupational therapy, this patient has not yet had an evaluation. Therefore, it is important to establish his current level of fine motor function as well as determine the need for occupational therapy intervention at this time. Overall, the patient is likely to benefit from occupational therapy services. Thus, an evaluation to determine the patients need for therapeutic intervention is medically necessary to establish goals and the necessity for ongoing services can be determined once the evaluation has been completed.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested the Dynasplint system (E1810) for treatment of her medical condition status post open reduction with internal fixation.  Findings:  Three physician reviewers found that in the peer reviewed literature, Stephenson and colleagues demonstrated that mechanical therapies combined with physical therapies significantly reduced rates of re-hospitalization in an elderly population who had had total knee replacement. Similarly, Dempsey and colleagues highlighted the importance of treating knee flexion contractures and presents a convincing argument that adjunctive use of mechanical therapies is an effective option for patients with knee flexion contractures. The patients studied had all reached a plateau when treated with physical therapy alone. The authors concluded that, We conclude that the adjunctive use of [high intensity stretch] HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures. Given this patients presentation, it was in her best interest to use the low intensity stretch mechanical treatment (Dynasplint) for her likely diagnosis of arthrofibrosis of the knee following lateral tibial plateau fracture. The medical records describe a prompt open reduction internal fixation requiring both homograft and allograft for a depressed lateral tibial plateau fracture. This fracture has a very poor prognosis because of the involvement of the joint surface. Due to this patients young age, it is important the treatment protocol be maximized. The records document a good response to post-operative physical therapy, CPM and low intensity stretch techniques, thus the addition of the Dynasplint was appropriate and should be reimbursed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested Vyvanse 20 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that Vyvanse is the only ADHD medication that includes data on abuse liability. The fact that extensive data is available for Vyvanse and other longer acting medication makes this group of medication a first-line in the treatment of ADHD. Additionally, the patients need to maintain effect for most of the waking hours would make the medication medically necessary. Therefore, the request for authorization and coverage for Vyvanse for this young patient with ADHD has been established to be medically necessary and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that to date, there is no evidence to suggest that proton therapy is superior to image-guided IMRT for prostate cancer. In Zietman and colleagues comparison of the two modalities, the authors found better bladder dose distributions with IMRT. The authors stated that, several authors have compared photon and PBT (proton beam therapy) dosimetry. While the techniques have varied (i.e. conventional, conformal, or intensity modulated), PBT generally can reduce the low (less than 30 Gy) and medium dose (less than 60-70 Gy) regions of the bladder and rectum. However, they also found that, Conventional PBT results in comparatively higher femoral head doses compared to photon therapy, whether conventional, conformal on intensity modulated is used. Ultimately, the authors concluded that, The outcome is similar to IMRT therapy with no clear advantage from clinical data for either technique either in disease control or prevention of late toxicity. Thus, based on the current data, proton therapy may be an option for prostate cancer but has inadequate support in the current literature demonstrating clear benefits over standard treatment with IMRT therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Ambien for treatment of her insomnia. Findings:  Two physician reviewers found that this patients insomnia has been treated ineffectively with Ambien (zolpidem). The records indicate that she was started on the medication a few years ago and steadily self-tapered to a maximum dose of 15 mg at night as she wasnt having the desired effect of sustained sleep for more than 4 hours at a time. As noted in the medical literature, Ambien instant release is indicated for the short-term treatment of difficulty with sleep onset (Greenblatt, et al). In addition, the authors stated that, The natural course of insomnia is thought to involve different symptoms (difficulty initiating sleep or maintaining sleep, non-restorative sleep) at different time points. This patient is requiring aid in initiating sleep onset and maintaining sleep, which is the indication for Ambien CR. Ambien CR (zolpidem MR), is a modified-release formulation of zolpidem developed with the objective of addressing both sleep induction and sleep maintenance (UpToDate). Further, there is no specification by the FDA that it is for short-term use only. Although zolpidem is the active ingredient in both Ambien and Ambien CR, the delivery system is what is different and makes Ambien CR indicated for both sleep induction and maintenance of sleep. As this patient has failed treatment with Ambien (zolpidem), a trial of Ambien CR for her insomnia is appropriate. Based upon the information set forth above, the medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 21-month-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends speech therapy for children with autism. Specifically, the organizations 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 ASD. In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. Studies have shown that occupational therapy prevents deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy and occupational therapy are standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism, it is medically necessary for him to receive the requested speech therapy and occupational therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee has requested radiofrequency neurolysis for treatment of his back pain and lower extremity pain.  Findings:  Two physician reviewers found that the patient underwent a diagnostic block that was shown to provide appropriate response prior to the provider performing the radiofrequency neurotomy. Thus, the patients symptoms are related to facet joint pain rather than radicular pain. Based on systematic review by Datta and colleagues, and applying the guidelines discussed by Manchikanti and colleagues, this patient has been provided with clinically appropriate treatment. Further, the prevalence of facet joint pain has been demonstrated to be 16% in suspected patients and overall 8% in chronic low back pain patients without disc herniation or radiculitis (Manchikanti, et al). Overall, this patient meets the generally accepted criteria for diagnosis of facet joint pain with failed response to transforaminal epidural for nerve root pain. The possible issue regarding a 6-month waiting period prior to repeating the procedure would be satisfied should the patient wait until the said date to undergo the follow-up procedure. As such, the radiofrequency neurotomy was and is indicated and must be approved based on the evidence-based literature and is likely to be more beneficial for management of this patients painful condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested AlloMap molecular expression testing for evaluation of his status post heart transplant.  Findings:  Three physician reviewers found that results of a randomized clinical trial have shown that a strategy using AlloMap testing is an appropriate alternative to a strategy using routine endomyocardial biopsies in stable patients at low risk for rejection who were six months to five years after cardiac transplantation.  This patient fits these eligibility criteria since he was at low risk of rejection based on the prior echocardiogram and prior endomyocardial biopsy results. Additionally, he was greater than six months but less than five years status post cardiac transplant. AlloMap molecular expression testing performed on the date in question was likely to have been more beneficial than available standard therapy since it had been demonstrated to be an effective alternative in this circumstance and involved less risk compared to invasive endomyocardial biopsy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested Lyrica, 100 mg, 3 times per day for treatment of his spinal cord injury with neuropathic pain.  Findings:  The physician reviewer found that in this case, the patient is suffering from complex neuropathy of the left lower extremity possibly due to shingles or a central spinal cord lesion. Etiology aside, neuropathic pain is the same mechanistically transmitted signal through the spinothalamic and dorsal horn tracks. Given the patients history, it is plausible that this could be affecting the conus medularis and the dorsal column of the thoracolumbar junction. This patient has been using Lyrica for 2 12 years with failure of other membrane stabilizers and anti-neuropathic pain agents. The mechanism of Lyrica is extremely effective in severe neuropathy. Given the success of Lyrica for this patient, the history of post-herpetic neuralgia the use of Lyrica has been established as clinically indicated. In addition, Lyrica should be approved for this patient at any strength needed for titration for maximum pain control as long as it is within the recognized therapeutic window of the medication and the patient does not experience any adverse reactions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested residential treatment center services for treatment of the enrollees substance abuse and depression.   Findings:  The physician reviewer found that based upon the documentation provided, the alternate level of care recommended by the Health Plan would have been medically appropriate for this patient. The patients presentation on admission and throughout the course of his RTC stay does not support a need for the intensity of services of an RTC level of care. The records do not demonstrate the patient posed a risk to self or others. Additionally, withdrawal symptoms or other medical issues are not documented in the clinical records. While the patient had a history of family conflict, his parents were noted to be supportive of his recovery. Further, the services recommended by the Health Plan included family therapy. All told, the medical necessity of RTC level of care is not established. The evidence demonstrates the patient could have been safely and effectively treated at a less intensive level of care.