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

The parent of a six-year-old female enrollee has requested neuropsychological testing for evaluation of the enrollees autism.  Findings:  The physician reviewer found that the relevant medical literature suggests that a neuropsychological assessment is indicated whenever a child has a known or suspected medical or neurologic condition that can be expected to have an impact on the developing brain. Specifically, ASD is a neurodevelopmental disorder for which neuropsychological studies have yielded profiles ranging from wholly intact to severe impairment. Simpler abilities including basic attention, elementary motor, simple memory, and formal language may be intact or enhanced with ASD. Higher-order cognitive abilities, or those requiring integrative processing, are often disproportionately impaired in ASD. Thus, neuropsychological testing is the basis for determining an estimate of the general level of functioning, assessing the integrity of specific behavioral functions, and evaluating functions. Further, it also helps to determine the services and supports needed from specialists. For these reasons, the neuropsychological testing performed on the date in question was medically indicated and necessary for proper evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested partial hospitalization program (PHP) level of care services for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient is severely impaired by his autism. The history reveals that the patient has received maximum services at the outpatient level beginning at two years of age. He was admitted to PHP because he posed a danger to himself due to his self-injurious behavior and lack of safety awareness. Additionally, the patient was showing signs of regression despite maximum support. The records indicate that he has been making some progress in PHP. While his progress is admittedly slow, this is the natural course of treatment with autistic disorders. Thus, the patients seemingly slow progress in PHP to this point is not unusual for this condition.  Based on the progress notes provided, the patient continues to be a danger to himself and continues to require an intensity of services that can only be provided at the PHP level. He is at risk of further regression if his treatment level is lowered at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested skilled nursing services eight hours per day for treatment of the enrollees multiple medical conditions.   Findings:  The physician reviewer found that this patient is medically fragile with very complex medical problems and the potential for severe decompensation. He requires round-the-clock diligence to prevent the myriad of complications that could occur. He has been assessed with chronic lung disease and reactive airway disease and requires aggressive pulmonary care, including frequent suctioning, breathing treatments, and Vest therapy. He also occasionally requires supplemental oxygen. He is at increased risk for aspiration because of gastroesophageal reflux and intractable seizures, and has been hospitalized multiple times with this diagnosis. While trained unskilled caregivers can safely administer routine enteral medications and feedings, only caregivers with professional training and expertise can detect subtle changes in respiratory status and respond with appropriate adaptations to the treatment regimen, thus preventing progression to more severe respiratory compromise. In addition, this patient requires frequent suctioning, medication administration, skin care, and therapeutic manipulations.This level of care requires experience and attention to detail so that needs are met, problems recognized promptly, and treatment administered in a timely fashion. While trained family members are often capable of assisting with care of children with this degree of complexity, skilled nursing is essential to provide adequate care. As such, I find that the skilled home nursing services the patient received during this period of time were medically appropriate and necessary for this patient. Furthermore, the submitted documentation demonstrates the patient continues to require this level of care, and therefore, the request for ongoing skilled nursing services at a frequency of eight hours per day is 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 speech delay. Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Differential diagnosis is critical to designing appropriate intervention, which should be tailored to the parents goals along with the patients clinical and educational needs. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. Shevell and colleagues evaluated patients under 5 years of age who were referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Of these patients, 99 children (71 boys) were found to have global developmental delay with 96% found to have a mild or moderate delay. It was concluded that an etiologic diagnosis is often possible in the young patient with global developmental delay, particularly in the absence of autistic features. Overall, research shows that children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. In addition, patients seen alone for treatment tend to progress better than those seen in groups. As the patient improves, treatment may be indicated less frequently, and group therapy may become a more appropriate alternative. DeThorne, in his article, found experimental support for 6 treatment strategies that have been used to facilitate speech development in young children with developmental disabilities, thereby showing that therapy does help. In this case, the report by the speech therapist is below standards as it fails to provide a diagnosis or degree of delay, goals, prognosis, or physical or anatominal examination. The patient in this case does not have any evidence of autism, however the provider apparently did not examine him further for an etiology of his speech delay. Thus, a detailed and complete speech and language evaluation should be performed by an independent therapist for an accurate diagnosis. A work-up should also be performed to look for possible etiology of the patients speech delay. Given this patients speech and language delay, it is medically necessary for this patient to receive the requested speech therapy services for a minimum of five hours per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested bilateral reduction and extended panniculectomy and abdominoplasty  for treatment of her excess skin and fat.  Findings:  The physician reviewer found that based on the records provided, the patients condition constitutes an abnormal structure of the body. Given the previous authorization for surgery and records from the treating surgeon indicating macromastia symptoms dating back to 2008, there is evidence supporting an abnormal structure as the patients macromastia is documented to cause her painful symptoms. Further, breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, when these symptoms are present. To further delineate this group of patients, a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. This also makes intuitive sense because if the surgeon removes a small amount of tissue it is highly unlikely that would have any effect on back pain. In general, as the amount removed is increased, the procedure shifts from a cosmetic procedure to a medically necessary and reconstructive procedure. The Schnur scale accounts for varying body types by relating the amount removed to body surface area of the individual patient. With regard to this patient, the removal of over 600 grams of tissue from one breast meets these criteria. In addition, the breast reduction surgery was performed to improve function by relieving the patients back and neck pain as well shoulder bra strap grooving. Despite the operative report listing sagging breasts as the indication for breast surgery, the removal of more than 600 gm from a breast indicates this procedure was performed with greater clinical justifications. The treatment for sagging breasts is just a breast lift (mastopexy) with little or no breast tissue removal. Considering the amount of tissue removed from each breast and the abdomen, it is likely that the surgery at issue improved the patients appearance however this was not the primary goal of the procedures.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a transcutaneous electrical nerve stimulation (TENS) device for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that a TENS unit is used to deliver electrical stimulation or a current to tissue from cutaneous pads or leads. The device is portable and not implanted. The existing scientific data suggests that TENS can be used for both chronic and acute pain relief, however the indications are controversial. There are only a few reports of TENS in bladder patients and no large, empirical evidence exists to support its utility in this patient population. Further, the contention that the TENS unit may be used to strengthen pelvic floor muscles is without merit as bladder dysfunction is not related to the strength of the pelvic floor sling, rather it is due to intrinsic bladder muscle dysfunction or irritability. Given the lack of studies demonstrating the efficacy of the TENS unit in the treatment of patients with unstable bladder symptoms, its use in the treatment of this patients condition was not likely to produce better results than standard, accepted therapies.
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 the records from the residential treatment facility do not demonstrate that the patient was and/or is a risk to himself or others. The patient appears to be motivated and is actively participating in treatment. No withdrawal or medical issues were noted. The patient was taking passes and spending time off the unit with no documented adverse consequences. He was expressing appropriate anxiety around his ability to maintain sobriety following discharge. Additionally, the records do not document the use of an evidence based treatment for substance abuse or depression. There is no evidence of physician monitoring or consultation during the patients residential stay. The records provide no indication that the patient was being prescribed any medications for the diagnosis of major depressive disorder. The evidence based practice guidelines indicate that patients with major depression and substance abuse should be treated in the least restrictive setting that is likely to prove safe and effective. The data submitted for review fails to establish that the patient could not have been safely and effectively managed in a less intensive setting such as partial hospitalization. As such, medical necessity for the disputed residential treatment services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested high dose rate (HDR) brachytherapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that while there is growing interest in HDR as an emerging technique for low-risk, early stage prostate cancer, the data supporting its use remains limited. There are no randomized studies to show a benefit of monotherapy HDR over other treatment modalities. In addition, some of the data on HDR has been retrospective, which is subject to bias. In summary, although HDR is a means to deliver radiation, and has a track record comparable to other radiation modalities, it is not medically necessary in this patients clinical situation given that other radiation approaches are available that compare favorably with respect to toxicity and cancer control.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for Oncotype DX Gene Expressing Profiling Assay (Oncotype DX Assay) for evaluation of his breast cancer. Findings:  Two physician reviewers found that the Oncotype DX Assay is multi-gene profile of an individuals breast cancer cells. It provides unique biologic information that predicts the risk of breast cancer recurrence within 10 years if chemotherapy is not used. Furthermore, it provides data as to whether chemotherapy is likely to be of benefit. The use of the Oncotype DX Assay has become standard of care in appropriate situations (female patients with estrogen receptor positive, node negative and HER2 negative breast cancer). For female patients, its use is within National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines. There is far less data in relation to male patients with breast cancer. A study by Shak demonstrated that males had a similar distribution of the genes within the assay as females. Generally speaking, male breast cancer is treated by the same guidelines as is female breast cancer. In view of its relative rarity, a study large enough to prove the validity of the Oncotype DX Assay in male patients is not likely to occur. However, the oncology community has accepted the validity of Oncotype DX analysis in this population. All told, there is adequate evidence demonstrating that the Oncotype DX Assay is likely to be of clinical benefit in men with breast cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Crestor 20mg for treatment of his hyperlipidemia and peripheral vascular disease. Findings: The physician reviewer found that in this circumstance, medical therapy for treatment of hyperlipidemia with an HMG-CoA reductase inhibitor is reasonable, appropriate, and considered standard accepted practice in the medical community. However, this patient has not had a trial of higher dose of the Health Plans preferred statin, Zocor, at 80 mg per day. As such, the patient has not demonstrated treatment failure to that regimen. In addition, there is no evidence of side effects to any of the preferred formulary statins. Moreover, the patients records do not document increased risk of intolerance such as a history of rhabdomyolysis, advanced age, uncontrolled hypothyroidism, or renal impairment. Since the Health Plans preferred statin, Zocor has been shown to improve cardiac outcome and there is no evidence of incremental outcome benefit with Zocor at similar lipid levels, the use of Crestor at this time is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested bariatric surgery (laparoscopic Roux-en-Y) for treatment of her obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient meets the National Institutes of Health (NIH) consensus definition of clinically severe obesity. The patient completed a thorough multidisciplinary evaluation that included dietary, behavioral, metabolic and medical clearance. However, while the patient reports participating in Weight Watchers as well as other weight loss programs, there is a lack of objective data documenting the patients weight loss attempts in the records provided. NIH criteria requires adequate documentation of sustained efforts to lose weight prior to consideration of bariatric surgery. In the absence of such evidence, the medical necessity of the requested laparoscopic Roux-en-Y procedure is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested psychiatric partial hospitalization program care for treatment of the enrollees autism.   Findings:  The physician reviewer found that a review of medical records supports the medical necessity for this patients continued participation in the PHP program for the dates of service in question. The providers progress notes document that the patient engaged in self-injurious behavior numerous times per day. The patient was noted to engage in verbal and physical self-stimulatory behavior on numerous occasions in the providers notes, requiring constant adult redirection. Based on the medical documentation, discharge to a lower level of care would likely have resulted in an exacerbation of symptoms related to the patients diagnosis of autism. Further, PHP level of care during the period at issue was consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care guidelines, the American Academy of Child and Adolescent Psychiatry (AACAP) recommendations and peer reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Novolog Flex Pen and Lantus Solostar Pen medications for treatment of his diabetes mellitus type II.  Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the Novolog Flex Pen and Lantus Solostar Pen are medically necessary for this patient. There is no evidence that the patient will experience adverse consequences in the absence of the specific medications requested. While the insulin pens such as those requested by the patient are generally easier to use, there are alternate options available in this setting. For example, as has been suggested by the patients provider, the insulin can be pre-loaded into a syringe to avoid breakage; another option would be to carry the insulin vials in a case. In the absence of evidence of a medically valid indication for the use of Novolog Flex Pen and Lantus Solostar Pen, the medical necessity of the proposed medications is not established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested occupational therapy and speech therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that based on the records provided, the requested speech and occupational therapy with sensory integration for this patients delays are medically necessary based on an overall evaluation of the literature, including a positive analysis from Myers and colleagues. Key to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease such as the pathogenetic process that gave rise to this patients speech and language delays, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, sensory integration-based occupational therapy and speech therapy for this patient are necessary to reduce the physical and mental effects of the patients underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that review of the submitted documentation reveals that this patient meets the criteria for weight loss surgery as set forth by the National Institutes of Health (NIH) recommendation guidelines. In addition, the patient has documented co-morbidities associated with morbid obesity. The overwhelming scientific evidence supports the position that weight loss surgery is the most effective method for sustained weight loss and should resolve or improve many of the patients co-morbidities that are associated with obesity. Further attempts at standard weight loss measures are not likely to allow this patient to achieve adequate weight loss. As such, bariatric surgery is medically appropriate and indicated in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Bystolic for treatment of her essential hypertension. Findings:  The physician reviewer found that from a review of the available records, it appears that the patient had adequate control of her blood pressure for several years but then was changed to Bystolic due to fatigue believed to be secondary to Atenolol. Bystolic is a third-generation beta-1 receptor blocker that has been shown to improve diastolic function and reduce mortality in elderly heart failure patients.Coverage for Bystolic was denied as multiple other beta-1 selective agents were available on the Health Plans formulary. This appears to be a very reasonable cause for denial since the patients records do not indicate that she has been treated with any of these other agents. Furthermore, the use of beta blockers for initial monotherapy in patients with uncomplicated essential hypertension is no longer considered to be optimal except in the post-myocardial infarction patient or heart failure patient population. Alternative therapies include thiazide diuretics, angiotensin converting enzymes inhibitors, angiotensin II receptor blockers, or calcium channel blockers. In view of these multiple considerations, the requested Bystolic has not been demonstrated to be medically necessary for treatment of this patients medical condition. Other medications, available under the patients formulary, would be appropriate for attempts at management in this patients case.