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

A 65-year-old male enrollee has requested for an interferential unit/TENS unit for treatment of his chronic shoulder pain. Findings:  The physician reviewer found that there is a lack of published, high-grade, randomized, controlled trials that have demonstrated the efficacy of interferential stimulation devices in musculoskeletal conditions or pain syndromes over placebo controls or basic conventional care consisting of analgesics, self-applied thermal modalities and a self-directed exercise program.  All told, the requested interferential unit/TENS unit is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested for the Power Standing Dani Dynamic device for treatment of the enrollees cerebral palsy and seizure disorder.  Findings:  Three physician reviewers found that being in an upright position including the ability to be free and move around is the goal in this setting. It is important to be upright to promote proper bone development and strengthen the body. Most wheelchairs, however, do not allow a child to explore his or her environment or be at height with peers. Most mobile standers, use large wheels like those found on a wheelchair to allow a child to self-propel them. These standers are excellent for placing a child at the same height as her peers. The vertical wheeler is a new mobility aid that was specifically designed to help improve quality of life by providing mobility while standing. Results of a clinical trial in a population of patients with cerebral palsy showed that the children in this cerebral palsy group all benefited from ambulation with the wheeler (Manley, et al.). Patients with spastic quadriparesis seemed to gain the most immediate benefit. The device contributed to improved mobility, posture, and self-image. The wheeler has the potential for improving the psychologic and medical status of individuals with severe locomotion impairment (Manley, et al.). The device will allow her to perform activities of daily living without much assistance and dependence on others. Therefore, the requested device is appropriate for treatment of this patients medical condition and is likely to be more effective than any standard equipment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Lantus Solostar 100 unit/MI (3MI) subcutaneous insulin pen for treatment of her type I diabetes. Findings:  The physician reviewer found that the patient was using a short 30 gauge pen needle manufactured by Novo Nordisk for use with the Solostar pen. A review of the available medical literature reveals there are many manufacturers of pen needles. They are available in different gauges, 29  32, and lengths, 4  8 mm. There are at least 10 manufacturers of insulin syringes and they also come in the same gauges and short lengths, usually 8mm. Thus, the patient has the alternative of using short needles either attached to the Solostar or a syringe. Therefore, the use of a Lantus Solostar pen is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for a bariatric surgical consultation for treatment of her obesity. Findings:  The physician reviewer found that two different heights are documented by the patients provider. The discrepant heights need to be reconciled before the appropriateness of a bariatric surgery consultation can be determined. Additionally, the medical necessity of bariatric surgery is not strictly determined based on minimum weight and co-morbid condition criteria to fulfill standard the definition of morbid or clinically severe obesity. If the patient is determined to have clinically severe or morbid obesity, in accordance with the standard guidelines for bariatric surgery such as the NIH consensus guidelines, there must also be clinical documentation of failed weight loss efforts in order to be considered for surgical intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested hyperbaric oxygen therapy treatments for treatment of his early onset Parkinsons disease. Findings:  Three physician reviewers found that hyperbaric oxygen (HBO) is a reasonable therapy in severe decompression sickness or arterial gas embolism and carbon monoxide therapy. HBO may be useful in the care of patients with cyanide poisoning, severe anemia, actinomycotic brain abscesses, acute crush injuries, prior radiation therapy, aggressive soft tissue infections, nonhealing ulcers, or compromised skin grafts and flaps. At present, there is limited evidence about the impact of hyperbaric oxygen on Parkinsons disease. Large, randomized clinical trials with long-term follow-up are required to demonstrate that hyperbaric oxygen provides health benefits, to define the clinical role of HBO, and to establish patient selection criteria. There is a paucity of such studies being performed in the available peer reviewed medical literature. As such, there is insufficient scientific data to support the use of HBO for the treatment of Parkisons disease.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested the Provent SR nasal device for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that Provent SR is an FDA approved device for patients with obstructive sleep apnea. Alternative therapies, such as a dental appliance and pillar procedure are also possibly effective, but would require additional sleep studies to confirm. Additionally, the patients provider has indicated that this patient is not a surgical candidate. The submitted clinical evidence demonstrates that this patient has failed a trial with a standard CPAP device and his sleep study results indicate a positive response with the Provent SR device. Therefore, this device is likely to be more beneficial for treatment of this patients obstructive sleep apnea than the available standard therapy.
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 this patient has an identified delay in expressive and receptive speech of approximately 25-50% per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children (DAYC). According to Law and colleagues, speech therapy is indicated with any delay greater than 25%. An extensive review of the literature including the meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the patients language profile and level of communication skills. Approximately 50% of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Children in bilingual households show language mixing in the early phases of language development but are able to segregate the languages into two separate systems as they acquire more language skills. Their development rate is not delayed if the accomplishments of the two languages are added together (Feldman and Messick). This patient has continued to display expressive and receptive language impairment with decreased acquisition of language skills. Therefore, speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested physical therapy for treatment of his delayed developmental milestones, visual impairment, autism and cerebral palsy.  Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life, and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits. Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.  Physical therapy is a mainstay of treatment for cerebral palsy. Its focus on function and movement maximizes a childs potential for independence and mobility.  This patient has cerebral palsy, visual impairment, and autism. He has shown progress with physical therapy up to this point, particularly with gait. However, he continues to have significant challenges that impact his functional mobility, and these challenges can be successfully addressed with physical therapy interventions. All told, the requested physical therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Nutropin for treatment of the enrollees hypothalamic growth hormone deficiency. Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Societys recent guidelines, a trial of growth hormone (GH) therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; growth velocity below the 25th percentile for bone age; bone age more than 2 SDs below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of GH deficiency. This patient meets most of the above criteria based on the information provided. As such, a trial of GH therapy is medically warranted for treatment of the FDA-approved indication of idiopathic short stature with poor adult height potential. After a trial of GH, the patient should be re-evaluated to determine the necessity of continued GH treatment, based on response to therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollees mixed receptive and expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al. and Feldman & Messick). An extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement then those children who receive no treatment (Feldman & Messick). This patient continues to display expressive and receptive language impairments with decreased acquisition of language skills. Therefore, speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Orecea for treatment of her rosacea. Findings:  The physician reviewer found that although doxycycline is not available in a topical form and therefore is not a treatment alternative for rosacea, it is reasonable to treat this patient with oral doxycycline for at least one month prior to authorizing the requested Oracea. The approved indications and usage guidelines for the use of Oracea in the treatment of rosacea specifically state that Oracea may be approved for the treatment of inflammatory lesions of rosacea in adult patients that have demonstrated failure of, or clinically significant adverse effects to, doxycycline 50mg. Similarly, the study conducted by Del Rosso and colleagues concluded that doxycycline 40mg once daily (Oracea) has been shown to produce clinically significant improvement in patients with rosacea. However, the Toossi and colleagues study reported improvement in rosacea patients when treated with subantimicrobial doses of oral generic doxycycline 20mg twice daily. Therefore, it is clinically reasonable to treat this patient with generic doxycycline for at least one month, and if she demonstrates failure to this therapy, then authorize the requested use of Oracea.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested magnetic resonance imaging (MRI) of the left breast for treatment of her dimpling in the lower inner quadrant of the left breast seen on mammogram.  Findings:  Two physician reviewers found that review of the peer-reviewed literature yielded support for the utility of breast MRI for evaluation of inconclusive findings following a standard evaluation including physical exam, mammography and breast ultrasound. As noted by the American College of Radiology (ACR) guidelines, MRI is useful for lesion characterization when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g., possible distortion on only one mammographic view without a sonographic correlate). Similarly, the American Society of Breast Surgeons recommend breast MRI for further evaluation of suspicious clinical findings or imaging results that remain indeterminate after complete mammographic and sonographic evaluations combined with a thorough physical examination. This patient has dimpling of a portion of the left breast that is often a clinical presentation of breast cancer. The patients mammogram and breast ultrasound were normal and it is not possible to perform a biopsy as there is no focal abnormality noted on physical exam, mammography or breast ultrasound. Overall, this patient has inconclusive findings following standard work-up for which the requested breast MRI is likely to be more beneficial for evaluation and treatment than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech therapy for treatment of the enrollees stated condition of a speech delay.  Findings:  The physician reviewer found that this patient has an identified articulation disorder of speech with a mild receptive/expressive delay.  Speech therapy is indicated with any delay greater than 25% (Feldman & Messick and Law, et al.). Extensive review of the literature including meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with articulation disorders typically have mild-to-moderate deficits in speech, and most of their speech may be intelligible to unfamiliar listeners despite the errors. The goal of articulation therapy is for improvements in functional communication. Speech therapy is particularly useful in helping affected children to identify and practice the mature patterns of speech. Children with speech disorders often experience embarrassment and poor self-esteem. Therapy is designed to reduce the negative psychological consequences of the disorder and direct remediation (Feldman & Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). This patient continues to display expressive and receptive language impairment with a significant articulation disorder.  Therefore, speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees delays in expressive language skills.  Findings:  The physician reviewer found that the current medical evidence supports the requested speech therapy services in this patients case. As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Per Nelson and colleagues, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age.  Thus, speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  Law and colleagues noted that approximately 6% of children have speech and language difficulties.  The authors noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. This patient has expressive language delay, negatively impacting his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested a wireless capsule endoscopy and dummy capsule for evaluation of his Crohns disease. Findings:  Two physician reviewers found that the peer reviewed medical literature provides ample data supporting the utility of a wireless capsule endoscopy in assessing small bowel Crohns disease (Cohen, et al). Use of a dummy, or patency capsule, is recommended when small bowel luminal diameter may be compromised as in this patients situation. Given this patients longstanding history of Crohns and extensive use of non-invasive methods to evaluate his condition, the requested wireless capsule endoscopy is likely to be more beneficial for acquisition of novel and useful information relevant to this patients care than any conventional alternative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the TMS therapy provided this patient from the date in question and forward will likely be more beneficial for treatment of the patients depression than any available treatment modality.
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 delayed speech.  Findings:  The physician reviewer found that this patient has an identified delay in expressive and receptive speech of 40-50% per the DAYC subtest and the RITLS with a 30-40% delay in pragmatics. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.