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

The parent of a 10-year-old male has requested speech therapy twice per week for 60 minute sessions for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has severe language deficits associated with the behaviors of ASD. Specifically, speech and language deficits are one of the core aspects of autism and appropriate speech therapy provides the professional help and guidance in communication development for autistic patients. Stone and Yoder found that at two-year follow-up, most patients with ASD developed useful speech or at least improved in their language development. The authors noted that chronological age, lack of typical prerequisite skills, or failure to benefit from previous language intervention, should not preclude speech therapy services from being provided when indicated. The only significant predictors were motor imitation and number of hours of speech therapy. In addition, Goldstein reviewed communication intervention in the peer-reviewed research articles published over the past 20 years and concluded that the evidence supported interventions to teach communication skills to children with autism including speech therapy. All told, language skills can make a significant difference in the ability of young patients to control their environment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested physical therapy sessions for one hour, twice per week for treatment of his quadriplegia status post brain stem stroke. Findings:  The physician reviewer found that this patient had a brain stem stroke more than 10 years ago.  His neurological recovery is expected to have plateaued.  He is reported to have been making recent progress with gait training, but the records do not clearly demonstrate significant functional progress.  It is not clear that the recent ambulation gains that are reported are not essentially just a reversal of a regression that occurred over a period of about eight months prior to the change in therapy venue. In the submitted letter, it was reported that the patient needed minimal assistance 75% of the time, but the level of assistance needed the other 25% of the time was not documented. Overall, his ambulation levels have been fluctuating, but have been very modest.  It is not evident that his ambulation has been functional outside of the therapy setting.  Furthermore, it is not evident that his overall functional status outside of the therapy setting has been improving.  He has continued to require 24-hour caregiver supervision and/or assistance. There is no documentation of significant progression towards independence with respect to his primary means of mobility at home or in the community (e.g., using a manual or power wheelchair). In addition, it is not evident from the records that functional ambulation in the home or community would have been a realistic or safe recent functional goal.  There are no documented physician examinations in the records that clarify what his cognitive status, manual muscle testing levels, proprioception, cerebellar functioning or spasticity levels are.  He had been undergoing extensive physical therapy, including gait training, for a long period of time.  Despite this extensive therapy, however, he had not achieved functional ambulation.  The additional physical therapy in question, therefore, would not have been expected to have resulted in significant, sustained functional gains.  The therapy was maintenance in nature.  All told, physical therapy sessions performed were not medically indicated. Additionally, the medical necessity of continued physical therapy, one hour, twice per week, has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on the available medical literature, 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) developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. 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. The authors concluded that, Individuals with mild autism should also receive adequate assessments and appropriate diagnoses.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, behavior, and classroom performance. In support of the need for occupational therapy, studies have shown benefits that prevent 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a bone growth stimulator (Orthofix) for treatment of her history of low back pain.  Findings:  The physician reviewer found that spinal fusion for the treatment of pain is done to gain stability and eliminate excessive motion at the involved spinal levels, and pseudoarthrosis limits success. Electrical stimulation has been shown to be of value in the management of long-bone non-union, and has been employed in spinal fusion in the attempt to increase the rate of fusion. However, conclusions regarding efficacy are difficult to establish because of inconsistencies in determining a reliable, reproducible end point for fusion, and further studies are necessary to evaluate the value of electrical stimulation in spinal fusion. Some reports have been encouraging, but problems remain. Improved fusion rates have been reported in patients in high-risk categories. In such cases, patients undergoing anterior cervical spine fusion showed increased fusion rates at six months, but no significant difference in fusion rate at twelve months, as noted by Foley and colleagues.  In this case, there is no documentation that the patient is at increased risk of non-union of the proposed spinal fusion, such as a prior history of lumbar spine surgery. There is no documented history of smoking, and a single-level fusion is planned.  In this clinical scenario, the device at issue was not medically indicated.  All told, the bone growth stimulator (Orthofix) was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for anterior L4-5 and L5-S1 discectomies and intervertebral fusions with femoral ring allograft bone grafts, autogenous local bone graft and calcium phosphates and placement L4 to S1 bioabsorbable buttress screws, followed by a posterior revision L4-5 left microdiscectomy/decompression, posterior revision L4-5 right decompression, posterior revision L5-S1 right decompression, L4 to S1 posterolateral instrumented fusions with pedicle screws, autogenous local bone graft, allograft bone graft and calcium phosphates for treatment of her low back pain.  Findings:  The physician reviewer found that surgery for radiculopathy with disc herniation or symptomatic spinal stenosis may be of benefit, but for non-radicular back pain associated with degenerative changes, it is no more effective than rehabilitation. Fusion may be indicated in specific pathologies and instabilities, but low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. Although MRI is an excellent tool to study morphology, these findings must be related to clinical examination and other studies to provide meaningful judgments.  In this patients case, the indications for spinal fusion have not been documented. There is no documentation of instability on the radiologic studies.  EMG/NCV evaluations on two occasions indicated the presence of polyneuropathy rather than radiculopathy. The polyneuropathy was not evaluated based upon the submitted documentation.  No consistent pattern of neurologic loss on examination is documented.  There is limited documentation of non-surgical management prior to the recommendation for fusion.  All told, the requested procedures are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A then 52-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients primary presenting symptom was a sore throat. The medical records do not substantiate the patients contention that he was experiencing severe ear pain. Sore throat is a common affliction treated by most adults with home remedies or by primary physicians. Sore throats are caused by viruses in the vast majority of adults. The patient contends that his condition, exudative pharyngitis, was more severe than a simple sore throat and required immediate medical attention. Exudative pharyngitis is a sore throat with the presence of pus or other thick drainage. It is not a condition that would cause a prudent layperson to believe that the absence of immediate medical care would result in serious jeopardy to his health, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested care rendered for treatment of his parent-child relational problem, bereavement and conduct disorder, adolescent-onset type. Findings:  The physician reviewer found that the medical necessity for treatment in a 24-hour residential setting during the time period at issue is not established. Treatment interventions during the stay reflect individual and group therapy. American Academy of Child and Adolescent Psychiatry guidelines for the treatment of conduct disorder indicate the benefit of multimodality community-based treatment and multi-systemic therapy. Other intense services, such as wraparound services and aggressive case management along with intense family interventions, have documented benefit.  Per the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System, this patient was a candidate for treatment in a less intense setting during the period at issue. In this patients case, outpatient services were medically appropriate. All told, care rendered during the time period in question was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested water physical therapy for treatment of his multiple sclerosis and sciatica. Findings:  The physician reviewer found that this patient does not have a condition for which water physical therapy is medically necessary.  The patient has weakness in the limbs, but not to the degree that he cannot participate in land-based therapy.  Notably, he has undergone extensive land-based therapy to date, including very recently.  While participation in some exercise is generally encouraged in the setting of multiple sclerosis for symptoms such as fatigue, there is a lack of high-grade evidence of its benefit.  Additionally, there is no specific recommendation supporting the need of aquatic therapy, particularly if land-based therapy is feasible.  The Health Plan has offered continued land-based physical therapy, and this alternative is medically reasonable and appropriate in this patients case. All told, the requested water physical therapy is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested compounded progesterone powder with compounded Tri-Est for treatment of her postmenopausal.  Findings:  Three physician reviewers found that Tri-Est is a combination of estriol, estradiol and estrone. In 2008, the Food and Drug Administration (FDA) stated that estriol is not a component of an FDA-approved drug and has not been proven safe and effective for any use. The FDA has noted concerns regarding the safety and efficacy of compounded bioidentical hormones. The FDA noted that compounded drugs are not reviewed by the FDA for safety and effectiveness.   The American Congress of Obstetrics and Gynecology (ACOG) has also weighed in on this topic. In 2009, ACOG reiterated its position that there is a lack of scientific evidence supporting the safety or efficacy of compounded bioidentical hormones.  ACOG noted that bioidentical hormones have not undergone rigorous testing for safety or efficacy, and hormone therapy does not require customized dosing.  Thus, at this time, the current medical evidence has not demonstrated that bioidentical hormones are more efficacious than other treatment options.  In this patients case, the superior efficacy of the requested compounded progesterone powder with compounded Tri-Est has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested left side radiofrequency neurolysis for treatment of her chronic low back pain and right leg pain. Findings:  Three physician reviewers found that the standard of care requires a diagnostic block to be conducted prior to a therapeutic block and this was not done in this patients case. Manchikanti and colleagues stated that, For therapeutic interventions, the diagnosis (of facet joint pain) must be established with a positive response to controlled local anesthetic blocks with 80% relief. It does not appear that a diagnostic block has been performed in this case. Further, Nalini and colleagues concluded that the available literature Pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain. Moreover, all of the studies that were used to prove the efficacy of medial branch blocks were conducted in patients who did not have prior surgery at the planned block levels. Thus, the requested procedure in this patient should not be expected to provide her with benefits beyond that anticipated with standard treatment modalities and was appropriately denied.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that this patient only showed a limited response to the TMS treatments as evidenced by the fact that her BDI score remained in the severe range following therapy. In addition, the evaluation notes are inadequate to establish that other factors which could have adversely affected the prognosis had been ruled out prior to initiation of TMS. There are some notations considering the diagnosis of bipolar disorder, which has not been shown to be responsive to TMS as noted in studies in the earlier part of this decade (Kaptsan, et al. and Nahas, et al). This patients records do not indicate that she has ever undergone a course of electroconvulsive therapy (ECT), which the American Psychiatric Association (APA) treatment guidelines support as the most effective treatment for depression. Further, a recent controlled study published in 2007 conducted by Eranti and colleagues corroborate these findings. Overall, the APA guidelines suggest that treatment resistance may be a negative prognosticator for treatment with TMS. Moreover, Lam and colleagues meta-analysis concluded that additional studies are needed before TMS can be established as effective in the treatment of refractory depression. Similarly, Martin and colleagues found that the evidence supporting the efficacy of TMS remains inconclusive. In this particular instance, the patient exhibited some response to TMS treatment and reported having a partial response to Vivactil in the past. All told, the current peer reviewed research does not establish that TMS is superior to, or even the equivalent of, standard, accepted therapies. Considering this patients history as presented in the records provided for review, it cannot be established that a re-challenge with Vivactil, a trial of an MAOI or a course of ECT would not have been more effective than the TMS treatments provided in the management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested surgery for treatment of her neuromas.  Findings:  The physician reviewer found that this patient has received multiple diagnoses from various providers as the cause of her foot pain. The diagnoses have included neuroma, neuropathy, complex regional pain syndrome, depression, and fibromyalgia. The record indicates that neither podiatrist who diagnosed the patient with neuroma could elicit a positive Mulders click. In addition, the MRI did not reveal a mass or neuroma to either foot, while in general, neuromas are recognizable on MRI. In practice, surgery is not clinically indicated for this patient given the lack of definitive diagnosis. For these reasons, the requested surgery is not likely to resolve this patients medical problem and therefore the procedure is not medically necessary for treatment of her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested neuropsychological testing for the date in question, for treatment of his metastatic gastroesophageal adenocarcinoma status post right paramedian cerebellum resection and radiosurgery. Findings: The physician reviewer found that upon reviewing the current medical literature, it becomes clear that whole brain radiation therapy (WBRT) is considered the standard of care for brain metastases. WBRT decreases the tumor burden, which delays neurocognitive decline and maintains quality of life. However, WBRT can also cause brain injury and neurologic complications. Specifically, there is risk of dementia in long-term survivors of brain metastases treated with WBRT, which is thought to be dependent on the total dose of radiation, the size of the irradiated field, and the fraction size. Understanding and measuring the neurotoxicity associated with WBRT is important for evaluating different treatment regimens beyond the effects on survival and time to disease progression. In addition, baseline neurocognitive function also is predictive of overall survival. In one publication from Li and colleagues, the researchers examined the short-term impact of WBRT on neurocognitive and quality of life measures. In the study, patients were administered neuropsychological tests at baseline, at the end of radiation therapy, and at one-month follow-up. Although declines in tests scores occurred immediately after radiation, improvements in neurocognitive and quality of life measures were found at one month post-WBRT compared to pre-WBRT, with the majority of patients showing improved or stable performance compared to baseline in memory, attention, and executive function. Further, most clinical trials employ neurocognitive assessments at the baseline as well as post radiation. Future clinical trials will be designed to answer questions such as the role of omitting upfront WBRT, the benefit of administering prophylactic cranial irradiation to highly metastatic cancers, the value of using hippocampal sparing techniques, and the addition of radiosensitizers. In order to answer these questions and evaluate various treatment regimens that may have minimal differential effects on survival and disease progression, it is important to assess other patient outcomes, especially functions affected by neurotoxicity. For these reasons, tests of neuropsychological functioning should be included as standard outcome measures in patients treated with WBRT. Thus, the diagnostic testing performed in this patients evaluation was therefore medically indicated and necessary for evaluation and treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested total disc replacement (TDR) utilizing the ProDisc-C artificial disc for treatment of his left sided cervical radiculopathy. Findings:  Three physician reviewers found that in regards to this particular patient, the manufacturer specifically states that the ProDisc-C device is contraindicated in patients with symptomatic cervical disc disease at more than one level. The patients provider reports cervical disc disease at both C5-6 and C-7. Given the guidelines for usage of this device and the clinical data, the prosthesis is intended for use at a single-level in patients with only one level symptomatic cervical disc disease. For these reasons, the requested surgery would not be expected to be more beneficial than conservative therapy for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested removal of benign lesions for treatment of his skin lesions. Findings:  The physician reviewer found that this patient is requesting coverage for treatment of seborrheic keratoses.  Seborrheic keratoses are benign skin lesions that do not have malignant potential.  Hafner and Vogt noted that this is a benign condition, and treatment of these lesions is not medically necessary, but may be done for cosmetic reasons.  Based upon the submitted medical records, there is a lack of documentation regarding the symptomatic nature of these lesions. There is no medical indication for removal of the skin lesions in this patients case.  All told, the medical necessity of the requested removal of benign skin lesions has not been established by the submitted clinical documentation.