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

The parent of a 15-year-old female enrollee has requested child/adolescent psychiatric residential treatment for treatment of the enrollees mood disorder, not otherwise specified, oppositional defiant disorder, post-traumatic stress disorder and parent-child relational problems.  Findings:  The physician reviewer found that the record indicates that the patient was largely oppositional and impulsive, culminating in an elopement attempt on the said date. However, a few weeks thereafter, she had shown significant improvement, and precautions were removed. She showed continued improvement during the course of her stay at the facility and did not show evidence of impulsivity or severe oppositional behavior. There is no indication of risk to self or others at any time during the course of her stay. She appeared to be participating avidly in the program and was motivated for recovery. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. The data submitted for review indicate that discharge prior to the said date would not likely have resulted in a positive treatment outcome due to the patients impulsivity. The patient could not have been safely managed on an ambulatory basis prior to the date in question.  All told, child/adolescent psychiatric residential treatment provided from during this time was medically indicated for the treatment of this patient.  The medical necessity of child/adolescent psychiatric residential treatment going forward has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested acute inpatient psychiatric treatment for treatment of her major depressive disorder, severe, eating disorder, not otherwise specified, post-traumatic stress disorder and obsessive-compulsive disorder. Findings:  The physician reviewer found that in this patients case, acute inpatient psychiatric treatment is medically indicated.  Per the submitted documentation, there is the presence of suicidal ideation with a specific plan and high suicidal intent. Per American Psychiatric Association guidelines, acute inpatient psychiatric treatment is indicated in this clinical situation. The most recent medical notes indicate ongoing concerns regarding the patients safety.  This patient cannot be safely and effectively treated at a lower level of care. All told, the medical necessity of the requested acute inpatient psychiatric treatment has been established by the submitted documentation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 76-year-old male enrollee has requested a positron emission tomography (PET/CT) scan for evaluation of the enrollees renal cell carcinoma.  Findings:  Two physician reviewers found that the records indicate the patient has been found to have widespread metastatic disease. Prior positron emission tomography/computed tomography (PET/CT) scans have shown the tumors to be PET avid. After different therapeutic trials, the provider has recommended a repeat PET/CT to evaluate the patients treatment success. The patients request for authorization for the PET/CT was denied by the Health Plan as they consider the requested diagnostic procedure to be investigational and experimental for evaluation of the patients response to treatment. The patient does not carry a diagnosis of the usual kidney cancer where PET has been shown to be of very limited value. Rather the patients diagnosis is transitional cell carcinoma of uroepithelium, which is a tumor type where PET has been proven in the medical literature to be useful (Patil, et al). As in this patients case, where the metastatic tumors have been PET avid in the past, findings on further PET/CT is being done to evaluate response to treatment (Jadvar, et al). Since the PET/CT is especially helpful in patients with this diagnosis and has proven beneficial in this patients evaluation and treatment in the past, the diagnostic procedure is likely to provide useful information relevant to this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her large heavy breasts and related back, shoulder, and head pain. Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS) guidelines, reduction mammaplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients with documentation of at least of two of the following: chronic breast pain caused by weight of the breasts; upper back, neck, and shoulder pain; unspecified backache; headache; and shoulder grooving from bra straps. This patients records reference upper back, neck and shoulder pain, shoulder grooving and headache on various evaluations by her providers. Therefore, she meets the ASPS criteria for reduction mammaplasty. In an effort to relieve her symptoms, the patient has been treated with non-surgical methods without substantial improvement. Thus, based on the photographs and documented exams, the requested surgery would offer this patient a more than a minimal improvement in her function and appearance. As such, the requested surgery is reconstructive and medically necessary as it is being performed to provide this patient with relief from her painful symptoms associated with macromastia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested speech therapy for treatment of the enrollees delays in receptive and expressive language and speech skills.  Findings:  The physician reviewer found that 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. 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.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  The authors concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has moderate speech and language delay that adversely impacts her ability to communicate with those around her. If not addressed, her communication delays may adversely impact interactions with peers and caregivers. Studies have shown that speech and language therapy can result in significant improvement in this clinical situation. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested vision therapy for treatment of the enrollees convergence insufficiency.  Findings:  The physician reviewer found that convergence insufficiency is a binocular vision disorder successfully treated with vision/orthoptic therapy. Convergence insufficiency is a condition presenting with an exophoria at near, orthophoria to low exophoria at distance, a reduced near point of convergence, reduced positive fusional vergence, and a low AC/A ratio. Convergence insufficiency often presents with symptoms of blurred vision at near, discomfort, strain and fatigue associated with near tasks. The goal of vision therapy is to stimulate and normalize vergence abilities. The endpoint of vision therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. The literature provides a solid base of research supporting vision therapy as an effective treatment mode for accommodative and convergence deficiencies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested psychological testing for evaluation of his autistic disorder.  Findings:  The physician reviewer found that young children are often referred for psychological evaluation because they appear to have features of autism, which can be difficult to assess given their limited social interaction and communication skills. According to a paper by Akshoomoff, Many features and behavior problems can further interfere with the accurate assessment of a young childs cognitive abilities, including difficulty maintaining attention, hyperactivity, sensory issues, and poor compliance, particularly in an unfamiliar setting. According to Akshoomoff, it is critical to identify cognitive strengths and weaknesses and developmental delays in a young child suspected of an autism spectrum disorder (ASD) as part of the initial diagnostic workup and to assist with treatment planning. A standardized psychological test can provide the clinician with a significant amount of information about the childs abilities and behavioral difficulties.In the case of this particular patient, it was medically necessary to perform a psychological evaluation to develop an individual treatment plan for the patients entire treatment team. It is very important to use his strengths and to enhance his weaknesses to develop a speech pattern by five years of age, which is one of the main prognostic factors in a patient diagnosed with an autistic spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested Erbitux for treatment of her metastatic vulvar carcinoma with multiple pulmonary metastases. Findings:  The physician reviewer found that off-label use of chemotherapy agents, especially in stage IV disease, needs to show some phase I/II data that are promising.  In this patients case, her tumor is so rare that one cannot expect that kind of evidence.  Due to the rarity of this disease, there is limited evidence in the peer-reviewed literature relating to the condition.  However, the report by Richard and colleagues provides support for the requested medication in this patients case. In this report, the authors discussed a case of widely metastatic vulvar cancer that derived a partial response from cisplatin and cetuximab combined.  There was evidence for palliation of symptoms in this case. In this patients case, she has progressed on prior chemotherapy regimens, and most chemotherapy regimens have no effect on this adenocarcinoma.  There is no standard alternative for the treatment of this patient. In this clinical scenario, Erbitux is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested occupational therapy for one hour per week for treatment of his autistic disorder.  Findings:  The physician reviewer found that in reviewing the available peer reviewed medical literature and the records provided, it is well established in the neurological community that despite underlying neurologic disease, there remains plasticity in the developing brain which can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, and self-help skills. Occupational skills relevant to age-appropriate activities of daily living and to a lesser degree, non-verbal skills improve with long-term application of occupational therapy during critical developmental periods in childhood. This conclusion continues to be supported by relevant studies, most recently the one by Papavasiliou et al. (2011), which documented a clear improvement in Childhood Autism Rating Scales (CARS) with occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested a pain management consultation for treatment of his pain.  Findings:  The physician reviewer found that a pain management consultation is medically necessary for proper evaluation and treatment of this patients medical condition. Despite previous reports of physical therapy, the patient continues to complain of severe pain that interferes with his daily life activities. According to Hayden and colleagues, exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. A systematic review of randomized controlled trials evaluating exercise therapy in populations with chronic low back pain was performed.  The authors concluded that exercise therapy consisting of individually designed programs delivered with supervision may improve pain and function in chronic nonspecific back pain. Future studies, however, are needed to test multivariable models and further assess specific patient-level characteristics and exercise types.The primary care provider documented that the patient failed conservative therapy including nonsteroidal medications, steroids, narcotics and physical therapy. The MRI illustrates pathological evidence for the patients pain.  At this time, a pain management consultation is medically indicated. Patrick and colleagues performed a prospective study to evaluated long-term outcomes in multidisciplinary treatment of chronic low back pain. In this 13-year follow-up, the data supported the long-term effectiveness of multidisciplinary treatment programs for chronic low back pain. Patients were able to maintain their treatment gains in all areas. All told, the requested pain management consultation is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested continued speech therapy for treatment of his status post stroke.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested speech therapy. This patient has residual aphasia following a stroke. Speech therapy efforts have been associated with substantial language and articulation gains.  The submitted records document specific clinical and functional goals.  The literature documents that recovery from acquired brain injury occurs at varying paces, and to differing degrees.  It is standard of care to continue rehabilitation services for as long as needed, if the patient is making documented clinical progress towards reasonable goals. This patient has been documented to be making progress, and his progress has not plateaued at this time.  All told, continued speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that this patient was suggested for transcranial magnetic stimulation (TMS) therapy by her treating psychiatrist due to her failure to respond to conventional treatments. She was provided TMS therapy on several dates during the said timeframe, and has refractory depression and had been undergoing treatment with many medications and psychotherapy for which she reported suboptimal results. She was recommended for TMS therapy which was approved by the FDA for the treatment of refractory depression. Moreover, TMS is considered a viable alternative to electroconvulsive therapy (ECT) or vagal nerve stimulation (VNS). This patient has documentation demonstrating failure of different categories of antidepressant medications and continued to experience depressive vegetative symptoms. As such, the TMS therapy provided was the next logical step in her treatment and likely to be more beneficial than any conventional alternative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested radiowave/laser vein surgery (endovenous surgery) for treatment of his foot ulcers.  Findings:  Three physician reviewers found that endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing.  Recent evidence suggests that perforator ablation is successful in promoting recurrent ulceration. Current guidelines recommend compression therapy as the primary treatment to aid healing of venous ulceration, which this patient has undergone for several years. To decrease the recurrence of venous ulcers, ablation of the incompetent superficial veins in addition to compression therapy is also recommended in the guidelines. Although selective treatment of perforating vein incompetence in patients with simple varicose veins is not recommended, it is suggested that patients with pathologic perforating veins located underneath healed or active ulcers receive treatment. Given, the above guidelines and available peer reviewed medical literature, the requested procedure is likely to be more beneficial for treatment of this patients ulcers than conservative management.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male  has requested speech therapy for treatment of his speech delay and suspected autism.  Findings:  The physician reviewer found that on the Rossetti Infant-Toddler Language Scale performed in April 2011, the patient who was then 21-months-old had no speech and his expressive and receptive language abilities were at 9 months age equivalence. Although a diagnosis of autism has not yet been confirmed, the medical necessity of speech therapy hinges on whether the patients speech delay requires such intervention; the etiology of the speech delay is not determinative. The issue is whether the patient has a speech delay that can benefit from speech therapy.If a diagnosis of autism is ultimately confirmed in this case, there is robust medical literature advocating speech therapy for autistic children. The scientific literature strongly supports speech therapy for autistic children. The paper by Myers and Johnson is frequently cited in the autistic literature as a definitive source on the evaluation and treatment of autistic children. According to the authors, People with ASDs [autism spectrum disorders] have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than those who did not receive therapy. Further, the report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.There is also wide support in the medical literature for speech therapy for children who are speech delayed, but not autistic. Law, et al. reports that children with speech delay can be readily treated. This finding is consistent with a review of multiple medical journal articles performed by Gorhus-Brower and colleagues, which specifically deals with speech-delayed children and points out that even intellectually delayed children are candidates for successful speech therapy. Prelock, et al. discusses the evaluation and therapy of speech delayed children and the successful utilization of speech therapy in this population.Regardless of the underlying diagnosis, this 23-month-old patient who is non-verbal is an appropriate candidate for speech therapy and such services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested a pneumatic compression device for treatment of her lymphedema secondary to breast cancer treatment.   Findings:  The physician reviewer found that from review of the available records it appears that this patient has failed an adequate trial of manual therapy as she is not able to maintain reduction of her lymphedema between sessions. However, there is no evidence in the records provided for review that demonstrate use of other conservative methods of care such as elevation and compression bandaging. The provider did make note of some attempts at use of compression garments, thus the patient meets the criteria for a single or multi-chamber non-programmable pneumatic compression device. Since the patient has not been able to successfully maintain edema reduction between PT treatments and the edema interferes with her ability to complete ADLs, a non-programmable multi-chamber pneumatic compression pump is medically necessary. In the medical literature, Wilburn and colleagues conducted a prospective evaluation of the Flexitouch device for maintenance therapy of breast cancer-associated lymphedema. In addition, a review of common treatments for edema secondary to breast cancer concluded that intensive therapies, including pneumatic pumps, yielded greater reduction in volume as compared to self treatments like massage, compression garments or elevation (Moseley, et al). Similarly, the Centers for Medicare and Medicaid Services (CMS) guidelines recommend intermittent compression pumps as the standard of care for treatment refractory lymphedema after trial and failure of four weeks of conservative therapy. All told, the use of a non-programmable pneumatic compression device should be sufficient to manage this patients treatment resistant lymphedema but use of a programmable device has not been established as medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested wireless capsule endoscopy for evaluation of the enrollee, who has a history of ulcerative colitis. Findings:  Three physician reviewers found that in this case, wireless capsule endoscopy was not likely to have been of greater benefit than other tools for evaluating this patient. Based upon the clinical history, endoscopic reports and MRI enterography report, it is unlikely that the patient had a small bowel source of gastrointestinal bleeding or inflammatory bowel disease of the small bowel. The MRI enterography is an excellent study for small bowel Crohns disease, and it is unlikely that the MRI enterography would have missed inflamed bowel. In this clinical scenario, a wireless capsule endoscopy was not likely to have been superior over other methods of evaluating this patient.