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

The parent of a 20-month-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25 % (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for an anterior spinal decompression and fusion at L5-S1 for treatment of back and leg pain.  Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain.  In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. While the patient did have a positive discogram, discography is not recommended as a procedure for diagnosing discogenic low back pain in patients with chronic non-radicular low back pain, as the diagnostic accuracy for identifying discogenic pain has not been clinically proven (Chou, et al.). Additionally, false positive responses are common in persons without significant back pain and there is no evidence that the use of provocative discography to select patients for fusion improves clinical outcomes. Therefore, the patients positive discography findings should not be used as a rationale for recommending spinal fusion. Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested authorization and coverage for a WalkAide functional electrical stimulator for treatment of multiple sclerosis.  Findings:  Two physician reviewers found that the patient has multiple sclerosis and left leg weakness.  She has an increased fall risk.  In the past, a WalkAide functional electrical stimulator trial was beneficial.  The patients provider has recommended a WalkAide functional electrical stimulator.  The Health Plan has denied coverage for the WalkAide functional electrical stimulator and reported that the requested device is investigational for the treatment of this patient.  Although the WalkAide functional electrical stimulator is not indicated for all patients with multiple sclerosis, there is medical literature supporting its use for a select population of patients.  The current medical literature has demonstrated the safety and efficacy of the use of the requested device for patients with chronic upper motor neuron disease, such as what occurs in foot drop induced by multiple sclerosis.  Daly and colleagues showed that a neuromuscular stimulation device improved gait component execution and knee flexion coordination compared to controls who did not receive the stimulation device.  Mesci and colleagues showed that spasticity decreased and dorsiflexion increased in a functional electrical stimulation group compared to controls during a single-blind randomized trial.  In this patients case, she has left-sided foot weakness secondary to multiple sclerosis.  She has had a positive response to a trial of the WalkAide functional electrical stimulator.  In this clinical situation, the requested device is likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that there is a robust medical literature supporting the efficacy of speech therapy in this patient population (Law, et al). In addition to data supporting the efficacy of speech therapy, Goorhuis-Brouwer and Kniff found that cognitive delays did not prevent patients from benefitting from treatment. Further, Buschmann and colleagues concluded that although catch-up development is to be expected in a substantial proportion of late talkers, our data demonstrate that a general wait and see approach is not justified in young patients with language delay. Consistent with the support in the clinical studies and standards of practice, speech therapy is medically indicated for this patient with speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female has requested coverage for speech therapy for treatment of her tongue thrust.  Findings:  The physician reviewer found that the current medical literature supports the requested speech therapy in this patients case.  According to the dental/orthodontic literature, tongue thrust often develops in the presence of anterior open bite in order to achieve anterior valve function.  Tongue thrust is thought to be associated with the resting posture of the tongue.   In this patients case, closure of the anterior open bite with orthodontic treatment did not resolve the tongue thrust, nor did her articulation disorder improve. In this clinical scenario, it is likely that the patients speech abnormalities are caused by an articulation disorder in conjunction with an anatomic abnormality. A comprehensive speech and language therapy assessment with subsequent treatment is medically necessary to address her speech difficulties.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female has requested coverage for magnetic resonance imaging (MRI) of the breasts for evaluation of her risk for developing breast cancer.  Findings:  The physician reviewer found that currently there is evolving evidence of the utility of breast cancer screening using MRI in certain subgroups of patients. The consensus is that MRI has a role in screening patients with a calculated lifetime risk of developing breast cancer of greater than 20-25%. While this particular patient does have a first degree relative who was diagnosed with breast cancer, the American College of Radiology (ACR) practice guidelines indicate that a strong family history usually refers to at least 2 first degree relatives or a known BRCA1 or BRCA2 genetic mutation. This patient has a negative physical examination and there is no mammography report in the records provided for review. There is mention of a mammogram which did not describe any abnormal findings. Thus, in the absence of extremely dense mammographic breast tissue, equivocal physical findings, or equivocal findings on standard imaging, the requested MRI of the breasts is not considered medically necessary. The standard first-line diagnostic procedure for screening is mammography, unless the breast tissue is characterized as extremely dense on mammography, which is a factor that may limit the utility of the technique. Such issues are not brought forward in this patients clinical picture and therefore the requested MRI of the breasts is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that in the relevant clinical studies, Schutter and colleagues reported that TMS was found to have a moderate effect on patients with treatment resistant depression. In addition, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Further, Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, although relatively new, TMS is an effective treatment supported in the medical literature and approved by the FDA for the treatment of treatment resistant major depressive disorder. However, this patients records do not document an adequate trial and the outcome of a second selective serotonin reuptake inhibitor (SSRI). Moreover, the patient has not reportedly undergone a trial of electroconvulsive therapy (ECT), both of which are likely to be more beneficial than TMS therapy for his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female has requested coverage of  speech therapy for treatment of her moderate expressive and receptive language delay and severe articulation delay.  Findings:  The physician reviewer found that per 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 reported 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.  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.   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.  In this patients case, she demonstrates moderate receptive and expressive language deficits and severe articulation deficits that negatively impact her ability to communicate with family and peers as well as achieve age-appropriate functional communication skills. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees severe expressive language impairment. 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 children with speech and language delays have also shown more behavior problems and impaired psychosocial adjustment (Nelson, et al.). While some children resolve their speech and language delays independently, those who do not may have long-term problems (Law, et al.). Law, et al. indicates that overall, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major also indicate that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the authors concluded that there is good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin). Studies have shown that speech therapy can result in significant improvement in such children. Therefore, it is medically necessary and appropriate to provide speech therapy to this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested coverage for a CT scan and an EMG nerve conduction study for evaluation of her tail bone and lower back pain.  Findings:  The physician reviewer found that the available peer-reviewed medical literature indicates that there is no need for a CT scan when an MRI is feasible to make the diagnosis. In the case of this patient, an MRI was performed and demonstrated mild grade 1 spondylolisthesis and facet arthropathy. Thus, a CT scan is not likely to be of clinical value in this setting. Further, this patients clinical picture is not consistent with a far lateral disc herniation; nor does the evidence suggest that a disc herniation is the causative agent for her low back and tail bone pain. Therefore, there is no medical indication that an EMG nerve conduction study is necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male has requested coverage for a continuous glucose monitoring system for treatment of his diabetes.  Findings:  The physician reviewer found that the documentation provided is not consistent with a diagnosis of diabetes mellitus type 1, which is indicated throughout the provider notes. The provider note indicates a recommendation that the patient take Victoza 0.3, which is not a medication approved by the Food and Drug Administration (FDA) for patients diagnosed with diabetes mellitus type 1, but rather for patients with diabetes mellitus type 2. Additionally, there is no evidence in the records provided of a positive GAD65 on islet cell hemoglobin test or of a very low c-peptide test. Further, the patients glucose log data shows only 6 results of a blood glucose level of less than 60 and only 2 results of less than 50 out of 160 total tests. The ratio of hypoglycemia to total tests is so low that it does not indicate a need for a continuous glucose monitoring system. Given that the patients symptoms are inconsistent with a diagnosis of diabetes mellitus type 1, the patient does not have frequent blood glucose level lows of less than 50, and the absence of documentation of true hypoglycemic unawareness, the requested continuous glucose monitoring system is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male has requested coverage for an MRI with contrast for evaluation of his extreme head pain.  Findings:  The physician reviewer found that the patient had a headache that was new in onset, and was severe enough to send him to the ER, take strong medications, and see a neurologist. The patient underwent a non-contrast CT scan, while in the ER, to rule out bleeding, a subarachnoid hemorrhage (SAH) or an acute finding. A full workup of the cause of the patients headache was not completed in the ER. The patients neurologist performed a complete history and physical.  Although no neurologic deficits have been identified, it is reasonable in this case to order a more definitive exam, to exclude a structural cause for the patients headache.  An MRI with contrast is superior to a non-contrast CT scan for this purpose, as clearly the headaches are new, and of different character than the patient has previously experienced.  For new onset headache, MRI with contrast would be superior to a non-contrast CT scan. All told, the requested diagnostic imaging is medically necessary for evaluation of the patients medical condition, given that his headaches are of a new characteristic and severity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested coverage for proton beam therapy for treatment of his prostate cancer.   Findings:  The physician reviewer found that this patient is categorized into the low risk group as defined by the medical literature (Zietman, et al). The management of low risk disease can include active surveillance, surgery, prostate brachytherapy, or external beam radiation. Based on the recommendations from Kuban and colleagues, dose escalation resulted in improved freedom from biochemical and clinical progression and can be achieved with brachytherapy, intensity modulated radiation therapy (IMRT) with or without image guided radiation therapy (IGRT), or proton beam therapy. Based upon the size of the patients gland being 138 grams, brachytherapy is not advised. Further, there is a paucity of studies demonstrating proton beam radiation therapy to result in improved health outcomes beyond that expected with standard therapies. There are no randomized trials comparing protons versus IMRT. For these reasons, the data do not currently support any definitive benefit of proton beam therapy over other forms of high dose conformal radiation and therefore is not medically necessary for treatment of the patients prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested for stereotactic body radiotherapy (SBRT)  or in the alternative, external beam radiation therapy (EBRT) for treatment of the his pancreatic cancer.  Findings:  The physician reviewer found that stereotactic body radiotherapy (SBRT), delivering high fractional (8-20 Gy) doses in 1-5 fractions, with image guidance or other means to improve precision, is an established approach for the treatment of discrete lesions from cancer. In addition, there are several publications describing improved health outcomes in patients treated with SBRT for pancreatic cancer. In 2004, Koong and colleagues conducted a Phase I trial in which 15 patients with unresectable pancreatic cancer received single fraction SBRT, escalated from 15 to 25 Gy. No acute grade 3 toxicity was observed. In the authors subsequent Phase II study, 16 patients received 45 Gy with intensity modulated radiotherapy (IMRT) followed by a single 25 Gy SBRT fraction. Late toxicity occurred in some patients who developed grade 2 duodenal ulceration 4-6 months after SBRT. Chang and colleagues reported on 77 patients (45 locally advanced/inoperable, 11 medically inoperable, 15 with metastases, and 6 with local recurrence) who received SBRT (25 Gy x 1). It was noted that 16 patients had received prior EBRT. The 12-month local control was 84%. At 6-months and 12-months, the rates of grade 2 or greater late toxicity were 11% and 25%, respectively. The authors concluded that, SBRT for pancreatic adenocarcinoma was effective for local control with associated risk of toxicity and should be used with rigorous attention to quality assurance. Efforts to reduce complications are warranted. Overall, clinical studies have shown SBRT to be effective in the treatment of unresectable pancreatic cancer. Although there are no published studies that directly compare SBRT to conventionally fractionated radiation (either with IMRT or conventional radiotherapy), a recent American Society of Radiation Oncology (ASTRO) model coverage policy supports SBRT as medically necessary for locally advanced pancreatic cancer. This model policy reflects not only expert opinion, but is also evidence-based on the current peer reviewed medical literature. SBRT is only considered medically necessary for patients with good medical condition/performance status and for those whose tumor burden can be targeted, as in this patients case. Thus, SBRT has been demonstrated to be a medically necessary treatment of this patients locally advanced pancreatic cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for Ambien and Lunesta for treatment of her insomnia. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested medications. This patient has a significant history of overuse of the requested medications.  American Psychiatric Association guidelines indicate that managing sleep is an important aspect of bipolar disorder.  This patient is on a sedating medication for this condition.  There are numerous alternatives, either as adjuncts or as mood stabilizing agents, which are less likely to be abused. Current evidence-based practice standards do not support the use of the requested medications in this clinical situation.   All told, Ambien and Lunesta are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female has requested coverage for a tapered outpatient psychotherapy schedule for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the records provided indicated that the patient has shown moderate to marked improvement since starting therapy. The patient has been receiving psychotherapy 5 times per week for the last 10 years. The records demonstrate that the patient has recently been working full time, has been compliant with her medication and has been able to function in the community independently. The Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) guidelines are not consistent with the request for a slow tapering schedule over a one year schedule. All told, the patients current level of functioning and the available treatment guidelines do not support the need for a tapered therapy schedule over a one year period. However, a tapering plan  reducing the number of sessions by one each month,  i.e., four sessions per week for a month, three sessions per week for a month, two sessions per week for a month down to one session per week, would be clinically appropriate. Once the patients therapy has been tapered to one session per week, she should be re-evaluated at regular intervals to determine the medical necessity for continued once weekly psychotherapy.