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

The parent of an 11-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollee diagnosed with autism. Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. Deficits in fine and gross motor skills as well as processing of sensory and motor information are also common. There are likely a multitude of etiologies, with clinical symptoms being the final common denominator.  Many approaches have been used to facilitate development of adequate communication and interpersonal skills for children with autism.  Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for children with autism.  In a study by Eikeseth and colleagues comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning and fewer social problems.  Howard and colleagues reported similar results.  Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy.  Volkmar and Pauls noted that behavioral therapy can effectively be used to foster desired behaviors and systematically decrease problem behaviors.  ABA therapy has been used and studied for decades, and studies show positive results from consistent implementation of this method.  Behavioral therapy is not limited to children in early intervention programs, although this is a group that has been well-studied. The principles and practices of behavioral analysis can be applied to people throughout their lifespan, with duration of therapy based on the clinical presentation and response to therapy. All told, 15 hours per week of ABA therapy from the date in question and forward was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for multidisciplinary rehabilitation therapy for treatment of the enrollee, who is status post traumatic brain injury. Findings:  The physician reviewer found that this patient demonstrates behavior and functional limitations consistent with a severe brain injury.  He is considered unsafe, and he is unable to participate within an outpatient supported living environment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested osteochondral allograft surgery for treatment of his right knee osteochondritis.  Findings:  The physician reviewer found that  the management of osteochondral defects is complex with little high-level evidence to favor one procedure over another, although encouraging short-term and midterm outcomes have been reported with osteoarticular transplantation (Harris, et al). Osteochondral allograft transplantation offers the advantage of no limitation in the size of tissue available. Therefore, the procedure is an option in treating lesions of 2 cm or larger, although disease transmission and rejection are justifiable concerns (Carter, et al). Timing of the procedure is also of concern, since chondrocyte death has been reported 2 to 3 weeks after procurement of the graft, and it is unclear whether duration of allograft storage affects the clinical results (McAdams, et al). Proper positioning has also been shown to be a factor of great importance in graft survival (DLima, et al). The importance of patient selection has also been emphasized, with the need for the absence of significant articular cartilage defects (McCulloch, et al). There is a paucity of prospective, randomized controlled clinical trials comparing the different techniques and options (Simon and Jackson). Further studies are needed to determine whether cartilage surgery can yield better functional outcomes than other treatment (Loken, et al). In this case, the presence of osteoarthritis has been noted. In addition, the arthroscopic evaluation of the joint was based on photographs of the initial procedure which may not be an accurate evaluation of the present status of the knee. There is no documentation of any conservative measures employed to treat the patient, or the results of that treatment. For these reasons, the medical necessity of the requested osteochondral allograft surgery has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested a bilateral bunionectomy for treatment of her foot pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure.  In this patients case, surgical intervention is necessary for the treatment of the patients medical condition.  The medical records support the diagnosis of hallux limitus.  Her physical examination correlated with the x-ray findings.  The patient continues to have significant pain involving both feet.  The documentation noted daily use of ibuprofen.  The current medical evidence supports the requested procedure in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male has requested human growth hormone Nutropin AQ 20mg/2ml. for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that this patients height is more than 2.25 standard deviations below normal.  He has a history of unexplained short stature and poor growth velocity that was responsive to growth hormone therapy.  Serial bone age radiographs have demonstrated significant delay in skeletal maturation.  The growth chart shows an improvement in growth velocity with growth hormone therapy administration, with a fall-off in growth velocity upon discontinuation of growth hormone therapy.  Most recently, he has demonstrated poor growth velocity of 2 cm. per year despite pubertal progression. With a normal weight-to-height ratio, malnutrition and malabsorption are not likely etiologies for his growth failure.   This patient meets generally accepted criteria for growth hormone therapy for idiopathic short stature. According to Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who exhibit certain criteria.  These criteria include height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile, growth velocity less than the 25th percentile for bone age, bone age more than 2 standard deviations below the mean for age, low serum IGF-1 and/or IGFBP-3, and other clinical features suggestive of growth hormone deficiency. This patient meets most of the above criteria.  Thus, the requested human growth hormone Nutropin AQ 20mg/2ml is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy at a frequency of one hour per week or two sessions per week for 30 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has a significant speech delay.  There are two important factors regarding his potential for improvement.  He has responded, although slowly, to speech therapy, and all testing has indicated that he is intellectually normal. Patients such as this child are routinely referred by the medical community for speech therapy.  The medical literature strongly supports the medical need for this patient to continue speech therapy.  There is a robust medical literature supporting speech therapy in this population. A study by Law, et al. found that children with speech delay can be readily treated. In addition, a paper by Goorhuis-Brouwer and Kniff stated that cognitively normal children are ideal candidates for successful speech therapy. Further, a study by Emmanuel, et al. concluded that speech therapy has been found to be efficacious in the treatment of speech delays in young children. Therefore, the requested therapy is medically necessary and appropriate and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for Oxycontin 80mg SR and Oxycodone-Acetaminophen 10/325 (Percocet) for treatment of her chronic pain.  Findings:  The physician reviewer found that there is no medical indication for the patients present dose requirements for Oxycontin. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy and at that point controlled release narcotics with close monitoring by a certified physician is recommended. Presently the maximum recommended dose for Oxycontin is 80mg twice per day as indicated for cancer pain. Ballantyne and colleagues noted that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Oxycontin as requested by the patient is contradictory to providing safe and effective healthcare. Oxycontin and Percocet are therefore, not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a panniculectomy for post gastric bypass treatment.  Findings:  The physician reviewer found that a panniculectomy may be medically necessary if the removed skin has a history of recurrent infections or is necrotic. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  The requested surgery would be performed to improve appearance rather than function, and a panniculectomy alone would only provide a minimal improvement in the appearance of this patient. Additionally, the patients panniculitis/intertrigo does not constitute an abnormal structure of the body.  The requested surgery would be performed to improve appearance rather than function, and a panniculectomy alone would only provide a minimal improvement in the appearance of this patient. All told, the requested panniculectomy is not reconstructive in nature and is not medically necessary for the treatment of this patient.The reviewed materials do not support the medical necessity of a panniculectomy in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male enrollee has requested for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that 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.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for intravenous immunoglobulin (IVIG) for treatment of his polyneuropathy and neurogenic atrophy.  Findings:  The physician reviewer found that IVIG has been used for multiple neurologic conditions, including CIDP where it can be beneficial, no medical evidence has demonstrated that IVIG is beneficial for idiopathic polyneuropathy. For these reasons, the requested therapy is not medically necessary for treatment of the patients medical condition.
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 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. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for molecular testing for evaluation of her non-small cell lung cancer.  Findings:  The physician reviewer found that the molecular testing, there is no current clinical justification for the utility of such testing, including the EGFR mutation and ALK fusion gene, done in lung cancer. Should the patient exhibit a recurrence, then these tests are routine, and should be done if she has further recurrence that can be biopsied. There is no real relevance in the outcome unless the patient has recurrent cancer that needs to be treated. As such, the requested molecular testing has not been demonstrated to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male has requested coverage for past substance abuse sub-acute residential rehabilitation for treatment of his alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  This patient completed two days of supervised detoxification treatment without any evidence of decompensation or medical instability.  The medical records noted no previous chemical dependency treatment.  In this clinical setting, the patient could have been treated safely and effectively in an outpatient setting.  Direct admission to a residential rehabilitation program is not considered generally accepted standard of practice.  Evidence-based therapies, such as individual therapy, group counseling, and office-based pharmacotherapy, show consistently therapeutic outcomes and can be offered in an outpatient setting.  This patients medical records do not reflect psychiatric or medical instability that required treatment in a 24-hour clinical setting under a physicians care.  The clinical notes do not reflect safety concerns requiring treatment in the substance abuse sub-acute residential treatment setting.  All told, substance abuse sub-acute residential treatment was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for Y90 radioembolization for treatment of her metastatic ocular melanoma. Findings:  Two physician reviewers found that the current medical evidence has not demonstrated that the requested Y90 radioembolization is likely to be superior to other available treatment modalities.  Gonsalves and colleagues noted that further investigation is needed to determine whether radioembolization should be used as an alternative first-line treatment for hepatic metastasis of uveal melanoma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested a Synvisc One injection for treatment of her left hip osteoarthritis.  Findings:  The physician reviewer found that although the benefits of viscosupplementation have been generally accepted in the treatment of osteoarthritis of the knee, there is less agreement with its use in the hip (van den Bekerom, et al). Some studies have been encouraging, but have also noted the need for further prospective, randomized, placebo-controlled studies before definite conclusions can be drawn. In the absence of placebo-controlled studies, the efficacy of hyaluronan injections cannot be conclusively determined (Conrozier and Vignon). Larger, placebo-controlled trials are needed to confirm the efficacy of viscosupplementation in hip osteoarthritis (Abate, et al). In addition, prospective controlled trials are needed to confirm the safety and efficacy of hyaluronic acid in the treatment of hip osteoarthritis, and rigorously designed studies are necessary, since the use of hyaluronic acid as a treatment for osteoarthritis of the hip is not based on large randomized controlled trials (Colen, et al). For these reasons, the requested therapy has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested Neulasta injections for treatment of her neutropenia.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  Chronic lymphocytic leukemia is associated with autoimmune disorders such as thrombocytopenic purpura, autoimmune hemolytic anemia and autoimmune neutropenia.  The hemolytic anemia also has an association with the use of fludarabine.  Autoimmune hemolytic anemia is treated with glucosteroids and stronger immunosuppressive agents such as azathioprine.  Azathioprine is known to cause bone marrow suppression, which may require growth factor support.  The use of Neulasta for azathioprine-induced neutropenia is medically necessary and is the standard of care in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male has requested Discrete Trial Model Applied Behavioral Analysis (ABA) for treatment of his autism.  Findings:  Two physician reviewers found that current treatment of autism involves ABA-based intervention. A recent 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and Applied Behavioral Analysis principles (Rogers, et al.).  Warren, et al. also reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Although multiple types of behavioral therapy exist, evaluation of efficacy among different therapy modalities is lacking (AHRQ Publication). The Vanderbilt Evidence-Based Practice Center systemically reviewed evidence on therapies for children ages 2 through 12 with autism spectrum disorders (ASD). The focus of the review was on treatment outcomes, modifiers of treatment effectiveness, and evidence for generalization of outcomes to other contexts. The outcomes of therapies for ASD noted that no studies directly compare effects of different treatment approaches (AHRQ Publication). In this case, there is no study comparing the Lovaas-based intervention involving Discrete Trial Training and the Early Start Denver Model. Positive results are noted using both intervention modalities. (AHRQ Publication). In sum, there is no data demonstrating that the Discrete Trial Model of ABA therapy is superior to the Denver Model of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested authorization and coverage for referral/laser toenail treatment for treatment her onychomycosis.  Findings:  The physician reviewer found that few studies have been done on the use of lasers in the treatment of onychomycosis. Further, the published trials do not demonstrate the superior efficacy of this modality for treatment of onychomycosis. The standard treatment for onychomycosis is oral Lamisil, which has been shown to be at least 80% effective in managing this condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested anesthesia services during a colonoscopy.  Findings:  The physician reviewer found that the patient has a history of Crohns disease and per the submitted documentation, she is status post resection of the small intestine and removal of appendix.  Her most recent colonoscopy was six years ago.  The patients provider has recommended a colonoscopy.  Per the provider, the patients previous colonoscopies have all been performed with anesthesiology assistance.  The American Society of Anesthesiologists position statement notes that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication, with or without analgesia, to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must continuously monitor the patient.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients who are younger than 12 years of age, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this patients case, the submitted documentation indicates that the patient has no specific medical comorbidity that necessitates the use of monitored anesthesia care for the recommended colonoscopy.  This patient is an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.