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

The parent of a 5-year-old male enrollee has requested coverage for 6 months of applied behavioral analysis (ABA) therapy for treatment of the enrollees disorder of childhood or adolescence, not otherwise specified (NOS). Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues 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 (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance, elopement and tantrums with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive six months of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested reimbursement for a knee brace for treatment post knee surgery.  Findings:  The physician reviewer found that the mainstay of therapy following anterior cruciate ligament reconstruction is physiotherapy with a focus on recovery of strength, range of motion, and agility.  This is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition.  If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion is restored.  A neoprene sleeve can be used for additional support.  The medical literature has not demonstrated the efficacy of the equipment at issue in this patients case.  Birmingham and colleagues published the results of a large-scale, randomized, controlled, clinical trial and concluded that a functional knee brace does not result in superior outcomes compared with a neoprene sleeve after anterior cruciate ligament reconstruction.  As noted by the authors, the current medical evidence does not support the use of an anterior cruciate ligament functional knee brace after anterior cruciate ligament reconstruction.  In 2009, Andersson and colleagues reviewed the literature and concluded that the use of a postoperative knee brace does not affect the clinical outcome after anterior cruciate ligament reconstruction.  Overall, there is insufficient evidence in the medical literature supporting the medical necessity of the knee brace in this clinical setting.  There is no documentation of unusual physical dimensions that would require custom fitting of a knee brace.  All told, the knee brace was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The conservator of a 21-year-old male enrollee has requested for an inpatient, post-acute traumatic brain injury program for physical, occupational, speech and vocational therapies for treatment of the enrollee status post traumatic brain injury. Findings:  The physician reviewer found that the standard care for patients with post-traumatic memory, judgment, and cognitive impairments includes multi-disciplinary therapies such as occupational therapy, speech therapy and physical therapy as appropriate, in order to facilitate safety and recovery to an optimal level of independence. The appropriate level of care is often patient specific and should include considerations of the patients level of safety, level of in-home support and strategies for community integration. The literature demonstrates that patient care in comparable cases is often best provided in a structured, inpatient setting. The peer reviewed medical literature has also demonstrated that recovery rates are often better in young adults, than in older individuals. In this case, the patients records indicate ongoing improvements, which can be anticipated to continue with appropriate future treatment. All told, ongoing care in an inpatient, post-acute traumatic brain injury program is appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female has requested past and future coverage for portable (home) sleep studies for evaluation of her sleep apnea.  Findings:  The physician reviewer found that home sleep monitoring is now considered an accepted alternative to laboratory testing in selected patients. Specifically, it is recommended by the American Academy of Sleep Medicine and is approved by Medicare. In this case, a follow-up after surgery was indicated to determine if the patients sleep apnea was controlled. Control of sleep apnea was one of the goals of the surgical procedure. A home sleep test is a clinically reasonable method for determining whether the surgical treatment for sleep apnea was effective. The Stardust II recorder was used during the test, which fully satisfies the American Academy of Sleep Medicine Level III device criteria for home sleep monitoring. With regard to future portable (home) sleep studies, there may be an indication for this, should the patient experience significant weight loss, which can lead to resolution or decrease in the severity of sleep apnea. However, use of the home sleep studies are not considered medically necessary to repeat if the patient has gained weight or if there are no changes in her condition. Moreover, they are not indicated for CPAP evaluation. For these reasons, the requested future use of portable sleep studies is not supported as medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female has requested coverage for past nasal surgery (radiofrequency of the bilateral nasal turbinates) performed for treatment of her sleep apnea.  Findings:  Two physician reviewers found that the patient has sleep apnea with a respiratory disturbance index (RDI) of 16. She has had previous surgery and has been unable to tolerate continuous positive airway pressure (CPAP). She was found to have obstructive 3+ turbinates.  The only method of treatment with the fewest risks given her medical problems is a radiofrequency reduction of the turbinates. Radiofrequency turbinate reduction is a standard treatment of turbinate hypertrophy in patients with sleep apnea (Troell, et al). In addition, radiofrequency turbinate reduction improves the quality of life in patients with sleep apnea (Li, et al). For these reasons, the surgery at issue was likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for osteopathic manipulation for treatment of her neck and upper back pain. Findings:  The physician reviewer found that the review by Posadzki and Ernst specifically reviewed the osteopathic manipulation literature with respect to musculoskeletal pain and concluded that, the data from the literature fail[ed] to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain. This finding is consistent with other studies examining spinal manipulation (Assendelft, et al.). Overall, no significant benefit would be expected with the requested therapy, over an independent exercise program, relative rest, self-applied palliative modalities and pharmacotherapy. Additionally, the documentation provided does not support any specific, clinically relevant benefit that has been achieved to date, which could be clearly attributed to osteopathic manipulation. The records indicate the patient continued to have severe pains despite the osteopathic manipulation that was being provided. Going forward, no significant, sustained benefit would be expected with further osteopathic manipulation for this patient. Thus, the requested osteopathic manipulation is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested coverage for six months of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues 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 (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive six months of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested authorization and coverage for labor and delivery services at a facility with a neonatal intensive care unit.  Findings:  The physician reviewer found that the majority of fetal arrhythmias are benign premature atrial contractions (Rasiah, et al). This arrhythmia represents immaturity of the electrical conduction system in the fetal heart and almost always resolves spontaneously either later in the pregnancy or at delivery (Respondek, et al). This arrhythmia does not affect the fetus or the neonate and does not require any change in obstetric or neonatal management. Consistent with the American College of Obstetricians and Gynecologists (ACOG) guidelines, this patient can deliver at any hospital, but the request to deliver at a facility with a neonatal intensive care unit (NICU) is not medically necessary. If the patient desires to deliver at a hospital with more neonatal services, she does not need to deliver at the closest hospital due to her prior rapid delivery, but can be induced at 39 weeks gestation at one of the In-Network hospitals that is 20 minutes away. Therefore, the requested labor and delivery services at a facility with a NICU have not been demonstrated to be medically necessary for management of this patients pregnancy and delivery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues 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 (Warren, et al.).  Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive at least six months of ABA therapy.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The representative of a 53-year-old deceased male enrollee has requested for ambulance transport services for treatment of the enrollees terminal bladder cancer. Findings:  The physician reviewer found that this patient had a bowel obstruction, which can cause abdominal distension, pain and vomiting. Given these risks, transport of the patient in a supine position was necessary. All told, given that the patient was still in considerable pain and that he was on oxygen at the time of transport, the ambulance transportation at issue was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for diagnostic testing for inflammatory bowel disease (IBD) markers for evaluation of the enrollees abdominal pain. Findings:  Three physician reviewers found that diagnostic testing for IBD markers is rarely indicated for patient management. However, this case is exceptional in that there is abnormal histology and radiology to suggest the patient has IBD, but there is not enough data available to give a conclusive answer. This is important for several reasons. If the testing is negative then stopping steroids (Entocort) would be reasonable and beneficial to the patient. If the tests are positive and clarify the type of IBD she has, this will be useful to plan for therapy in the future and anticipate potential problems associated with IBD. Thus, the requested diagnostic testing is likely to more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested authorization and coverage for Lyrica 300mg for treatment of the enrollees upper extremity pain, secondary to neck pain.  Findings:  The physician reviewer found that Lyrica is supported in the peer-reviewed literature as a safe and effective treatment for radiculitis and chronic pain due to spinal pathology. A multi-center trial demonstrated that patients being treated with Lyrica reported significantly lower mean pain scores than those being treated with placebo (Jeffrey). The study by Durkin, et al. indicated that pregabalin (Lyrica) is a safe and effective medication that may decrease perioperative opioid use in patients with more acute neuropathic pain than acute inflammatory pain and may also decrease the incidence of chronic pain. A randomized controlled study assessing patient outcomes following lumbar discectomy and administration of perioperative Lyrica found that perioperative administration of the drug is associated with less pain intensity and improved functional outcomes three months after lumbar discectomy (Burke, et al.). Therefore, Lyrica is medically necessary for treatment of the patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating.  Therefore, the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested for acute hospital eating disorder treatment for treatment of the enrollees major depression, severe, single episode, bulimia nervosa, and panic disorder without agoraphobia. Findings:  The physician reviewer found that depressed patients with suicidal ideation and plan, who also have significant medical comorbidities, history of physical abuse, and limited family and social support, are at elevated risk for suicide.  In such cases, psychiatric hospitalization is recommended by the American Psychiatric Association.  As noted by the American Psychiatric Association, determining the appropriate level of care requires consideration of the patients overall physical condition, psychology, behaviors, and social circumstances.  The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  Considering the clinical presentation and documentation, coupled with relevant peer-reviewed medical literature, acute hospital eating disorder treatment level of care was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested authorization and coverage for continued inpatient psychiatric treatment (psychiatric acute inpatient care) and inpatient electroconvulsive therapy for treatment of the enrollees major depressive disorder, severe, recurrent, without psychotic features.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  This patient is severely depressed, with multiple risk factors.  Mood disorder, such as depression, is the psychiatric diagnosis most commonly associated with suicide.  Electroconvulsive therapy is the most effective intervention for severe mood disorders.  Inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  The current medical evidence supports continued inpatient psychiatric treatment in this patients case.  The requested services are appropriate to treat this high-risk patient and are consistent with standards of good medical practice.  All told, continued inpatient psychiatric treatment (psychiatric acute inpatient care) and inpatient electroconvulsive therapy are medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female has requested psychiatric partial hospitalization (with dialectical behavior therapy) for treatment of her borderline personality disorder, major depressive disorder, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that partial hospitalization programming is primarily indicated for patients with functionally impairing symptomatologies that have failed the less restrictive outpatient setting or for those who are transitioning from a higher level of care.  The documentation provided indicates that the patient had not achieved remission, or minimal functional impairment, with comprehensive outpatient therapy.  This treatment failure, coupled with her acute-on-chronic symptom complex, places this patient at significant risk.  Considering the clinical history, the patient would likely experience undue morbidity and require acute psychiatric care if more intensive services are not provided.  Accordingly, psychiatric partial hospitalization (with dialectic behavior therapy) is appropriate and is consistent with good medical practice.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested  applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (ASD). All told, treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. An article from Dawson and colleagues discusses a 5-year randomized and controlled study on 48 children with autism. The authors found significant improvements in IQ and adaptive behaviors using an Early Start Denver Model interaction based on developmental and ABA principles and with at least 25 hours of intervention services weekly. Similarly, Warren and colleagues reviewed 34 studies on early intervention in autism. The authors concluded that studies of Lovaas-based approaches, early intensive behavioral intervention variants, and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills.  Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The requested duration of therapy for this three-year-old patient with autism is medically reasonable and appropriate. Given the patients documented deficits, it is medically necessary that he receive six months of ABA therapy beginning on the date requested.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested six months of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (ASD). All told, treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. An article from Dawson and colleagues discusses a 5-year randomized and controlled study on 48 children with autism. The authors found significant improvements in IQ and adaptive behaviors using an Early Start Denver Model interaction based on developmental and ABA principles and with at least 25 hours of intervention services weekly. Similarly, Warren and colleagues reviewed 34 studies on early intervention in autism. The authors concluded that studies of Lovaas-based approaches, early intensive behavioral intervention variants, and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The requested duration of therapy for this three-year-old patient with autism is medically reasonable and appropriate. Given the patients documented deficits, it is medically necessary that he receive six months of ABA therapy beginning as of the date in question, as requested.