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

The parent of a six-year-old male has requested  speech therapy twice per week for one hour for treatment of his Prader-Willi Syndrome with speech language disorder.   Findings:  The physician reviewer found that based on review of the available records, this patient has an identified genetic syndrome that includes profound hypotonia with developmental issues involving gross motor, fine motor, and speech delays and speech articulation disorders. The American Academy of Pediatrics (AAP) guidelines for Prader-Willi Syndrome note anticipatory guidance includes speech therapy (McCandless, et al). Successful programs are designed and individually tailored to meet the childs functional needs and should be coordinated and integrated with educational and medical treatment plans (Michaud, et al). In addition, a longitudinal study of four years of speech therapy in a child with Prader-Willi Syndrome noted an increase in vocabulary, oral comprehension, and narrative abilities. The speech and language intervention was effective in multiple linguistic levels including phonological, syntactic, lexical and pragmatic abilities (Misquiatti, et al). This patient has significant articulation and pragmatic difficulties noted on speech and language evaluation, although no standardized methods were utilized during the testing. Given this patients noted difficulties and underlying diagnosis, speech therapy is medically necessary at the requested frequency of one hour sessions twice per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested reimbursement for admission and services provided at a psychiatric hospital for three days for treatment of the enrollees obsessive compulsive disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient was in a state of severe decompensation at the time of psychiatric admission. He was completely incapable of caring for himself and had been treated as an outpatient without substantial improvement. Further, he expressed suicidal thoughts and was completely incapable of functioning. During the period under review, the patient meets the American Psychiatric Association (APA) criteria for inpatient level of care based on these facts, as he was an acute danger to himself. Thus, the inpatient services provided services provided are supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested coverage for continued applied behavior analysis (ABA) therapy (15 hours per week of code H2019, 6 hours per month of code H0032, and 3 hours per month of code H2012) from a specific date and forward.  Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech and language and social interaction.  Deficits in fine and gross motor skills and 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 in these children.  Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.  Applied behavior analysis (ABA) is a behavioral approach with a longstanding history of application with children on the autistic spectrum.  ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism.  In the 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, as well as less aberrant behaviors and social problems, than did the other group.  Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy.  There is a growing body of evidence in support of ABA therapy, demonstrating improvement in development and intellectual performance in young children with autism.  The results regarding individuals who are three years of age or younger are particularly compelling.  However, ABA therapy has been used effectively in many patient populations, including adolescents, for over 40 years.  According to Foxx, it is the primary method of treatment for children and adolescents on the autistic spectrum with aberrant behavior.  All told, continued ABA therapy (15 hours per week of code H2019, 6 hours per month of code H0032, and 3 hours per month of code H2012) from the requested date and forward was and is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female has requested coverage for past and continued residential treatment, psychiatric, and adolescent treatment level of care services provided from the date at issue, and forward for treatment of her behavioral health issues.   Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings offer optimization of treatment gains. Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions and substance dependence is a challenging endeavor. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. This patients records indicate that residential treatment was recommended by the treating providers who best knew the patient and the family system. Due to significant affective symptomatologies and persistent suicidal ideation, a sedating antidepressant medication was added. A therapeutic family pass, which represents a tangible step in the discharge process, was denied two days later due to fear of self-harm. Nursing notes reported that the patient was isolating, needy and tearful. However, the patient subsequently improved as evidenced by descriptive terms of positive day, uses leadership skills, and patient is skillful with minimal coaching. The providers note on a day at issue was suggestive of medication adherence with good tolerability and efficacy coupled with the ability to use skills and refrain from engaging in self-harming behaviors. Further, suicidal ideation was not endorsed in the mental status examination. Thus, the patient had entered a phase where transition to a less restrictive setting would have been safe and appropriate to address her underlying issues with self-esteem, pathological self-defenses and negative schemas. Consistent with the American Psychiatric Association (APA) guidelines, discharge on the date at issue would have been consistent with good medical practice. All told, the services provided for the dates at issue are supported as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested coverage for past real-time heart monitoring (CPT code 93229) for evaluation of her paroxysmal symptomatic supraventricular tachycardia.  Findings:  Three physician reviewers found that the patient has a history of paroxysmal symptomatic supraventricular tachycardia.  She was evaluated using a real-time heart monitor (CPT code 93229).  There is a lack of documentation indicating that the patient underwent or was unable to undergo other types of monitoring, including continuous off-line 24-hour to 48-hour Holter monitoring or off-line patient-activated or auto-triggered event recording.  The Health Plan has denied reimbursement for real-time heart monitoring and reported that the services at issue were investigational for the evaluation of this patient.The services at issue were not likely to be more effective than other available methods of evaluation.  In this clinical setting, non-real-time (off-line) monitoring devices, such as 24-hour to 48-hour Holter monitoring or self-activated event monitoring, would have been appropriate.  In less common cases of infrequent asymptomatic dysrhythmias that require identification, non-real-time (off-line) monitoring devices with auto-triggering capability should be sufficient.  There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the patients condition.  Current expert consensus guidelines endorsed by several national organizations consider Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias.  All told, real-time heart monitoring (CPT code 93229) was not likely to have been superior over other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female has requested coverage for past partial hospitalization program services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is a challenging endeavor, especially for patients with eating disorders.  Per the American Psychiatric Association, when determining the appropriate level of care, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances.  Based on the submitted medical documentation, this patient would have experienced undue morbidity if discharged on the date at issue.  Although she had made progress related to her physical health and eating disorder, the patient had not integrated the sustained learned behaviors necessary to maintain her weight and was still enduring intrusive thoughts about eating and appearance.  This patient had not consolidated the treatment gains necessary to successfully transition to the outpatient setting.  The current medical evidence supports partial hospitalization program level of care in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female has requested residential treatment services for treatment of her bulimia.   Findings:  The physician reviewer found that in the American Psychiatric Association (APA) practice guidelines, it is noted that although there is a growing evidence base for the treatment of eating disordersthere are many situations that arise in clinical care for which recommendations must be based on expert opinion and experience in the absence of data from randomized controlled trials or other systematic research studies. The APA guidelines further state that for treatment of patients with anorexia nervosa, research that addresses the optimal length of hospitalization or the optimal setting for weight restoration is sparse. There is no available evidence to show that brief stays for anorexia nervosa are associated with good long-term outcomes. The APA indicates that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. This patient has diagnoses of major depression and bulimia nervosa. Outpatient treatment has been tried and failed multiple times. The records indicate the patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that cannot be safely managed in a less restrictive setting. Residential treatment has previously been successful in managing this patients illness and would therefore almost certainly be successful again. As such, residential treatment is in accordance with generally accepted standards of medical practice and is clinically appropriate for the patients illness. Therefore, the services provided from the date at issue and forward are supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested minimally invasive lumbar decompression for treatment of his back pain.   Findings:  Three physician reviewers found that the patient has a history of back pain and neurogenic claudication. His neurologic exam has not shown any significant neurologic deficits. A magnetic resonance imaging (MRI) shows spinal stenosis worse at L3-4 and second at L4-5. An electromyography (EMG) demonstrated peripheral neuropathy. He has been on escalating doses of morphine to control his pain. He has had various forms of treatment, without good relief of his symptoms. His provider wants to perform the MILD procedure.  This man is said to have spinal stenosis at two levels.  There is a paucity of large, scientific, randomized, prospective studies that have shown the long term safety and effectiveness of this procedure. There are many small, short-term, retrospective studies (Deer and Kapural; Armin, et al; Mekhail, et al), and a small prospective study of only 27 patients that have shown some promising results (Basu). However, in the absence of properly designed studies demonstrating the long-term safety and efficacy of this approach, especially compared with standard therapies, the requested MILD procedure is not likely to be more beneficial than conventional alternatives in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male has requested brand name Glucophage for treatment of his type II diabetes.   Findings:  The physician reviewer found that based on review of the available records, this patient was treated with generic metformin extended release (XR) or slow release metformin as well as brand name Glucophage. It is well known in clinical diabetology that the XR form of metformin is tolerated by a significant number of patients who could not tolerate regular metformin or Glucophage. This patient was given the generic, which is generally a better tolerated form of metformin, yet he experienced GI side effects. In addition, the records indicate the patient did not have GI side effects with Glucophage. Therefore, it is reasonable to give the patient the form of the metformin that he was able to tolerate. As such, the requested brand name Glucophage is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested past and future coverage for speech therapy twice per week for 12 weeks for treatment of his speech delay.   Findings:  The physician reviewer found that based on review of the available records, this young patient has an identified delay in receptive and expressive speech of greater than 40%. Consistent with the recommendations 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. Further, 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. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the recommended speech therapy twice per week for 12 weeks was and is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested reimbursement for intensive outpatient program services over a one-month period for treatment of the enrollees mood disorder, not otherwise specified, cocaine dependence, alcohol dependence, post-traumatic stress disorder, and borderline personality disorder. Findings:  The physician reviewer found that the medical documentation provided on behalf of the patient fails to support the medical necessity for intensive outpatient program services.  The discharge summary from the residential treatment facility described her prognosis as fairly good and indicated the patient would be following up with her previous healthcare providers and residing in sober community housing.  There were no specific recommendations or arrangements for intensive outpatient program services upon discharge.  The notes from the intensive outpatient program facility lack an initial psychiatric assessment and treatment plan, which represent medical documents that justify particular treatment settings and interventions.  All told, intensive outpatient program services provided on the dates in question were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested coverage for past and continued chemical dependency residential treatment center (RTC) level of care services for treatment of her opioid addiction.   Findings:  The physician reviewer found that in general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment. Physicians and health care providers rely on clinical judgment in the context practice guidelines, peer reviewed literature and placement criteria to assist with level of care determination process. Regarding residential treatment placement for patients with substance use disorders, the American Psychiatric Association (APA) recommends residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. In this particular case, the patients drug use dominates social and family dynamics and precludes vocational pursuits. Further, she poses an imminent risk to relapse upon discharge in her current state as she lacks a harmonious living environment and sober social supports to facilitate recovery. These factors represent Dimensions 5 and 6 of the American Society of Addiction Medicine (ASAM), which in turn support placement at the residential level of care. Moreover, the patient failed a less restrictive treatment setting prior to the disputed service as she was using during her intensive outpatient services. Consistent with the current practice guidelines and peer-reviewed literature, residential placement is safe, appropriate and consistent with good medical practice for this patient at this time. In sum, the chemical dependency residential treatment center services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested coverage for brand name Prevacid for treatment of her stated condition of gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that based on review of the available records, there is no clinical evidence that this patient suffers from an acid related disorder as there is inadequate documentation of gastroesophageal reflux disease (GERD) endoscopically or by esophageal pH study. In addition, there is no evidence to support an advantage of one PPI over another for a likely case of functional dyspepsia. In summary, the requested medication has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested authorization and coverage for growth hormone therapy with Nutropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on review of the available records, this patient does not meet standard criteria for GH deficiency, as his pre-treatment height is not more than 2.25 SDs below normal for age and gender, his pre-treatment growth velocity is normal, and growth factors are normal. His adult predicted height is not short enough to meet the Food and Drug Administration (FDA) criteria for a trial of GH therapy on the basis of idiopathic short stature. Although the patients adult predicted height is more than 2 SDs below the calculated mid-parental target height, note that his parents heights are on both extremes of the spectrum for adult height, and an accurate assessment of the genetic potential may be misleading using the formula for mid-parental height that averages the heights of the two parents. The most likely diagnosis is a combination of familial short stature and constitutional delay, for which GH treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this clinical setting.  The medical records do not demonstrate the medical necessity of non-emergency transportation in this patients case.  There is no documentation indicating that she requires transportation other than by means of public or private conveyance.  She has no specific impairments which require transportation to and from medical visits.  The clinical notes indicate that the patient is able to ambulate without documented deficits, and she has no medical condition which requires structured transportation.  All told, the requested transportation is not medically indicated in this case.