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

The mother of an eight-year-old male enrollee has requested a 3-wheeled power scooter for him for the treatment of the enrollees metaphyseal chondrodysplasia. Findings:  The physician reviewer found that mobility needs at this patients age are considerably different from those of other, older patients.  This pediatric patients mobility is significantly impaired due to his congenital disorder.  From the available records, it appears that the patient will be able to operate a power scooter and would not be able to utilize a manual wheelchair for the distances required.  The patients condition and physical limitations demonstrates the indicated medical need for the requested equipment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech-language disorder. Findings:  The physician reviewer found that Speech and language delay must be taken very seriously in young children as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The analysis provides, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The patient in this case is a small child with severe speech and language delay that adversely impacts communication with those around him. These difficulties prevent him from acquiring the usual skills of childhood. In addition to expressive and receptive language delay, he exhibits feeding issues that affect his ability to obtain adequate nutrition. Successful feeding clinics incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. Speech therapy is imperative to this work. The current lack of underlying diagnosis does not negate the medical necessity of intervention for this child. This patient has significant delays in multiple areas and has not shown spontaneous improvement over time. He requires therapy to maximize his skills in communication and feeding. Speech therapy is therefore medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a computerized tomography (CT) of the pelvis for an evaluation of his abdominal and chest pain. Findings:  The physician reviewer found that this patient has no documented symptoms pertaining to the pelvis region. On physical exam, no abnormalities are noted that relate to the pelvic area. There are no other imaging studies that show an abnormality of the pelvic region. Therefore, there is no medical evidence to support a CT scan of the pelvis for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested for a vascular surgery consultation for treatment of his medical condition. Findings:  The physician reviewer found that the patient has no weakness motor function deficits or muscle wasting. In addition, the patient has had a normal EMG with a good left radial pulse present and only mild discomfort with median nerve compression. A vascular work-up is not indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a two-year-old female enrollee has requested for chiropractic care for treatment of the enrollees subluxation. Findings:  The physician reviewer found that the fact that her eye condition may improve with this care is an added benefit in this situation. There is documentation of abnormal findings on examination of the musculoskeletal system, including tenderness, spasm and decreased mobility associated with the subluxation. These findings are being addressed by the chiropractic care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism spectrum disorder and speech-language disorder. Findings:  The physician reviewer found that the etiology of autism has not been clearly delineated, but the consensus is that it is a congenital disorder. The highlight of dysfunction in autism is a communication defect. Consistent speech therapy on a one-to-one basis is the only known method of improving communications in an autistic child.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female enrollee has requested sensory integration therapy for the treatment of the enrollees cerebral palsy and cortical visual and developmental speech delay. Findings:  Two physician reviewers found that the patient's physician ordered one month of sensory integration therapy. The childs parent is seeking reimbursement for these services. Sensory integration therapy is not a proven intervention for patients with cerebral palsy. There is no evidence base for this intervention for this diagnosis. Additionally, it is unclear why one month of therapy was ordered.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to a prudent layperson standard. A patient must be suffering from symptoms of such severity that a prudent layperson would expect the lack of immediate medical attention to jeopardize her health. This patients symptoms were not acute in onset. They had commenced gradually over several days. The patient had suffered allergic reactions in the past. Her symptoms do not meet the prudent layperson standard for an emergency.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested emergency services for the treatment of his medical emergency. Findings:  The physician reviewer found that the symptoms of difficulty breathing and persistent coughing are consistent with a variety of potentially life-threatening emergent medical conditions including exacerbation of asthma, pneumothorax, pneumonia, and other respiratory and cardiac disorders. Given that these symptoms were new to the patient and that he had no prior history of respiratory difficulties, it is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested an emergency room visit for the treatment of his coughing and abdominal pain. Findings:  The physician reviewer found that the symptoms of difficulty breathing, excessive coughing, abdominal/chest pain are consistent with a variety of potentially life-threatening emergent medical conditions including exacerbation of asthma, pneumothorax, pneumonia, and other respiratory disorders. It is reasonable for a prudent layperson to access emergency medical care for such symptoms. Although he had seen his physician on the previous day, his condition worsened despite being prescribed additional medications to treat his respiratory distress.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a positron emission tomography (PET) study for an evaluation of her endometrial cancer of the uterus. Findings:  Three physician reviewers found that the patient is a 61-year-old female with surgically proven endometrial cancer with negative nodes upon pelvic lymph node dissection. The Health Plan has denied reimbursement for a PET scan, and the patient is appealing this denial. The patients Health Plan has clear guidelines for authorization and coverage for PET and CT scans. These guidelines are medically appropriate and do not list endometrial cancer as a diagnosis for which PET scans would be covered. The American Cancer Society describes PET imaging for endometrial cancer as needing further study and not routinely ordered. PET scan was not medically indicated in this patients case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 17-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that the symptoms of shoulder pain after a motor vehicle crash could be indicative of a fracture, dislocation or bruise of the shoulder. Although rarely life-threatening, it is critical to evaluate patients who might have such injuries in order to manage these injuries in a timely fashion. A delay in diagnosis and treatment can lead to loss of function of the limb. Other disorders of the thorax, such as pneumothorax, may also manifest as shoulder pain and need to be ruled out given the mechanism of injury.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested for continuing intensive outpatient program (IOP) services for eating disorders.  Findings:  The physician reviewer found that her need for continued care should be reviewed at least monthly.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for Electron Beam Computed Tomography (EBCT) for evaluation of her coronary condition. Findings:  Three physician reviewers found that cardiac CT scan is able to detect coronary artery calcification present in artherosclerotic plaque but not in the wall of normal arteries.  Studies have demonstrated only a moderate increased risk for hard cardiac events associated with calcification detected in high-risk asymptomatic patient populations. Additionally, even large amounts of calcium do not necessarily imply the presence of significant stenosis.  There is a lack of outcome data showing calcium scoring impacts the quality or quantity of life.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for compound Lidocaine gel for treatment of her nerve pain. Findings:  The physician reviewer found that the compound Lidocaine gel is not deemed therapeutically equivalent to the Lidoderm patch which is approved by the FDA. The literature submitted pertains to the Lidoderm patch and not to Lidoderm gel. There is no evidence in the literature to support the use of the gel in this medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested intravenous immune globulin (IVIG) therapy for the treatment of her unspecified immune disorder and chronic sinusitis. Findings:  The physician reviewer found that there is no evidence the patient has undergone appropriate laboratory testing to establish immune deficiency. Without the results of the laboratory studies listed above, IVIG therapy cannot be supported for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for partial hospitalization for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient appears to suffer from a slightly atypical form of regurgitation as part of her bulimia, she nonetheless does suffer from this disorder.  Given the complexity of her problems, attest to her continued struggles with regurgitation and mood irregularities, her course of partial hospitalization was not near completion.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested physical therapy (PT) services for the treatment of her cervical and left hand pain. Findings:  The physician reviewer found that the patient is a 57-year-old female who required surgery. She underwent cervical discectomy and fusion. The patient was prescribed physical therapy postoperatively. This type of postoperative treatment was indicated and medically necessary. The therapist provided modalities not available at home and provided numerous benefits that are used in conjunction with home exercises and medication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for speech therapy for treatment of her dysphonia. Findings:  The physician reviewer found that the requested therapy sessions may be beneficial and are medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested continued ABA therapy for the treatment of his autism. Findings:  The physician reviewer found that ABA therapy has been shown to be efficacious in the treatment of autism and autism spectrum disorders. Improvements as a result of intensive early intervention with ABA therapy have been demonstrated in terms of measured IQ as well as in adaptive, social and communicative skills in comparison to control patients who did not have ABA treatment. These gains have been shown to be sustained over time, with documented follow-up of as long as 6 years in one follow-up study. Further, these findings have been replicated by other studies. In the case of the enrollee, progress with the ABA therapy has been documented with regard to his communication skills (particularly receptive language) and adaptive functional skills. There is no alternative treatment modality that would be as effective for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 24-year-old male enrollee has requested dental implants for the treatment of the enrollees cleft lip/palate and congenital malformation due to root resorption. Findings:  The physician reviewer found that patients with facial clefting present many challenges. The goal of treatment is to provide normal function and esthetic appearance. The optimal management of patients with cleft lip and palate is usually done under the direction of a multidisciplinary team in order to achieve satisfactory results. Treatment can often last into the patients late teenage years to early twenties. Specific therapeutic goals for maxillofacial deformities include improving mastication/swallowing, improving occlusion and improving dental and periodontal health. Given that the patient had a congenitally missing #7 as well as malformed ##8-10, dental implant placement in order to reconstruct his anterior maxilla was necessary in order to achieve the therapeutic goals for this patient with cleft lip and palate. In addition, reconstructive surgeries performed to correct deformities caused by congenital or developmental abnormalities for the purpose of improving bodily function or symptomatology or creating a normal appearance is a covered benefit per the coverage of benefits which was provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech impairments. Findings:  The physician reviewer found that this young man has significant speech and language deficits involving expressive language skills, negatively impacting his ability to communicate and maintain social interaction. It is not typical for speech and language disorders to arise de novo in the adolescent years unless associated with neurologic disease or trauma. This young man does not have either in his medical background. His therapist has diagnosed him with an adjustment disorder with anxiety. While anxiety may result in rapid speech, the examples of the patients speech patterns included in the documentation reveal more deficiencies than just rapid speech. In fact, it may be that he has had speech and language deficits all along, partially masked by his bilingual background, yet concurrently exacerbated by and exacerbating his anxiety. Prathanee and colleagues (2006) looked longitudinally at children with a history of specific language impairment. Natural history data indicated that approximately 50% of children with specific expressive language delay spontaneously remitted or outgrew it at age 5-8. However, long-term follow-up studies showed their language problems emerged later at age 15. The rest of the childrens (50%) language impairment persisted and had a high risk for SLI [specific language impairment] later. They recommended active intervention for these children. Speech and language therapy is thus medically necessary and appropriate for this young man. In addition, neuropsychological testing would be quite helpful in delineating mental health issues from processing difficulties and language deficits.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested an X-Stop procedure for the treatment of her degenerative disc disease and spinal stenosis.  Findings:  Two physician reviewers found that the success rate with this relatively new procedure varies. The initial study (Zucherman, et al) supporting its FDA approval involved patients with degenerative spinal stenosis who received either conservative treatment or the X-STOP device. It reported significant improvement in symptoms in the X-STOP treated patients, but only involved relatively short-term follow-up (2 years). One study (Verhoof) that included patients both with and without spondylolisthesis demonstrated only a 45% success at two years follow-up for the patients with spondylolisthesis who received the X-STOP device. Failure rates and the need for reoperation are higher in patients with spondylolisthesis and the X-Stop procedure. Given this patients spondylolisthesis, it is unlikely that the patient will get any long-term benefit with the X-Stop procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested multi-agent chemotherapy regimen of 5-FU, leucovorin, Erbitux, Camptosar, Avastin and oxaliplatin for the treatment of his colon cancer metastatic to liver. Findings:  The physician reviewer found that the patients current regimen, including 5-FU, leucovorin, Avastin, Erbitux, oxaliplatin and Camptosar, is a regimen with no clinical evidence to support its use. Though each of these drugs is approved in certain combinations and situations in metastatic colon cancer, using all of them together is rather unprecedented. There is no clinical trial suggesting improved efficacy with this combination. Unfortunately, his cancer is progressing. The usual recommendation in such a circumstance is to recommend a different protocol. There is little basis to say that this current regimen is slowing the progression of disease. This combination is, at best, investigational, of no proven benefit in this situation and not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested a PET/CT scan for an evaluation of his thyroid cancer. Findings:  Three physician reviewers found that the patient is a 38-year-old male with thyroid cancer and negative whole body scan. He has a measurable thyroglobulin and is on thyroid hormone. An MRI showed abnormal enhancing soft tissue in the left vallecula. The patient is appealing the Health Plans denial of coverage for a PET/CT scan. This diagnostic study is not experimental or investigational. The presence of a measurable thyroglobulin when the TSH is suppressed is indicative of thyroid tissue being present. The requested diagnostic test is medically indicated to detect recurrence of thyroid carcinoma.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested hospital services at a facility that can meet the immediate needs of her unborn child for the treatment of her highrisk pregnancy. Findings:  The physician reviewer found that this fetus has a significant congenital cardiac anomaly which will require intervention immediately after birth. A fetal echocardiogram is done prenatally to allow for the provider to plan the delivery at a tertiary center which can best deal with the defects and reduce mortality. Double outlet right ventricle (DORV) can have a mortality rate as high as 50% when combined with other cardiac anomalies. Transporting a sick newborn even for a short distance can add to that mortality rate. Additionally, it is not in the best interest of this patient to deliver in one hospital and immediately be separated from her baby. The baby may have to go to surgery before the mother can be medically discharged from the hospital, and it will also interfere with the bonding process. If the mother is in the same hospital as the child, she may be able to hold and nurse the child up to the time of surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a follow-up consultation with an allergist for the treatment of her lupus and exposure to mold/mildew. Findings:  The physician reviewer found that there is no clear or close relation between mold exposure and lupus. This patients lupus is very well-controlled on her current regimen, which implies two things. First, there is no evidence that mold exposure has caused any worsening of her condition. Second, she does not have active disease of such severity that she would be at clear risk for opportunistic infection. I agree with the allergists recommendation that the patients concerns fall into the realm of industrial hygiene and occupational medicine.  Given that the patient has already seen the allergist and received his opinion, the fact that she did not like his opinion does not require the Health Plan to authorize further allergy consultation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested an emergency room visit for the treatment of her right knee pain. Findings:  The physician reviewer found that the patient is a 19-year-old female who went to an emergency room for a dislocated knee. She was asymptomatic at the time of examination in the emergency department. She has had this chronic problem with the knee popping in and out. The evidence in the emergency department was that her problem, perhaps worse than usual, was nonetheless mild. There is no basis for determining that the problem was significantly worse than usual or constituted a medical emergency.  It would have been prudent to contact the on-call staff before going to the emergency room, given the chronic nature of her illness and the history of intermittent symptoms that spontaneously resolved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested partial hospitalization program (PHP) services for the treatment of her depression. Findings:  The physician reviewer found that the patient was not a major suicidal risk at the time of admission to the PHP. The admission note is silent as to what treatment, if any, the patient received from the time of acute hospital discharge until PHP admission. A note from the PHP purports that the patients mental illness constitutes a serious threat to health. Further, the provider states, patient is a significant safety risk thus necessitating her admission in our partial hospital program. The latter statement does not agree with the information contained in the PHP admission note. There is no record that the patient was treated in any way from the time of acute hospital discharge to the time of PHP admission. Her need for PHP treatment is not demonstrated. She could have been safely and effectively treated in a less restrictive program of care, such as an intensive outpatient program.