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

A 20-year-old female enrollee has requested gender reassignment chest surgery (bilateral mastectomy) for the treatment of her gender disorder of adulthood. Findings:  The physician reviewer found that the Harry Benjamin International Gender Dysphoria Associations (HBIGDA) Standards of Care for Gender Identity Disorders represent the generally accepted standard of care in this setting and are applicable in this case. This patient meets HBIGDA diagnostic criteria for gender identity disorder based on the following:the patient has a desires to live and be accepted as a member of the opposite sex accompanied by a wish to make the body congruent with this desire; the patients desire has been present for at least two years; andthe patients disorder is not a symptom of another mental disorder or chromosomal abnormality.Before beginning hormone therapy or performing breast surgery, HBIGDA criteria requires a letter from a mental health professional indicating the following:1.the patients general identifying characteristics;2.the initial and evolving gender, sexual and other psychiatric diagnoses;3.the duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent;4.eligibility criteria that have been met and the mental health professionals rationale for hormone therapy or surgery;5.the degree to which the patient has followed the HBIGDA Standards of Care to date and the likelihood of future compliance;6.whether the author of the letter is part of a gender team; and7.a statement that the sender of the letter welcomes a phone call to verify the fact that the mental health professional actually wrote the letter. Psychotherapy is not an absolute requirement for treatment and there is no specific number of required sessions before treatment. However, breast surgery produces relatively irreversible changes to the body. This is usually the first surgery performed by female to male transgender patients. For some patients (as may be the case with this patient), it is the only surgery they undertake. It is not necessary that the patient take hormones prior to this surgery. However, before performing the requested surgery, steps must be taken to ensure the patients well being. In this case, there is an absence of a letter from a mental health professional/therapist which details his or her involvement with this patient over an extended period of time and which adequately addresses all of the points mentioned above. Thus, based upon the documentation provided at this time, the medical necessity of the proposed procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested a wheelchair with a power recline feature for the treatment of his medical condition. Findings:  The physician reviewer found that the requested wheelchair with a power recline feature is medically necessary for this patient because he is at high-risk for development of pressure ulcers and has a history of such pressure ulcers. In addition, he cannot transfer independently and is unable to weight shift/position himself in his wheelchair due to his poor upper extremity muscle strength and poor trunk control. Furthermore, this patient uses a catheter and undergoes blood treatments and would benefit from the power recline feature which would allow him to increase the hip angle while in his wheelchair. All told, the patient meets Centers for Medicare & Medicaid Services (CMS) criteria for a power recline feature, and this device is a medically appropriate and necessary accessory to his power wheelchair.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested social skills group therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that social skills deficits are considered key features in patients with autism spectrum disorder (ASD). However, as noted in Bellini and Peters paper on social skills training (SST) for children with ASD, multiple strategies are often needed to address patients social skills deficits. The authors comment that, Social skills assessment is a crucial first step to SST. Treatment strategies include employing social stories, video modeling, coaching, social problem solving, behavior rehearsal, feedback and reinforcement. The treatments, when determined to be medically indicated, usually involve multiple settings. Williams White and colleagues concluded that the state of research about the effectiveness of social skills groups is still in its infancy. Given that there are multiple treatment modalities available to address social skills deficits in young patients with ASD, as well as the lack of a descriptive social skills assessment for this patient, the medical necessity of the requested therapy as treatment for this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five year old male enrollee has requested one hour of occupational therapy per week for the treatment of the enrollees autism. Findings:  The physician reviewer found that the American Occupational Therapy Association (AOTA) supports the use of OT services for the purpose of treating functional deficits in patients with autism as outlined in their guidelines. This patient has sensory and fine motor delays that are affecting his ability to attend to self-care as well as his independence in the community. Review of the submitted information demonstrates that twice-monthly therapy has been inadequate to address the patients functional deficits. For instance, while OT is generally helpful in improving dressing skills, this patient has not achieved adequate gains in this area from his current therapeutic regimen. As such, it is medically appropriate and necessary to initiate weekly OT sessions, which focus on development of adequate short-term objectives and long-term goals related to ADLs and fine motor skills for community play.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested magnetic resonance spectroscopy (MRS) for treatment of his prostate cancer. Findings:  Two physician reviewers found that the MRS uses a strong magnetic field to obtain metabolic information as there are metabolic differences in normal prostate tissue, benign hypertrophic prostate tissue, and cancerous prostate tissue. This patients clinical situation (localized prostate cancer with a Gleason score of six, a PSA of 8.2, and a normal feeling prostate) carries a high probability of his disease being organ confined. In this case, radical prostatectomy is indicated as the treatment of choice. With standard radical prostatectomy, his five and ten-year probability of being progression free is between 89 and 97 percent. There is no evidence that a MRS would add clinically significant information that would alter the treatment of this patients condition. An MRS may be indicated in patients with high-risk/high-grade cancer. Accurate localization of cancer is of increasing value when focal therapies evolve (e.g., localized cryosurgery or high-intensity focused ultrasound), which is not the case with prostate cancer. A radical prostatectomy is planned for this patient regardless of any small subtle findings that may be revealed by the requested MRS. The proposed exam is not routinely used for preoperative evaluation in this setting and is not likely to confer additional benefit in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested an i-Limb prosthetic hand for the treatment of his medical condition status post left hand amputation. Findings:  The physician reviewer found that the prescription of an upper limb prosthesis is highly individualized and must be client-centered in order to achieve a positive clinical outcome (Biddiss and Chau). Desmond and MacLachlan indicate that the treating team must consider multiple factors including the patients clinical status and psychological needs, the functionality of the device, and his or her functional needs. In the absence of such an approach, the likelihood that the patient will successfully use the prosthesis is greatly diminished. In the case of this patient, the records demonstrate that he will derive significant benefit from the enhanced ability to perform fine motor tasks that the i-Limb provides. The submitted records justify the need for a myoelectric prosthesis as well as the unique capabilities of the i-Limb hand prosthesis. A cable operated alternative is contraindicated due to the patients shoulder, neck and back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy and an apraxia test for the treatment of the enrollees speech disorders. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood (Nelson and colleagues). Thus, the long-term consequences of speech and language may be substantial. Law and colleagues concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensori-motor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, communication at all levels may ultimately be impaired (Lewis and colleagues). In summary, the literature supports the efficacy and medical necessity of speech and language therapy for verbal apraxia as well as phonological disorders. Intensive speech therapy and associated apraxia testing is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of an 87-year-old female has requested skilled nursing facility services for the treatment of the enrollees cellulitis at gastrostomy tube site and urinary tract infection. Findings:  The physician reviewer found that the patient had been in an acute hospital prior to her skilled nursing facility admission. The medical records note that she was medically stable. The physician orders included an order for vital signs to be checked two times per day. Intravenous treatment every 12 hours can be administered at a lower level of care than skilled nursing care. The patients vital signs and examination were stable and did not suggest that the patient required skilled nursing facility care. This patient could have safely been treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested a robotic-assisted laparoscopic partial nephrectomy for treatment of his renal mass. Findings:  Two physician reviewers found that small renal neoplasms as seen in this case can be treated via partial nephrectomy through approaches including non-laparoscopic (conventional surgery), laparoscopic and robotic-assisted laparoscopic techniques. The superiority of robotic-assisted laparoscopic partial techniques has not yet been demonstrated. At this time, there is a lack of outcome data from large, randomized studies demonstrating better results with robotic-assisted laparoscopic partial nephrectomy as compared to standard techniques. Further studies are needed to see if this approach is equal to or better than the other approaches for partial nephrectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested bilateral temporomandibular joint arthroscopy for treatment of her jaw pain. Findings:  The physician reviewer found that the patient has been treated with an adequate and appropriate course of non-surgical therapy consisting of physical therapy, occlusal appliances and medical management including nonsteroidal anti-inflammatory medications and muscle relaxants. Despite these measures, she continues to have symptoms. The patient has clinical and imaging evidence of mechanical disruption of joint structures. Given that she has failed non-surgical treatment, surgical intervention is indicated. Guidelines for surgical intervention have consistently recommended consideration of surgery if non-surgical modalities do not result in significant improvement within 6 to 12 weeks. In this patients case, bilateral TMJ arthroscopy is clinically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees apraxia. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, involves impairment in planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, communication at all levels may ultimately be impaired. This patient has verbal apraxia and dysarthria, and his skills fall below those of other children his age. These deficits negatively impact his ability to communicate effectively. Studies have shown that speech therapy can result in significant improvement in such patients. This patient has demonstrated some improvement with previous speech therapy and is likely to benefit from additional therapy. Thus, speech therapy was and is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested physical therapy (six visits) for the treatment of her bilateral knee pain. Findings:  The physician reviewer found that this patient has right knee meniscal pathology and she is status-post ACL repair and tibial plateau fracture on her left knee. The patients physical therapist documents that the patient has swelling at the back of her knees and hamstring tendons and her bilateral knee range of motion has decreased (with pain). The physical therapist also documents that the patient has significant functional deficits including bilateral posterior knee pain with walking, pain with palpation, and pain with deep squatting. Thus, the requested six sessions of PT are medically warranted, reasonable and necessary in this patients clinical situation given her persistent pain, functional deficits, and findings on her MRI scans.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested reimbursement for use of a Dynasplint for the treatment of his contracture. Findings:  Two physician reviewers found that the patient underwent palmer fasciectomy to release the contracture. Dynamic splinting devices such as the Dynasplint can be beneficial following this procedure. The use of the Dynasplint allows for a low-load, prolonged duration stretch to the finger joint and helps improve range of motion. It is an important adjunct to the rehabilitation process for patients such as this patient. The use of the Dynasplint in this setting was likely to have been more successful than hand therapy alone or a standard static splint.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested total ankle replacement surgery for the treatment of his right ankle pain. Findings:  Two physician reviewers found that the scientific literature reveals adequate outcome data to support the efficacy of total ankle replacement. The data demonstrates the procedure preserves mobility in the ankle over fusion and is safe and effective in the long-term. In addition, this patients clinical presentation lends to the conclusion that he will likely benefit from total ankle replacement surgery, especially after failing to receive long-term benefit from the earlier procedures. Therefore, considering the current orthopedic standard of practice this patient is an appropriate candidate for total ankle replacement and the procedure is likely to be more beneficial for the treatment of the patients right ankle arthritic condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested monthly electrical stimulation and chiropractic adjustment for the treatment of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation does not specifically indicate the daily lifestyle and function of the patient. The office notes lack information related to an outcome assessment of the patient. The provider noted that the patient has instability of the lumbar spine and has been given therapeutic exercises and instruction for use of heat or ice when exacerbations occur. Per the provider, treatments have been effective in reducing his symptoms and have allowed him to continue to perform physical activities. The submitted documentation does not indicate the location of pain, quality of pain, level of function and whether the condition is better, worse or the same. Additionally, there is no documentation as to the severity of the pain. There is a lack of documentation as to the resolved issues from the previous office visit or new complications which may have arisen and the cause of these conditions. The submitted records do not include any completed orthopedic, neurological or muscular analysis. There is no documentation of any short-term or long-term goals and expected functional outcomes. The providers notes do not indicate treatment effectiveness from visit to visit or document functional gains. The submitted documentation does not describe the exercises that were given, and there is a lack of support justifying lumbar instability. Based on the records provided, clinical indications for monthly electrical stimulation and chiropractic adjustment have not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested speech therapy services for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the speech therapy records provided for this patient do not demonstrate that she has achieved specific or adequate functional gains. The reports show no changes or improvements in the goals listed. The treatment summary goals are identical for each date and do not demonstrate a change from one visit to the next. As such, there is a lack of evidence demonstrating that the patient has benefitted from speech therapy. Furthermore, a literature review by Pennington and colleagues concluded that Firm evidence of the positive effects of SLT [speech and language therapy] for children with cerebral palsy has not been demonstrated by this review. The authors further indicate that there is insufficient information on outcomes regarding the use of augmentative and alternative communication (AAC) systems in this setting. As such, additional speech therapy to improve the patients oral motor skills and/or to help facilitate use of the AAC device is not supported by peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested acute inpatient psychiatric treatment at Palomar Medical Center for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patients admission was prompted by deterioration in poor self-care due to non-adherence to her psychiatric treatment (with resultant psychosis). This exacerbation of her paranoia and hallucinations resulted in her not eating or caring for herself and her unborn fetus  and led to her being detained into an inpatient setting for both her safety and the well being of her unborn fetus. While she showed ongoing limited insight into her psychiatric symptoms, the submitted documentation indicates that the patient responded to treatment and was compliant with treatment (including medications and frequent fetal monitoring). She also was allowed to sign for her own medical procedures. Additionally, she had no evidence of dangerous behaviors during the period under review. Furthermore, she was accepting of medications during the disputed period and was described as responding to that treatment by her community nurse. All told, the submitted evidence demonstrates the patient could have been treated in a less restrictive setting during the period at issue.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. In the Emergency Department (ED), the patient was noted to have stable vital signs and no fever. The patients toe was swollen, painful and draining purulent fluid. The services provided were appropriate in terms of nail excision and antibiotics however the patient did not require emergent treatment for his condition. The patients condition was non-urgent and had been progressing for four weeks. At the time he presented to the ED, he had no fever or chills and could have been safely and adequately treated on an outpatient basis. All told, a layperson with this patients symptoms would not reasonably believe he was having an emergent medical condition such that his health would have been in jeopardy had he not obtained immediate medical services