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

A 44-year-old female enrollee has requested weekly outpatient therapy visits for treatment of her major depressive disorder.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) treatment guidelines for depression state that, use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder. In addition, the APA reports that the clinical evidence also supports the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy, psychodynamic therapy and problem-solving therapy. This patients records indicate that in addition to participating in outpatient therapy, she was also being treated with a mood stabilizer. The providers notes indicate that as the patients condition appeared more severe, medical therapy was added to the treatment regimen. As such, this provider has complied with the APA practice parameters, in that she started the patient with psychotherapy alone, but sought help with the addition of medication to the regimen when the patients condition appeared more severe.Moreover, the patients provider recorded progress in the records provided for review. Specifically, the treatment notes initially document a woman who was quite distraught and needed frequent support. However, as treatment progressed and medication was added, the patient slowly showed improvement, as anticipated with an appropriate treatment regimen. In this case, the successful outcome proves that outpatient therapy provided from the said date was and is medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that regarding the medical necessity of speech therapy for the treatment of this patient with autistic spectrum disorder (ASD), these services are medically necessary based on overall evaluation of the literature. An additional point with regard to this patients case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development that is seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male has requested applied behavior analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that the disputed ABA therapy services provided during the said timeframe ongoing are medically necessary for the treatment of this patients autistic disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including therapy that may encompass a wide variety of modalities including ABA therapy, can be used to help induce brain plasticity. The ultimate goal of the therapy is to retrain neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, self-help skills, and sensorimotor repertoires essential to the activities of daily living. The evidence demonstrates that the skills relevant to age-appropriate activities of daily living improve with long-term application of ABA services during critical developmental periods in childhood. Therefore, the denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has a congenital expressive aphasia. Cognitive studies have indicated that she is likely of normal intelligence. She has made definitive gains, demonstrated by testing on the RITLS, during a 5-month period of 1 hour of weekly speech therapy.  Children with speech delay can be effectively treated with speech therapy, as confirmed in a meta-analysis of multiple medical journal articles (Law, et al.). Goorhuis-Brouwer, et al. specifically studied speech-delayed children with normal intellect, such as this patient, and found that such children are ideal candidates for successful speech therapy. Two-year olds who test below the 10th percentile for their age often require and benefit from speech therapy (Emmanues, et al. and Buschman, et al.). All told, speech therapy is medically indicated in this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Neurontin 300mg, Ambien 10mg, Lamictal 150mg, prazosin 1mg, clonazepam .5mg, alprazolam .5mg, fluoxetine 20mg and bupropion 15mg  for the enrollees bipolar disorder, obsessive-compulsive disorder and panic disorder.  Findings:  The physician reviewer found that per the submitted documentation, medication changes were made frequently, and there is no documentation regarding degree of compliance.  This patient has been diagnosed with bipolar disorder, and Lamictal is an evidence-based treatment for this condition according to the American Psychiatric Association practice guidelines. The patient seems to have been fairly stable throughout her treatment with her current provider, and she appears to have been on this medication the entire time. The concurrent use of two antidepressants for bipolar depression is not indicated per the American Psychiatric Association guidelines, and the history given by the patient suggests that she has failed both fluoxetine and bupropion in the past. Hence, the documentation fails to justify the use of these medications. In this patients case, clonazepam was not and is not medically indicated. She has been on this medication for a long time, and there is no evidence that the provider has attempted to titrate the dose or discontinue this medication. Ambien has also been added with no indication that the patients response has been monitored, and with insufficient documentation to justify its use. Neurontin has no indication for sleep according to FDA guidelines or current literature. The record documents a complaint of frequent nightmares. This is a sound rationale for use of prazosin in this case. The prescription of alprazolam is supported by the indication of situational anxiety for which this medication is indicated.All told, Neurontin 300mg received on the said date was not medically indicated, and continued use of Neurontin 300mg is not medically indicated. Ambien 10mg provided on the said date was not medically necessary, and the submitted documentation fails to establish the medical necessity of continued use of Ambien 10mg. In this patients case, clonazepam .5mg received on the said date was not medically indicated, and continued use of clonazepam .5mg is not medically necessary. Fluoxetine 20mg provided during the said timeframe was not medically necessary, and continued use of fluoxetine 20mg is not medically indicated.  In this patients case, bupropion 15mg received from this time period was not medically indicated, and continued use of bupropion 15mg is not medically indicated.  However, the medical documentation demonstrates the medical necessity of Lamictal 150mg provided on the date in question, and continued use of Lamictal 150mg is medically indicated.  Additionally, prazosin 1mg received on the said date and continued use of prazosin 1mg was and is medically necessary.  Also, the medical records demonstrate the medical necessity of alprazolam .5mg provided on the date in question, and continued use of alprazolam .5mg is also medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested gluten-free medication/injections with a certification from the manufacturer for treatment of her Celiac disease. Findings:  The physician reviewer found that the patient is tolerating the allergy shots twice weekly with only local reaction manageable with hydrocortisone cream, and has no systemic reaction. There is no evidence in the peer-reviewed medical literature to support the contention that gluten in allergy shots (if any) has any impact to gluten enteropathy. For these reasons, the request by the patient to have gluten-free allergy shots from a different manufacturer with certification is not medically necessary and therefore should not be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested surgical replacement and local tissue rearrangement with scar revision of the nipple for treatment of her breast implants. Findings:  The physician reviewer found that this patient has experienced known complications including capsular contracture and implant rupture. In this patients case, the ruptured silicone breast implant is considered an abnormal structure of the body as the effects of silicone implant rupture and free silicone may contribute to an abnormal state. While removal of the implant would return the breast to a normal state and should be considered reconstructive, replacement of the implant would re-create a cosmetically enhanced state and would be considered a cosmetic enhancement. However, the color photograph of the patients areola clearly demonstrates an abnormal structure of the body as it was created from the removal of a breast mass. In addition, the records suggest the patients healing was complicated with infection. The photograph depicts an asymmetrical deformity caused by the previous surgery and revision by a qualified plastic surgeon should correct this scarring. Thus, implant removal and revision of the scar is consistent with medically necessary reconstructive surgery, whereas replacement of the implant itself does not meet this standard
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The spouse of a deceased female enrollee has requested 24-hour in-home nursing care services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition or urgent medical condition for four months. Upon review of the submitted documentation, a prudent layperson would not have believed he or she was experiencing an ongoing emergent situation for four months. Therefore, these services do not meet prudent layperson criteria for an emergency medical condition. However, there can be the possibility of imminent death especially in terminally ill patients with cancer and these patients may require palliative care. Based upon the documentation provided, this patient appeared to be quite ill upon discharge from the hospital. She had a very poor performance status. This would have precluded travel back to the in-Plan service area for palliative care. Although there is not a clear clinical description of the patients performance status or respiratory status, it appears she did experience a significant deterioration of her medical condition while out of the country. A prudent layperson in this patients circumstances would reasonably expect that the worsening of her symptoms constituted an urgent medical situation which precluded travel back to the in-Plan service area.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested reimbursement for surgical services in an emergent or urgent. Findings:  The physician reviewer found that he had a significant injury to his right arm that needed immediate attention in the emergency department. After stabilization, the wound was bleeding only minimally, there was no pain, and there was good vascular supply to the hand distal to the injury. By prudent layperson criteria, the emergency/urgency had resolved. A prudent layperson in this situation would have been sufficiently stable to discuss coordination of his medical care with hospital staff.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a lumbar spinal fusion for treatment of her low back pain. Findings:  The physician reviewer found that fusion in the lumbar spine is generally accepted in cases of instability associated with trauma, tumor, or infection, and in scoliosis and spondylolisthesis, but other indications are variable and not accurately defined. Arthrodesis remains controversial for the treatment of discogenic back pain. With an established indication, improvement can be expected after fusion, although patients with chronic low back pain experience less improvement. The presence of disc degeneration can be noted in the absence of back pain or any other symptoms. Lumbar discography also remains controversial, with reports of false-positive findings and abnormal results in normal subjects.  In this case, there is no documentation of instability of the spine, and the discogram is not definitive. The submitted documentation fails to establish the medical necessity of the requested lumbar spinal fusion in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested CyberKnife stereotactic body radiation therapy (SBRT) for treatment of his prostate cancer. Findings:  Three physician reviewers found that according to the current National Comprehensive Cancer Network (NCCN) guidelines, the standard of care would be either radical prostatectomy or radiation therapy. The NCCN also suggest that 3D conformal and intensity modulated radiation therapy (IMRT) technique should be employed, given in conventional fractions while image guided radiation therapy (IGRT) is required if dosing exceeds or equals 78 Gy. Furthermore, the criteria state that in patients with intermediate risk disease, doses between 78-80 Gy have been shown to provide improved PSA-assessed disease control. However, the guidelines do not mention SBRT given at 7.25 Gy given in 5 fractions either alone or as a boost for prostate cancer patients. Patients also with intermediate recurrence risk may also be considered for short-term neoadjuvant/concomitant/adjuvant androgen deprivation therapy. Overall, there is a paucity of data establishing SBRT as likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy as outlined in current NCCN practice guidelines for prostate cancer.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a fecal transplant for treatment of the enrollees history of C. difficile enteritis.  Findings:  Three physician reviewers found that fecal transplantation for refractory C. difficile-associated diarrhea has been reported in the medical literature. There have been controlled clinical trials involving small number of patients that seem to show effectiveness.  However, the submitted documentation does not demonstrate that the patients current symptoms are due to persistent or recurrent C. difficile toxin infection.  A colonoscopy performed on the said date was endoscopically normal, and colon mucosal biopsies were reportedly normal. No pseudomembranes were endoscopically detected which, if present, could have perhaps supported a diagnosis of C. difficile toxin-associated colitis/diarrhea. Even if C. difficile toxin was present in her stool and confirmed by stool analysis, there is no guarantee that the presence of C. difficile toxin would be the reason for her diarrhea. There are no current stool study results that demonstrate that the patients diarrhea, nausea, and vomiting are due to persistent C. difficile-associated diarrhea.  There is a potential detrimental effect of transplanting a pathogen into an immunocompromised patient.  Thus, the requested fecal transplant is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for a colonoscopy for evaluation of his colon polyp.  Findings:  The physician reviewer found that if the polyp discovered and removed during the colonoscopy were proven to be an adenoma, then a repeat colonoscopy would be justified before waiting the required 7 years. However, the histology of the polyp is not documented. In addition, the patchy inflammatory changes seen on the original colonoscopy were likely due to the colon preparation itself and would not be an indication for a repeat colonoscopy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested a circulating cold pad/pump for treatment of his status post shoulder surgery.  Findings:  Three physician reviewers found that Konrath and colleagues performed a randomized prospective study of postoperative use of cold therapy following anterior cruciate ligament reconstruction. Patients were randomized into four groups after the surgery. Group 1 was prescribed a cooling pad applied to the knee, and this was set at 40 to 50F. Group 2 had a cooling pad set at 70 to 80F.  Group 3 received ice packs. Group 4 received no cold therapy of any kind. These authors found that there were no objective benefits in the early postoperative course and no significant differences between the groups of patients studied.  In the article by Daniel and colleagues, 131 patients were followed after arthroscopically-assisted anterior cruciate ligament reconstruction. These patients were randomized into five treatment groups. These groups were cooling pads at 40, 45, 55 and 70, or no cooling pads. In the study of these patients, there were no differences between groups referencing hospital stay, pain medication use, pain scale, knee girth or range of motion.  Overall, the medical literature does not support the increased efficacy of an active cooling system over the use of cold by standard cooling pads and ice packs in the management of postoperative pain.  Thus, the circulating cold pad/pump was not likely to have been more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested one hour of speech therapy, twice per week, and one hour per week of occupational therapy services for treatment of the enrollees deficits in fine motor skills and delays in receptive language, expressive language and pragmatic skills.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence indicating that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  A 2004 systematic review by Law and colleagues determined that speech and language therapy might be effective for children with phonological or expressive vocabulary difficulties. Studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this case, the evaluation of his speech and language function on the said date showed global issues in speech delay.  Thus, in this patients case, one hour per week of speech therapy services is medically indicated. However, the submitted documentation fails to establish the medical necessity of occupational therapy. There are conflicting reports about his developmental skills, particularly as it relates to motor delay.  Furthermore, the patient has maintained his weight, and there is no particular documentation of oral-motor aversion.  Per the submitted records, he does not meet the criteria for a sensory feeding disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-month-old male enrollee has requested brand Daptacel T-dap vaccine for treatment of the enrollees unremarkable medical history.  Findings:  The physician reviewer found that based upon the current medical literature, there is a lack of evidence demonstrating that this patient should receive the requested brand Daptacel instead of Infanrix. The media has been fraught with concerns regarding the presence of aluminum in some vaccines. There are discussion about the amount of aluminum in injectables and the effects on children. Those at most risk for aluminum toxicity are extremely premature infants and those with inadequate kidney function. However, there is little information in the literature about the effects of aluminum in vaccines.  Daptacel contains 330mcg per dose, and Infanrix contains 625mcg per dose.  The amount of aluminum adjuvant in Infanrix is considered to be safe. The literature does not support the use of one vaccine over another in a healthy infant.  All told, the requested brand Daptacel T-dap vaccine is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested the X-stop procedure for treatment of his low back and bilateral leg pain.   Findings:  Three physician reviewers found that the X-Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication.  These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain with or without back pain that was relieved with flexion forward bending, and the ability to walk at least 50 feet. However, FDA documents released before a public hearing on the product raise concerns that the X-stop's effectiveness decreases over time. According to the FDA, it appears that the X-stop is only effective for a brief period and then begins to decline. While this patient has severe low back pain, as well as bilateral radial leg pain, there is insufficient evidence that the implantation of the X-stop device would be more efficacious than standard therapy in the treatment of this patients medical condition. Based on the scientific evidence available at this time, the X-stop device is not likely to provide greater relief for this patient than non-operative therapy.