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

The parent of a nine-year-old male enrollee has requested speech and occupational therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Whereas many speakers with ASD develop more or less developmentally appropriate forms and meanings for words and sentences, deficits in the use of language for social purposes are universally seen in this population. These deficits can serve as major impediments to successful social adaptation and acceptance. Explicit training in social uses of language can be helpful to reduce these handicaps. Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. In addition, research supports the utility of teaching social skills to children on the spectrum, with the expectation that skills learned in therapy can be generalized to different settings and people. According to experts, social skills deficits are a pervasive and enduring feature of ASD. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. Speech and language therapy is therefore medically necessary and appropriate for this patient. In addition children on the autistic spectrum typically have complex deficits in the processing of extrinsic and intrinsic sensory information. Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy (OT) is well suited to affect positive change in children with ASD. OT is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested an electromagnetic bone growth stimulator for the treatment of her bilateral pars interarticular fractures. Findings:  The physician reviewer found that electrical bone growth stimulators are not indicated and have not been proven effective for treatment of stress fractures. Thus, use of the device for an L5 stress fracture would not be deemed necessary in this case. This patient had complaints of back pain.  An MRI was felt to show probable left L5 pars defect, and a subsequent CT scan was felt to show bilateral pars defect more prominent on the left. Electromagnetic bone growth stimulators are not indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a consultation for breast reduction surgery for the treatment of her thoracic and cervical spine pain. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the patient is seeking a procedure that is reconstructive in nature. Breast reduction surgery removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with a patients body and to alleviate discomfort associated with excessively large breasts. Although this patient has large breasts, given her body mass index (BMI) of 41, her breast size is not overtly large. Nor is there evidence of breast asymmetry or disease or infection affecting the breast tissue. As such, the patients condition is not considered an abnormal structure of the body. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to general concepts of medical necessity, the patient has complaints of thoracic and cervical spine pain. She is morbidly obese, has fibromyalgia and had MRI evidence of cervical disc disease. Given her multiple comorbidities, it is not clear that her breasts are the source of her musculoskeletal symptoms. She is said to have frequent infections, but there is only one primary care physician note that describes breast fold infections. A plastic surgery consultation is not medically necessary as it is not documented that the patient's neck and thoracic pain are secondary to the size of her breasts. She has fibromyalgia and cervical disc disease as the possible etiologies for her symptoms. Based upon the size of her breasts in the photographs, those diagnoses appear to be the more likely cause(s) of her pain than her breast size. There is no evidence that she has tried and failed standard treatments for those diagnoses, including weight loss and physical therapy, to assess the response of her symptoms to those more conservative measures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested an endoscopy for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that this patient has had multiple EGD exams, which were all negative. Another EGD in this case is not likely to yield any data that will alter the management of this patients condition. In the absence of any evidence that an EGD would affect the medical management or outcome of this patients condition, the clinical utility of another EGD in this setting has not been established. As such, the proposed study is not clinically indicated or necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Benicar (olmesartan) for the treatment of her chronic Lyme disease. Findings:  The physician reviewer found that the medical records reveal little supportive evidence for either early or late stage Lyme disease. Additionally, the diagnosis of chronic Lyme disease is not supported by the scientific literature. Furthermore, standard treatment for late-stage Lyme disease is one month of intravenous ceftriaxone. There is no evidence that repeated or prolonged courses of antibiotic have any clinical efficacy. Although the theory of creating a 1,25-dihydroxyvitamin D deficiency and using an angiotensin-II receptor blocker to treat Lyme disease is intriguing, it is unproven in the peer-reviewed literature. There is no proven role for the use of Benicar, at any dose, in the treatment of Lyme disease. There are no clinical trials published in peer-reviewed journals that demonstrate the efficacy of this treatment regimen. Moreover, high doses of Benicar can cause significant side effects and it is not FDA-approved for this indication. As such, there is no medical necessity for the use of Benicar in the treatment of Lyme disease in any stage.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested vision therapy for the treatment of the enrollees strabismus. Findings:  The physician reviewer found that strabismic patients exhibiting esotropia with many associated conditions (likely anomalous correspondence, no fusion  similar to this patient) tend to be the most difficult to successfully treat with vision therapy. These patients require extremely aggressive programs of vision therapy, none of which can be administered to a two-year-old toddler. In general, the treatment period tends to be lengthier for long-standing, infantile esotropia than other types of strabismus.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested vision therapy for the treatment of the enrollees strabismus. Findings:  The physician reviewer found that strabismic patients exhibiting esotropia with many associated conditions (likely anomalous correspondence, no fusion  similar to this patient) tend to be the most difficult to successfully treat with vision therapy. These patients require extremely aggressive programs of vision therapy, none of which are typically administered to a five-year-old. In general, the treatment period tends to be longer for long standing, infantile esotropia than other types of strabismus. (Berard, et al.). However, vision therapy is appropriate and medically necessary for treatment of the patients oculomotor dysfunction and accommodative infacility. The patient should receive 12-24 sessions depending on his response to the therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of 6-year-old male enrollee has requested speech therapy three times per week for the treatment of the enrollees verbal apraxia. Findings:  The physician reviewer found that the medical literature supports the use and medical necessity of speech and language therapy for verbal apraxia. However, there are no studies concerning the frequency of therapy. Because this patient has shown significant documented improvements with the frequency of therapy he has been receiving, it is reasonable and medically appropriate to continue this regimen, with timely evaluations (i.e., every three months) to document progress.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested vertebral axial decompression for the treatment of his sciatica and three herniated discs. Findings:  Three physician reviewers found that there is insufficient evidence available in the peer-reviewed journals to support the use of vertebral axial decompression for treatment of the patients condition.  As the clinical literature is lacking, the procedure remains of unproven efficacy. Although there may be anecdotal reports of decompressive therapy providing relief, this is not supported by the scientific studies available. It is also not clear as to whether the patient has tried all other standard treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a skilled nursing facility stay for the treatment of her medical condition. Findings:  The physician reviewer found that this patient received skilled PT/OT and was mostly at a SBA/CGA level and was discharged to a restorative nursing program for maintenance care. The patient refused care at times due to fatigue/pain. Due to the patients medical diagnosis it is expected that the patient will have days of feeling weaker/stronger with her fatigue/endurance level being variable. Hence, in this setting there can be no significant improvement expected with continued daily skilled PT/OT in a reasonable period of time. In addition, further decline could be prevented with a maintenance program.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for continued Skilled Nursing Facility (SNF) care for treatment of her  left bimalleolar fracture. Findings:  The physician reviewer found that this patient has significant co-morbid medical conditions including neuropathy, DM retinopathy, pleurisy, and a history of breast cancer, that all complicate her recovery from the ankle injury. Due to these co-morbid medical conditions, she requires a higher level of care than she could receive with PT and OT services at home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male has requested Genotropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that there has been a question of hypotonia, but no diagnosis of Prader-Willi Syndrome has been suggested. The patients mid-parental height is 57.5 while his predicted adult height is 52.3. Thus, he has idiopathic short stature, and is under the care of a pediatric endocrinologist. Based upon FDA guidelines of July 2003, growth hormone therapy is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Zegerid 40 mg for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that the available literature does not support that any one proton pump inhibitor (PPI) is superior to the others. However, it is clear that some patients respond better to one agent than to others, although the reasons for this are not clear. In the case of this patient, she has tried and failed the plan's alternatives in the past and therefore further trials with these medications are likely to also be unsuccessful. The patient has intermittent symptoms of GERD which have been well controlled on Zegerid and she requires the use of an NSAID (non-steroid anti-inflammatory) for another condition. Therefore, the continued use of the Zegerid is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware. Findings:  The physician reviewer found that the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation. It was imperative that pain relief was adequate after the patients nerve block wore out and prior to discharge. The acute hospital stay services provided on the dates in question were medically indicated and appropriate for this patients postoperative care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested endovenous ablation therapy for the treatment of her varicose veins. Findings:  The physician reviewer found that this patient has severe reflux to her mid and distal greater saphenous veins. She has undergone a trial of conservative therapy (compression stockings) without relief. Based on the clinical findings and the failure of conservative treatment, she is an appropriate candidate for endovenous ablation therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested facial augmentation surgery for treatment of his lipoatrophy. Findings:  The physician reviewer found that although the proposed soft tissue filler injections are not required to treat a physiologic functional problem, they are appropriate from a reconstructive standpoint. The American Medical Association (AMA) defines reconstructive surgery as surgery performed on abnormal structures of the body caused by congenital deformity, trauma, infection, tumors or disease. The AMA notes that reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance. Based on this definition, which is consistent with California law regarding reconstructive surgery, the proposed injections are reconstructive to correct an abnormal structure of the body resulting as a consequence of a disease (HIV) and to restore the patient to a more normal appearance. The FDA has approved Sculptra as a treatment to correct HIV-induced lipoatrophy, and this particular proposed treatment is reasonable to try to correct a deformity that is secondary to an illness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested speech therapy services for the treatment of the enrollees communication delay. Findings:  The physician reviewer found that this patient exhibited significant language delays on her initial evaluation. Speech therapy was initiated. She had made progress but still had a cognitive verbal delay of 12 months, and a language delay of about 12 months as well. Thus, continued speech language therapy was therefore clearly indicated, with the likely need for at least an additional 12-18 months of treatment based upon her rate of progression up until that point. Re-evaluation showed a 1-2 year delay depending on the assessment tool used, in both receptive and expressive language skills. Although different tests were employed at the two evaluations, and therefore direct comparison of scores is not possible, it is clear that continued speech therapy was warranted. However, the therapy provided in the second round utilized the Tomatis method. While traditional speech therapy services have established efficacy in this setting, the Tomatis therapy has not been proven to be efficacious. A recent study of the Tomatis method in 2008 (Corbett, et al.) showed no improvement in the condition of the treatment group, compared to a positive result in the placebo group. Given the lack of evidence demonstrating the benefit of Tomatis therapy it was not indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 13-year-old male enrollee have requested Sensory Integration therapy programs and services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that Sensory integrative programs rely on reinforced behavioral programs that typically require many hours (2-4 hours) of intensive one-on-one training progressing to group therapy. This patient with normal intelligence and minimal speech deficit is an excellent candidate to show improvement in such an intensive therapy program. The medical literature notes the need and value of an intensive program; it also notes the need for intervention at as many hours per week as available. The proposed services are medically indicated and appropriate and likely to be of greater benefit to the patient than the specific therapies offered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old male enrollee has requested vertical axial decompression for the treatment of his neck pain. Findings:  Three physician reviewers found that there is a lack of scientific literature supporting the use of decompression treatment, and there are no large controlled studies validating the efficacy of decompression treatment. There are a number of appliances on the market offering spinal decompression. There is no supportive large scale scientific data showing the efficacy of these devices. There is also no data to suggest that vertebral axial decompression is more beneficial than alternative treatments such as NSAIDs, muscle relaxants and pain medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested an MRI of the spine for an evaluation of his back pain. Findings:  The physician reviewer found that the patients imaging studies for musculoskeletal pain show fairly minor changes.  An MRI of the lumbar spine was performed for complaints of back pain. The findings were modest to mild facet arthropathy and minimal disc changes. The patient has been approved for physical therapy, and the records do not demonstrate that he has seen an orthopedic specialist or neurologist. An MRI of the spine is not medically indicated for evaluation of this patient. This patient does not have any of the worrisome symptoms listed in the paper by Rankine and colleagues. These include progressive neurologic deficit, associated fevers, systemic illness, history of cancer or unexplained weight loss.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested chemical dependency inpatient detoxification for the treatment of his chemical dependency. Findings:  The physician reviewer found that the patient does indeed have a serious and long-standing chemical dependency issue; he was in need of detoxification at the time of his admission. However, I concur with the Health Plan that he did not meet criteria for treatment in a chemical dependency inpatient detoxification program. His symptoms were not sufficiently severe and he did not require 24/7 supervision as provided at that level of intervention. There were no associated clinical complications requiring an inpatient level of care. As such, the patient could have been effectively and safely treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for Avastin in combination with Temodar for treatment of his anaplastic astrocytoma. Findings:  The physician reviewer found that there are no established phase III trials because of the rarity of the disease. Expert guidelines and compendium listing have relied on phase II studies. The studies with the combination of irinotecan and bevacizumab are extremely new and thus have not been evaluated for listing by the compendium.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested for continued Skilled Nursing Facility (SNF) stay for treatment of her femoral fracture status post spiral osteotomy of the femur and intramedullary fusion.   Findings:  The physician reviewer found that that there is insufficient evidence to support on-going therapy. She made no meaningful clinical progress. The physical therapy notes assert that the patient is making progress and needs more intensive therapy. However, this assertion is not supported with comparable findings.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for out-of-network services for treatment of her soft-tissue sarcoma. Findings:  The physician reviewer found that it was found that imatinib has activity for gastrointestinal stromal tumors (GIST), dermatofibroma protuberans and desmoids tumors (Demetri, et al. and MacArthur, et al.). Other tyrosine kinase inhibitors may have activity against soft tissue sarcomas such as sorafenib (DAdamo, et al.).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested for speech therapy for the treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that this patient has documented speech articulation dysfunction which placed him in the 16th percentile. He was noted as intellectually bright with normal receptive and expressive speech abilities. The origin of this deficiency is congenital. Speech therapy is medically indicated and appropriate for this patient.