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

The parent of a seven-year-old male has requested occupational therapy, at a frequency of one session per week for treatment of his sensory processing disorder.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman; and Polatajko and Cantin). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children, when sensory processing concerns exist.  A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has identified fine motor delays and sensory processing issues. Given the history of colpocephaly in addition to his noted delays in fine motor and sensory processing skills, occupational therapy at a frequency of one session per week is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for a full body PET scan for evaluation of the enrollees cervical cancer.  Findings:  Three physician reviewers found that the patient has stage IV cervical cancer. The patients cancer was noted to have invaded the bladder and there was also noted involvement of the periaortic lymph nodes at the time of diagnosis. She was originally diagnosed in two years prior and subsequently treated with surgery, chemotherapy and radiation therapy. The patient also has a distant history of right breast cancer, which was treated with mastectomy and chemotherapy. The patients bone biopsy, performed was noted to be benign. Her most recent PET/CT scan showed no evidence of recurrence. A follow-up PET/CT scan for surveillance purposes was recommended by the patients provider. The Health Plan has denied this request, which is the subject of this review. The peer reviewed medical literature evidences ample support for the use of PET/CT studies for the surveillance of patients with known cervical cancer. The National Comprehensive Cancer Network (NCCN) guidelines indicate that in the case of patients at high risk for loco-regional failure, a combined PET/CT scan may be useful for detecting asymptomatic disease. Whole body FDG-PET scan is a sensitive imaging modality for the detection of recurrent cervical carcinoma in both symptomatic and asymptomatic women (Unger, et al.) and aids in deciding treatment plans and, eventually, may have a favorable impact on prognosis and patient survival (Chung, et al.).  Important in cases of asymptomatic patients is the fact that surveillance FDG-PET can detect asymptomatic recurrent disease that is potentially amenable to salvage therapy (Brooks, et al.)  This patient has a history of advanced cervical cancer and is at high risk for developing recurrence. A PET/CT study can detect recurrent cancer that may be asymptomatic. The outcome of the PET/CT scan may have a direct impact on the treatment plan for this patient.  In conclusion, the requested whole body PET/CT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested orthognathic surgery for treatment of her malocclusion.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Per the submitted records, this patients condition does not require orthognathic surgery. Based upon the medical notes and imaging, the patient does not have an anterior posterior discrepancy that warrants the requested procedure, nor does she have a transverse discrepancy that necessitates orthognathic surgery.  Additionally, the patient does not have any documented functional impairment as a result of her malocclusion.  The current medical evidence does not support the requested orthognathic surgery in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Bicillin LA for treatment of the enrollee, who has a stated condition of Lyme disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue in this patients case.  Per serological testing , there is no evidence of Babesia, Bartonella, Ehrlichia, or Borrelia infection.  The medical records do not support a diagnosis of viral encephalitis.  There is no record of a tick bite, and there is no documentation regarding the characteristic rash of early Lyme disease.  Per the submitted documentation, there is no clinical or serological evidence of infection in this patients case.  This patients medical records do not demonstrate the medical necessity of antibiotics in this patients case.  Of note, Bicillin LA has not been proven to be an effective treatment for patients with Lyme disease.  All told, Bicillin LA was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested one hour per week of occupational therapy and one hour per week of speech therapy for treatment of his global developmental delays.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of one hour per week of occupational therapy and one hour per week of speech therapy in this patients case.  This patient has significant deficits in both receptive and expressive language skills.  At the time of the evaluation, he was not yet using any true words or following directions.  Speech and language therapy is particularly important for children with developmental delay to facilitate development of functional communication skills to express needs.  Children with global developmental delay are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information.  It is important to aggressively and thoroughly address these deficits to prevent further impact on growth and development.  This patient has delays in fine motor skills, self-help skills, and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  In addition, with its focus on developing teaching self-help skills including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case.    All told, the requested one hour per week of occupational therapy and one hour per week of speech therapy are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female has requested coverage for past and future services for formal pelvic floor therapy, electrostimulation and biofeedback therapy for treatment of her interstitial cystitis.   Findings:  Two physician reviewers found that the patient has a history of irritative symptoms that have not recently been associated with urinary tract infections (UTIs). The patient had a period of frequent UTI symptoms, which persisted despite treatment. She was found to be negative for a nuclear matrix protein 22, however, a cystoscopy did show erythematous areas. The patient has received intravesical instillations of kenalog, sodium bicarbonate, lidocaine, sterile water and heparin. The patient also underwent treatment with pelvic floor therapy, electrostimulation and biofeedback therapy.  In accordance with the American Urological Association (AUA) Guidelines, the treatment course of interstitial cystitis includes general relaxation, pain management, patient education and behavioral modification. If these first line therapies fail, the AUA recommends the following: second line treatment with manual physical therapy techniques, pain management and treatment with oral-amitriptyline, cimetidine, hydroxyzine and PPS; third line treatment with cystoscopy under general anesthesia with hydrodistension, pain management, and treatment of Hunner ulcer if present; fourth line treatment with neuromodulation; fifth line treatment with cyclosporine, intradetrusor botulinum toxin and pain management; and sixth line treatment with diversion with or without cystectomy, pain management and substitution cytoplasty. The peer reviewed medical literature has not proven instillation therapy, pelvic floor therapy, electrostimulation or biofeedback therapy to be more beneficial for treatment of interstitial cystitis than any of the  above accepted therapies, as outlined by the AUA. There is no indication in the medical records that the patient has attempted treatment with all the above standard therapeutic models without success. In the absence of evidence that the services at issue were or are likely to result in a superior clinical outcome for treatment of this patients condition compared to standard modalities, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested inpatient psychiatric residential services for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that while this patient had significant anxiety and affective symptoms, it is clear that the addictive influences combined with the patients underlying pain and personality disorder were the primary vehicles of his symptoms. The American Psychiatric Association Clinical Practice Guideline on substance use and depressive disorders both support the use of residential programming in instances where less restrictive treatment settings have failed. Ultimately, the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this particular case, the treatment team recommended residential treatment for this patient, as he had already attempted treatment at the outpatient, partial hospitalization and inpatient levels of care. Although he was motivated for recovery, he had failed multiple treatment settings. Thus, a 24-hour supervised setting with the benefits of a comprehensive treatment encompassing all elements of the bio-psycho-social-spiritual model was required.  Accordingly, the services at issue were consistent with good medical practice in the United States and were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of breast implants would be considered medically necessary for the treatment of active infection, impending or actual implant extrusion, painful symptomatic grade IV capsular contracture, or leakage of silicone gel.  The existence of any of these conditions is not documented in the reviewed materials.  It is unlikely that a deflated saline implant in the absence of grade IV capsular contracture or infection would cause any functional deficit.  Based on the information provided, removal of breast implants is not medically necessary for the treatment of this patient. Given the absence of high-grade capsular contracture, capsulectomy is also not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested authorization and coverage for a wireless endoscopy for evaluation of the enrollees chronic diarrhea.  Findings:  The physician reviewer found that a review of the submitted documentation does not demonstrate the patient meets accepted indications for wireless capsule endoscopy. He has had longstanding diarrhea without evidence of malabsorption or symptoms of obstruction. The patient has no systemic symptoms to suggest inflammatory bowel disease, or a hormone secreting tumor such as carcinoid. If carcinoid is a concern then a work-up including 5-HIAA levels would be indicated as opposed to capsule endoscopy. There is no mention of overt or occult gastrointestinal blood loss. Therefore, there is no clinical indication at this time to perform wireless capsule endoscopy. All told, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female has requested coverage for past psychiatric acute inpatient services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, including the admission to a post-treatment facility, continued stay criteria for inpatient level of services were no longer met as of the date at issue. The treatment record and providers summary indicate that this patient was very compliant with treatment and participated well in groups. She had some clandestine behaviors of scraping herself with an eraser three times, which did not put her at any risk of harm. She also reported purging when staff was not watching her. The patients weight, body mass index (BMI), and vital signs remain within normal range.  These behaviors are typical of those routinely evaluated and treated at a lower level of care, and do not require the 24-hour level of care typically provided in the acute hospital setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Celebrex for treatment of her back pain.  Findings:  The physician reviewer found that the patient has requested Celebrex to treat her inflammatory pain related to trochanteric bursitis and lumbar radiculopathy, post decompression surgery.  She failed to find relief with ibuprofen and is on Neurontin and Methadone.  The patient was previously treated with Celebrex 200mg per day and it had been efficacious for her, she has no contraindications to the medication and has a relative contraindication to traditional NSAIDS. Although, treatment with NSAIDs is appropriate therapy, the patient has already failed treatment with ibuprofen. Given her previous success with Celebrex, combined with a history of a gastroduodenal ulcer and inflammatory pain, it is appropriate to treat the patient with Celebrex at this time.  Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 22-year-old female has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a major depressive disorder.  Her symptoms include depressed mood, excessive sleep, suicidal ideation, lack of motivation, and anhedonia.  The patient has received inpatient psychiatric treatment.  The patient reported that her prior medications have included Depakote, Lexapro, Prozac, Cymbalta, Ritalin, and Wellbutrin.  Psychopharmacotherapy has not achieved remission.  The patients provider has recommended transcranial magnetic stimulation.  The current medical literature supports the requested transcranial magnetic stimulation in this patients case.  There is sufficient evidence in the published, peer-reviewed medical literature supporting the use of transcranial magnetic stimulation in this clinical setting. The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  This patient has failed to achieve remission with multiple medication trials.  Therefore, transcranial magnetic stimulation is likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested biocompatibility testing of dental materials for evaluation of her facioscapulohumeral muscular dystrophy.  Findings:  Three physician reviewers found that the patient has a reported history of facioscapulohumeral muscular dystrophy.  She reported that her symptoms began after she received multiple dental fillings, at approximately age 10 or 11.  The patient reported that she had the old fillings removed and underwent detoxification.  Per the submitted documentation, she now requires new dental work, and she reports that she is sensitive to many materials used in dental work. Her dentist reported that biocompatibility testing will indicate which materials can be safely used without causing additional health problems.    There is a lack of evidence suggesting that muscular dystrophy is worsened by any particular dental exposure.  The current medical evidence has not demonstrated the benefits of the testing at issue in this clinical setting.  There is insufficient evidence suggesting that biocompatibility testing will indicate which materials can be safely used without causing additional health problems.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the lumbar spine with and without contrast for evaluation of her back pain.  Findings:  The physician reviewer found that there is no documentation of any neurological deficit, evidence of infection, or tumor. In addition, there are no findings suggestive of cauda equina syndrome. Conservative management including lumbar exercises should be performed prior to resorting to further evaluation with MRI.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for Botox injections for treatment of her urge incontinence.  Findings:  Two physician reviewers found that intravesical Botox is currently being evaluated in multiple studies, its use has not yet been established as superior to conventional therapies in the treatment of this patients medical condition. Dowson and colleagues evaluated patients with bladder oversensitivity refractory to anticholinergics. This randomized, double-blind, placebo-controlled study of 58 patients revealed a significant increase in maximum cystometric capacity (MCC), but this did not translate to clinical benefit with no change observed in the symptoms and quality of life for the majority of patients. In the absence of adequate data demonstrating the safety and efficacy of Botox in this clinical setting, the requested therapy is not likely to be more beneficial than any available standard therapy in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for keloid removal for treatment of the enrollees keloids. Findings:  The physician reviewer found that the medically necessary treatment is debridement of necrotic tissue and administration of antibiotics.  Given the degree of inflammation surrounding the keloids, they cannot just be removed with suture approximation of the remaining skin edges. The keloid removal will create a normal appearance to the extent possible, and these services will likely result in more than a minimal improvement in the appearance of the patient. The keloid removal is medically necessary for the treatment of this patient and is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested for speech therapy provided for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male has requested coverage for past residential treatment center (RTC) services for treatment of his bipolar disorder and polysubstance abuse.  Findings:  The physician reviewer found that two progress notes from the patients therapist during the period in question are available. In the first note, the patient was informed by his provider that he would be attending partial hospitalization program (PHP) after discharge. He became upset when he realized he would have to go. The patient then talked about continuing to feel like he doesnt have a drug problem and that he has learned everything he needs to know. In the following progress note, the provider documents that the patient hates the treatment program and talked about feeling like the staff is corrupt and that he didnt learn anything from the program. He continued to talk about the injustices that have occurred in his mind with the staff and his peers. He was not able to identify his part in interactions and what he could learn from them. He continued to make excuses for why he has reacted negatively in different situations. Applying the American Psychiatric Association (APA) treatment guidelines, this patient had not developed an acceptance of his problem. He has not developed any appropriate skills to deal with his anger nor with his substance abuse. For these reasons, he meets the APA criteria for treatment at the RTC level of care during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for occupational therapy for treatment of the enrollee, who has a history of developmental delay and feeding difficulties. Findings:  The physician reviewer found that in the study by Feder and colleagues, children with a history of prematurity demonstrated significantly lower legibility of writing and slower speed scores compared to healthy children born at term.  Motor disabilities are also more common in children born prematurely.  Occupational therapy, with its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, is well-suited to affect positive change in this clinical setting.