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

A 60-year-old male enrollee has requested a power wheelchair or scooter for the treatment of his left lower extremity paralysis. Findings:  The physician reviewer found that multiple aids are available to a patient with mobility difficulty. Depending on the severity of the limitation, one type of assisted device may be more helpful than another. According to nationally accepted guidelines in this setting (Medicare), a power mobility device such as a power scooter may be appropriate for a patient with a personal mobility deficit that significantly impairs participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within the home, provided the patient's condition is not ameliorable by a walker, cane or manual wheelchair. In addition, the patient must be able to safely operate the power mobility device. In this patients case, he is independent in all of the activities of daily living mentioned above despite having difficulty with walking. In addition, this patient does not use any assisted device such as a walker or cane. The evidence provided does not demonstrate that a power wheelchair or scooter is necessary for the patients activities of daily living. Furthermore, his condition, even his difficulties with walking for distances greater than 25 feet, would likely be ameliorated by use of a walker, cane, or a manual wheelchair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested continued physical therapy services for the treatment of her neck pain. Findings:  The physician reviewer found that nonspecific neck pain is common in the general population. In 50% to 75% of these cases, individuals will experience a recurrence of their neck pain within one to five years of their initial symptom onset, as noted by Carroll and colleagues. Manual therapy and therapeutic exercise are standard clinical practice for the treatment of nonspecific neck pain, as noted by Hoving and colleagues. In many instances, additional physical therapy will be required for the treatment of nonspecific neck pain, which is often recurrent in nature. This patient has nonspecific recurrent neck pain that has responded in the past to physical therapy. Additional physical therapy is medically indicated for the treatment of her myofascial pain with the goal of further reduction in symptoms. Physical therapy for neck pain should include a detailed treatment plan, proposed frequency and duration of treatment, and specific treatment goals.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested use of a cold therapy unit for the treatment of his condition status post anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that cold as a therapeutic modality is commonly employed in the treatment of soft tissue and other orthopedic problems, but the evidence of efficacy is not clear. Bleakley and colleagues noted that there is some support for the use of cold as a passive analgesic modality, but further high-quality trials are needed to provide evidence-based guidelines for its use. Sauls suggests that contrary results in different studies indicate the need for further investigation. With regard to the use of cold after ACL surgery, a similar pattern exists. Raynor and colleagues state that there are reports of decreased pain with the use of cold in the post-operative period, but no improvement in range of motion or drainage. Konrath and colleagues indicate that randomized trials demonstrating objective benefits are still needed. Thus, there is a lack of consistent evidence demonstrating the necessity of cold therapy as a medically necessary modality, and even less data regarding the use of a cold therapy unit versus standard ice packs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested individual speech therapy for six months duration, beginning on the date in question for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the review of the submitted evidence reveals no documentation of a hearing test and all other developmental milestones are age-appropriate. There is a lack of literature support demonstrating that direct individual speech therapy is beneficial for an isolated expressive speech delay. In a randomized controlled trial, a parental home program was efficacious in the treatment of an expressive language delay in the absence of other neurodevelopmental findings(Buschmann and colleagues). The authors had previously reported that speech therapy should not be delayed for children with delays at 24 months. However, they noted that most children with isolated expressive language delay will self-correct. Further, a meta-analysis by Law and colleagues demonstrated there is insufficient evidence that direct speech therapy improves outcomes in cases of isolated expressive developmental speech delay.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for therapeutic apheresis for treatment of his tendinosis.   Findings:  Three physician reviewers found that the use of platelet-rich plasma injections for this patient is not likely to be more beneficial than standard therapies. One reason for this is the non-specificity of this patients diagnosis. The MRI findings of pathologies other than just hamstring tendinosis suggest that it is unlikely that treatment with platelet-rich plasma injections would eliminate significant contributing pain generators. In addition to the patients right hamstring pathology, the presence of similar changes in the patients opposite left hamstring origin (which is presently asymptomatic) also diminishes the likelihood that there would be an effective treatment response to platelet-rich plasma injections. The orthopedic literature is not supportive of the requested therapy at this time. While this is a promising area for future treatment protocols, to date there have not been sufficient studies to demonstrate the efficacy of platelet-rich plasma injections in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested real-time cardiac monitoring for evaluation of her mitral valve prolapse. Findings:  Two physician reviewers found that remote ambulatory long-term cardiac monitoring is now recognized and accepted as a useful diagnostic adjunct to detecting and characterizing underlying symptomatic and asymptomatic cardiac arrhythmias, for both risk assessment and to inform best management on a real-time basis.  In most settings, the information obtained is not easily or promptly ascertained using other diagnostic approaches. In this patient with significant arrhythmias detected at the time of stress testing, the services at issue were medically appropriate even absent test evidence for ischemia. It is true that the value of remote monitoring remains to be definitively established.  However, there is significant value in having diagnostic information available promptly on a real-time basis, especially when the patient is not in a position or location to bring recording equipment in for prompt analysis of symptomatic arrhythmias. Real-time cardiac monitoring is also beneficial when potentially more threatening arrhythmias may be asymptomatic and earlier awareness of them becomes clinically important for best patient management.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested office visits, physical medicine rehab and injection of tendon and coverage for future services for treatment of her pancreatitis and lumbar spondylolisthesis. Findings:  Three physician reviewers found that the medical records provided are brief and are accompanied by a typed document of an unknown source entitled Auriculoneural Therapy which describes this therapy as a technique involving the detection of tender spots or points with reduced electrical resistance on the ear which coincides with painful and/or symptomatic areas of the body. In review of this case, there is a lack of detailed medical records from the attending physician demonstrating the necessity of the services at issue.  The providers records do not include a history of physical examination, impression and discussion of a treatment plan and a possible alternative treatment plan. There is limited mention of prior treatments that have been provided.Although multiple articles have been submitted which report some benefit with auriculotherapy, these studies do not demonstrate that this therapy is more effective than alternative conventional treatment for this patients condition. Anecdotal reports regarding the benefits of this treatment are not valid as a means of determining the efficacy of treatment.  In order to determine the efficacy of such treatment, it should be compared to alternative treatments. This is particularly important in a situation such as spondylolisthesis, where there are numerous generally accepted invasive and noninvasive treatment options. Therefore, the medical records and the medical literature do not support that the services at issue were and/or are likely to be more efficacious than treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested occupational therapy including sensory integration techniques for the treatment of the enrollees Aspergers syndrome. Findings:  The physician reviewer found that sensory integration is a widely used intervention in occupational therapy. Pfeiffer and Kinnealey presented at the American Association of Occupational Therapy Associations Annual Conference in 2008 with findings of their double-blind study that children with autism who received sensory integration therapy through occupational therapy had a modest but significant decrease in displaying autistic mannerisms. Schaaf and Miller also discuss sensory integration as it is used in occupational therapy practice for young patients with developmental disabilities. A treatment plan based on sensory integration theories and techniques is appropriate in this setting given this patients deficiencies in his personal sensory system including limited awareness of body and failure to grasp the concept of personal space and sensory issues with food.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-month-old male enrollee has requested  for a cranial band orthotic for treatment of the enrollees plagiocephaly and brachycephaly. Findings:  The physician reviewer found that the American Academy of Pediatrics published prevention and management guidelines for positional skull deformities in infants. These guidelines noted that skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. The guidelines also noted that surgery may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis. As noted by Graham and colleagues, for infants who do not make progress with repositioning and tummy-time and have severe persistent brachycephaly (cephalic index greater than 90%) at age five months, use of an orthotic helmet will correct the brachycephaly and any associated plagiocephaly. For infants with extreme occipital flattening, prolonged treatment may be necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested the Zostavax vaccine (shingles vaccine)for treatment of her diagnosis with multiple sclerosis. Findings:  The physician reviewer found that The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) recommends routine vaccination of all individuals greater than 60 years of age with one dose of zoster (shingles) vaccine. The ACIP notes that individuals with a previous episode of zoster and individuals with chronic medical conditions can be vaccinated, unless those conditions are contraindications or precautions. No recommendations are made for immunization of individuals younger than 60 years of age who have had zoster. Data is limited about the recurrence rate of zoster, and there is no evidence that immunization would prevent recurrences. Several references as well as the CDC recommendations note that additional studies of the vaccine in patients less than 60 years of age are needed. Thus, at this time the CDC recommends the zoster vaccine only for those aged 60 or older. There is no provision in the guidelines for younger immunocompromised patients because disseminated zoster is quite uncommon and no studies have been reported. Additionally, the vaccine is contraindicated in patients receiving high-dose steroids because dissemination may occur in that setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested laparoscopic gastric Lap-Band for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the criteria set by the National Institutes of Health (NIH) for weight loss surgery. According to NIH criteria, weight loss surgery is indicated for patients with a body mass index (BMI) of 40 or more or a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. The submitted documentation does not demonstrate the patient has any serious obesity-related comorbidities as required in order for patients with a BMI of less than 40 to be considered for surgical intervention. With a BMI of 38.09 and no serious comorbidities, the patient does not meet nationally accepted criteria for weight loss surgery. Further attempts at conservative management are more appropriate than surgical intervention in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested inpatient residential care services provided for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has a very mixed presentation in terms of her symptoms and diagnoses. She has symptoms across the mood, anxiety, ADHD, PTSD, and learning disorder classes. Upon the patient's admission to the residential treatment center (RTC) her symptoms were not much worse than her baseline, as her attending psychiatrist estimated her prior year maximum GAF at 42, and her GAF on admission was slightly lower at 38. Further, treatment at an RTC is usually reserved as the last step when less intensive treatment modalities have failed. There is no documentation that the patient had been treated in less restrictive settings such as an intensive outpatient program (IOP) or partial day hospital (PDH) program prior to the RTC treatment at issue. Moreover, the patient had serious difficulties adjusting to new situations and with social interaction. As such, it would have been more beneficial for the patient to receive intensive services while remaining at home so as to avoid having to readjust to her home life again upon discharge.In this setting, evidence-based instruments such as the Level of Care Utilization System (LOCUS) and Child and Adolescent Level of Care Utilization System (CALOCUS) are useful in determining the necessary level of care to ensure the patients level of care meets his or her individual needs at the least restrictive setting possible. Taking into consideration this patients low risk of harm, mild functional status, significant co-morbidity, mild level of stress, supportive recovery environment, moderate resiliency, treatment history, and acceptance and engagement reported as obstructive, she has a CALOCUS composite score of 18. This score correlates with a treatment intensity level of an IOP program. This score is judged by the acuity of the patients symptoms and environment upon her presentation to the RTC. According to CALOCUS criteria, a score of 23-28 is needed in order to require treatment in an RTC. All told, this patient did not require the restrictiveness of an RTC in order to manage her needs. The least restrictive setting is always preferred, particularly in young patients such as this patient
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that this patient presented with paraphimosis, and after reduction of that paraphimosis, now has irritation and phimosis. Options include surgical treatment via circumcision or conservative therapy via application of topical steroid cream for six weeks and watchful waiting. A trial of topical steroids would require the proper and regular use of the medication and is in some cases likely to fail as it is too user-dependent. In addition, in the event of such a trial and failure, circumcision would then be performed as it is the definitive therapy for paraphimosis.This patient has a proven history of phimosis after paraphimosis, and therefore circumcision is indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested a continuous passive motion (CPM) device and a vasopneumatic compression/cold therapy device for the treatment of her hip condition status-post surgery. Findings:  The physician reviewer found that the use of a CPM machine was not medically necessary for this patient. While early motion is a positive influence on soft tissue healing, formation of fibrocartilage, and maturation to cartilage surfaces, there is no consensus as to the application of a CPM device post-operatively, particularly in the hip joint. The hip joint is complex in that there are many planes of movement. The use of a CPM machine in terms of the design and fit of the device at the hip is more difficult than its application to simple hinge joints such as the elbow and knee. Even when a CPM machine is utilized in the simple hinge joints, there is no scientific evidence available to determine the appropriate duration of treatment, post-operatively. Although it is medically appropriate to encourage gentle passive and active range of motion in the rehabilitation of a patients hip post-surgery, better results are obtained with the guidance of a physical therapist than with the use of a CPM machine which provides only passive and not active motion. In addition, as wound healing allows, isokinetic exercise, pool therapy and kinesiotherapy represent more appropriate treatment in post-surgical patients than CPM use. With regard to the use of the vasopneumatic compression/cold therapy device, while post-operative site cooling is important and efficacious, there is no scientific evidence demonstrating that the application of the device at issue to any joint results in a better outcome than the use of conventional cooling methods. The standard ice pack method is generally accepted and utilized by most practitioners and renders a device that applies intermittent pressure and cold application unnecessary. Furthermore, the effective use of cooling to diminish edema and pain at the operative site is generally limited to the 24-hour period following surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested a power wheelchair seating elevation system for the treatment of his quadriplegia. Findings:  The physician reviewer found that a study by Garber and Rintala notes that patients similar to this patient are at high risk of developing pressure ulcers and pulmonary complications due to immobility. Hemming and colleagues suggest that these complications can be severe and life-threatening. For these patients, Trefler and Taylor recommend a detailed wheelchair assessment be performed in an effort to minimize the risk of complications and optimize patient function. Such is the case for this patient, whose provider completed a detailed wheelchair seating assessment and recommended a specialized seating system. Since this patient is at high risk of skin breakdown, the prescribed wheelchair seating elevation system is medically necessary to reduce the risk of severe medical complications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested a cardio-thoracic specialist for evaluation of the enrollees thoracic pain. Findings:  The physician reviewer found that there is no medical literature that supports the proposition that this patients diagnoses of arthritis, mild scoliosis, and disc bulging require evaluation by a cardio-thoracic specialist. The patients diagnoses and MRI/x-ray findings do not reveal any information that would necessitate evaluation and/or treatment by a cardio-thoracic surgeon. The patients chest MRI revealed an area of incomplete fusion within her sternum. This finding probably reflects the patients young age. In any event, this patients situation is not one in which referral to a cardio-thoracic specialist would provide clinically useful information.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Genotropin for treatment of her panhypopituitarism. Findings:  The physician reviewer found that according to current medical standards and U.S. Food and Drug Administration (FDA) recommendations, in order to justify treatment with GH therapy, there must be evidence or medical history of hypothalamic/pituitary disease and two other pituitary deficiencies (without stimulation testing), or two GH stimulation tests with subnormal response and a repeat IGF-1 level. In this case, there is only one low IGF-1 level contained in the submitted records. Thus, applying the criteria set forth above, one low IGF-1 test result is insufficient to make the diagnosis of GH deficiency. Although this patient appears to be IGF-1 deficient, this may or may not be the result of a GH deficiency, and there is no indication in the records provided that the patient has been ruled out for a possible pituitary dysfunction. The patient presents with features of malabsorption including hair loss, low ferritin, and low Vitamin D. The patient does not present with any history of brain, pituitary, or hypothalamic structural disease. Her other hormone deficiencies are related to hysterectomy and early surgical menopause. It is unclear whether the diagnosis of hypothyroidism was based on pituitary or hypothalamic origin and there is no suggestion of secondary adrenal insufficiency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested upper eyelid blepharoplasty for treatment of her chronic dermatitis and dermatochalasis. Findings:  The physician reviewer found that while the submitted evidence shows only minimal changes in the patients field of vision secondary to ptosis, the patient also presents with chronic dermatitis and dermatochalasis which have not responded to conservative therapy. According to guidelines set forth by the American Academy of Ophthalmology, chronic eyelid dermatitis is an indication for upper eyelid blepharoplasty when the dermatitis persists despite maximal medical therapy. This patient has chronic upper eyelid dermatitis and has been maintained on steroidal and non-steroidal medications without improvement. Continuation of medical management is not likely to be successful. The patient has a functional impairment secondary to eyelid dermatitis and dermatochalasis which requires treatment with upper eyelid blepharoplasty.