Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech/oral function therapies (including Kinesio Taping, oral stimulation and thermal therapy) for treatment of the enrollees swallowing difficulties and cerebral palsy.   Findings:  Three physician reviewers found that this patient is severely neurologically impaired. She had not gained weight over an 18-month period. At 4 12 years of age, her weight was 5 SDs below the average compared to her peers. The patients difficulty in swallowing and excessive oral secretions have prevented adequate caloric intake. The options for therapy include invasive placement of a gastrostomy tube with surgical reduction of the esophagus by a Nissen procedure and a speech pathologist retraining the patient to swallow. The Food and Drug Administration (FDA) approved oral stimulation for swallowing retraining in neurologically impaired patients. Further, there are studies in the scientific publications that demonstrate the effectiveness of oral stimulation therapy for this indication (Ludlow, et al. and Kiger, et al.). Moreover, Otapowicz and colleagues noted the severe problem of dysphagia in young patients with cerebral palsy and the extreme difficulty in teaching these children to feed. In this case, oral stimulation therapy is being combined with Kinesio Taping and thermal therapy as part of a comprehensive treatment program. Although Kinesio Taping and thermal therapy are still being studied, there is adequate evidence to support the utilization of these techniques in a patient as severely affected as this patient. The use of Kinesio Taping and thermal therapy combined with oral stimulation is an appropriate treatment plan that has been shown to be effective for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her hypertension and obesity.  Findings:  Three physician reviewers found that a consensus statement on LSG was issued and recently published by the American Society for Metabolic and Bariatric Surgery (ASMBS). This report compiles the most recently published studies and best available data and follow-up for the currently available surgical interventions for treatment of morbid obesity and moderate to severe co-morbid conditions. The LSG procedure is endorsed by the ASMBS as a primary procedure without the requirement of second stage. It has also been recommended as a primary procedure for those with inflammatory bowel disease, severe small bowel adhesions, and patients with the need to continue specific medications including non-steroidal anti-inflammatory drugs (NSAIDs), as is the case with this patient. For these reasons, the LSG procedure is likely to be superior for treatment of this patients obesity as compared to other standard treatment options. Therefore, I have determined the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient required ongoing placement in a structured residential treatment environment during the period at issue.  Given the intensity of the patients prior behaviors, her struggle with genuine insight into her emotional issues, and her fragile sense-of-self, she required the therapeutic approaches associated with a residential treatment level of care. This level of care was appropriate and necessary to develop distress tolerance skills, affect regulation, and more adaptive impulse control. As such, residential treatment level of care during the time period at issue was medically necessary and should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees speech delay and gross motor delay. Findings:  The physician reviewer found that this patient has expressive language delay and articulation disorder. Her skills fall below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adults, resulting in behavioral difficulties. She has demonstrated improvement with speech and language services. Studies have shown that speech and language therapy can result in significant improvement in such children. Therefore, the requested speech and language therapy is medically indicated for this patient. Furthermore, with its focus on developing motor planning skills, fine motor skills, processing information and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this patient. She has demonstrated improvement with occupational therapy intervention, but she continues to have deficits that impact her ability to successfully accomplish the daily occupations of childhood. Thus, the requested occupational therapy is also medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested individual intensive outpatient psychotherapy five times weekly for treatment of her bipolar disorder. Findings:  The physician reviewer found that based on medical documentation, the medical necessity for psychotherapy five times per week is not apparent. There was evidence of improvement since the progress notes, and no severe symptoms were described. Several symptoms were rated mild on the date in question. The article by Miklowitz indicated that psychotherapy and psychosocial interventions are beneficial in the treatment of bipolar disorder, and such interventions can be tapered to less frequent sessions based on clinical functioning. In this patients case, based on medical documentation, it was reasonable to taper the frequency of sessions from five sessions per week to three sessions per week as of the said date.  Thus, from the date in question going forward, although five sessions per week were not and are not medically indicated, three sessions per week were and are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested partial hospital program/day treatment program services for treatment of her behavioral health issues. Findings:  The physician reviewer found that the literature shows the need for and success of the partial hospitalization program/day treatment program is the subject of debate. A study by Abbate-Daga and colleagues concluded that further investigation is required to make DH [day hospital] treatment [programmes] measurable and comparable. Based on a review of the literature and a review of this patients records, the medical necessity of the partial hospitalization program/day treatment services is not established. The patient could have been appropriately treated in an intensive outpatient program during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female has requested Lyrica 75mg capsules for treatment of her pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical scenario.  The patient has a mechanical derangement due to meniscal tear, with minimal postoperative physical therapy and minimal attempts at aggressive anti-inflammatory therapy.  Based upon the clinic notes, the patient has not tried moderate analgesics, such as tramadol, NSAIDs or topical agents.  Lyrica treats neuropathically-modulated pain. However, in this patients case, there is a lack of evidence of direct neuropathic pain on examination. All told, there is insufficient evidence supporting the medical necessity of Lyrica 75mg capsules for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested a consultation with a registered dietician for treatment of the enrollee, who is a vegetarian. Findings:  The physician reviewer found that a well-planned vegetarian diet is a healthy way to meet nutritional needs. There have been reports that the resultant benefits include lower body mass index, lower cholesterol and lower blood pressure. Per Goroll and Mulley, individualized nutritional evaluation and counseling is medically necessary and indicated for the management of any medical condition for which appropriate diet and eating habits are essential to the overall treatment program. Medical conditions that typically require nutritional evaluation and counseling by a registered dietician include anorexia nervosa/bulimia, celiac disease, cardiovascular disease, Crohns disease, diabetes, disorders of metabolism, hyperlipidemia, hypertension, liver disease, malabsorption syndrome, metabolic syndrome, multiple or severe food allergies, nutritional deficiencies, obesity, post-bariatric surgery, renal failure and ulcerative colitis.  The submitted documentation indicates that the patient is a healthy 18-year-old who can receive counseling and advice from her primary care physician. There is enough available information for the patient to understand how to supplement and organize a healthy vegetarian diet. All told, a consultation with a registered dietician is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested a dermatology consultation for treatment of the enrollees rash.   Findings:  The physician reviewer found that the medical notes indicate that the lesions are increasing in size and number. The patients primary care physician recommended the consultation with a dermatologist for evaluation. The primary care physician does not offer a diagnosis, etiology, or treatment plan in the submitted records. Given that a referral to a skin specialist is thought necessary by the patients provider and a treatment plan has not been implemented, the requested dermatology consultation is medically reasonable in this case. The evolving eruption as described warrants evaluation by a dermatology specialist. Pigmentation of the legs can represent a number of diagnoses which should be evaluated by a dermatologist (Hogeling, et al. and Pimentel, et al.).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical necessity of occupational therapy utilizing sensory integration for the treatment of this patient with autism is medically necessary based on overall evaluation of the literature, including positive analysis from Myers, et al. 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 occupational therapy with an emphasis on sensory integration, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Given this patients deficits, the requested occupational therapy services are strongly supported by the scientific data as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested brachytherapy and hyperthermia radiation treatments for treatment of her vulvovaginal cancer.  Findings:  The physician reviewer found that recurrent gynecologic cancers are challenging tumors to treat, particularly when surgical options are not available, as with this patient. The standard treatment option is chemotherapy.  Other available options include re-irradiation, hyperthermia (usually with radiation), radiofrequency ablation and cryotherapy.  The latter two are generally not viable options for patients with nodal spread.  For re-radiation, several techniques can be used to minimize normal tissue exposure, including IMRT, IGRT, SBRT or proton therapy. There are few published studies describing the use of hyperthermia and radiation for gynecologic cancers. Furthermore, there are scant publications describing brachytherapy plus hyperthermia for salvage therapy of recurrent gynecologic cancer. There are no National Comprehensive Cancer Network guidelines for vulvar or vaginal cancer, presumably due to the rarity of these tumors.  For patients with recurrent cervical cancer (which is similar to recurrent vaginal or vulvar cancer), or newly diagnosed cervical cancer, hyperthermia is not listed in the National Comprehensive Cancer Network guidelines as an appropriate treatment option. In this patients case, the requested brachytherapy and hyperthermia radiation treatments are not established as effective treatment options in the scientific literature. There is insufficient medical evidence supporting the requested services in this clinical scenario and therefore the proposed treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested intensive outpatient program (IOP) treatment for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patients participation in IOP helped accomplish his successful return to school. Having been absent for almost half of the academic year, the patients return to school was a significant stressor, placing him at risk. By having the patient continue the IOP during his first week of school re-entry, he was afforded some stability, as well as a means to express his frustrations and to receive encouragement to continue to attend school. After his first successful week of school, further therapy could have been continued as an outpatient, by incorporating one group therapy session, one family therapy session and one individual therapy session each week.  The notes from the program beyond the date in question do not describe any major problems that could not be safely and appropriate addressed his outpatient psychiatrist and therapist. The patient appears to interact well with the group and to be compliant with therapy. As such, the patient was appropriate for step-down to a less intensive level of care after the said date.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested Gamunex intravenous immunoglobulin (IVIG) for treatment of the enrollees infantile spasms.  Findings:  Two physician reviewers found that this young patient has been tried on the standard medications with little success. His provider has recommended treatment with intravenous immunoglobulin (IVIG) therapy, which was denied by the Health Plan, as it is thought to be experimental. The available medical literature provides multiple studies attesting to the benefit of IVIG for treatment of infantile spasms when other standard medications fail to produce a positive outcome. Based on the current scientific data, there is sufficient evidence to suggest that IVIG should and can be used for patients who have failed conventional therapies. Given that this patients condition has been resistant to various standard medications and there is data to support the efficacy of IVIG in infantile spasms, this patient should be approved for treatment with IVIG.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested a PET scan with CT for attenuation for evaluation of her history of malignant spindle cell sarcoma.  Findings:  Three physician reviewers found that this patient has suspected local recurrence of her spindle cell carcinoma as documented on MRI.  A PET scan with CT for attenuation has been requested to determine if the abnormal finding on the MRI is secondary to local recurrence and to determine if there is associated metastatic disease.  The requested diagnostic procedure would also be useful to determine the appropriate site for a biopsy, if clinically indicated.  There is sufficient support in the peer-reviewed literature for the use of PET scan with CT for attenuation in the restaging of patients with known soft tissue sarcoma.  Multiple studies have shown PET scan to be more accurate in restaging than conventional imaging, including CT and MRI.  All told, the requested PET scan with CT for attenuation is likely to be superior over all other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a PET scan for evaluation of her adenoid cystic carcinoma.  Findings:  Three physician reviewers found that the patients disease status has been monitored with serial PET scans.  Adenoid cystic carcinoma (ACC) of the trachea is a rare tumor.  This patient has had surgical resection of the tumor followed by radiation.  Standard imaging with MRI has shown some soft tissue within the posterior trachea felt to be post-surgical change.  The prior chest MRI also showed a mildly increased subcarinal lymph node which did not have increased uptake on the corresponding PET study.  Recurrence of ACC is usually found locally, although there are reports of distant metastatic disease.   As ACC is a rare tumor, the PET studies on patients with known ACC are limited.  Of the studies published in the peer-reviewed literature in regards to ACC, PET studies have been shown to be clinically useful for staging purposes and for evaluation for distant metastases in patients with known ACC.  As this patient has had multiple tracheal surgeries, PET scan can assist in the differentiation of scar tissue versus recurrent tumor.  Thus, the PET scan was likely to have been superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested speech and language therapy for treatment of the enrollees receptive and expressive language delays.  Findings:  The physician reviewer found that Cerebral damage following complications of pregnancy and prematurity is an important factor in fetal and neonatal mortality. Additionally, children born prematurely are at risk for developmental and speech delay. Children with speech delay are at risk for developing reading difficulties if appropriate and early interventions are not implemented.  Van Baar and colleagues concluded that term and preterm children differed in all developmental domains. The subgroup of preterm children without school problems is characterized by less serious neonatal difficulties, better drinking capacities in the first month, faster early head growth and better early mental and motor development. Cognitive developmental course gradually diverged during the first two years between the preterm subgroups and seemed to stabilize thereafter. All told, early identification of speech delay is important to maximize the development of the child.  In this patients case, the requested speech therapy is medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested radiofrequency lesioning of the sacroiliac joint nerves treatment of her chronic back pain.  Findings:  Two physician reviewers found that this patients records demonstrate clear SI mediated pain isolated to the left posterior SI joint and capsule. In the medical literature, Dreyfuss and colleagues concluded that L5 dorsal ramus block and S1-3 lateral branch blocks were successful at demonstrating diagnostically mediated pain of the SI complex. There is emerging literature that would support the safety and efficacy of RF ablation of the L5 primary dorsal ramus and S1-3 lateral branches as medically appropriate in this case (Cohen, et al. and Kapura, et al.). All of this patients objective findings on exam and interventional diagnostics indicate the SI joint is her pain generator. She has failed all standard therapies including PT, a home exercise program (HEP), medications, and cortisone injections. Given the length of pain duration and the patients level of disability due to the pain, the best option for long-term control of the pain is the requested RF ablation. Based upon the foregoing, I have concluded that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested mobile continuous outpatient telemetry (MCOT) monitoring at 6, 12, and 24 months after atrial fibrillation (AF) ablation for evaluation of his medical condition status post AF ablation.  Findings:  Two physician reviewers found that over an eight-year interval the patient underwent repeated cardioversions. Definitive treatment in the form of pulmonary venous isolation was performed a few years ago. That procedure was successful over nearly 12 months of follow-up. His attending cardiologist recommended mobile outpatient continuous monitoring (MCOT) utilizing the CardioNet device to be performed at 6, 12, and 24 months for 7-10 days each. The relevant scientific evidence includes recommendations for cardiac monitoring following pulmonary venous isolation. Options include Holter monitoring, standard looping recorder monitoring and MCOT monitoring. The type of monitoring best utilized in this clinical setting has been the subject of debate. Guidelines indicate that an auto-trigger event monitor or MCOT system may identify less frequent atrial fibrillation. There is randomized clinical trials data to support the use of MCOT versus Holter monitoring or standard looping recorders in certain clinical circumstances. In a case such as this where asymptomatic atrial fibrillation is a concern, 6, 12, and 24-month follow-up with MCOT monitoring is superior to standard monitoring devices. Therefore, I have determined the services at issue were and are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.