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

The parent of a five-year-old female enrollee has requested PediaSure for treatment of the enrollees short stature.  Findings:  The physician reviewer found that a childs growth must be assessed over multiple visits over time to determine any growth abnormalities. Definition of short stature when not attributed to an underlying organic disease is classified as familial short stature, constitutional short stature or idiopathic short stature (ISS). Children with familial short stature have a bone age corresponding to chronologic age and height standard deviation which also corresponds to parental height standard deviation. Those with constitutional short stature have a bone age corresponding to adjusted height age and will have a normal adult prognosis. Children with ISS have a negative two standard deviation for bone age and for mean parental height. These children are candidates for growth hormone. According to Rosenbloom, normal short stature does not require treatment for physical health benefits. This patient has been shown to have no deficiency at this time other than short stature with bone age equaling adjusted height age which indicates that she has constitutional short stature. This does not lead to nutritional deficiencies and therefore, a nutritional supplement is not needed. The patients labs also demonstrated that she is not anemic. Therefore, there is no medical justification for a nutritional supplement at this time.
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 treatment of the enrollees mixed receptive/expressive language delay and expressive speech delay consistent with childhood apraxia of speech. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, is an impairment involving planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders that affect the brain such as Down syndrome, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to the articulation problems. Communication at all levels may ultimately be impaired.  The literature supports the use of intensive speech and language therapy for verbal apraxia as well as expressive language delay.  In this patients case, all speech therapy services provided during the time period at issue were medically indicated.  Additionally, continued speech therapy services at the requested frequency are medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested a Xopenex inhaler for treatment of the enrollees asthma. Findings:  The physician reviewer found that levalbuterol, the R-isomeric form of albuterol, was developed to increase the efficacy of bronchodilation while decreasing side effects such as tachycardia and loss of potency. However, in head-to-head studies, levalbuterol has not consistently been shown to be more efficacious, nor has it demonstrated decreased unwanted effects, when compared to racemic albuterol. In the case of this patient, the provider decided to change rescue bronchodilator therapy from albuterol to levalbuterol, without introduction of a preventive medication such as inhaled corticosteroid. There is no documentation that the patient was experiencing unwanted side effects from racemic albuterol, and no objective data to demonstrate better asthma control with levalbuterol. Therefore, in the absence of clear documentation of a contraindication to the use of racemic albuterol, the use of levalbuterol is not medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested inpatient psychiatric care services for treatment of her major depressive disorder, panic disorder, eating disorder not otherwise specified (NOS) and alcohol dependence.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate that the patient met the severity of symptoms which would require her to be in a 24-hour supervised inpatient hospital setting as of the said date.  This patient did not have any suicidal or homicidal thoughts. She did not have any difficulty with her thought process which would require a 24-hour medical supervision. The patients substance abuse did not show acute withdrawal or previous severe withdrawal from alcohol or benzodiazepines. The patient was calm and cooperative with coherent and logical thoughts. In light of these findings, the patient did not meet American Psychiatric Association criteria for treatment in a 24-hour supervised inpatient psychiatric unit during the period at issue. Step-down to a partial hospitalization program (PHP) was medically necessary and appropriate for this patient as of the date in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested laser treatment for treatment of her rosacea.  Findings:  The physician reviewer found that the patient is requesting coverage for treatment of telangiectasias associated with rosacea using laser therapy.  The use of pulse dye laser treatment for telangiectasias is considered to be a cosmetic procedure that is expected to provide little more than minimal improvement to her appearance.  The requested services do not qualify as reconstructive in nature, as the treatment is not expected to correct abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.  Treatment of telangiectasias associated with rosacea is not considered to be a medically necessary procedure. Overall, the requested laser treatment is not reconstructive in nature 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 17-year-old male enrollee has requested group, individual, and family therapies for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that given this patient's presentation, he was a candidate for outpatient services during the period under review. The clinically reasonable therapeutic services for this patients medical condition should have consisted of individual therapy, substance abuse group therapy, and family therapy. This conclusion is consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for oppositional defiant disorder and substance use disorders. As such, the medical necessity has been established for individual therapy sessions, substance abuse therapy sessions, and family therapy sessions provided during the period at issue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested percutaneous tibial nerve stimulation for treatment of her interstitial cystitis and urinary urgency.   Findings:  Two physician reviewers found that posterior tibial nerve stimulation is a therapy that involves electrical stimulation to a nerve in the lower leg to try to affect bladder function/symptomatology, also called neuromodulation. The Journal of Urology states that neuromodulation therapy incorporates electrical stimulation to target specific nerves that control bladder function. The specific mechanism of action is unknown but it is postulated that neuromodulation may have a direct effect on the bladder or a central effect on the micturition centers of the brain.  Sacral nerve stimulation/interstim is another FDA approved treatment for urinary urgency, frequency, urge incontinence and nonobstructive urinary retention. The Journal of Urology goes on to state that percutaneous tibial nerve stimulation (PTNS) delivers neuromodulation to the pelvic floor through the S2-S4 junction of the sacral nerve plexus via the less invasive route of the posterior tibial nerve. PTNS has been proposed as an alternate treatment to InterStim for urge incontinence and associated symptoms, and there is now substantial literature support of efficacy, in well-controlled studies. Most of the studies have related to treatment for overactive bladder.  In this case, this patient has been labeled as having interstitial cystitis, though she also has symptoms suggestive of overactive bladder. A study by Zhao, et al. concluded that intermittent percutaneous posterior tibial nerve stimulation might be an alternative treatment for patients with interstitial cystitis symptoms. This patient has had a marked improvement in her symptomatology using PTNS.  The current literature is extensive and PTNS is a well accepted therapy. Additionally, this patients positive response to treatment would support the need for ongoing coverage of this treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for hypnotherapy for treatment of his irritable bowel syndrome and fibromyalgia. Findings:  Two physician reviewers found that there is insufficient evidence demonstrating the superior efficacy of the requested services over other available treatment alternatives. The literature notes an association between psychological conditions, including depression and anxiety, with fibromyalgia and irritable bowel syndrome, but there is inconclusive evidence as to the benefit of hypnotherapy in these conditions.  Zijdenbos and colleagues performed a review of literature on psychological treatments for irritable bowel syndrome. The authors noted that most studies suggest that these therapies are not superior to placebo, and the sustainability of their effect is questionable.  All told, the requested hypnotherapy is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested for inpatient care services for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that there is no acute depression and no acute/active suicidal ideation with plan were reflected in the clinical notes during the dates of service at issue.  No safety concerns were recorded in the noted. All told, the medical necessity of inpatient care services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for mental health outpatient therapy for treatment of her bipolar disorder. Findings:  The physician reviewer found that the clinical practice guidelines state that psychological interventions are not indicated in patients with psychotic features when the treatment plan does not indicate either psychological or medical interventions to address this symptomatology. Furthermore, the treatment plan is discrepant with the letter from the patient. The former indicates a static clinical scenario with a GAF score of 40, but the patient indicates that she has improved significantly in her functioning. American Psychiatric Association guidelines cite evidence in support of short-term focused psychotherapy, but do not indicate long-term therapy for this condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested individual speech and language therapy in English and Vietnamese for a total of two hours per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that children with speech delays, including those with cognitive delays, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff).  Two-year olds who tested below the 10th percentile, such as this patient, do require and benefit from speech therapy (Emanuel, et al. and Buschman, et al.). In this case, speech therapy has been requested in English and Vietnamese. As the patient is not currently speaking, it would be most beneficial from a clinical standpoint to have him participate in only English-speaking speech therapy at this time. However, if his parents ability to speak English is limited, their ability to participate as co-therapists is hampered and a bilingual therapist will be needed to treat the patient in English and communicate with the parents in Vietnamese.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested individual speech and language therapy in English and Vietnamese for a total of two hours per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that this patient had essentially not developed any speech when his expressive language was noted to be at 6 months when tested both in English and Vietnamese at the age of 2-years-5-months old.  Law, et al. reported that children with speech delay can be effectively treated with speech therapy. Children with speech delays, including those with cognitive delays, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff). Two-year olds who tested below the 10th percentile, such as this patient, do require and benefit from speech therapy (Emanuel, et al. and Buschman, et al.). Speech therapy is medically indicated for this patient. The medical community standard for a two-year-old non-speaking child is speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  speech therapy at a frequency of one time per week for one hour for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has cerebral palsy and both cognitive and language delay. However, with one hour weekly of speech therapy he has made slow but definitive gains. Law, et al. reports that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. A study involving both speech-delayed normal and abnormal intellect children, informs us that both groups of children are candidates for successful speech therapy (Goorhuis-Brouwer & Knijff).  Two-year olds, who tested below the 10th percentile for their age in both receptive and expressive language, did benefit from speech therapy in prospective studies (Emanuel, et al. and Buschman, et al.).  The literature is replete with publications supporting the medical necessity of speech therapy in a speech delayed, two-year old population, with either normal or delayed intellect. In summary, it is medically necessary for this patient to receive speech therapy for one hour per week in order to continue the progress he has made.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue is whether a reasonable and prudent layperson in the patients circumstance would believe he or she was experiencing an urgent medical condition on the dates of service at issue. Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area. The acute joint pain experienced by this patient did represent an urgent medical condition which required care without prolonged delay. The submitted evidence demonstrates the patient had a history of similar though less severe symptoms and had been treated for an inaccurate diagnosis. The medications previously used led to side effects with only partial control of the joint symptoms. After arriving in a destination outside of the Plan's service area, he developed a more severe episode, which made it very difficult for him to walk and required the use a cane. He was seen by a physician and appropriately referred to a rheumatologist. The addition of daily medication controlled his symptoms but it was important to determine the mechanism of this joint inflammation, as prolonged treatment with the prescribed medication carries significant risk of its own and would be inappropriate if this acute joint inflammation had been related to infection. For the reasons stated above, a reasonable and prudent layperson in these circumstances would believe this was an urgent medical condition for which treatment could not be delayed until he returned to his Plans service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that 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. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested occupational therapy and speech therapy for treatment of his autism.  Findings:  The physician reviewer found that this patient has been receiving occupational therapy and the patients parent has requested that this therapy continue. The patients parent has also requested that this patient receive speech therapy to treat his autistic disorder. Occupational therapy and speech therapy are standard treatment modalities for children with autism. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Based on an overall evaluation of the literature regarding children with autism, I find the requested occupational and speech therapies to be medically necessary in the treatment of this five-year-old male patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested Lipoprotein-associated phospholipase A2 (LP-PLA2) and homocysteine laboratory testing for evaluation of his cardiovascular issues. Findings:  Three physician reviewers found that the current guidelines do not recommend routine use of advanced lipoprotein tests primarily because it is unknown if any incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. A consensus statement endorsed by the American Diabetes Association and the American College of Cardiology Foundation advocate measuring atherogenic particle concentration either as apolipoprotein B (apoB) or LDL particle concentration in patients at high risk for cardiometabolic disorders. At this time, non-HDL cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength and supported in the scientific studies for use in patients at low risk for coronary artery disease (CAD), as in this patients case. Thus although the LP-PLA2 may provide valuable information in patients at moderate to high risk for CAD, this patient cannot be regarded as having moderate to high risk. Therefore, the diagnostic testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested ProDisc-C total disc arthroplasty for treatment of his neck pain and left arm pain and numbness. Findings:  Three physician reviewers found that the medical records note left cervical radiculopathy from left C5-6 disc extrusion. Significant spinal stenosis was noted at this level. There is a lack of long-term level one or level two evidence in the peer-reviewed literature concluding that cervical arthroplasty is more beneficial than fusion in terms of safety and effectiveness.  Randomized controlled trials to date, while demonstrating favorable findings in support of cervical arthroplasty, are short-term to intermediate-term in follow-up length. The most touted advantage of arthroplasty over fusion, reducing adjacent-level degeneration, has not been demonstrated in randomized controlled trials to date.  At this time, reduction of adjacent-level degeneration remains only a theoretical advantage, not a clinical reality. Additionally, long-term, adverse effects of arthroplasty materials, such as metals and polymers, are not known at this time.  All told, the superior efficacy of the requested ProDisc-C total disc arthroplasty has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee has requested a robotic-assisted sacral colpopexy for treatment of her vaginal prolapse.  Findings:  The physician reviewer found that the current medical evidence supports the requested procedure in this patients case.  As noted by Di Marco and colleagues, robotic-assisted laparoscopic sacral colpopexy may provide the same long-term durability of open sacral colpopexy with the benefit of a minimally invasive approach.  Elliott and colleagues noted decreased hospital stay, low complication rates and high patient satisfaction with a minimum of one-year follow-up for patients following robotic-assisted laparoscopic sacral colpopexy. Gilleran and colleagues noted that the primary advantages for robotic-assisted sacral colpopexy include decreased blood loss and shorter hospital stay.  Overall, the medical literature supports the use of robotic-assisted sacral colpopexy in this clinical situation. In experienced hands, the robotic approach has less blood loss, shorter hospital stays, and quicker recovery than traditional open or vaginal approaches.  All told, the requested robotic-assisted sacral colpopexy is medically indicated in this patients case.