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

A 46-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that Lam and colleagues found that for patients with treatment resistant depression, TMS appears to provide improved health outcomes in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the lack of studies with systematic follow-up suggest that further data are needed before TMS can be considered a first-line monotherapy for treatment resistant depression. Similarly, Gershon and colleagues reported positive responses of TMS as an antidepressant treatment, but cautioned that the need for verification and standardization of best practices and type of patient that would benefit still remain unknown. As such, the use of TMS in this patients care was not likely to provide him with superior results when compared with standard proven therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested a speech and language assessment and speech therapy services for the evaluation and treatment of the enrollees suspected language delay.  Findings:  The physician reviewer found that this patient has an identified speech delay in receptive and expressive language of approximately 50% per the Rossetti Infant-Toddler Scale and Hawaii Early Language Profile. Speech therapy is indicated with any delay greater than 25%. An extensive review of the literature, including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately 50% of children delayed at 2 years catch up to peers by 3 years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who do not receive early intervention. Children who participate in speech-language treatment show better improvement than those children who have no treatment. This patient has been involved in early intervention services without improvement in language delay. Speech therapy is medically necessary for this significant delay, at greater than 50%, of expressive and receptive language.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested outpatient mental health therapy treatments received at a frequency of 3 times per week and outpatient mental health therapy at a frequency of 4 times per week for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that from a review of the available records, this patient has chronic depression related to multiple years of abuse in childhood and the alienation he experiences due to his sexuality. He states that he finds comfort and empathy in his current therapist unlike his previous providers and needs ongoing care. However, applying the practice guidelines from the American Psychiatric Association (APA), the severity of this patients illness and lack of acuity does not meet the generally accepted criteria for the length of time in outpatient care. In addition, the APA guidelines do not recommend the requested frequency of sessions given this patients current level of function. For these reasons, the therapy at issue has not been proven medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, six-month-old male enrollee has requested occupational therapy and physical therapy for treatment of the enrollees delayed developmental milestones. Findings:  The physician reviewer found that this patient was extremely premature with a prolonged neonatal hospital stay and relatively few complications for his gestational age. However, the patients overall motor and cognitive development are delayed and his prematurity should no longer affect adjusting his development parameters. Thus, he clearly has developmental and motor delays likely consistent with a diagnosis of cerebral palsy, spastic diplegia. There is a robust medical literature establishing the medical need and value of OT and PT in the physically and developmentally delayed pediatric population. Arpino and colleagues conducted a meta-analysis of many controlled studies demonstrating improvement in motor skills resulting from PT. In addition, Novak and colleagues reported significant advancements with even a relatively short period of intensive OT treatment. Given this patients delays, the requested services have been established as medically necessary and are supported as a well-established standard of treatment. Specifically, the patient should receive two hours weekly of both PT and OT services weekly with re-assessments at 6 and 12 months for progress reports and updated goals.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested corrective spinal surgery/kyphoplasty for treatment of her L1 compression fracture.  Findings:  Three physician reviewers found that many of the available peer reviewed medical literature reviews studied the use of vertebroplasty and found that this treatment was not likely to be more beneficial than sham intervention. As for kyphoplasty, only one randomized controlled trial has been reported (Wardlaw, et al.).  This trial randomized 300 patients to kyphoplasty or usual medical care. The kyphoplasty group experienced significantly greater improvement in quality of life and decreased pain at all the measured time points from 1 month to 1 year. Compared with the medical care group, the reduction in pain in patients receiving kyphoplasty mirrored the results of the Vertos II trial, in which there was initially a considerably larger differential decrease in pain that tapered off over time. (Miller, et al.) Given the lack of double-blind evaluation, results of that trial should be interpreted with caution. Moreover, the similarity between this procedure and vertebroplasty makes it probable that the results reflect a placebo effect. Given the unproven benefit of kyphoplasty over placebo, kyphoplasty was not likely to be more beneficial for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy, physical therapy and occupational therapy services for treatment of the enrollees developmental delay. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers. (Shevell, et al.) The main goal of treatment is to enhance an individuals level of functioning. This patient has expressive and receptive speech of approximately 40% per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children with mild cognitive delays. Speech therapy is medically necessary with any delay greater than 25%. Extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, this patient has delays noted in gross motor skills and fine motor skills. Appropriate therapies in this setting include physical and occupational therapy, which are medically necessary and promote adaptive skill development and independence. (Wolraich, et al.)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, nine-month-old male enrollee has requestedfor speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues reported that children with speech delay can be readily treated. These findings are consistent with the publication from Goorhuis-Brouwer and Knijff who found that verbal and non-verbal development can improve in young children with developmental language delay.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) scan for evaluation of her osteopenia.  Findings:  Two physician reviewers found that the patient has already sustained two fractures to her extremities since menopause and her 25 hydroxy vitamin D level is low, which is another risk factor for bone demineralization leading to increased risk for fracture. The patients treatment plan will likely be changed based on the findings of the DEXA scan in an attempt to prevent future fractures. Therefore the BMD assessment with the DEXA scan was likely to be more beneficial in this patients treatment than any alternative diagnostic procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  All told, the superior efficacy of the services at issue has not been established in this clinical scenario. Transcranial magnetic stimulation was not and 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

A 48-year-old male enrollee has requested residential mental health treatment for treatment of his alcohol dependence and major depression.  Findings:  The physician reviewer found that this patient was in need of intensive treatment in order to achieve sobriety. However, he had sober supports and appeared motivated for recovery based upon the submitted documentation. While he had unsuccessfully attempted to cut back prior to admission, he had not attempted either intensive outpatient treatment or partial hospitalization program treatment prior to admission to the facility. There is no indication of imminent serious risk to the patient, and there was no evidence of serious withdrawal symptoms or medical complications during the time period under review. Per American Psychiatric Association practice guidelines, residential treatment was not medically necessary during the dates of service at issue. All told, residential mental health treatment provided during the said timeframe was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, three-month-old male enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that down syndrome is a chromosomal disorder characterized by hypotonia, dysmorphic features, and global developmental delay. This diagnosis requires intervention and continuous treatment from specialized providers. Occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for the patient with motor delays. These goals often involve social interaction, behavior, and classroom performance. To support the need for OT, studies have shown benefits that prevent a deterioration or reversal of function and a significant improvement in activities of daily living. Further, the peer reviewed medical literature suggests that the OT affected gross motor gains for preschool children who exhibited moderate motor delays. Specifically addressing the needs of young patients with Down syndrome, the results of the study by Uyanik and colleagues showed that sensory integration, vestibular stimulation and neurodevelopmental therapy were effective interventions. The authors concluded that when designing rehabilitation programs for children with Down syndrome, all treatment methods should be applied in combination, and should support each other according to the individual needs of the child. In a study of older children with Down syndrome the research indicated that a wide range of performance of self-care activities appeared most delayed on activities that required fine motor skills. As such, the requested OT is medically necessary and should be provided at least three hours per week by an occupational therapist. Additionally, the patients caregivers should be instructed on how to provide therapy at home.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-month-old female enrollee has requested for chiropractic services for treatment of the enrollees torticollis and plagiocephaly. Findings:  The physician reviewer found that studies suggest that chiropractic intervention is a viable treatment option for congenital muscular torticollis. According to the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines), chiropractic care for the treatment of torticollis is acceptable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested budeprion XL 450mg per day and sertraline 200mg per day for treatment of her depression. Findings:  The physician reviewer found that this is a rational medication combination for the treatment of depression based on American Psychiatric Association guidelines. The dosages are consistent with the maximum recommended dose and are not considered excessive for a patient with severe depression. In sum, the medication dosages at issue were medically appropriate and necessary in this setting and consistent with treatment guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested Saunders Cervical Hometrac Deluxe device for treatment of his degenerative disc disease at C4-5 and C6-7. Findings:  The physician reviewer found that this patients records do not establish that the traction provided in PT resulted in any significant, sustained symptomatic relief, or functional benefit. The patient was receiving multiple concomitant therapeutic interventions and therefore it is not clear which, if any, modality was responsible for any symptom relief that may have occurred during the course of therapy. Furthermore, it is not evident how much of the patients symptomatic improvement was due to active interventions and not just part of the natural course of a waxing and waning pain syndrome. Finally, the requested device would not be expected to significantly alter the need for any future surgery that may be indicated for his cervical spine. For these reasons, given the limitations of the extant published literature the requested device is not within the standard of care and therefore not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested an MRI of bilateral breasts for evaluation of the enrollees family history of breast cancer.  Findings:  The physician reviewer found that the guidelines for the use of screening breast MRI are well-established in the medical literature. The American Society of Breast Surgeons recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA1 or BRCA2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of 18.8% of developing breast cancer, which is less than the recommended guideline of 20% calculated lifetime risk.  She has no personal history of radiation to the chest.  Additionally, there is no documentation that a first-degree relative has a BRCA1 or BRCA2 mutation.  At this time, the patient does not meet the established guidelines for a screening breast MRI.  All told, the requested MRI of bilateral breasts is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested an interstitial glucose monitoring device (continuous blood sugar monitoring) for treatment of the enrollees Type 1 diabetes. Findings:  Three physician reviewers found that the American Diabetes Association (ADA) clinical practice guidelines for the treatment of diabetes mellitus recommend use of a continuous glucose monitor (CGM) in younger populations with adherence to ongoing use of the device in conjunction with intensive insulin regimens. The ADA also reports that CGM may be a supplemental tool in patients with hypoglycemia unawareness. This patient has recurring hypoglycemia and hyperglycemia. She has inadequate glycemic control as evidenced by her wide fluctuations of glucose with use of an insulin pump. She is at risk for hypoglycemic events due to her age, erratic eating schedule, and active lifestyle. The patient is expected to be compliant with the CGM, and it is therefore likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested authorization and coverage for computed tomography angiogram (CTA) of the heart. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees hypercholesterolemia.Findings:  Three physician reviewers found that based on the records provided, the patient has some coronary risk and marked hyperlipidemia. In this circumstance of coronary risk and hyperlipidemia in a patient without chest symptoms, a screening coronary CT angiography is not medically indicated and not considered standard accepted practice. The national guidelines for evaluation and management of high cholesterol currently do not recommend coronary CT angiography in this clinical situation. In addition, the current expert consensus appropriateness guidelines that are endorsed by several national organizations also do not recommend coronary CT angiography for this purpose (Mark, et al). Moreover, results of coronary CT angiography in this particular patient would not likely change treatment since he is asymptomatic and has already proved to be intolerant of all statin therapy. Therefore, the requested coronary CT angiography is not expected to improve this patients health outcome and was appropriately denied by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested Bone Anchored Hearing Aids (BAHA) for treatment of the enrollees CHARGE syndrome with bilateral hearing loss.  Findings:  The physician reviewer found that in the current published peer-reviewed medical literature, Hakansson and colleagues reported that improvements in traditional bone conduction aids have made them comparable to the soft band devices. In a study from Verhaegen and colleagues, the researchers recommended conventional amplification devices or cochlear implantation in patients with severe sensorineural hearing loss. The authors concluded that a cochlear implant is a valuable option in patients with mixed hearing loss when the sensorineural hearing loss component exceeds 70 dB. From a review of this patients records, the degree of the hearing loss has not yet been established. Further, the soft band BAHA devices have not been demonstrated to be superior to conventional hearing aids in this patient population. For these reasons, the requested soft band BAHA devices have not been established as medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency than in their same aged peers. As a result, the prevention of secondary disability is important. Central hypotonia slows the acquisition of gross motor and fine skills. Ligamentous laxity and decreased strength with hypotonia complicates the ability to acquire appropriate fine motor skills. Occupational therapy with early intervention services are needed for continued improvement in fine motor skills acquisition and helps to promote arm and hand movements that lay the foundation for later developing fine motor skills. Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. This patient has identified fine motor and adaptive delays in all domains during the most recent occupational and physical therapy evaluations. She will clearly benefit from ongoing occupational therapy and it is medically necessary and a standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, four-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to the text by Carey and colleagues, they found that children involved in early intervention services with parental interaction and teaching showed stronger language skills than children who did not receive early intervention. Consistent with these findings, Law and colleagues extensive review of the literature reported on the positive effects of speech therapy intervention for children with expressive phonological and vocabulary difficulties. Given that children with documented speech delays treated with therapy show improvement when compared with their untreated peers, the requested speech therapy is clinically indicated for this patients expressive language delays. This patient was found to have expressive language delays during an evaluation, with later tests revealing progressively worsened delays. As this patients delays have persisted and actually increased, the requested speech therapy is medically necessary for management of his medical condition and should therefore be approved.