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

A 42-year-old female enrollee has requested reimbursement for anesthesia services.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who underwent an esophagogastroduodenoscopy with biopsies.  Findings:  The physician reviewer found that the American Society of Anesthesiologists generally recommends moderate sedation for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients age 70 or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require deep sedation.  The submitted medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective esophagogastroduodenoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested  speech therapy and occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that Stone and Yoder evaluated 34 children with autism at 2 years of age and re-evaluated them 2 years later to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The individuals with significant speech and language intervention improved in their language development (Stone & Yoder). Goldstein reviewed communication intervention for autism in peer-review research articles published over the past 20 years and he indicated that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volmar & Wiesner). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Goldstein).The therapy is indicated when deficits exist in functional skills or occupational performance as well as in areas of self-maintenance and activities of daily living (Goldstein; Dawson & Watling). The goal is to enable the child to participate in daily activities including taking care of oneself, i.e., dressing, bathing, and toileting; and to help the child develop skills such as posture and coordination (Goldstein; Dawson & Watling; and Baranek). The research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of the autistic childs performance to develop intervention strategies. In sum, the request for speech therapy and occupational therapy is medically reasonable and necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested five hours of speech therapy per week and five hours of occupational therapy per week for treatment of his autism.  Findings:  The physician reviewer found that the in-Plan speech therapist and the non-Plan speech therapist had good concordance in reporting a severe expressive speech delay and essential non-functional language skills. The medical communitys standard of practice for autistic children is to provide both occupational and speech therapy to autistic children.  The medical literature supports both occupational therapy and speech therapy in this population.Pfeiffer, et al. reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many of the problematic mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles involving occupational therapy utilizing sensory integration techniques for autistic children. Their conclusion based on the meta-analysis was that sensory integration was effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects.  According to Myers, et al. people with autistic spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Further, Turner, et al. reports on a controlled study comparing autistic children who did and did not receive speech therapy. Those that did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.In sum, it is medically necessary for this patient to receive individual speech therapy for one hour per week and individual occupational therapy for two hours per week as recommended. The parents request for additional hours is not consistent with the therapists recommendations and is not supported by the record. Both modalities should reassess the patient at 6 and 12 month intervals.  If the patient is making progress, the therapies should continue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees chronic migraine and occipital neuralgia.  Findings:  Two physician reviewers found that the patient has documented migraine headaches with a frequency of more than 15 headache days per month and occipital neuralgia. In the past, the patient has failed multiple abortive and preventative medications for her headaches including Topamax, Elavil, Inderal, Maxalt, and Imitrex. Her headache specialist has recommended a trial of Botox to help reduce her headaches. The patients request for coverage for Botox injections was denied by the Health Plan as investigational. The patients treating provider reports that this patient has been treated with Botox for about eight years with substantial relief in her migraine symptoms. Since the patient has tried and failed treatment with multiple preventive and abortive agents in the past, treatment with Botox is likely to be more beneficial than standard alternatives. In addition, Botox is now FDA approved for treatment of patients with this patients clinical history and presentation and supported in the clinical trials as safe and effective. Accordingly, the use of Botox should be approved for this patients refractory migraines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-six-month-old male enrollee has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that there is a robust medical literature advocating speech therapy for autistic children. The scientific literature strongly supports speech therapy for autistic children. Myers, et al. state, People with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services.  Turner, et al. reported the results of a controlled study comparing autistic children, who did and did not receive speech therapy.  Those that did receive therapy had far greater communication skills than those that did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.All told, based on the patients diagnosis of autism and documented deficits, he is an appropriate candidate for speech therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A then 36-year-old female enrollee has requested reimbursement for services provided in Hong Kong. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis for treatment of the enrollees uterine fibroids.  Findings:  The physician reviewer found that the patient was traveling out of the country in Hong Kong. The patient reports that she developed abdominal pain, difficulty with urination and excess bleeding. According to the provider in Hong Kong, the patient presented with uterine fibroid with difficulty in urination and abdominal pain and her symptoms could not be relieved by conservative means. The patient was admitted to the hospital and underwent a laparoscopic myomectomy. At issue in this case is whether a prudent layperson in the patients circumstances would have sought urgent services.There are many treatment modalities available for abnormal uterine bleeding related to leiomyomas. In this case, the patient consulted a provider in Hong Kong for her symptoms and decided to undergo surgical intervention. There is no indication in the records provided that the patients symptoms were of such severity to cause a prudent layperson to seek surgical intervention on an urgent basis. No details regarding conservative treatment methods have been provided. There is no evidence that treatment of the patients uterine fibroid could not have been delayed until she returned home. There is a lack of objective clinical documentation in the records provided to demonstrate that the patients symptoms were sufficiently severe to cause her to seek surgical intervention on an urgent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Provigil 100mg for treatment of his multisystem atrophy.  Findings:  The physician reviewer found that provigil has been recommended to manage this patients fatigue.  Fatigue can be a disabling symptom in many neurologic disorders, and can be very difficult to treat, with a lack of therapies that are well-proven or uniformly effective.  Per the current medical literature, a significant improvement in excessive daytime sleepiness was seen in a small trial of patients with Parkinsons disease.  In a randomized, placebo-controlled trial of patients with Parkinsons disease, Adler and colleagues noted that modafinil was very well-tolerated and was associated with few side effects.  This patient has tried and failed other medications used for fatigue, without benefit.  The current medical evidence supports the requested medication in this clinical situation. All told, Provigil 100mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for vaginal reconstructive surgery for treatment of her lower pelvic pain and urinary incontinence.  Findings:  The physician reviewer found that the literature supporting the use of a gluteal flap in cases of vaginal stenosis is very limited. The incontinence maybe a combination of urge and stress and further medical therapy may be attempted before a sling procedure is performed. In any event, based upon the work-up to date, there is insufficient evidence that the patient requires a sling or gluteal flap for vaginal stenosis at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for Fentanyl for treatment of her fibromyalgia and hip, knee and ankle pain. Findings:  The physician reviewer found that pure opioid agonists have long-term side effects on the immune and endocrine system, as well as the sleep system, the depression anxiety system and the gastrointestinal (GI) system that can be detrimental to fibromyalgia patients and other type of chronic pain patients if they are not monitored. The risk of patients obtaining narcotics outside of their prescribed dosage can exacerbate these risks and cause morbidities. Furthermore, the treatment of fibromyalgia is evolving with newer novel agents and opioid use in this illness is decreasing as better mechanisms of pain control are being elucidated; as such, a non-narcotic regimen may be the best course of action for this patient.  All told, there is no compelling evidence that this patient requires Fentanyl for pain control.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-eleven-month-old male enrollee has requested for speech therapy, occupational therapy and physical therapy for treatment of the enrollees multiple medical conditions. Findings:  The physician reviewer found that children with speech delay can be readily treated (Law, et al.) and children with severe cognitive delays can be candidates for successful speech therapy (Goorhuis and Brower).  In regards to occupational and physical therapy, Carboni, et al. states that muscle stretching by physical therapists is essential for patients in this situation to develop improved motor function. Schaaf and Miller report that sensory integration by occupational therapists for children with multiple combinations of developmental sensory and motor delays has been effective. Although the study by Roberts is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques.Given the patients medical conditions and the medical consensus found in the peer reviewed medical literature, it is medically necessary that this patient receive physical therapy, occupational therapy and speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested authorization and coverage for a bariatric surgery consultation. The Health Plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that per the adolescent bariatric surgery guidelines, adolescents who are potential candidates for bariatric surgery meet the following criteria with regard to BMI and co-morbid conditions: a BMI of 35 with one of the following severe co-morbidities, type 2 diabetes mellitus, moderate or severe obstructive sleep apnea, and/or pseudotumor cerebri; or a BMI of 40 with one or more of the following obesity-related co-morbidities, hypertension, dyslipidemia, obstructive sleep apnea, venous stasis disease, panniculitis, urinary incontinence, significant impairment in activities of daily living, moderate to severe non-alcoholic fatty liver disease, gastroesophageal reflux disease (GERD), severe psychosocial distress, significantly impaired quality of life, and/or weight-related arthropathies. The submitted documentation indicates this patient has a BMI greater than 40 with a diagnosis of GERD and is therefore a potential candidate for surgery. Thus, it is medically appropriate for the patient to undergo a bariatric surgery consultation at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested YAG laser posterior capsulotomy for treatment of the enrollees injury to right eye due to failed cataract surgery.  Findings:  The physician reviewer found that based on review of the available records, YAG laser capsulotomy is medically necessary for the patient. In the medical literature, Hayashi and colleagues evaluated the correlation between visual acuity, contrast sensitivity, and contrast sensitivity with glare source (glare sensitivity), and the degree of posterior capsule opacification (PCO) before and after neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy.  The authors reported that, Before Nd:YAG laser capsulotomy, visual functions correlated significantly with the degree of PCO and after capsulotomy, these visual functions improve markedly and no longer have a significant correlation with PCO. Due to the patients symptoms of debilitating glare and intolerance of contact lenses, it is medically necessary to perform YAG laser capsulotomy for treatment of her symptoms.Since this patient had a complicated surgery and poor outcome under the care of an In-Plan provider, it is reasonable for the patient to be uncomfortable with continuing care with that provider. However, the Health Plan has offered access to other well qualified ophthalmologists within the network to provide care. Accordingly, the requested procedure has been demonstrated to be medically necessary for treatment of the patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested residential  treatment services for his substance abuse.  Findings:  The physician reviewer found that based on review of the available records, this patient had no acute medical or psychiatric condition during the period under review. He had no documented history of severe or complicated withdrawal. He was a binge pattern drinker with periods of extended sobriety in his past. By the said date the patients symptoms had abated and he was in no acute distress or suffering from any acute medical problem. According to the American Society of Addiction Medicine (ASAM) placement guidelines, the patient was stabilized and could be safely and effectively treated in a less restrictive setting such as intensive outpatient program (IOP). Consistent with these findings, the residential care provided this patient during the said timeframe has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested weight loss surgery (laparoscopic band (Lap-Band) or gastric bypass) for treatment of her obesity.  Findings:  The physician reviewer found that from a review of the available records, this patient has a BMI of 39 with diabetes, which meets the generally accepted standard criteria for clinically severe obesity (Colquitt, et al). At this time, the medical necessity of the bariatric surgery cannot be established given the lack of completion of a multidisciplinary evaluation including dietary and behavioral evaluations. Otherwise, this patient has failed dietary efforts and has obtained medical clearance and therefore meets all standard nationally accepted criteria for bariatric surgery (Smith, et al). Therefore, the medical necessity for the requested bariatric surgery has not been demonstrated at this time given the lack of a multidisciplinary evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested  the insulin pump OmniPod System for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that several studies in the peer-reviewed literature have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared to conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, and reduces the frequency of hypoglycemic events.  However, the submitted documentation fails to establish the medical necessity of the requested equipment in this patients case.  This patient was diagnosed with diabetes on the date in question. A six-month trial of injections is medically appropriate prior to transition to insulin pump therapy.  Information regarding the precise number of daily injections and blood glucose values at least four times per day were not submitted.  The submitted documentation does not demonstrate that the patient and his family have completed a comprehensive pump education class.  All told, the requested insulin pump OmniPod System is not medically necessary for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees delays in expressive language skills. Findings:  The physician reviewer found that Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested for vancomycin and ceftriaxone for treatment of his condition of a central nervous system infection. Findings:  The physician reviewer found that there is substantial evidence in the records provided that this patient does not have neurosyphilis, and there is no evidence that he has any infection involving his brain or meninges. It would not be appropriate to treat this patient with vancomycin and/or ceftriaxone.  Vancomycin may be associated with nephrotoxicity, and ceftriaxone is also associated with side effects.  All told, there is no evidence that this patient has any infection that should be treated. Therefore, vancomycin and ceftriaxone are not medically indicated for the treatment of this patient.