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

A 36-year-old male enrollee has requested Tibia Lengthening via Taylor Spatial Frame for treatment of her slipped capital femoral epiphysis.  Findings:  The physician reviewer found that based on review of the available records, the requested tibial and fibula lengthening in an attempt to correct his leg length discrepancy has not been demonstrated to be medically necessary. The patients foot pain and low back pain is multifactorial and is not likely to be causally related solely to the leg length discrepancy. In addition, a simple orthotic is likely to accomplish the same effect in equalizing leg length without the potential complications associated with surgical intervention. In addition, the patient has well documented extra-articular and intra-articular changes at the left hip representing a late complication of slipped capital femoral epiphysis. These changes will be progressive and will lead the patient to total hip replacement. At least a portion of leg length discrepancy can be addressed at that time. By adopting this course of continued conservative care, the patient will not be exposed to the potential complications of tibiofibular leg lengthening which would further complicate his difficult clinical problems. The general orthopedic literature supports the fact that leg length discrepancies are widely distributed in the population and often well tolerated with no symptoms. One study from Benedetti and colleagues consisted of 20 patients after total hip replacement. The authors found a high level of satisfaction after total hip replacement independent of any leg length discrepancy. The same issue was studied by Plaass and colleagues who reported on a prospective study of 94 patients and noted that the Harris Hip Score and patient satisfaction scores were only marginally affected by any leg length discrepancy after total hip replacement. At 26mm of leg length discrepancy, it is appropriate to take conservative measures to slightly under correct the leg length shortening. This patients leg length discrepancy is best dealt with at the time of total hip replacement. Procedures which may delay total hip replacement such as extra-articular and arthroscopic procedures may help, but tibial fibular lengthening is likely to further complicate the patients difficult condition. A simple heel sole built-up shoe, which under corrects the shortening is appropriate. Therefore, the requested tibial fibular lengthening procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male has requested therapeutic facet joint injections for treatment of his severe low back pain.  Findings:  The physician reviewer found that this patient has documented facet pathology and had a positive response to previous medial branch blocks and steroid blocks. In this particular case, the patient has failed treatment with other standard therapy. Additionally, the peer reviewed medical literature supports the utility of therapeutic facet joint injections for low back pain due to facet arthropathy and lumbar spondylosis, as is the case with this patients chronic medical condition.Manchikanti, et al. conducted a randomized, double-blind, controlled-trial to determine the clinical effectiveness of therapeutic local anesthetic lumbar facet joint nerve blocks with or without steroid in managing chronic function-limiting low back pain of facet joint origin, and concluded that therapeutic lumbar facet joint nerve blocks, with or without steroid, may provide a management option for chronic function-limiting low back pain of facet joint origin. Additionally, facet joint blocks appear to have a beneficial medium-term effect in one third of patients with chronic lower back pain and may therefore be considered a reasonable adjunct to non-operative treatment (Gorbach, et al.)There is strong support in the medical literature for therapeutic facet joint injections for treatment of chronic spinal pain due to facet arthropathy. Per the patients medical records, facet joint injections were previously shown to provide adequate relief of the patients back pain. Standard therapy has failed to provide the same results as facet joint injections. Therefore, therapeutic facet joint injections are medically necessary treatment for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested a bunionectomy on the right foot for treatment of her right foot pain and blisters.  Findings:  The physician reviewer found that bunionectomies have long been a standard treatment for painful bunions. The musculoskeletal deviation/abnormalities seen in patients with bunions can be very painful and debilitating and most often require surgical intervention. For some patients conservative care such as shoe modification, non-steroidal anti-inflammatory drugs (NSAIDS), or padding can alleviate pain, but do not correct the problem. In this case, the patient states that conservative measures have not alleviated her pain and she now is unable to wear shoes or ambulate comfortably. Thus, in this patients case, the requested procedure is medically necessary for treatment of her medical condition.
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 expressive and receptive language delays. Findings:  The physician reviewer found that Law and colleagues, 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 therapy for children with primary expressive language disorder.  This patient demonstrates significant expressive language delay, and this is negatively impacting her ability to communicate in a functional and age-appropriate manner.  The current medical literature indicates that speech therapy can result in significant improvement in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. According to 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.  Per Bernhardt and Major, early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  This patient demonstrates significant expressive language delay, and this is negatively impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male has requested treatment including left radial approach cardiac catheterization, attempted percutaneous coronary intervention of the diagonal branch, and physiologic measurement of pressure loss across the tandem right coronary artery lesions, with stenting if fractional low reserve is positive for treatment of his two vessel coronary artery disease, total occlusion of diagonal artery, persistent angina and hypercholesterolemia.   Findings:  The physician reviewer found that this patient presents with coronary artery disease, persistent limiting angina, and provocable coronary ischemia in the territory of a known occluded diagonal branch.  In this circumstance of limiting angina despite a trial of adequate medical therapy, an attempt at opening up the occluded diagonal artery is medically indicated.  Persistent limiting angina that has failed medical therapy is an accepted indication for coronary revascularization.  However, there is no provocable ischemia in the distribution of the right coronary artery by stress echocardiography.  Thus, these asymptomatic right coronary lesions are best managed by risk factor modification without revascularization.  Fractional flow reserve measurement in the right coronary artery would not be expected to provide incremental information about right coronary ischemia beyond that already obtained from stress echocardiography.  Finally, while a radial approach to percutaneous revascularization may offer some potential mild advantages, a femoral approach has similar outcomes and has been a standard approach since the advent of percutaneous revascularization. The submitted medical records fail to demonstrate the medical necessity of the radial approach in this patients case.  All told, attempted percutaneous intervention of the diagonal branch is medically indicated in this patients case.  However, left radial approach cardiac catheterization and physiologic measurement of pressure loss across the tandem right coronary artery lesions, with stenting if fractional low reserve is positive, are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested a repeat right-sided uterine artery embolization for treatment of her uterine fibroids.   Findings:  Two physician reviewers found that the patient has a history of diabetes and is status post kidney-pancreas transplant.  Her provider noted that the she had episodes of complete urinary retention related to large fibroids during the past two years.  The provider noted that a non-hysterectomy approach was preferred in light of the patients transplant status.  The submitted documentation noted that the patient has to self-catheterize for complete bladder emptying.  Uterine fibroid embolization is based upon the hypothesis that reduction of myometrial arterial blood flow will result in infarction of fibroids and control of symptoms. It is an option for symptomatic premenopausal women who wish to retain their uterus, avoid side effects associated with prolonged medical therapy, and avoid surgical treatment.  However, there is insufficient evidence in the peer-reviewed medical literature to show the long-term efficacy and safety of a repeat uterine artery embolization for the treatment of uterine fibroids after initial artery embolization has failed.  Although uterine artery embolization is an effective primary treatment for leiomyomas, studies have recorded a recurrence rate of 10% at just more than two years.  Longer follow-up and more events are needed to define risk factors for recurrence.  Hysterectomy and myomectomy are considered the gold standard for the treatment of uterine fibroids and would not cause concern for compromising the transplanted kidney function.  All told, the requested repeat (right-sided) uterine artery embolization is not likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male  has requested  a somnoplasty procedure for treatment of his obstructive sleep apnea and snoring.  Findings:  The physician reviewer found that the patient has had a previous radiofrequency procedure on the palate using the coblator device. The requested somnoplasty device uses the same radiofrequency technology as the coblation approach (Boudewyns and Van De Heyning). A study comparing the two techniques reported that there was no difference in the effectiveness of the devices (Blumen, et al). Since this patient has already undergone a radiofrequency procedure for the soft palate, a procedure with the somnoplasty device has not been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female had requested speech therapy for treatment of her severe expressive language impairment.  Findings:  The physician reviewer found that the patient had a profound deficit in her expressive language skills when she was tested at the age of 18 months. The patients scores on standardized objective testing were significantly below average. The submitted documentation demonstrates the patient made significant improvements in her speech, from being a non-speaker to being only 28% delayed after 4 months of speech therapy, which confirms the validity of the effectiveness of speech therapy for speech delayed children.   The common practice of the medical community is to refer a speech-delayed child to a speech therapist to develop speech. There is a robust body of medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). Thus, it is medically necessary and appropriate for this patient to continue to receive speech therapy. Given the patients previous gains, it is likely that she will continue to benefit from additional therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested speech therapy for treatment of her severe expressive language impairment.  Findings:  The physician reviewer found that the patient had a profound deficit in her expressive language skills when she was tested at the age of 18 months.  The patients scores on standardized objective testing were significantly below average. The submitted documentation demonstrates the patient made significant improvements in her speech, from being a non-speaker to being only 28% delayed after 4 months of speech therapy, which confirms the validity of the effectiveness of speech therapy for speech delayed children.   The common practice of the medical community is to refer a speech-delayed child to a speech therapist to develop speech. There is a robust body of medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). Thus, it is medically necessary and appropriate for this patient to continue to receive speech therapy. Given the patients previous gains, it is likely that she will continue to benefit from additional therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that the medical literature supports speech therapy in the autistic population. The report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, 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 (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than those who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male has requested Temodar 140mg tablets for treatment of his hemangiopericytoma.  Findings:  Two physician reviewers found that the patient presented one year ago with neurologic symptoms. He was found to have an intracranial mass, and multiple liver lesions. He underwent resection of the brain mass, which revealed a hemangiopericytoma. The patients provider has recommended whole brain radiation to follow surgical resection, and temozolomide (Temodar) for treatment of the systemic disease.The patient has an extremely rare tumor, for which no standard therapy exists.  There are no large scale studies which have been conducted regarding the treatment of this disease, due to its rarity. The best level of evidence available, regarding the treatment of this disease is retrospective case studies. A small study examining 14 patients with hemangiopericytomas reported a significant positive impact of Temodar in the treatment of this disease (Park, et al.). There are no other proven alternatives for the treatment of this disease. In sum, given the results of the small cases series as well as the lack of alternative treatment options in this setting, the use of Temodar is medically appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male has requested coverage for past residential treatment services for treatment of his polysubstance dependence and anxiety.  Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry (AACAP) recommends the least restrictive setting in the treatment of adolescents with substance use disorders. In fact, this recommendation receives their strongest endorsement, meaning adherence is expected more than 95% of the time, and when this minimal standard is not applied clinically, documentation should support the rationale for the deviation in care.  The AACAP also states although residential programs, including therapeutic communities, have a place in the range of setting options, community intervention settings, if feasible, may offer optimal generalization of treatment gains. In the patients case, there is no evidence that he had participated in a community and/or school-based intensive outpatient or partial hospitalization program following his treatment at the Second Nature Wilderness program. Accordingly, and in the absence of other clinical information, transition from that nearly three-month program to an intensive outpatient program would have been consistent with accepted standards of practice. Further, review of the residential treatment facilitys records reveals no mention of psychiatric instability such as suicidality, homicidal ideation or psychosis that would warrant 24-hour supervision during the period at issue. Moreover, the psychopharmacological treatment the patient received (venlafaxine, trazodone, melatonin, hydroxyzine, and ramelteon) did not exceed a level of complexity appropriate for outpatient care. In sum, the submitted documentation does not demonstrate that the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for  speech therapy for treatment of the enrollees delays in expressive and receptive language skills. Findings:  The physician reviewer found that according to 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.   Law and colleagues noted 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 and language therapy, particularly for children with primary expressive language disorder.  In this patients case, he demonstrates significant expressive language delay that is negatively impacting his ability to communicate in a functional and age-appropriate manner. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested cervical nerve block injections with fluoroscopy/x-ray guidance for treatment of her cervical spondylosis with degenerative disc disease.  Findings:  Three physician reviewers found that based on the patients records and the peer reviewed medical literature, epidural injections are clinically indicated and likely to be superior to any alternative treatment for this patient at this time. The patient has specifically requested nerve blocks as she had in the past and the records indicate that she was previously treated with cervical epidural injections. Since the patients clinical findings are more consistent with radiculopathy than facet joint pain, epidural injections are likely to provide this patient with relief of her symptoms and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female has requested an MRI of the breast for evaluation based on her personal history of breast cancer.  Findings:  Three physician reviewers found that the patient has a family history of breast cancer in her mother and grandmother.  She has a personal history of breast cancer.  Per the medical records, she presented with a lump, and core biopsy revealed invasive ductal cancer.  She is status post right lumpectomy performed three years prior.  This was followed by re-excision one year later.  A bilateral MRI was performed nine months following and revealed no sign of malignancy.    Per the medical records, the original tumor was not seen on conventional mammogram.  The patients provider has recommended a repeat MRI of the breast.  The Health Plan has denied coverage for the requested diagnostic procedure and reported that MRI of the breast is investigational for the evaluation of this patient.  In this patients case, the requested diagnostic procedure is likely to be superior over other available tools for evaluating this patient.  The requested diagnostic procedure is the most sensitive technique available for breast cancer detection in this patients case. This patient has already been evaluated with a breast MRI.  In this patients case, the requested diagnostic procedure will provide a valuable comparison for any change to indicate possible malignancy.  Additionally, the initial cancer was not demonstrated by mammography.  All told, MRI of the breast is likely to be more effective than other methods of evaluating this patient.