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

The parent of a two-year-old male enrollee has requested speech therapy (one day per week, one hour per session for treatment of the enrollees severe expressive language delay.  Findings:  The physician reviewer found that as noted by 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. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  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.  Bernhardt and Major concluded that 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 has severe expressive language delay that is significantly impairing his ability to communicate effectively.  The current medical evidence supports the requested speech therapy in this clinical scenario.  All told, speech therapy, at a frequency of one day per week, one hour per session, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested epidural steroid injections for treatment of her back pain.  Findings:  The physician reviewer found that epidural steroid injections are medically necessary for the treatment of this patients chronic back and leg pain.  The patient has tried and failed to receive relief with anti-inflammatory and opioid medications.  She has participated in physical therapy and a home exercise program. The patient had significant reduction in her pain lasting about three months at a time following previous epidural steroid injections.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy. The study concluded that fluoroscopically-guided transforaminal epidural injections serve as an important tool in the non-surgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.  Botwin and colleagues performed a prospective cohort study to identify the short-term and long-term therapeutic benefit to fluoroscopically-guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. They found that fluoroscopically-guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis.  Rosenberg and colleagues performed a prospective study to determine the effectiveness of transforaminal epidural steroid injections. They found that epidural steroid injections might offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.  All told, the requested epidural steroid injections are medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested Nuvigil 250mg for treatment of his depression complicated by chronic insomnia.  Findings:  The physician reviewer found that in this case, the submitted documentation demonstrates the medical necessity of Nuvigil 250mg.  The medical records document that the patient uses a CPAP, and the patient reported fatigue and poor quality sleep.  The patients treating physician has indicated that Nuvigil is requested for sedation related to chronic insomnia secondary to depression.  American Psychiatric Association guidelines indicate that there is evidence to support stimulants as an adjunct in treating depression.  The requested medication is medically necessary for this patients condition according to current evidence-based practice standards and expert consensus.  All told, the requested Nuvigil 250mg is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has significant delays in expressive and receptive speech per the DAYC subtest and the RITLS subtests. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. This patients records indicate that he is not yet using words, rather grunting to communicate. An extensive review of the relevant publications including meta-analysis by Law and colleagues reports a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. Currently there are only a few well-controlled studies that examine the effectiveness of pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life. A systemic review by Polatajko and Cantin concluded that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. However, no firm conclusions can be made regarding specific approaches due to the methodological flaws of the study quality and great variability in interventions. The occupational therapy sessions in this patients records focused on sensory processing issues. Since the efficacy of sensory integration therapy has not been objectively demonstrated the requested occupational therapy is not medically necessary in this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that this patients depression is treatment-resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the clinical studies, Schutter and colleagues reported that TMS resulted in a moderate effect on treatment-resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Further, Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, TMS is an effective treatment as demonstrated in the referenced evidence-based literature, has been granted a category I CPT code by the AMA and is FDA approved for the treatment of treatment-resistant major depressive disorder. As this patient has failed numerous standard medical therapies for treatment of major depressive disorder and has had positive results with TMS, the therapy at issue is likely to be more beneficial for treatment of her condition than any available standard modality and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female has requested speech therapy and physical therapy for treatment of her pervasive developmental disorder, not otherwise specified. Findings:  The physician reviewer found that according to guidelines for the treatment of autism set forth by the American Academy of Neurology and Child Neurology Society in 2000, the immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The guidelines support evaluation and treatment of sensorimotor skills including assessment of gross and fine motor skills, praxis, sensory processing abilities, and unusual or stereotyped mannerisms, and the impact of these components on the autistic persons life. Additionally, early identification of speech and language problems is recommended in order to initiate early intervention, which has been shown to improve outcomes for children who have ASD. In this patients case, her motor skills have been noted to be moderately low and she has documented receptive and expressive language delays. Therefore, she is likely to benefit from speech therapy and physical therapy, which are standard modalities for patients with ASD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.  Findings:  The physician reviewer found that this patient has ASD but does not exhibit other symptoms to suggest a mitochondrial disorder. Signs of mitochondrial disease include elevations of lactic acid, which the patient does demonstrate.  However, blood lactate and pyruvate measurements are known to be prone to erroneous increases due to such issues as prolonged tourniquet application, (see Bonini, et al. and Haas). Other biochemical markers are often present including elevation of plasma alanine in the amino acids, elevations of urine organic acids and especially dicarboxylic acids due to omega oxidation of fat in the cytoplasm when mitochondria are not functioning normally.  Elevations of acylcarnitine derivatives are usually seen, as well.  Ammonia can also be elevated with mitochondrial disease (Haas). The patient exhibited none of these biochemical markers. Finally, patients with mitochondrial diseases usually have progressive deterioration in their neurological functioning (Haas) which is also not evident in the documentation provided regarding this patient. Therefore, without additional signs or symptoms as outlined above, a muscle biopsy for the purpose of a mitochondrial disease work-up is not medically necessary for the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested for bilateral core decompression with implantation of autogenous iliac crest bone graft for treatment of his bilateral hip avascular necrosis status post left core decompression.  Findings:  The physician reviewer found that the value of core decompression for treatment in early cases has been recognized for some time, and has been reported to be effective in 60% to 80% of cases at 5 to 10 years follow-up, as noted by Mont and colleagues. The addition of bone graft to increase structural support and provide a scaffold for bone and vascular growth is also well-recognized. The current medical evidence supports bilateral core decompression with implantation of autogenous iliac crest bone graft in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested authorization and coverage for laparoscopic excision of endometrioses, lysis of adhesions, enterolysis, ureterolysis, left ovarian suspension, cervical conization, and possible left upper abdominal adhesiolysis. The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees endometriosis.  Findings:  The physician reviewer found that based on review of the available records, the patient has evidence of a recurrent right ovarian endometrioma. Her records confirm a history of an incomplete treatment of her endometriosis including drainage of a right endometrioma and endometrial implants left behind. The recurrence of an endometrioma associated with pelvic pain is an indication for a surgical procedure. In addition, the untreated endometrial implants as well as potential adhesive disease may be treated during such procedure. Therefore, the proposed procedure itself is well within the standard of care and is medically necessary. Although the surgical treatment of endometriosis may require the resection of lesions on multiple organs and the peritoneum as well as adhesiolysis, these are procedures that are within the expertise and skill of a board-certified, competent gynecologic surgeon. In complex situations when there is intestinal or urinary tract involvement, the gynecologist has the option of referring the patient to an In-Plan surgical specialist who can provide advanced care for her condition. This patient was appropriately referred to the director of a university-based pelvic pain program, partially for these reasons. This program apparently has the capability of providing multispecialty care for the patients condition including surgical care. If the patients opts for surgery, the specialist has the surgical expertise to treat this condition and also has the advantage of consulting the universitys staff of advanced surgical specialists for gastrointestinal and urologic involvement if needed. For these reasons, the requested surgery is medically necessary for treatment of the patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested a second opinion with a craniofacial team/craniofacial reconstructive surgeon for evaluation of the enrollees skull deformity.  Findings:  The physician reviewer found that Kung and Sloan provide a description of frontometaphyseal dysplasia and its treatment, which includes reshaping of the frontal bone or a cranioplasty. The patient described in their study had clear exam findings of a bony supraorbital ridge for which the above treatment options were provided. In the case of the patient involved in this appeal, given his history of craniotomy for a similar condition and the unclear exam findings, his case would warrant a second opinion. The patient underwent an initial surgical procedure and now questions whether he needs a second procedure. The patient has received an initial opinion from plastic surgery; however, there is no evidence of a second plastic surgery opinion in the documentation provided. The first opinion from the plastic surgeon appears to address the need for further surgical intervention adequately, but there is no evidence of a second opinion to confirm his findings. Although the patient has requested a referral to a craniofacial team/craniofacial reconstructive surgeon, plastic surgeons are trained to evaluate craniofacial deformities and therefore a referral to a craniofacial specialist is not necessary. A board certified plastic surgeon will be able to appropriately evaluate the patients condition and make recommendations for future treatment, if required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested laboratory testing for evaluation of her multiple medical conditions.  Findings:  The physician reviewer found that  There is no peer-reviewed evidence scientific evidence to support the efficacy of this testing at this time. The physician reviewer found that there is no peer-reviewed data demonstrating that such testing has any clinical utility in this setting. Therefore, Realtime Labs  urine mycotoxin panel is not medically necessary for this patient.
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 expressive speech delay.  Findings:  The physician reviewer found that there is robust medical literature supporting speech therapy in this speech delayed population including the meta-analysis from Law and colleagues that reported that children with speech delay can be readily treated. Goorhuis-Brouwer and Kniff specifically deals with speech-delayed children, such as this possibly cognitively normal child, and points out that such normal, as well as cognitively delayed, children are candidates for successful speech therapy. Emanuel and colleagues specifically addressed the accuracy of speech testing in a two-year-old population.  Speech therapy is medically indicated in this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  speech therapy, at a frequency of two sessions per week for one hour each session for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of 37%, with delays in her social interaction. Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including 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 & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period when compared to no intervention or nursery-based intervention. The provided medical records and review of the above peer-reviewed medical literature demonstrates that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Orthovisc injections for treatment of his advanced degenerative arthritis of the left ankle. Findings:  The physician reviewer found that the use of hyaluronic acid for viscosupplementation in the treatment of osteoarthritis has been generally accepted for use in the knee, however, there is limited published literature relating to its use in treating osteoarthritis in the ankle (Sun, et al.). Studies of larger size and longer duration are needed to evaluate this technique (McKee). Some preliminary studies have been favorable, but further evaluation is necessary (Kosia & Baumhauer). A paper by Migliore and colleagues found that the potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date. Thus, the evidence currently available is insufficient to establish the safety and efficacy of Orthovisc for arthritis of the ankle. As such, the requested medication is not a medically necessary therapy for treatment of the patients ankle pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested enhanced external counterpulsation (EECP) therapy for treatment of his angina.  Findings:  The physician reviewer found that this patient does not meet accepted criteria for EECP therapy. EECP is indicated for the treatment of refractory angina, not amenable to other forms of medical or interventional therapy. Based on the documentation provided, it appears that the patient has not had diagnostic testing in over a year. He was found to have moderate, diffuse coronary disease at catheterization in 2009. In 2011, his symptoms were noted to have possibly increased. It does not appear that repeat diagnostic testing to determine a precise diagnosis was performed. Such testing would likely allow for definitive therapy. Manchando, et al. outlined the role of EECP in treating patients with angina. The accepted indications are for patients with refractory angina. This patient does not meet this criteria and lacks diagnostic support for an ischemia diagnosis. Therefore, EECP is not a medically necessary treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested residential treatment for treatment of the enrollees major depressive disorder, recurrent, mild, oppositional defiant disorder and intermittent explosive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. A recent article by Wilmshurst provides research evidence indicating that children with attention deficit/hyperactivity disorder do better when treated in the community with their families.  Per the submitted documentation, there is no indication of risk to self or others requiring containment on a 24-hour basis.   Per the submitted medical records, the patient received approximately five to ten hours of programming per week which were conducted by therapists, with occasional visits by a psychiatrist.  However, there is no indication that the psychiatrist provided direct input into treatment planning.  American Psychiatric Association guidelines were not met, as there is no indication that the patient could not have been safely and effectively managed in the context of a less restrictive setting.  The services provided at the residential treatment center during the said time frame were not medically indicated according to current standards of evidence-based practice and expert consensus. The patient could have been managed with outpatient psychotherapy and medication management during this time.  All told, services provided were not medically indicated for the treatment of this patient.