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

The parent of a 3-year-old male enrollee has requested skilled nursing care for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that it is clear that continuous observation is necessary for this patient to prevent aspiration, pneumonia, intractable seizures, and respiratory distress possibly progressing to respiratory failure. To manage his condition the services of a skilled nurse is required to recognize and treat any seizure activity with prompt intervention. This type of care is not passive in nature and requires active participation and commitment of a trained and experienced caregiver. While parents may function as skilled caregivers for a portion of the day, given the extent of this patients medical needs, the requested skilled nursing services are medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested biofeedback for treatment of his pain.  Findings:  Two physician reviewers found that the article by Newton-John and colleagues was submitted in support of this appeal.  However, these authors noted no significant difference between cognitive behavioral treatment and electromyographic biofeedback. The article by Glombiewski and colleagues noted that biofeedback did not lead to improved outcome of psychological intervention.  Cognitive behavioral treatment was noted to be effective.  This patient has had cognitive behavioral treatment, and this article indicates that biofeedback would not improve efficacy.  In summary, the current medical evidence does not show that the requested biofeedback is likely to be more efficacious than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a metabolic brain positron emission tomography (PET)/computed tomography (CT) scan for evaluation of her language and cognition difficulties. Findings:  Two physician reviewers found that the available peer reviewed medical literature provides a review of the use and limitations of PET/CT scan, including its use to differentiate frontotemporal dementia and Alzheimers disease, as well as its use and limitations for the initial evaluation of dementia. The scientific data does not demonstrate PET/CT scans are a substitute for detailed clinical evaluation, simple laboratory tests and basic structural imaging (Visvanathan). PET/CT imaging as a primary diagnostic tool for early cognitive symptoms has not been proven to be beneficial or effective for patients and is not currently considered the standard of care. In addition, it is unlikely that such a study would substantially change management in a case such as the one documented through this record. Although a PET scan is useful in some instances, such as differentiating between Alzheimers and frontotemporal dementia, or in some cases of malignancy, there is no documentation in this case that is suggestive of these indications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that despite the enrollee's diagnosis of autism, this patient has the potential to communicate. He has developed rudimentary signing skills and his receptive language was found to be at 19 months when his chronological age was 31 months.  Thus, he does have the intellect to develop speech, albeit at a slow skill level.  An in plan therapist has recommended speech therapy, however, the Health Plan cites the paper by Meyers, et al. as supporting their position that there is not demonstrable oral pharyngeal pathology. This report is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children.  Specifically, the authors state People with [Autism Spectrum Disorder] 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. The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than children who did not receive speech therapy. The report from 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. Thus, in accordance with the peer-reviewed medical literature, speech therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested residential treatment center services for treatment of her substance use disorder and major depressive disorder.  Findings:  The physician reviewer found that this patient was admitted as a result of a family intervention. She resisted her care to the point of signing out AMA after spending weeks in treatment. She was returned to treatment by her mother and was subsequently enrolled in residential day treatment. During this admission, she did not suffer from severe withdrawal, medical complications or acute psychiatric co-morbidity. Applying the American Society of Addiction Medicine placement criteria, a patient with such a low level of severity in symptoms is typically treated successfully at an outpatient level of care such as intensive outpatient program (IOP) services, with or without buprenorphine assistance. This conclusion is also consistent with the practice guidelines from the American Psychiatric Association, which states that, Individuals should be treated in the least restrictive setting that is likely to prove safe and effective. Given this patients level of function and lack of withdrawal symptoms, medical complications or acute co-morbid conditions, she could have safely and effectively been treated in less restrictive level of care than RTC. As she did not require the intensity and supervision provided in a 24-hour residential treatment facility, participation in an IOP would have likely been medically indicated during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested the second session per week of outpatient psychiatric services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that the patients treatment goals, current assessments of functioning, specific plans for therapy and considerations for treatment termination were not delineated by the provider. All told, the patients current request for coverage of additional one-hour weekly therapy sessions provided since the date in question does not meet the criteria in the generally accepted practice guidelines as medically necessary (Gelenberg, et al). Further, applying the Level of Care Utilization System (LOCUS) recommendations as discussed by Sowers and colleagues, the frequency or duration of the desired outpatient therapy was not medically necessary or required for a safe and timely achievement of this patients treatment goals based upon the records provided for review. As such, this patients records fail to support the medical necessity of additional outpatient psychotherapy visits at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested deep brain stimulation (DBS) using interventional MRI technique/ClearPoint software (performed by a pediatric neurosurgeon) for treatment of the enrollees DYT1 positive primary generalized dystonia. Findings:  Three physician reviewers found that the requested referral to a pediatric neurosurgeon for DBS is likely to provide this patient with an improved health outcome beyond that attainable with other standard interventions. Moreover, use of the interventional magnetic resonance imaging (IMRI) with ClearPoint software should facilitate electrode placement, thereby decreasing operative time, which also assists in maintaining the patients sedation during the procedure. Thus, utilization of ClearPoint software during the DBS is likely to confer significant added benefit in this patients case. All told, the requested procedure should be approved in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested bilateral breast magnetic resonance imaging for evaluation of her family history of breast cancer. Findings:  Three physician reviewers found that in the medical literature, a patient who has inherited a harmful mutation in BRCA1 or BRCA2 is believed to be about five times more likely to develop breast cancer than a patient without the mutation. Overall, studies have found high sensitivity for MRI, ranging from 71% to 100% versus 16% to 40% for mammography in these high-risk populations. The American College of Radiology (ACR) appropriateness criteria recognizes the increased sensitivity of MRI for high risk women and recommends MRI in this setting. Clearly, the increased sensitivity of MRI has been established in the screening of high risk patients. If mutation testing is not available, has been done and is non-informative, or if a patient chooses not to undergo testing, pedigree characteristics suggestive of high risk may be considered. This patient has personal history of ovarian cancer, family history of breast cancer, and extremely dense breasts. However, applying the definition of a high risk patient as suggested by the ACR, this patient does not meet these criteria, and therefore is not a candidate for MRI breast cancer screening. This is not only due to the lack of the BRCA gene, but the fact that this patient does not meet the criteria based on the other established models, not solely on the presence or absence of this gene. Thus, although MRI is an extremely sensitive diagnostic tool, if used to screen patients who are not at high risk, there would be a significant false positive, and it would lose its ability to be an effective screening exam. As such, its use would not likely provide any additional data relevant to this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a full body positron emission tomography (PET) scan for evaluation of her melanoma. Findings: Two physician reviewers found that National Comprehensive Cancer Network (NCCN) guidelines recommend the use of PET studies every 6 to 12 months for the first 5 years after treatment for melanoma. Other studies in the peer-reviewed medical literature also support the use of PET studies in the surveillance of patients with a history of melanoma. PET is superior for the detection of distant metastases in both the staging and surveillance of melanoma patients (Xing et al.). PET is more sensitive and specific than CT for detection of melanoma metastasis and should be considered the primary staging study for recurrent disease(Swetter et al.). FDG-PET is a metabolic, noninvasive imaging modality for detecting distant metastatic and recurrent melanoma (Kumar et al.). Additionally, when interpreted with a high threshold approach, PET demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes management in patients with stage II-IV disease referred for a variety of indications(Falk et al.). As there is more than adequate support in the peer-reviewed medical literature for the use of PET scans for surveillance of patients with melanoma for five years after treatment, the requested PET scan is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested applied behavior analysis (ABA) therapy for 25 hours per week for treatment of the enrollees autism. Findings:  Three physician reviewers found that in the peer reviewed medical literature, applied behavioral analysis (ABA) therapy has been shown to be effective in treating behaviors associated with ASD (Sallows and Graupner). In addition, the National Research Council recommends the use of ABA in young patients in this patient population and noted that treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. In another study, a 5-year randomized-controlled study involving 48 children with autism and found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and ABA principles (Dawson and colleagues). This patient continues to have behavior issues including aggression, atypical sensory behaviors, and poor pragmatics, which are likely to respond to ABA intervention. The goals are to improve cognitive flexibility, pragmatic language and social functioning. ABA offers a program that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills (Rogers and Vismara). This autistic patient has shown impressive gains in all domains since the start of therapies and will continue to benefit from intensive ABA therapy. As such, the requested 25 hours of ABA therapy per week are likely to improve this patients behavioral issues associated with ASD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.   Findings:  The physician reviewer found that this patient meets criteria for treatment with GH, as he has short stature, delayed bone age, and poor results on provocative GH testing. However, there is insufficient evidence in the medical studies that one brand of GH therapy is more efficacious or less likely to cause adverse reactions than another brand. For this reason, a Health Plan formulary-approved brand of GH would be appropriate, and treatment with Genotropin specifically is not medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested two hours per week of speech therapy or treatment of the enrollees autism.  Findings:  The physician reviewer found that in the clinical literature, Carey and colleagues noted that language deficits are one of the core aspects of autism, and speech therapy provides professional help and guidance in communication development for patients with autism. A study by Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to determine factors related to the development of spoken language. Overall, the only significant predictors were motor imitation and number of hours of speech and language therapy. The researchers reported that patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions in the peer-reviewed medical publications and found that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism. Further, the author indicates that teaching language to children with severe communication deficits has profound impact on the lives of children and the people who interact with them as language skills can make a tremendous difference in the ability of children to control their environment. In addition, language skills have been found to be an adaptive alternative to highly disrupted forms of communication. The language evaluation in this patients records documents impairment with difficulty understanding complex speech both receptively and expressively. Given the support in the scientific data on the effectiveness and importance of speech therapy in young patients with ASD, the requested therapy is medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Lipitor 20 mg for treatment of her hyperlipidemia.  Findings:  The physician reviewer found that with reference to the current medical literature regarding the use of statins in patients without known or symptomatic heart disease for primary prevention, Lipitor has been extensively studied in the primary and secondary prevention of cardiovascular events. In addition, some studies suggest that Lipitor may offer some clinical advantages over various other statins (Arca and Gaspardone). In the principal primary prevention study, Sever and colleagues reported on the ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm) study. The researchers found that Lipitor reduced the relative risk of primary coronary heart disease (CHD) events by 36% compared with placebo in patients with hypertension at median follow-up of 3.3 years. In addition, substantial published data confirm the secondary preventive benefits of Lipitor in various clinical settings (Arca and Gaspardone). As this patients hyperlipidemia has been adequately managed with Lipitor and the medication is supported as beneficial in the scientific data, its use has been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested psychiatric residential care for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and Tourettes syndrome.  Findings:  The physician reviewer found that based on a review of the medical documents provided, this patient was a candidate for RTC level of care as he required intense services with 24-hour supervision. Given the level of safety concerns, deteriorating behavior, aggression, and the patients refusal to attend outpatient sessions, intense treatment in a 24-hour setting was medically necessary. This level of care is also consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) practice parameters and the Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines. Therefore, the RTC services provided have been established as 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 speech therapy in a group of two or more for treatment of the enrollees expressive and receptive language disorder.  Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. While most young patients difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school achievement. In the medical literature, Shevell and colleagues evaluated children younger than 5 years of age, referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Overall, 99 patients were found to have global developmental delay with an etiologic diagnosis determined in 44 patients. It was concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. When therapy is recommended, the primary goal is to give the patient a reliable way to exchange ideas and information in his daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the problem. Any speech or language intervention requires that the patients family and educators be involved to provide ongoing support for the patient outside of the clinical setting. Further, research shows the children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. As the child improves, they may need treatment less often, and group therapy may be a better alternative. Additionally the American Academy of Neurology (AAN) practice parameters recommend evaluation of a young patient with non-progressive global delay as a specific etiology can be determined in the majority of children with developmental delay. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed. This patients records indicate that a complete work-up has not been performed to determine the etiology of his speech and language delay. Therefore, the requested speech therapy is medically necessary based on the evidence in the literature and should be provided this patient at a minimum of 5 hours a week. A work-up should also be performed to look for possible etiology of the patients speech delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested excision of excessive skin and subcutaneous tissue (CPT 15830 and 15847) (abdominal wall panniculectomy) for treatment of her abdominal wall panniculitis. Findings:  The physician reviewer found that the reviewed materials lack documentation of the severity of the panniculitis and non-surgical treatments employed for panniculitis or response to such treatments. The request is for panniculectomy or removal of infraumbilical skin (CPT 15830) and abdominoplasty, or placement of incisions around the belly button and in the lower abdomen to shift supraumbilical skin caudally with removal of the excess at the bottom and creation of a new umbilical opening in this downwardly shifted skin (CPT 15847). The medical necessity of CPT 15847 has not been established, since there are no skin conditions such as rashes or complaints related to the upper abdominal skin fold. Additionally, the reviewed documentation does not justify the medically necessity of CPT 15830.  Documentation including actual prescriptions for topical medications for panniculitis and office visit notes over time listing medications employed to treat panniculitis and the responses to such treatment were not provided.  Based upon the submitted documentations, the pannus is a normal variant and is not large enough to be considered an abnormal structure of the body.  All told, the requested excision of excessive skin and subcutaneous tissue (CPT 15830 and 15847) (abdominal wall panniculectomy) is not medically indicated for the treatment of this patient and is not reconstructive in nature.