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

A 61-year-old female enrollee requested prospective authorization and coverage for intravenous Rocephin.  The Health Plan denied the request indicating that the medication at issue is considered investigational for treatment of the enrollees stated condition of Lyme disease.Findings:  Three physician reviewers found that the patient reported a 20-year history of Lyme disease. She relates ongoing symptoms of headaches, joint pain, fatigue, abdominal pain, memory loss, headaches, vision impairment, cognitive impairment, muscle pain, tremors, numbness, nausea, and anxiety. Her prior treatment has included amoxicillin, azithromycin, Flagyl, and Bicillin. The patient requested reimbursement and prospective authorization and coverage for intravenous Rocephin.  The Health Plan denied this request and reported that the medication at issue was and is investigational for the treatment of this patient.   As noted by Goroll and Mulley, Lyme disease can have three stages. Stage III infection occurs months to years after the initial infection and primarily manifests as musculoskeletal, neurologic, and skin disease. The classic manifestation of late disease is monoarticular or oligoarticular arthritis, most commonly affecting the knee or other large weight-bearing joints. Chronic arthritis can develop in about 10% of patients. Rarely, the nervous system (both central and peripheral) can be involved in late Lyme disease. A sub-acute encephalopathy characterized by memory loss, mood changes and sleep disturbances is the most common form.   The establishment of late Lyme disease requires objective evidence of clinical manifestations and evidence of disease with two-stage testing with ELISA and Western blot.  In terms of therapy, there are established treatment regimens for initial infection, neurologic disease, cardiac disease and arthritis. The prolonged use of intravenous antibiotics is not recommended. Parental therapy with Rocephin has been associated with adverse effects, including cholelithiasis. The accepted duration of therapy is two to four weeks. This patient has a long history of non-specific symptoms and has undergone previous antibiotic therapy without resolution of her symptoms. There is no indication that she would benefit from intravenous Rocephin therapy.  Thus, intravenous Rocephin 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 66-year-old female enrollee has requested facet block injections for treatment of her low back pain.  Findings:  The physician reviewer found that The imaging studies are significant for multi-level lumbar degenerative disc disease and neural foraminal stenosis. It is difficult to determine the true pathology of the patients chronic pain based on an essentially normal physical examination without mention of findings on facet loading and imaging studies.  In addition, the medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The facet joint as a source of low back pain is controversial.  The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. These authors performed a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results demonstrated that local anesthetic injections are useful for the diagnosis of non-radicular low back pain, but may yield false positive results with respect to lumbar facet pain depending on the technique utilized.  The current medical evidence does not support the services at issue in this clinical situation. All told, facet block injections provided on the date in question were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested residential level of care for treatment of the enrollees bipolar disorder, mixed, without psychotic features, attention deficit/hyperactivity disorder, oppositional defiant disorder, marijuana dependence and alcohol abuse.  Findings:  The physician reviewer found that in this patients case, residential level of care from the date in question forward was not and is not medically necessary.  The patient was cooperative, and there is no documentation of any behavioral issues which warranted containment on a 24-hour basis. There is no indication of serious risk to self or others. The progress notes submitted showed that the patient received on average no more than one hour per day of active programming.  He did well in his classes, and there were no medication changes during the course of his stay.  The intensity of services rendered was not commensurate with that expected in a residential facility.  He could have been safely and effectively managed in the context of outpatient therapy. Therefore, outpatient therapy was medically necessary for the treatment of this patient.  The review by Wilmshurst provides evidence that residential treatment is not more effective and may in fact be less effective than services rendered in the community. Finally, American Psychiatric Association standards indicate that patients should be treated in the least restrictive setting which is likely to prove safe and effective. The data reviewed do not establish that this setting was the least restrictive one in which the treatment could have been reasonably provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested individual or group speech and language therapy once per week in the home and/or clinic setting for 60 minutes for treatment of his autistic disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with autism with clear evidence of receptive and expressive language delays. The relevant scientific literature reveals that plasticity in the developing brain still exists, even in the presence of underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including modalities such as speech and language therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Therefore, individual or group speech and language therapy once per week for 60 minutes is medically appropriate and necessary for treatment of the patients medical condition. The submitted evidence does not document any barriers to the patient receiving services in the clinic setting. As such, it is not medically necessary for the patients speech therapy to be home based.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested reduction mastectomy for the removal of excess breast tissue for treatment of his hypertrophy of breast.  Findings:  The physician reviewer found that gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males. This patient has excess fat and a skin fold of the chest related to the patients weight.  The requested reduction mastectomy for the removal of excess breast tissue is not medically necessary in this patients case.  The submitted documentation does not indicate that the patient has classical gynecomastia.  The condition does not constitute an abnormal structure of the body, as there is no visible feminization of the breast in this male patient. There is no functional deficit related to the excess chest skin and fat such as a rash, skin breakdown or decreased range of motion. Therefore, removal of the fat and skin would not improve function. All told, the requested reduction mastectomy for the removal of excess breast tissue is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested a podiatrist consult for treatment of her calcaneal spur.  Findings:  The physician reviewer found that in this patients case, his treating provider has recommended follow-up care with a podiatrist.  X-rays were ordered due to swelling to his posterior heels.  The x-rays confirmed posterior calcaneal spurs, which can cause significant pain.  The Health Plan has indicated that conservative care has not been attempted.  However, this conservative care, including foot inserts, ice or NSAIDs, must be instituted and monitored by a podiatrist.  The requested podiatrist consult is within the accepted standards of medical practice in this clinical situation.  The submitted medical documentation establishes the medical necessity of the requested services.  All told, the requested podiatrist consult 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 for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25%. 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, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. According to the authors, approximately one-half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show greater improvement than those children who have no treatment. Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement 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. As such, speech therapy is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested authorization and coverage for BioniCare knee device (joint nerve stimulator).  The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees knee pain.  Findings:  Three physician reviewers found that the patient has osteoarthritis of the knee.  The medical records noted that the patient reported a three-year history of right knee pain.  Per the submitted documentation, this pain was not associated with an injury.  The patient has requested coverage for a BioniCare knee device (joint nerve stimulator).  The Health Plan has denied this request and reported that the requested device is investigational for the treatment of this patient.  The patient is appealing this denial.  The superior efficacy of the requested device has not been established.  The current medical evidence does not provide support for the use of the requested BioniCare knee device (joint nerve stimulator).  There is a lack of evidence supporting the requested device in this patients case.  The evidence in published peer-reviewed literature does not support the efficacy of transcutaneous electrical joint stimulation devices for any indication.   Therefore, the requested BioniCare knee device (joint nerve stimulator) is not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female has requested home based, individual speech therapy for one hour per week for treatment of her autism.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with autism with clear evidence of receptive and expressive language delays. The relevant scientific literature reveals that plasticity in the developing brain still exists, even in the presence of underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including modalities such as speech therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Therefore, individual speech therapy for one hour per week is medically appropriate and necessary for treatment of the patients medical condition. However, the submitted evidence does not document any barriers to receiving services outside the home. As such, it is not medically necessary for the patients speech therapy to be home based.
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 moderate receptive language delay, severe expressive language delay and severe speech delay.  Findings:  The physician reviewer found that Nelson and colleagues noted that 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.  Per these authors, 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.  The current medical evidence indicates that speech and language delay must be taken seriously in young children, as 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, behavior, socialization and school attainment.  McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. This patient has mild to moderate receptive language delay and severe expressive language delay that are significantly impairing his ability to communicate effectively.  The medical literature supports the requested speech therapy in this clinical situation.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested an MRI for evaluation of the enrollees back pain.  Findings:  The physician reviewer found that this patient has back pain with no neurological deficits. There is no documentation within the enclosed medical records of conservative therapy, including physical therapy.  There is no clinical concern of infection or metastatic disease. There is no history of recent trauma. Management of uncomplicated back pain is supported by multiple published guidelines, including the American College of Radiology, the American College of Physicians and the American Pain Society.  For patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma and no neurological deficits), it is medically acceptable for the patient to undergo a trial of conservative therapy, including physical therapy, prior to advanced imaging such as MRI.  If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate. As there is no documentation of a recent trial of conservative therapy, and this patient has uncomplicated back pain, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested residential care services for treatment of his depression, not otherwise specified, generalized anxiety disorder, panic disorder, alcohol abuse and cannabis dependence.  Findings:  The physician reviewer found that there were no symptoms of withdrawal or serious medical complications requiring monitoring and containment on a 24-hour basis.  The data reviewed fails to establish the medical necessity for this level of care.  American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to prove safe and effective.  As such, residential services during this time period fail to conform to current standards of medical practice and expert consensus as indicated by the American Psychiatric Association.  All told, residential care services provided during the said timeframe  was not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested cervical artificial discectomy for treatment of his cervical spondylosis and degenerative disc disease at C6-7.   Findings:  Three physician reviewers found that the patients MRI shows a solid fusion and minimal adjacent segment pathology at C6-7, with only a 3mm bulge of the disc without significant canal stenosis, cord compression, or myelopathy. The records further indicate that he has continued symptoms after C5-6 ACDF, carpal tunnel surgery, and ulnar nerve surgery. His EMG/NCV studies show continued abnormalities at those levels. His surgeon has proposed artificial disc arthroplasty. However, there is a paucity of any reliable data establishing the long-term safety and efficacy of the proposed procedure in this patient population. There are small studies which offer some promising results, but issues regarding potential complications and durability remain unresolved (Sasso, et al and Murrey, et al). To this end, the Food and Drug Administration (FDA) required a 7-year post-approval study to establish the long-term safety and effectiveness of the ProDisc-C device. These studies are ongoing and have not been completed or reported. Given this patients symptoms and the lack of evidence supporting the benefits of artificial disc replacement at this time, the requested surgery is not likely to be more beneficial than standard treatment alternatives for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested authorization and coverage for a bilateral breast MRI. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee, who has a history of atypical ductal hyperplasia. Findings:  Two physician reviewers found that this patient has atypical ductal hyperplasia.  An MRI of the breasts was performed.  The provider noted several enhancing small lesions.  The provider noted that this was likely benign, although a follow-up breast MRI in six months was recommended to ensure stability.  The patient has requested authorization and coverage for a bilateral breast MRI.  The Health Plan has denied this request and reported that the requested diagnostic procedure is investigational in this clinical situation.  The patient has appealed this denial.  In this patients case, the requested bilateral breast MRI is likely to be superior over other methods of evaluating this patient.  She has been diagnosed with atypical ductal hyperplasia.  The MRI report described findings requiring surveillance to ensure a benign etiology.  These findings are best evaluated with the requested bilateral breast MRI.  Since the abnormal findings were noted using breast MRI, a repeat MRI is the imaging of choice for follow-up evaluation.  The current medical evidence supports the requested diagnostic procedure in this patients case.  All told, the requested bilateral breast MRI is likely to be more efficacious than other tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested Excimer laser treatments for treatment of the enrollees segmental vitiligo.  Findings:  The physician reviewer found that according to Schwartz and Janniger, vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by circumscribed depigmented macules and patches that cause significant morbidity due to cosmetic disfigurement. Segmental vitiligo manifests as one or more macules in a dermatomal or quasidermatomal pattern. Lotti and colleagues reported that treatment for vitiligo is difficult and prolonged. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist as not all patients respond to available therapies. Thus, variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Medical treatments include topical corticosteroids and other topical treatments, such as Protopic. Segmental vitiligo can be treated with narrow-band ultraviolet B, monochromatic Excimer light and psoralen phototherapy (Mahmoud, et al). The Excimer laser is a type of phototherapy that focuses directly on individual lesions of and penetrates deeper into the skin. The Excimer laser has the advantage of treating only involved skin, therefore minimizing potential risks of exposing normal-appearing skin to UV radiation. However, treatment periods of more than 12 weeks may be necessary to obtain satisfactory clinical repigmentation particularly when vitiligo lesions are treated only once or twice per week compared with 3 times weekly (Hofer, et al). The important clinical aspects of this patients vitiligo, the attempted and failed treatments, as well as the results of clinical research trials of Excimer laser in the treatment of vitiligo, support Excimer laser therapy as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 11-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the benefit of speech therapy for a developmentally language delayed child has been well documented in the medical literature. Law and colleagues concluded in their meta-analysis of numerous medical studies that children with speech delay can be readily treated. In addition, Goorhuis-Brouwer and Kniff found that cognitively normal and delayed children with delayed speech are candidates for improvement with speech therapy. Further, Buschmann and colleagues addressed the accuracy of speech testing in a 2-year-old population and found that these patients are likely to benefit from speech therapy. All told, speech therapy is medically necessary to address this patients speech and language delays.