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 speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this young patient with autism and a history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions for autism in peer-review research articles and found sufficient evidence supporting the effectiveness of interventions to teach communication skills to children with autism. Specifically, language skills make a significant difference in the ability of children to control their environment, especially with disruptive behaviors. As language deficits are one of the core aspects of autism for which speech therapy provides professional guidance on communication development, the requested two hours per week of speech therapy (past and future) has been shown to be medically necessary for treatment of this patients autism related delays. Concerning the requested occupational therapy, this modality is considered a standard treatment intervention for patients with autism. The submitted records indicate the patient has previously had documented delays in fine motor and gross motor abilities. Therefore, I find that the patients previous occupational therapy was medically indicated and necessary. With regard to the requested future occupational therapy, the patients most recent occupational therapy on the date in question (by an in-plan provider) indicated the patient presented with no apparent occupational therapy problems. However, this evaluation did not include a reliable testing measure to determine the extent of the patients fine motor and gross motor abilities. The Vineland Adaptive Behavior Scales-second edition (VABS) and Mullen Early Scales of Learning on the said date found deficits of up to 33% on fine motor abilities. Given the inconsistent results on previous evaluations, the patient should have an objective independent evaluation to determine his occupational therapy needs going forward.
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 speech delay.  Findings:  The physician reviewer found 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. The current medical evidence indicates 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. Children with untreated speech and language delay may be at risk for learning disabilities once they reach school age. Thus, speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial.  This patient has significant delays in speech and language that negatively impact his ability to express his needs and interact with peers and adults. Objective testing has demonstrated functioning overall at the 9 to 12 month level at a time when he was 31 months of age. It is also apparent from his evaluation that he has lost some skills (no longer points to body parts), and has poor social skills. The current medical evidence supports speech therapy in this clinical scenario.  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 42-year-old female enrollee has requested  magnetic resonance imaging for evaluation of her low back pain.  Findings:  The physician reviewer found that from a review of the available records, this patient presents with a history of acute low back pain without current radicular symptoms. The records indicate that her symptoms improved after a short trial of non-steroidal anti-inflammatory drugs (NSAIDs). The patient has no history of trauma, neurological deficit or fever. The American College of Radiology (ACR) guidelines do not recommend the use of MRI scanning in this scenario absent a trial of conservative therapy. The records do not demonstrate that the patient has been treated with physical therapy, activity modification, or medical therapy aside from Ibuprofen. In addition, the patient experienced approximately 25% improvement in pain with NSAIDs. Therefore, based upon the information provided, the requested MRI is not medically necessary for evaluation of this patients low back pain at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested Tev-Tropin growth hormone (GH) for treatment of the enrollees short stature.  Findings:  The physician reviewer found that during early childhood, this patient did not meet the standard criteria for GH deficiency, as his height was not less 2 standard deviations below normal for age and gender, his bone age was not delayed, and his growth factors were normal. Based on poor results on provocative GH testing, the patient was treated with GH therapy with a modest increase in his linear growth velocity. After discontinuation of GH therapy, the patient underwent rapid pubertal progression at a young, though not precocious, age and then completed his growth after experiencing a normal pubertal growth spurt. Currently, the patients skeletal age is 17 years, which indicates that his epiphyses are fused and a fall-off in growth is expected. As such, GH therapy has no role in improving his height potential. The fact that he apparently responded to GH therapy with improvement in linear growth velocity during early childhood does not prove that he is GH deficient or that therapy is clinically indicated. Provocative GH tests have poor sensitivity and specificity for the diagnosis of GH deficiency, and even children who are not deficient may demonstrate a transient increase in growth velocity in response to GH therapy. All told, reinstatement of GH treatment will not likely improve the patients growth, as his epiphyses are already fused. Thus, the medical necessity of GH therapy has not been established as medically necessary for treatment of the patients short stature at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  residential treatment services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity for residential treatment from the said date onward. The patients status has not changed significantly during her time at this facility, and medication management has not been aggressive. The materials submitted document less than five hours per week of active treatment, and there has been minimal containment of suicidal impulses. The patients condition has not changed appreciably at this level of care. American Psychiatric Association practice guidelines indicate that individuals with PTSD should be treated in the least intensive setting which is likely to be safe and effective. For patients such as this patient with cluster B traits, Dialectical Behavioral Therapy (DBT) is appropriate and indicated therapy. Thus, according to current evidence-based practice standards, this patients needs could best be met in an intensive outpatient program with a focus on DBT. All told, residential treatment during this period of time was not and is not medically necessary for this patient. The patient could have been treated at a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested psychiatric evaluation and NeuroStar Transcranial Magnetic Stimulation (TMS) therapy for treatment of her major depression. Findings: Two physician reviewers found that based on the information provided, it appears the patient had a response to Effexor, but the antidepressant was not maximized prior to the trial of TMS. Further, the record does not substantiate the trial and failure of an adequate course of electroconvulsive therapy (ECT). Per American Psychiatric Association guidelines, ECT would have been the most effective treatment for this patients condition. TMS has not been shown to be superior to ECT (Eranti and colleagues). There is insufficient evidence supporting the use of TMS in this clinical scenario (Martin and colleagues). All told, the psychiatric evaluation and NeuroStar Transcranial Magnetic Stimulation (TMS) therapy provided during the dates in question were not likely to have been the most efficacious treatment for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested a registered dietician who specializes in treating anorexia patients for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that as noted in the American Psychiatric Association (APA) guidelines for eating disorders, Registered dieticians with specialized training in eating disorders often provide nutritional counseling. The APA guidelines further state that, For children and adolescents, the recommended treatment model is the team approach. In this interdisciplinary management approach, general medical care clinicians (e.g., specialists in internal medicine, pediatrics, adolescent medicine, or nutrition) manage general medical issues, such as nutrition, weight gain, exercise, and eating patterns, whereas the psychiatrist addresses the psychiatric issues. Thus, the APA criteria are clear that the nutritional advisor must be a person with individualized training in this area. As such, it would be insufficient, according to the guidelines, to have a psychologist undertake this role. Consistent with these recommendations, the request for a dietician with special expertise in adolescent eating disorders is medically necessary in managing this patients eating disorder according to the APA guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a PET/CT scan for evaluation of her fibrosarcoma.  Findings:  Two physician reviewers found that the use of PET/CT scans for evaluation of patients with soft tissue sarcoma is limited to the initial staging, monitoring response to treatment and for determining prognosis of the patients tumor.  There is a lack of support in the peer-reviewed literature for the use of PET/CT scans for surveillance purposes in asymptomatic patients with prior history of soft tissue sarcoma.  Ilaslan and colleagues noted that after definitive treatment, MRI remains the most sensitive imaging tool for diagnosing local recurrences of either bone or soft tissue sarcomas.  For patients who have been treated for sarcoma, PET/CT studies are useful if there is clinical evidence of recurrence or metastatic disease or if findings on conventional imaging are equivocal.  This patient has no clinical evidence of recurrence or suspected metastatic disease.  All told, the requested PET/CT scan is not likely to be the most beneficial method for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  Holistic Bipolar treatment for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that the official guidelines of the American Academy of Child and Adolescent Psychiatry (AACAP) for the treatment of children and adolescents with bipolar disorder provide specific recommendations for young patients with bipolar disorder. The AACAP suggest that, Most youth with Bipolar I Disorder will require ongoing medication therapy to prevent relapse; some individuals will need lifelong treatment. Further, they recommend that, Psychotherapeutic interventions are an important component of a comprehensive treatment plan for early-onset bipolar disorder. Despite these recommendations, the AACAP do not indicate that chiropractic manipulation, herbal supplements, amino acids and a low sugar diet as part of the treatment plan for bipolar disorder. For this reason, the holistic approach requested has inadequate scientific research or evidence to establish it as an accepted treatment modality. The requested services are therefore not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested Botox injections 4 times per year for treatment of her chronic headaches.  Findings:  The physician reviewer found that Botox injections are not medically necessary for treatment of this patients chronic daily headaches because its effectiveness has not been proven or confirmed within the peer-reviewed literature for this diagnosis. Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache free days compared to baseline. The primary time point difference, however, for Botox when compared to placebo was not statistically significant. The treatment also met secondary efficacy outcome measures, including the percentage of patients experiencing a 50% or more decrease in the frequency of headache days. Botox treatment for chronic daily headaches seems promising and is well tolerated. However, Botox treatment efficacy for chronic daily headaches is not proven to be statistically significant in trials or peer reviewed literature. Similarly, Silberstein and colleagues studied the safety and efficacy of different concentration of Botox for prophylactic use in chronic tension type headaches. The outcome suggests that Botox was effective as more patients had a decrease in tension headache days when compared to placebo. The primary endpoint, however did not demonstrate a statistically significant difference between Botox and placebo. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The researchers concluded that there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. Overall, Botox injections for episodic, chronic, tension-type headaches or migraines may provide improvements in symptoms. However, a statistically significant difference between treatment groups and placebo could not be obtained to prove that Botox is more beneficial than any available standard therapy for headaches. Further, there was no documentation by this patients treating provider of headache frequency being substantially reduced by the end of the initial trial. All told, the patients request for coverage for Botox injections four times per year has not been established as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Botox injections for treatment of her chronic migraine. Findings: The physician reviewer found that this patient has a history consistent with chronic migraine, with daily disabling headache for months.  A practical definition of chronic migraine is of headache more days than not, over a period of at least three months, with migraine or probable migraine by symptoms or history.  She has been tried on several standard preventives as well as standard abortive treatment, without success. The literature regarding Botox treatment for chronic migraine shows that it is beneficial for the majority of treated individuals, with nearly 70% of people treated over the course of the clinical trial showing at least a 50% reduction of headache days. The current medical evidence supports the use of Botox injections in this patients case. All told, the requested Botox injections are medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested a PET scan for evaluation of his stage IIIc malignant melanoma. Findings: Three physician reviewers found that the peer-reviewed literature supports the use of PET scans for surveillance of patients at high risk for developing recurrent/metastatic melanoma. The National Comprehensive Cancer Network guidelines for melanoma advocate for serial follow-up PET scans for patients with a history of stage III melanoma. PET scans are superior for the detection of distant metastases in both the staging and surveillance of melanoma patients (Xing and colleagues). The requested diagnostic procedure demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes patient management (Falk and colleagues).  Therefore, the requested PET scan is likely to be more efficacious than other methods of evaluating this patient.
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 speech delay.  Findings:  The physician reviewer found that this young patient has an identified delay in expressive speech that is estimated to be greater than 50%. In addition, he has a greater than 33% delay in receptive language abilities. In the clinical studies, speech therapy is indicated with any delay greater than 25% (Carey, et al). Further, an extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Similarly, Feldman and colleagues concluded that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. With intervention, approximately half of children delayed at 2-years catch up to peers by 3-years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders while those who participate in speech-language treatment show better improvement than those without therapy. This patient has a history of prematurity and transient communication hydrocephalus which are both associated with language and speech delay. Given the reliable scientific data in support of the effectiveness and utility of speech therapy, its use in the management of this patients speech delay is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested an insulin pump for treatment of her diabetes.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient does not meet general practice guidelines for an insulin pump, as she does not perform blood glucose monitoring at least four times daily and there is no evidence of attempted frequent self-adjustments of insulin doses (Scheiner, et al). Several studies published in peer-reviewed medical literature have shown that insulin pump therapy is safe and effective in children and adolescents with Type 1 diabetes. Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients (Hanas and Ludvigsson). However, insulin pump therapy in a patient who does not possess basic self-care and management skills can present a significant danger, as there is no long-acting insulin reserve present in case of pump malfunction. All told, the medical necessity of the requested insulin pump has not been demonstrated in this patients clinical situation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue is whether a reasonable and prudent layperson in the patients circumstance would believe he or she was experiencing an urgent medical condition on the dates of service at issue. Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. The submitted evidence demonstrates that the patient presented on the first date of service at issue with low back pain. The patient did not experience an acute injury. In a letter, the patient indicates that he had an urgent need for services because of severe pain that caused him to be physically incapacitated with mobile impairment in his ability to walk. The MRI was recommended during the initial urgent care visit; no urgent neurological problem was noted. At that time, the patient had a negative straight leg raising exam and negative elevated leg test. No impairment in mobility was noted. On the second date of service at issue, the neurosurgeon indicated that upon gait exam, walking is normal. The patient has no difficulty with walking on his toes or heel. Tandem gait is normal. Romberg is negative. The patients back exam showed mildly limited range of motion. No tenderness to palpation. After the initial urgent care visit, a reasonable and prudent person would have sought authorization for follow-up care or returned to the plans service area to seek further evaluation and treatment. The record does not substantiate the patients contention that he was unable to return to the plans service area due to physical incapacity or impaired mobility. The submitted evidence does not demonstrate that a prudent person in this patients situation would reasonably believe that the disputed services, including an MRI, neurosurgical evaluation and multiple physical therapy sessions, were necessary to prevent serious deterioration of his health prior to returning to the plans service area. The patients symptoms on the dates of service at issue did not meet prudent layperson criteria for urgent care. The services the patient received could have been delayed until the patient returned to the plans service area and the evidence does not demonstrate that the patients condition precluded him from returning to the service area.