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

A 46-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) beginning on a specific date and forward.   Findings:  Two physician reviewers found that the patient has a history of two-year duration of severe depression. He has received prescription medication therapy with antidepressants and cognitive therapies. He has reportedly been tried on both selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) agents, along with a trial of Bupropion with reported limited effectiveness. There is no documentation of augmentation strategies or electroconvulsive therapy (ECT) or other treatment approaches made for this patients depressive disorder. The patient has requested retrospective and future coverage for repetitive transcranial magnetic stimulation (TMS) therapy. Repetitive TMS was first introduced in 1985 as a novel method of non-invasive stimulation of the brain. The peer-reviewed medical literature evaluating antidepressant treatment consists of varying reports on the long-term efficacy and potential side effects of repetitive TMS. Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results suggest repetitive TMS has significant antidepressant effects, larger multicenter studies are still necessary to confirm these findings. Lam and colleagues concluded that for patients with treatment resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the relative lack of systematic follow-up studies suggest that further data are needed before repetitive TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Gershon and colleagues also report positive responses of repetitive TMS as an antidepressant treatment, but note continued need for verification and standardization of best practices and type of patient that would benefit. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Technical parameters possibly affecting treatment success include intensity and duration of treatment, but their summary suggestion promotes ongoing systematic testing of this treatment modality. Consistent with these findings, the therapy at issue was not and is not likely to be more beneficial than any available alternative for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested a continuous passive motion machine for treatment of his arthrofibrosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  The efficacy of a continuous passive motion machine following knee surgery has not been demonstrated in this clinical setting.  There is a paucity of evidence supporting the use of the equipment at issue in this patients case.  No significant difference between the range of motion in patients undergoing anterior cruciate ligament reconstruction with or without continuous passive motion has been demonstrated, and no advantage was found with or without its use.  The current medical evidence does not support the use of the continuous passive motion machine in this clinical situation.  All told, the continuous passive motion machine provided was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy once per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this young patient has an identified delay in receptive speech and expressive speech of 55%. Speech therapy is indicated for patients who present with any delay greater than 25%. 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. 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 two years catch up to peers by three years of age, while children with mild to moderate disorders are most likely to resolve their delay. Moreover, the authors found that young patients treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. All told, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported 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. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. For these reasons, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested reimbursement for the AlloMap molecular expression tests performed on three occassions for evaluation of the enrollee, who is status post two heart transplants. Findings:  Two physician reviewers found that the patient has a history of two prior heart transplants.  These transplants were performed approximately two decades apart.  The patient has been followed by her providers for possible signs of rejection.  She has requested reimbursement for AlloMap molecular expression tests performed on three separate dates.  AlloMap testing is intended to aid in the identification of rejection in stable heart transplant patients.  In order to monitor the heart muscle for cellular rejection, right ventricular biopsies are typically obtained at a decreasing frequency of intervals after transplantation.  These biopsies carry a risk of complications, including vascular complications and damage to the heart.  Per the International Society of Heart and Lung Transplantation guidelines, AlloMap testing can be used to rule out the presence of acute cellular rejection in appropriate low-risk patients between six months and five years following heart transplantation.   However, the U.S. Food and Drug Administration noted that the testing at issue may be indicated for patients who at least 55 days post heart transplantation.  Thus, some heart transplant centers use AlloMap molecular expression testing routinely beginning at 55 days post transplantation, and the use of AlloMap molecular expression testing during this time frame is medically acceptable.  In this patients case, AlloMap molecular expression testing performed on the second and third dates were likely to be of greater benefit than other tools for evaluating this patient, as these tests occurred greater than 55 days, and less than five years, post heart transplantation.  AlloMap molecular expression testing performed on the first date in question was not likely to be more effective than other methods of evaluating this patient, as this occurred more than 20 years following the initial heart transplantation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested authorization and coverage for partial hospitalization program level of care with evidence-based treatments for post-traumatic stress disorder and depression.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  The patient requires intensive evidence-based psychotherapy for her major depressive disorder and post-traumatic stress disorder.  Due to this patients co-occurring depression and post-traumatic stress disorder, the literature suggests that this patient is at high-risk for suicide.  Her condition has been treatment-resistant, and she has failed the outpatient treatment setting.  The patient has required treatment in the inpatient setting twice in the past two months.  Although the inpatient setting can help negotiate pressing crises, it cannot approach resolution of the underlying intrapsychic conflicts that fuel a symptom complex, such as in this patients case.  Per the American Psychiatric Association guidelines, the determination of the appropriate level of care should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.  The peer-reviewed literature supports the requested services in this patients case.  All told, the requested partial hospitalization program level of care with evidence-based treatments for post-traumatic stress disorder and depression is medically indicating for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested reimbursement for intradermal skin testing using intradermal dilutional testing (IDT) provided for evaluation of the enrollees allergies.  Findings:  Three physician reviewers found that the patient is a has a long history of nasal symptoms. She was evaluated with skin testing. The patient had positive reactions to many inhalants on prick testing. She also had endpoint titration identification testing done. The patient has requested reimbursement for the intradermal skin testing using intradermal dilutional testing (IDT), performed at two different times. Although endpoint titration intradermal skin testing is performed by many providers, it has not been shown to be more accurate or safer than traditional intradermal testing in the peer-reviewed medical literature. Although intradermal skin testing is considered within the standard of care, endpoint titration has not been shown to be more effective or safer than traditional intradermal testing in this clinical setting. All told, the diagnostic testing at issue was not likely to be more beneficial than standard approaches for evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female has requested hormone replacement therapy medication Vivelle-Dot for treatment of her menopausal symptoms.  Findings:  The physician reviewer found that hormone replacement therapy (HRT) is an effective treatment for menopausal symptoms, especially hot flashes and its associated symptoms such as fatigue, and sleeplessness.  In addition, HRT can be helpful for emotional instability.   When a woman has not had a hysterectomy, if estrogen is prescribed, a progesterone product also needs to be taken to prevent the development of uterine cancer, which can occur if unopposed estrogen is prescribed.  There is no information in the record to indicate that the patient has had a prior hysterectomy, and if she has not, then prescribing estrogen alone is contraindicated.Though there can be increased risks of cardiovascular complications and other risks with hormone therapy, those risks are relatively low in the younger perimenopausal and postmenopausal woman. There are also indications that transdermal therapy (i.e. patches) as opposed to oral therapy may reduce some of the clotting risks due to avoiding passage through the liver as occurs with oral intake.  However, there is no evidence that any particular transdermal route or patch is safer or superior to any other.Thus, this patient may be a candidate for hormone therapy. However, this would need to be decided after discussion of the risks and benefits of such therapy with her Ob/Gyn.  The appropriate route, dosing, and the need for progesterone therapy with the estrogen would be part of this discussion.  If it were decided that a patch was appropriate for the estrogen portion of her therapy, then the Plans formulary patch Climara would be appropriate, as Vivelle Dot has not been proven to be more efficacious in the peer-reviewed medical literature.  Climara and Vivelle Dot both deliver the same hormone estradiol, and are available in similar dose levels.  There is no medically necessary reason for her to use Vivelle Dot rather than Climara if a patch is chosen. However, this patient has not been evaluated by a Plan Ob/Gyn provider. All told, the requested Vivelle Dot medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male has requested coverage for past bovine insulin and future coverage for porcine and bovine insulin for treatment of his type 1 diabetes.   Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the medication at issue at this time.  Additional details regarding the patients prior medical history are required in order to establish the medical necessity of porcine and bovine insulin.  The submitted medical records do not describe why the patient was unable to tolerate synthetic insulin and do not indicate details regarding prior regimens of synthetic insulin.  Patients who switch from animal insulin to synthetic or human insulin typically require additional insulin injections.  However, they are generally able to regulate their blood sugars with the newer insulin.  Of note, this usually takes time, as the duration of action of the synthetic insulin is different, given the immunogenic properties of the animal insulin.  In some cases, patients have rare insulin allergies.  However, the documentation does not indicate that this patient has an insulin allergy.  In order to demonstrate the medical necessity of the requested porcine and bovine insulin, medical records evidencing suboptimal results despite adequate dosing, blood glucose monitoring, and medical follow-up are needed.  Absent this information, the medical necessity of the medication at issue cannot be established at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested sensory integration occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that the patient is significantly impaired, as he is diagnosed with autism, cognitive delays, has limited vision, epilepsy, and cerebral palsy.  When he was assessed by the Plans occupational therapist, he was noted to be difficult to test as he had trouble modulating his responses and overreacted to external stimuli. Sensory integration occupational therapy is a therapeutic approach to modify such over-reactive phenomena. It would be the customary medical practice of community-based child neurologists to refer this developmentally delayed patient for sensory integration occupational therapy. Occupational therapy involving sensory integration techniques (OT) attempts to improve the patients abilities to adapt and function in activities of daily living. Given this patients degree of sensory processing and motor impairment he has a medical necessity for OT services. Schaaf and Miller performed a study and conclude that sensory integration techniques enabled occupational therapists to assist the developmentally delayed child in developing the ability to integrate into normal motor and personal-social patterns and to function with his peers. In a well controlled study by Miller, et al., the authors reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children.  Further, Roberts and colleagues describe improvement of behavior patterns in children who have been treated with OT utilizing sensory integration techniques. Based on the documentation provided for review and the data available in the peer reviewed medical literature, it is medically necessary that this patient receive the requested sensory integration occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female has requested a computed tomography (CT) scan of the chest/spine and CT of the lumbar spine for evaluation of her low back pain.  Findings:  The physician reviewer found that based on review of the available records, the patient has low back pain without any noted prior history of trauma or malignancy. The patients blood count is normal without signs of infection. There is no documented neurological deficit. The patient has not reportedly been treated with physical therapy. Due to a lack of concerning signs or symptoms such as radiculopathy, weakness, or abnormal neurological findings, and the lack of attempt at physical therapy, the requested CT scan is not medically necessary to evaluate this patients non-specific low back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 35-month-old male enrollee has requested authorization and coverage for individual speech therapy at a frequency of 2 sessions per week for 30 minutes per session for treatment of the enrollees expressive language disorder and childhood apraxia of speech. Findings:  The physician reviewer found that the patient has a history of an expressive speech delay of greater than 40%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Childhood apraxia of speech is a condition where children have difficulty with the controlled production of speech sound and it is presumed to be neurologic in origin (Feldman and Messick). Intensive treatment levels are needed to help children with this speech disorder learn to produce sounds in syllables of increasing complexity (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 23-year-old male has requested coverage for emergency services provided.  Findings:  The physician reviewer found that the patient sustained a flexor tendon laceration to his small finger. The patient presented to the emergency room and was informed that he would require surgery in order to restore function to the finger. He underwent a surgical consultation three days later. The patient reports that this surgeon informed him he should undergo repair of his damaged tendon within three to five days of the date of injury to prevent permanent dysfunction. The surgeon reports that he and the patient discussed the necessity for surgical repair in a timely fashion, ideally within 3-5 days for best results. The surgeon performed a left small finger flexor digitorum profundus tendon repair the next day. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Due to the severity and nature of the patients injury he was advised by his surgeon that he should proceed with tendon repair as soon as possible to avoid any complications and in order to restore function to his finger. A review of the literature indicates that routine tendon repairs are preferably done no later than 7 days after injury to fully restore function and that after 6 weeks primary repair and restoration of function is unlikely to be possible at all (Green, et al.). Although this patient had up to 7 days to establish care and find an in-network provider, he was advised by his treating provider that repair of his damaged tendon was required within a 3 to 5 day time frame to fully restore function to his finger and the provider recommended emergent surgical intervention. Under these circumstances, a prudent layperson would have thought his symptoms were severe enough that the absence of immediate medical attention would result in serious dysfunction of his hand. Therefore, a prudent layperson would have reasonably believed that the services provided were required on an emergent basis and would have sought immediate medical attention.