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

A 55-year-old female enrollee has requested radiofrequency neurolysis procedure for treatment of her sacroiliac joint dysfunction.   Findings:  Two physician reviewers found that in the peer reviewed medical literature, Ferrante and colleagues reported on the results of radiofrequency denervations performed in 33 patients with SI joint syndrome. The results of the study suggested that radiofrequency denervation of the SI joint can significantly reduce pain in selected patients with SI syndrome for a protracted period. In addition, Yin and colleagues performed a retrospective audit to determine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant SI joint pain. The researchers concluded that a sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic SI joint complex pain. Moreover, Cohen and Abdi conducted a study to determine the efficacy of reducing SI joint pain by percutaneous radiofrequency lesioning of the nerves innervating the SI joint. The authors concluded that in patients with SI joint pain who respond to L4-5 dorsal rami and S1-3 lateral branch blocks, radiofrequency denervation of these nerves appears to be an effective treatment. For these reasons, the requested radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee has requested an automatic external cardioverter defibrillator for evaluation of his ventricular tachycardia.  Findings:  The physician reviewer found that based on review of the available records, the patient has documented exertional ventricular tachycardia in addition to inducible sustained ventricular tachycardia on electrophysiology study that required cardioversion for termination. This diagnosis is a Class I indication for an implantable cardioverter defibrillator. However, the patient wanted to delay the implant until he sought a second opinion and other possible treatment options. In the medical literature, it is clinically reasonable and appropriate in this high-risk situation to have the patient wear an external defibrillator. The standard criteria for an external wearable defibrillator were also met since the patient also met the requirements for an implantable defibrillator. In this case, the wearable external defibrillator was intended as a bridge to an implantable defibrillator only during a period of delay while the patient pursued a second opinion and other treatment options. For these reasons, the medical necessity of the LifeVest used by this patient during this timeframe has been established as medically necessary and should be reimbursed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for one hour per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, 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. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her 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 condition. Thus, speech therapy is the standard of care modalities for patients with speech delay. Given this patients deficits, it is medically necessary for this patient to receive the requested speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested an Elite Seat flexion device for treatment of his cruciate ligament reconstruction.  Findings:  The physician reviewer found that the most common complication of anterior cruciate ligament reconstruction is loss of extension, which can be functionally worse for patients than their preoperative instability.  Preventable surgical etiologic factors have been identified and have been advocated.  Early range of motion and avoiding flexion are important postoperative considerations.  However, stretching the knee into full extension can be achieved via exercises and bracing, if needed, without medical devices.  There is a lack of high-grade medical literature of a disinterested nature supporting the efficacy of the proposed device.  Its marginal efficacy in comparison or in conjunction to an active stretch program for the knee has not been demonstrated in a conclusive manner.  The requested device is not part of rehabilitation protocols that are based on the evidence-based literature. Although this patient has had prolonged difficulties with his left knee range of motion, the proposed device would not be expected to significantly improve the patient's health or functional outcomes in comparison to an exercise and bracing program alone or in conjunction with an exercise and bracing program.  All told, the requested Elite Seat flexion device is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested Humira Pen 40mg every 14 days for treatment of his stated conditions of inflammatory spondylopathy and ulcerative colitis.  Findings:  Three physician reviewers found that the provided medical records describe a patient with severe ulcerative colitis and colitic arthropathy, no longer controlled with high-dose Remicade. Remicade is typically only prescribed if the patient has already failed conventional treatments, including prednisone, methotrexate and agents such as Dipentum. It is standard and appropriate practice when faced with loss of benefit from a tumor necrosis factor (TNF) inhibitor, to then switch to a different TNF inhibitor, as this has often proven to be effective. Patients treated with Remicade may develop human anti-chimeric antibodies (HACA) as an immune response to the medication itself, and this may neutralize the benefit of the drug. Switching to fully humanized Humira can then prove to be effective, as it is much less prone to immunogenic responses by the patient, and would not cross react with the antibodies generated by the Remicade. This is a phenomenon which has been seen repeatedly in clinical practice, and which is supported by the above cited peer reviewed medical literature references, which describe a beneficial response to Humira when used to treat patients who have failed Remicade previously. Therefore, the requested Humira treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
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 patient has an identified delay in expressive speech of greater than 50% per the DAYC subtest with severe difficulties with intelligibility and articulation. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. 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 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment. Based on the foregoing discussion, the requested speech therapy has been shown to be a medically necessary intervention in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy services for evaluation and treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  These authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has expressive speech and language delay that adversely impacts his ability to communicate with those around him.  If not addressed, his communication delays may adversely affect interactions with peers and caregivers.  Studies have shown that speech and language therapy can result in significant improvement in children such as this patient.  All told, the requested speech therapy services (evaluation and treatment) are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested inpatient hospitalization for treatment of his bipolar II disorder.  Findings:  The physician reviewer found that the progress notes reflect a subjective report of depression in the absence of acute psychotic features, and the absence of acute suicidal ideation with plan.  The patient was reportedly compliant with medication and treatment and was able to take care of his personal needs.  In general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective. The acute course of electroconvulsive therapy typically consists of six to 12 treatments, and generally does not exceed 20 treatments.  Electroconvulsive therapy is increasingly being provided in an outpatient setting.  This patients progress notes do not show evidence of psychiatric or medical acuity requiring inpatient hospitalization during the dates of service at issue.  Continued electroconvulsive therapy could have been provided in an outpatient setting.  The documentation does not indicate that the patient would have deteriorated in functioning if transitioned to a lower level of care as of the said date.  All told, the medical necessity of inpatient hospitalization at Sutter Center for Psychiatry provided during the said timeframe has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested for readmission to acute inpatient rehabilitation at or continued skilled nursing level of care, occupational, physical, and/or speech therapy for treatment of the enrollees medical condition status post acute ischemic stroke.  Findings:  The physician reviewer found that there is strong evidence that early stroke intervention improves outcomes beyond early intervention, particularly acute hospital-based services in the immediate few days following a stroke, the outcomes do not differ between acute, subacute or home-based services. Since the rate of recovery is dependent upon neurological recovery, more time is needed for severe injuries. However, as there is no benefit to be gained with a transfer to an acute rehabilitation hospital at this stage in her recovery process, the requested services have not been shown to be medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has residential treatment services for treatment of the enrollees anorexia nervosa, restricting type. Findings:  The physician reviewer found that the submitted evidence demonstrates that this 12-year-old patient has a history of anorexia nervosa restrictive type. She was found to be below her 85% ideal body weight.  This patient's BMI increased yet her percentage of ideal body weight remains below 85. She continues to have difficulty with restriction of her food intake and shows manipulation of her eating process. The patient continues to make progress but has not shown a clear ability to function without consequences outside of the residential treatment facility. Thus, the request for continued residential treatment is reasonable and medically necessary, as the patient continues to show severe restrictive behaviors and manipulating behaviors that require the intensity of 24-hour supervised care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has been diagnosed with anorexia nervosa, MDD, panic disorder with agoraphobia and alcohol abuse in remission was admitted to the residential treatment facility for treatment of her eating disorder. Upon admission, this patients vital signs were normal and her weight showed her BMI to be 17.5. This patients physical examination was also normal. She was not showing any signs of physical compromise and did not reportedly demonstrate any psychiatric symptoms other than the eating disorder and occasional anxiety related to discharge. Applying the American Psychiatric Association (APA) treatment guidelines for patients with eating disorders this patient does not require 24-hour medical and nursing supervision for her condition as provided at the residential treatment facility level of care and is a candidate for treatment at a lower level of care such as an outpatient program. All told, this patient does not meet the medical necessity criteria for admission and treatment in a residential treatment facility for mental health issues including her eating disorder as of the said date and forward.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for rituximab injection. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Sjogrens syndrome.  Findings:  Two physician reviewers found that the patient has symptoms consistent with Sjogrens syndrome.  A biopsy confirmed Sjogrens syndrome and a small fiber neuropathy.  The patient has been diagnosed with fibromyalgia associated with Vitamin D deficiency and hyperparathyroidism.  Per the submitted documentation, she has been treated with prednisone, hydroxychloroquine and methotrexate, without a therapeutic response.  The provider reported that the patients treatment has included Cymbalta and other antidepressants, although further details were not provided.  The patient continues to be symptomatic.  She has requested authorization and coverage for rituximab injection.  The Health Plan has denied this request and reported that the requested medication is investigational for the treatment of this patient.  The patient has appealed this denial.  In this case, the requested rituximab injection is likely to be more efficacious than other available treatment options. She has failed steroids, methotrexate and hydroxychloroquine.  The current medical evidence supports the requested rituximab injection in this patients case. Ramos-Casals and colleagues published a systematic review and reported that several small trials with rituximab have had some success.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested outpatient psychotherapy visits 4 times per week for treatment of her major depressive disorder with history of suicide attempt.  Findings:  The physician reviewer found that based on review of the available records, this patient has a history of major depression recurrent, and schizoid personality disorder and has been in therapy 4 hours per week since this year. The documentation presented by the provider showed a patient with chronic suicidality with intense feelings of hopelessness. This patient has apathy and listlessness with a strong family history of depression. The patient appears to be socially isolated and appeared to improve with therapy at times but then would slip back into the pattern of hopelessness and strong depressive symptoms. The records suggest that this patient has shown some response to psychotherapy on an outpatient basis utilizing dialectical behavioral therapy (DBT) and cognitive behavioral therapy (CBT). The medical literature supports the efficacy of DBT and a CBT for the treatment of this patients depression. Although the benefits of long-term outpatient therapy remain varied, this patient has been safely and adequately treated on an outpatient basis. As such, individual psychotherapy appears to be medically necessary at the frequency of 4 times per week since the date in question and forward for management of this patients depression and personality disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees expressive language delays. 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 authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, children with speech and language difficulties which persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  This patient is a bilingual child with significant delays in receptive and expressive speech/language skills that negatively impact his ability to express his needs and interact with peers and adults. Objective testing initially demonstrated language comprehension at the nine-month to 12-month level and language expression at the six-month to nine-month level. The literature supports therapeutic intervention for children such as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested individual occupational therapy services for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the current medical evidence supports the requested individual occupational therapy services in this patients case.  This patient has global delays in fine motor skills, adaptive skills and language as a result of Down syndrome.  On the said date, evaluation revealed fine motor skills at the six-month level. Children with Down syndrome often demonstrate difficulties in the areas of strength, balance and visual motor skill control.  These children often have delays in overall gross motor and fine motor skills. With its focus on teaching motor planning skills and facilitating the development of fine and gross motor skills, occupational therapy is well-suited to benefit this patient. All told, the requested individual occupational therapy services are medically indicated in this patients case.