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

A 36-year-old male enrollee has requested a power seat lift, articulating leg rests, power reclining seat, and related accessories for treatment of his Beckers progressive muscular dystrophy. Findings:  The physician reviewer found that in the medical literature, Emery discusses Beckers muscular dystrophy as a genetic disorder characterized by a slowly progressive generalized weakness. The author further notes that some patients may experience a very mild disease course and maintain ambulation for prolonged periods of time, if not indefinitely, while other patients may have a more severe disease progression. In patients with more severe disease progression, a power wheelchair is required for mobility. In addition, activities should be encouraged and stretching may be needed to prevent contractures. In the present case, the patient has insufficient body strength to perform an independent lateral transfer. A power elevating seat would provide significant benefit for this patient by facilitating these independent transfers. The power seat is beneficial from the standpoint of reducing dependency and for the purpose of exercise. Similarly, the power reclining function and power articulating leg rests are appropriate for allowing the patient to stretch, reduce contractures, and to minimize edema and pain. For these reasons, the requested wheelchair features are medically necessary for this patient and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment for the enrollees attention deficit hyperactivity disorder, anxiety disorder, not otherwise specified, and pervasive developmental disorder, not otherwise specified.  Findings:  The physician reviewer found that in this patients case, residential treatment was not indicated according to current evidence-based practice standards and expert consensus. The study by Wilmshurt involved random assignment of patients into two groups, one of which was treated in the community and the other of which received residential treatment. The residential group had worse outcomes on the whole than the group who remained in the community. In this particular case, the patient was described as cooperative throughout his stay. The incident in question occurred several weeks prior to his admission, and there was no further indication of risk to self or others. Per the submitted documentation, there is a lack of evidence of acute deterioration from his baseline or reasonable expectation that his condition would improve with this level of care.  Additionally, there is a lack of evidence that he failed an alternative level of care, and there is no indication of temporary social stressors which would potentially be improved with residential treatment. The data reviewed in sum fail to establish the medical necessity for residential treatment.  All told, during the dates of service  residential treatment was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested coverage for residential treatment center (RTC) services for treatment of the enrollees mood disorder not otherwise specified (NOS), bipolar disorder mixed, cannabis abuse and attention deficit hyperactivity disorder (ADHD)-inattentive type.  Findings:  The physician reviewer found that the initial criteria are still met and likelihood of benefit and return to outpatient (OP) treatment is shown by adherence to the treatment plan. The treatment notes indicate that the patient is still struggling with his mood disorder and that the family conflicts are still present, but in active treatment. Additionally, the patient is still struggling with substance abuse issues that continue to require him to avoid being around his previous peers and social environments. Further, there is more than ample documentation from the patients treatment providers who have a long history with this patient. Each of these providers explains that this patient has a persistent pattern of sudden improvement with quick relapse, time and time again. They have indicated that they are unable to provide appropriate treatment for him and all agree that he needs long-term care in a residential facility where he can stabilize and improve over an extended period of time.  In sum, the patient is likely to quickly relapse if discharged to a lower level of care at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested residential treatment his polysubstance dependence.  Findings:  The physician reviewer found that residential treatment was not medically necessary during the said timeframe according to current standards of evidence-based practice and expert consensus. The patient did not show any behavioral issues which required 24-hour supervision.  There were no withdrawal symptoms or serious medical complications requiring residential treatment.  His last use of medication was 10 days prior to admission.  The admitting assessment describes the patient as being very motivated, and the clinical records indicate that he was attentive and participated actively in the program. Given the fact that he tried propofol, partial hospitalization program services would have been a clinically appropriate alternative for this patient during the dates of service at issue.   Residential treatment was not indicated according to American Society of Addiction Medicine Patient Placement Criteria or American Psychiatric Association practice guidelines.
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 moderate to severe delays in expressive and receptive language skills. Findings:  The physician reviewer found that 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.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The current medical literature supports therapeutic intervention for children such as this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested physical therapy incorporating eccentric strengthening exercises for treatment of her Achilles tendonitis. Findings:  The physician reviewer found that achilles tendinopathy is essentially a degenerative condition related to overuse.  It can be a difficult condition to treat. At present, treatment recommendations generally revolve around relative rest (e.g., using heel lifts to reduce tendinous excursion), stretching, strengthening exercises, and passive modalities for palliation and improved tolerance for exercise.  Eccentric load training is generally considered to be an appropriate measure for relieving symptoms and improving outcomes.  In this case, the patient has undergone extensive physical therapy, including training in eccentric exercises. She has been receiving passive modalities and been performing basic general and lower limb exercises that she could have been performing independently. There is no proven benefit of prolonged supervised physical therapy consisting of formal modalities, manual therapy and supervised exercises for the patient's condition. The patient should have been performing eccentric loading exercises on her own after a very short course of training with physical therapy.  All told, the requested physical therapy incorporating eccentric strengthening exercises is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder. Findings:  Two physician reviewers found that TMS is not likely to be more beneficial to this patient, based on the current literature and this patients clinical scenario. The most recent note provided from the patients treating psychiatrist indicates that her depressive symptoms improved on a therapeutic trial of an antidepressant. Additionally, she has a comorbid diagnosis of generalized anxiety disorder and there is no evidence to support the use of TMS for this disorder or in depression where this condition is comorbid. The study by Eranti, et al. indicates that electroconvulsive therapy (ECT) is more effective in this setting and the American Psychiatric Associations practice guidelines indicate ECT is the most effective treatment for depression. ECT also has evidence based efficacy in reduction of suicidality. Additionally, the Cochrane review indicates that there is insufficient evidence supporting the efficacy of TMS to warrant its use in standard practice and the current research does not establish its superiority over antidepressant medications, especially in treatment-resistant patients. In sum, the data reviewed fail to demonstrate that TMS is likely to be more beneficial than any treatment alternative and TMS does not appear to be warranted clinically, given the patients response to an antidepressant.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female has requested speech therapy for treatment of the enrollees mild impairment of speech production skills. Findings:  The physician reviewer found that as noted by 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, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  When dealing with trauma, speech therapy facilitates return of functional communication. Without intervention, an optimal outcome may not be achieved.  As noted by Turkistani and Hanno, dentoalveolar traumatic injuries result in fractured, displaced, or lost anterior teeth, and this could have significant negative functional, speech, and psychological effects on children.  This patient has articulation delay as a result of dental trauma and necessary delay in prosthesis placement.  The medical evidence supports speech therapy in this clinical situation.  All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested aquatic physical therapy for treatment of his tendonitis, rotator cuff syndrome, and herniation of lumbar intervertebral disc.  Findings:  The physician reviewer found that swimming and aquatically based exercise can be beneficial for overall health for almost everyone (Becker, et al). Aquatic exercise may be helpful in conditions such as low back pain or joint pains, but the role of formal aquatic therapy is not established (Waller, et al.). Formal aquatic therapy is medically necessary only for patients in specific circumstances such as for patients who require therapy in a partially body weight unloaded environment given significant weight-bearing restrictions or profound neurological weakness. An example of an appropriate rationale for formal aquatic therapy is a patient who requires significant body weight unloading of both lower limbs due to major lower limb surgeries. As such, this patient does not have a condition for which formal aquatic therapy is medically necessary. Specifically, he does not have weight-bearing restrictions or weakness in the limbs to the degree that he cannot participate in land-based therapy or exercise. While participation in some exercise is generally encouraged in the setting of chronic pain conditions and swimming or aquatic exercise are good options, there is no specific circumstance in the present case supporting the need of formal aquatic therapy. Water aerobics, swimming or pool walking can be pursued independently however these therapies are not clinically necessary for the patient to obtain functional improvement. Overall, no marginally significant benefit with respect to the patients health or functional outcomes would be expected with the requested formal aquatic therapy over ongoing independent exercise performed on land or in water. For these reasons, the aquatic therapy at issue is not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested the Elite Traveler Plus scooter for treatment of her foot pain and back pain.  Findings:  The physician reviewer found that the submitted records do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility-related activities of daily living within an appropriate community setting using an optimally configured manual wheelchair.  The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs and thorax to the degree that would preclude manual wheelchair use.  In addition, the patient does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish her mobility-related activities of daily living.  Generalized pains and lack of strength or endurance should be treated with appropriate exercise and training, not with disuse.  The records forwarded for review do not establish that the patient would be confined to a bed or chair without a power mobility device.  In addition, there are no indications that her home is wheelchair accessible.  There is reported to be an entry with 15 steps, but no documented ramp or other accessible entry.  All told, the submitted documentation fails to establish the medical necessity of the requested Elite Traveler Plus scooter.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested surgical excision of pterygium, conjunctival graft and mytomycin C of the left eye for treatment of his pterygium.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the patient has bilateral recurrent pterygia with associated symptoms of pain, irritation, and blurred vision.  There is no evidence in the medical literature that non-surgical treatment is preferred for symptomatic recurrent pterygia.   It is well-established that recurrent pterygia can progress more quickly and aggressively than primary pterygia.  In situations where the visual axis is threatened, there is typically no alternative to surgical management.  In many other situations, the decision to proceed with surgery is based on other factors such as high astigmatism, restriction, atypical appearance, or pain.  All told, in this patients case, the requested surgical excision of pterygium, conjunctival graft and mytomycin C of the left eye are medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested for speech therapy for treatment of the enrollees developmental disorder with speech 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. These 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.  The authors reported that language-delayed children have shown more behavior problems and impaired psychosocial adjustment.  Thus, 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 concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has 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 has demonstrated language comprehension functioning at the 18-month to 24-month level and language expression functioning at the 12-month to 15-month level. The medical literature supports therapeutic intervention for children such as this patient to improve communication skills.
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 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 with delayed acquisition of language skills. Consistent with the recommendations in the clinical literature, the requested speech therapy is medically necessary 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 for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the speech of this patient who is more than two-years-old is below a one-year level. His speech is significantly delayed, both by parental description and formal testing.  The etiology is due to a severe developmental delay in the maturation of speech.  There is no history of any prior developmental evaluations when the patients speech was evaluated.  Regarding medical necessity, it is the medical communitys standard practice to offer speech therapy to a two-year-old whose speech is at a one-year level.  There is a robust medical literature supporting speech therapy in this speech delayed population. Law, et al. reported that children with speech delay can be readily treated.  Speech-delayed children, such as this patient, with normal cognitive skills, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff).  Two-year olds who tested below the 10th percentile, as did this patient, do require and benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).   In sum, speech therapy is medically indicated in this patient, with reassessment at six months. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a MRI of the breast for evaluation of her segmental mastectomy.  Findings:  Three physician reviewers found that this patient has a history of invasive ductal cancer of the left breast which is triple negative. There is a known propensity for this type of tumor to be multifocal in the involved breast and sometimes occurs in the contralateral breast.  The providers caring for this patient have observed several foci of abnormal enhancement in the treated left breast outside of the surgical resection site on an outside MRI. Mammographic and sonographic evaluation of these areas has been negative. Since the abnormalities were only visible on MRI it is reasonable to image the breast to evaluate for any progression using the only modality on which they have been evident. Also, an additional benefit of the MRI was the evaluation of the probably benign lesion which had been noted in the right breast. MRI is the procedure of choice for this patient and is not considered investigational in this clinical scenario. In sum, the MRI in question was likely to be more beneficial for evaluation 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 at a frequency of two sessions per week, for 30 minutes per session for treatment of the enrollees severe expressive language impairment.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25% (Feldman & Messick).  An 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 & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately 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 better improvement than those children who receive no treatment (Feldman & Messick). This patient has a history of severe expressive language delay and should receive appropriate intervention including speech therapy at the requested frequency.