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

A 43-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that currently there is evolving evidence of the utility of breast cancer screening using MRI in certain subgroups of patients. The consensus is that MRI has a role in screening patients with a calculated lifetime risk of developing breast cancer of greater than 20-25%. While this particular patient does have a first degree relative with breast cancer, the practice guidelines indicate that a strong family history usually refers to at least 2 first degree relatives or a known BRCA1 or BRCA2 genetic mutation. Although this patients dense breast tissue may limit findings on mammography, she is not known to have at least 2 first degree relatives with breast cancer or a documented BRCA genetic mutation. As such, there is inadequate evidence establishing the medical necessity of the MRI screening performed for this patients evaluation.
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 autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this young patient with ASD and history of expressive and receptive language delays with socialization deficits. In the 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 authors reported that the only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, the patients with significant speech and language intervention improved in their language development. Similarly, Goldstein reviewed communication intervention for autism in the peer-reviewed research articles published over the past 20 years and found that effective interventions exist to teach communication skills to children with autism. The author concluded that language skills make a significant difference in the ability of children to control their environment. Further, Volmar and Weisner stated that language deficits are one of the core aspects of autism for which speech therapy provides professional guidance with communication development. For these reasons, this patient will benefit from speech therapy as part of a dedicated intervention program as it is medically necessary and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested 5 Supartz injections for treatment of her suspected meniscal tear in the left knee.  Findings:  The physician reviewer found that viscosupplementation for the treatment of osteoarthritis of the knee is an accepted procedure in mild to moderate cases (Brzusek and Petron). To date, no superiority has been shown among the various products (Dagenais). Viscosupplementation is not considered a treatment for a torn meniscus, although it is being studied as a potential technique for reducing pain after meniscectomy in current clinical trials. In the case of this patient, the diagnosis of symptomatic osteoarthritis of the knee is not documented; the provider only commented that the degenerative process was starting at the time Supartz was initiated. In addition, there is no documentation of any other treatment for osteoarthritis, such as anti-inflammatory medications, having been attempted. Further, there is no documentation of the use of the Plans preferred medications prior to the use of Supartz. For these reasons, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 8-year-old male enrollee has requested a cardiology consultation featuring ECG/EKG monitoring while the enrollee is on ADHD medication for evaluation and treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this case involves a patient with no known heart disease or arrhythmia, being treated with Concerta and Intuniv. He has not had any reported cardiac symptoms. His parents are requesting cardiac evaluation and ECG/EKGs while the patient is on these medications. A review of the current literature regarding the use and monitoring of children taking stimulant medications reveals no peer reviewed studies which support this practice. Studies have shown a lack of cardiac side effects associated with these medications and no evidence of any important ECG/EKG changes. It is generally recommended that monitoring of pulse rate and blood pressure be performed periodically with stimulant use. The 2008 recommendation published by the American Heart Association (AHA) for the use of an ECG/EKG prior to starting stimulant therapy is not supported by peer reviewed scientific data. Further, the AHA did not recommend ECG/EKGs for patients while on stimulant medication in the absence of symptoms, arrhythmias or structural heart disease; only blood pressure and heart rate measurements were recommended.All told, cardiology consultation featuring ECG/EKG monitoring is not medically warranted for this patient in the absence of any cardiac symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the notes indicate that anxiety was a significant complicating factor in treatment. The patient was on several different antidepressants. Additionally, he underwent two electroconvulsive treatments in the past, but reportedly was unable to tolerate this treatment. Details of past treatments in terms of compliance, length, dose, side effects and response are not noted in the record. Details of the electroconvulsive therapy treatments in terms of electrode placement, dosing, side effects and adjunctive medications administered were not provided. Details regarding past trials are lacking. His condition has been complicated by comorbid anxiety which evidently did not improve significantly. There is a lack of data available regarding the efficacy of transcranial magnetic stimulation in patients with comorbid anxiety disorders. Additionally, the patient did not have an adequate course of electroconvulsive therapy, which is recognized by the American Psychiatric Association as the most effective treatment for depression. The record fails to establish whether mitigating variables such as comorbid substance abuse and/or Axis II disorders and psychosocial stressors have been investigated and addressed.  Thus, transcranial magnetic stimulation provided during the said timeframe was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested 12 additional physical therapy sessions for treatment of her status post partial right knee replacement.  Findings:  The physician reviewer found that the patient had not achieved functional flexion in her right knee and required the skills of a therapist to continue manual treatment. Following a knee replacement, one of the most important elements of physical therapy is to achieve good flexion. This is necessary for normal ambulation, sitting and climbing. This patient progressed with her active flexion, albeit slowly, but needed continued skilled PT to maximize flexion. Medicare guidelines consider PT necessary for treatment of a malfunctioning body part when progress is expected in a reasonable period. A systematic review published in 2007 concluded that there was a small but significant difference in range of motion with PT after knee arthroplasty. Standards of practice generally include providing skilled PT following knee replacement until the patient achieves maximal range of motion. This patient had not reached a plateau and would not have been able to achieve continued improvement without additional skilled PT. Thus, the disputed PT services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-month-old female enrollee has requested physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency. As a result, the prevention of secondary disability is important. The central hypotonia slows the acquisition of gross motor skills.  Ligamentous laxity with hypotonia complicates the ability to acquire appropriate gross motor skills. Physical therapy is needed for continued improvement in gross-motor skills acquisition. The long-term benefit of physical therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. This can lead to orthopedic and functional problems if not corrected. Physical therapy is medically necessary for individuals with gross motor delays greater than 25%. This patient had minimal gross motor delays during her most recent physical therapy evaluation. As such, she is likely to continue to benefit from early intervention services. However, a physical therapy evaluation is recommended in 4 months to evaluate the need for PT services through the Health Plan if gross motor delays are greater than 25%.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that in this case, the submitted clinical information fails to establish that transcranial magnetic stimulation is likely to be superior over other available treatment options. The details of past antidepressant trials in terms of dose, length, degree of compliance, side effects, and response are not noted in the material supplied. Furthermore, there is insufficient data to ascertain that variables which could have adversely affected her prognosis, such as comorbid Axis II conditions, substance abuse and/or psychosocial stressors, have been investigated and addressed. American Psychiatric Association guidelines indicate that electroconvulsive therapy is the most effective treatment for depression. Eranti and colleagues noted the superiority of electroconvulsive therapy over transcranial magnetic stimulation.  Martin and colleagues indicated that there is insufficient evidence regarding the efficacy of transcranial magnetic stimulation to warrant its use in standard practice.  Based upon the current medical evidence, in this clinical scenario, the superior efficacy of transcranial magnetic stimulation has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a knee Dynasplint system for treatment of his knee contracture.  Findings:  Two physician reviewers found that there are some published case reports and case series related to the use of low-load prolonged-duration dynamic orthoses, such as the Dynasplint, for various joints.  However, there is a lack of high-grade data in the published, peer-reviewed, medical literature supporting the efficacy of the Dynasplint for chronic knee contractures.  Steffen and Mollinger showed no improvement in knee contractures treated with low-load prolonged stretch in a series of 28 subjects with chronic bilateral knee contractures (lacking at least 10 degrees from full extension), using one affected knee in each subject as the untreated control.  There is a lack of published high-grade data establishing that the requested knee Dynasplint system is more effective than a rigorous stretching and exercise program combined with appropriate analgesics and palliative modalities.  There is a lack of published high-grade data establishing that it is an effective adjunct to a basic exercise and modality program. It would not be anticipated to significantly impact the need for any potential future surgeries.  Overall, the requested equipment has not been proven to be effective for this patients condition.  While the patient does not have full range of motion at the left knee, it is not anticipated that the requested equipment would provide marginally significant improvements in outcomes compared to his present program. Thus, the requested knee Dynasplint system is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested bio-identical hormone pellet therapy with re-dosing every 3 to 4 months for treatment of her status post hysterectomy.  Findings:  Three physician reviewers found that there is no evidence that compounded bio-identical hormones are safer or more efficacious than standard FDA-approved and tested options. In fact, because of issues related to compounding, dosing is frequently inconsistent.  This may actually increase the risk of such treatments. While the patients provider indicates that the patients recent hysterectomy was the trigger of her menopausal symptoms, she is in her mid-60s and it is likely that she became menopausal before her surgery. There are numerous FDA-approved hormone therapies available for menopausal symptoms, with oral and non-oral route options. Available FDA-approved therapies include bioequivalent estradiol, molecularly identical to human hormones that do not require compounding, and the dosage and pharmacokinetics are well established. There is no evidence from the records provided that these alternate treatments have been tried and failed. At the present time, compounded bio-identical hormone replacement therapy is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy, and may in fact pose additional risks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollees mild to moderate delay in expressive language skills. 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. 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. While there is some controversy regarding the role that recurrent otitis media has on language development, the literature acknowledges the presence of speech and language delay in this population. This patient has a history of frequent otitis media with resultant conductive hearing loss, attention deficit/hyperactivity disorder, and articulation deficits. These challenges are negatively impacting his ability to communicate effectively with peers and adults.  All told, speech therapy was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech therapy services at a frequency of two sessions per week for 30 minutes per session for treatment of his autistic disorder and speech delay.  Findings:  The physician reviewer found that this patient carries dual diagnoses of autism and a developmental delay. In addition, initial studies also suggest the possibility of hyperactivity. His prognosis for normal development, social skills, and language is limited without significant intervention. There is robust medical literature advocating speech therapy for autistic children. The above cited evidence demonstrates that speech therapy is a medically necessary intervention for patients with autism. In this case, the requested speech therapy sessions for 30 minutes twice a week are medically indicated and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested a reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) guidelines argues that a minimal weight should not be required and that reduction mammoplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients when two of the following criteria are met: chronic breast pain caused by weight of the breasts, intertrigo unresponsive to medical management, upper back, neck and shoulder pain, unspecified backache, acquired thoracic kyphosis, shoulder grooving from bra straps, headache, congenital breast deformity and upper extremity paresthesia caused by brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area. This patient is documented by the plastic surgeon to have macromastia with significant breast pain, back pain, neck pain and shoulder pain.  The patient has attempted treatment with non-operative measures without success. As documented by Freire, et al., neck, shoulder, and lower back pain and reduction of functional capacity can be caused by breast hypertrophy and successfully treated with breast reduction. Thus, based on the recommendations of the ASPS, this patient would satisfy medically necessary criteria. With respect to the amount of tissue resected, the ASPS has stated that there is Level II evidence that indicates that resection volume is not correlated to the degree of postoperative symptom relief and thus a minimum amount is not required.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female has requested speech therapy for treatment of her autism.  Findings:  The physician reviewer found that in addition to being in the 3rd percentile for both receptive and comprehensive language, this patient carries multiple additional diagnoses including autism/pervasive developmental disorder and attention deficit/hyperactivity syndrome. Intellectually, however, based on the Woodcock-Johnson III test the patient is probably of normal or near-normal intellect.  Despite her normal capacity to learn, she remains in the 3rd percentile for language. This implies that she has not benefitted from the school-based group language instruction she has been receiving since the age of three. This may be related to her inattention and hyperactivity, which becomes most dysfunctional in a large group compared with an individual setting. The current group sessions have been inadequate for her to progress and develop language. The patient requires more intensive and individual speech therapy to develop any significant gains in language acquisition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested psychotherapy treatments at a frequency of one time per week (rather than the authorized one time per month) and continued weekly psychotherapy for treatment of her major depression, recurrent, moderate, post-traumatic stress disorder from childhood and history of anorexia nervosa in adolescence, currently in remission.  Findings:  The physician reviewer found that there is no evidence of acute decompensation warranting inpatient treatments. Additionally, there is no evidence of acute/continuation/maintenance strategies previously employed other than psychotherapy. In this patients case, the treatment goals identified include prevention of increase in anger and depressive feelings and providing emotional support in the context of this patient being isolated. These goals do not warrant the frequency and duration of the psychotherapy sessions requested. The treatment plan does not reflect any current or planned coordination with available community or peer support services. Ongoing weekly psychotherapy sessions are not likely to support progress towards recovery. The medical literature supports the efficacy of psychotherapy in the treatment of major depressive disorder. However, the patient can be effectively treated with psychotherapy treatments at a frequency of one time per month. As noted in the study by Frank and colleagues, monthly psychotherapy sessions were sufficient to prevent depression relapse/recurrence. All told, psychotherapy treatments provided from the said date onward at a frequency of one time per week (rather than the authorized one time per month) and continued weekly psychotherapy treatments were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld 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 approximately 25% with normal receptive language abilities, per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children. There is no noted delay in play skills or pragmatics.  Speech therapy is indicated with any delay greater than 25%. An extensive review of the literature, including a meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. However, approximately 50% of children delayed at 2 years catch up to their 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. Receptive delays that are greater than expressive delays are more concerning. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who did not receive early intervention. This patient is currently involved in early intervention services and speech therapy is not medically necessary at this time. A repeat speech and language evaluation is recommended at 30 months of age to monitor progress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for a referral to a dermatologist for evaluation of his scalp lesions.   Findings:  The physician reviewer found that per the Milliman Care Guidelines, treatment of actinic keratoses, lesions that are large or in high risk areas, including the head, should be referred to a dermatologist. Specifically, Brantsch and colleagues noted that there are squamous cell carcinomas that exhibit risk factors for metastasis based upon growth pattern, location on the skin, and tumor depth. Because of this, lesions that are suspicious for squamous cell carcinoma should be treated by a dermatologist who is trained in the treatment of all cutaneous malignancies. As such, the requested referral to a dermatologist for further care of this patients scalp lesion has been demonstrated to be medically necessary and should therefore be approved.