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

The parent of a one-year-old female enrollee has requested Synagis injections for treatment of the enrollees risk of contracting respiratory syncytial virus.   Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in prematurely born infants, up to 12 months of age. The most striking of these complications is a birth weight of less than 2500 grams. Further, Holman and colleagues caution that an infant with a birth weight less than 1500 grams is 25 times more likely to develop complications with the RSV infection than an infant with a birth weight greater than 2500 grams. Despite the fact that this ex-premature female infant does not meet the criteria as set forth in the American Academy of Pediatrics (AAP) guidelines for Synagis administration, she is at risk for severe disease based on her family history of asthma and low birth weight. Further, there are currently no treatments currently available for the RSV infection, thus the only available prophylaxis is Synagis, which is likely to be more beneficial for prevention of this infection than the standard alternative of no vaccination.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a light therapy (ultraviolet B) system for home use for the treatment of her vitiligo and granuloma annulare. Findings: Three physician reviewers found that based upon the submitted documentation, the patient had not been treated with topical steroids or immunomodulators. She has recently been started on Plaquenil (hydroxychloroquine) and Humira. The patient has requested a light therapy (ultraviolet B) system for home use. The patient has been having in-office phototherapy appointments, but there is no documentation as to whether this is having any effect on repigmentation to determine whether the vitiligo is responding to ultraviolet light treatments. Based upon the submitted medical records, the patient has not failed typical first-line therapies, and there is no documentation that in-office phototherapy treatments are effective.  All told, the requested light therapy (ultraviolet B) system for home use is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that based on the records provided, this patient has a serious articulation deficit that places him approximately two years behind his peers. He is intellectually normal or above normal, so his articulation defect is not due to a developmental delay, but is secondary to a neurological dysfunction of his brain/oral pharynx/tongue network.  Consistent with the publication from Tyler, this patients difficulties stem from this abnormality in his nervous system. Further, Sharp and Hillenbrand state that reviews of the literature indicate the necessity and effectiveness of speech therapy in children over the age of three-years of age with articulation defects. As such, this patient certainly has a specific congenital defect in his brain circuitry and qualifies for speech therapy as required by the Health Plan. Moreover, Pennington and colleagues offer an opinion of the effectiveness of therapy for children with articulation defects in a meta-analysis of the medical literature regarding the treatment of articulation defects in children. The authors concluded that there is limited evidence that demonstrates that speech therapy can alter the natural history of articulation abnormalities in children. As this controversy exists, it is recommended that this patient receive one hour of speech therapy per week for one year and continued if he has made significant improvement in his Goldman-Fristoe score (approximating low normal for age) by the end of the therapy year. All told, the requested speech and language therapy is clearly appropriate and medically indicated for treatment of this patients articulation disorder and should be approved. Moreover, Pennington and colleagues offer an opinion of the effectiveness of therapy for children with articulation defects in a meta-analysis of the medical literature regarding the treatment of articulation defects in children. The authors concluded that there is limited evidence that demonstrates that speech therapy can alter the natural history of articulation abnormalities in children. As this controversy exists, it is recommended that this patient receive one hour of speech therapy per week for one year and continued if he has made significant improvement in his Goldman-Fristoe score (approximating low normal for age) by the end of the therapy year. All told, the requested speech and language therapy is clearly appropriate and medically indicated for treatment of this patients articulation disorder and should be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested occupational therapy for the enrollees autism. Findings: The physician reviewer found that the prevalence of impairments in fine and gross motor skills in children with autism appears to be relatively high based on the studies that have been published in the literature. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the autistic patient. These goals often involve social interaction, behavior, and classroom performance. Studies have shown that OT benefits such patients by preventing a deterioration or reversal of function and increasing ability to participate in activities of daily living. Case-Smith evaluated six categories for the need of occupational therapy and showed that in all six areas, occupational therapy significantly helped the patient. According to the Guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. Thus, occupational therapy in this patient population is standard of care in the community. This patient has documented deficits in sensory processing, gross and fine motor skills, and self care skills secondary to a diagnosis of autism. Thus, the requested occupational therapy is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested automated percutaneous discectomy for treatment of her low back pain.  Findings:  Three physician reviewers found that at this time, there is a lack of large, randomized, scientific studies noting the safety and efficacy of the requested procedure. Goupille and colleagues noted that percutaneous discectomy cannot be validated for disc herniation associated with radiculopathy resistant to medical therapy. Gibson and Waddell noted that there is insufficient evidence to draw any conclusions regarding percutaneous discectomy. Boswell and colleagues also noted the limited evidence for any long-term results of percutaneous discectomy. The consensus based on the available literature is that there is a lack of long-term outcomes from appropriately designed clinical trials showing the safety and efficacy of percutaneous discectomy compared to standard treatment modalities (Gibson and Waddell). All told, the superior efficacy of the requested automated percutaneous discectomy has not been established in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested genetic testing to rule out non-polyposis colorectal cancer for evaluation of her history of polyps.  Findings:  Three physician reviewers found that the relevant medical literature suggests that there is utility in testing well selected patients without a personal history of colorectal cancer. Jo and colleagues reviewed the association between polyps and family history of colon cancer and showed that over 15% of patients with more than 15 adenomatous polyps not associated with familial adenomatous polyposis had a biallelic MYH mutation. These findings suggested that presentation with polyps may be sufficient reason to proceed with testing. In addition, Beck and colleagues concluded that genetic testing in patients with polyps and a personal or strong family history of cancer is indicated. This case involves a female with a strong cancer history involving both her maternal and paternal lineages, with a personal history of polyps on at least two occasions. As such, if this patient tested positive, she would be a candidate for prophylactic bowel resection to reduce the risk of colon cancer and would be subjected to increased screening for other HNPCC-associated tumors. As noted in this patients genetic consultation, no affected members in either the maternal or paternal line are alive to proceed with testing, save one paternal uncle which would not address any potential risk she may have inherited from her mothers lineage. For these reasons, the patients genetic counselors have adequately demonstrated that this patients case should be viewed as the exception to standard testing guidelines as the collected data is likely to have an impact on decision making regarding her treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested residential treatment center level of care services for treatment of her bulimia and depression.  Findings:  The physician reviewer found that based on a review of the records provided, the medical necessity for RTC level of care at the time of admission on the said date through discharge has not been established. The patient was in need of ongoing treatment for recurrent depression and a history of bulimia. However, applying the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria for RTC level of care, this patient was a candidate for treatment at a less restrictive level of care, specifically, intensive outpatient services. Further, the adult criteria for RTC level of care were not met. Consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychiatric Association (APA) treatment guidelines, this patient did not require the 24-hour direction and supervision provided at the RTC level of care during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested acute inpatient treatment for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patients medical records do not clearly and adequately support the primary and secondary diagnoses. The providers first deny the existence of an eating disorder, and then describe the patients history of an eating disorder that had persisted for about three years. In addition, she was switched from the mood disorders program to the eating disorders program ostensibly because of age of the patient population and not due to her primary disorder. She had an EEG performed with positive findings, which were not apparently further investigated. Despite this disparity, the patient was prescribed at least one medication that could enhance seizures. Applying the criteria set forth by the American Psychiatric Association (APA), this patients records do not substantiate the clinical necessity for the intensive, 24-hour monitoring and supervision provided during the period at issue. The patients history and symptoms suggest that she could have been safely and adequately treated in a less restrictive level of care such as intensive outpatient program (IOP) or outpatient care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested stretching device (Dynasplint) for treatment of his plantar fasciitis. Findings:  Three physician reviewers found that the medical records indicate that the patient has been diagnosed with joint contracture and plantar fasciitis. He has a history of pain in the right heel. The patient denied any trauma, and the pain was localized to the plantar aspect of the right heel. There was no documentation to support ankle contracture. The patient was started on stretching, icing and anti-inflammatory medication. He also received a steroid injection. Although splinting has been shown to be effective for the treatment of fasciitis, the documentation provided does not support the use of other conservative treatment options. The patient has not tried a series of steroid injections, and there was no documentation to evaluate the benefit of the first injection or the benefit of stretching or oral NSAIDs. Based upon the medical records provided, the patient has not failed treatment including orthotics, physical therapy, an extended course of NSAIDs, oral steroids or a series of steroid injections. There are few studies supporting the benefit of the Dynasplint for improving ankle range of motion. Therefore, in this patients case, the requested Dynasplint is not likely to be superior over other treatment modalities
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary in nature if the removed skin has a history of recurrent infections or is necrotic. The mere presence of a pannus does not automatically make its removal medically necessary. There is no documentation of office visits for or treatment of any skin condition related to the pannus in the reviewed materials. There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy.  Additionally, the patients current condition does not constitute an abnormal structure of the body.   All told, the requested panniculectomy is not medically indicated for this patient, and the requested procedure is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that regarding the request for occupational therapy for this patient with autistic spectrum disorder, the requested services are medically necessary based on overall evaluation of the literature. Research shows that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy with an emphasis on sensory integration, can be used to help induce brain plasticity with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. This patient has already made some progress with respect to tactile issues with sand and this suggests that he may be amenable to further advancements with this specific type of occupational therapy with sensory integration features. Thus, the requested therapy should be approved as it is medically necessary for management of this patients sensory related deficits secondary to autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Reclast for treatment of her osteopenia.  Findings:  The physician reviewer found that in this patients case, the bone loss has significantly progressed over two years. The patient has osteoporosis in L4 with a T-score of -2.6, and femoral neck T-score of -2.2, which is close to the osteoporosis score. As reported by Watts and colleagues, these findings place this patient at increased risk for compression fracture in the spine and fracture of the femoral neck. In the clinical studies on the effectiveness and safety of Reclast, Lyles and colleagues found decreased rates of fractures and fewer complications from femoral fractures. Therefore, the requested use of Reclast therapy for this patient has been demonstrated to be medically necessary for her care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a six-year-old male enrollee have requested applied behavioral analysis (ABA) services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has multiple behavior issues including non-compliance, tantrums, and visual stereotyping as well as other maladaptive behaviors. The scientific data suggests that these behaviors respond well to ABA programs that are intensive, structured, and individualized with explicit teaching of social skills, communication and learning to learn skills. The progress reports indicate that he has already made significant gains in his behavior and no longer displays maladaptive behavior and his stereotyping has decreased. For this reason, the ABA services provided were medically indicated and necessary during the period at issue. As this patient is likely to continue to benefit from ABA therapy, it has been shown to be medically necessary in the continuation of his care and should be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested a panniculectomy for treatment of her status post gastric bypass.  Findings:  The physician reviewer found that in this patients case, a symptomatic abdominal pannus is well-documented. The photographs also support this finding.  Based upon the submitted medical records, this is a functional issue, as the redundant tissue has caused rashes and infections.  These functional concerns have been supported by multiple physicians in different areas of practice. The requested surgery is likely to improve this patients symptoms. In summary, the medical documentation supports a functional problem following weight loss surgery that can be relieved with a panniculectomy.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that the patient is documented in the medical records to have macromastia, which is abnormal enlargement of the breasts. Her photographs clearly demonstrate significant macromastia. Her very pendulous breasts were noted to significantly limit normal breast/chest exam. According to the medical records, the patients cup size was reported as DDD which is greater than size DD, which the Health Plan requires. In addition, the patient is documented to have significant complaints of pain due to her large breasts with exacerbation of her degenerative disc disease from the pressure of her bra. She is documented to have right shoulder impingement syndrome and sensory changes of the hand. The patients plastic surgeon does not consider the size of the patients breasts to be a significant contributor to these symptoms. However, based on the size of the patients breasts and the shoulder grooving as seen in the photographs, the patients breast size could be significantly exacerbating her symptoms. Thus, there are documented functional concerns in this case that can be addressed with breast reduction surgery.Furthermore, the American Society of Plastic Surgeons guidelines indicate reduction mammaplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients when the following criteria are met:Documentation of two of the following:-Chronic breast pain caused by weight of the breasts-Intertrigo unresponsive to medical management-Upper back, neck, and shoulder pain -Backache, unspecified -Thoracic kyphosis, acquired -Shoulder grooving from bra straps-Upper extremity paresthesia caused by brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area-Headache-Congenital breast deformityGiven this patients documented upper shoulder, neck and back pain, as well as shoulder grooving from bra straps, she meets at least two of the above criteria for breast reduction surgery.With regard to the concerns over the patients obesity, complications increase with the weight of the resection and not necessarily with the weight of the patient.  Additionally, a study by Zubowski and colleagues disputes the fact that weight loss to a level other than within 15% of ideal body weight, affects the rate/severity of complications. The authors state, Although weight loss is advisable from an overall health standpoint, there are no data in the surgical literature to support the supposition that weight loss will reduce breast size to such a degree as to relieve the symptoms of macromastia. The authors further note that denial of reduction mammaplasty on the basis of weight alone is not supported by the plastic surgery literature.In summary, the submitted medical record documentation demonstrates breast reduction surgery is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested mechanized spinal distraction therapy for spinal decompression for treatment of his neck and right arm pain.  Findings:  Three physician reviewers found that vertebral axial decompression for the cervical or lumbar spine is an unproven treatment modality.  High-grade peer-reviewed medical literature supporting the efficacy of vertebral axial decompression in the management of cervicalgia with or without radicular symptoms has not been published.  The manual or mechanical distraction of vertebral bodies and facet joints to reduce pain from nerve irritation has been shown in some smaller studies to be possibly effective for radicular neck pain.  The quality of evidence in support of this, however, is not strong.  The small case series that do demonstrate efficacy of cervical distraction suggest that over-the-door cervical traction devices can be effective.  There is a lack of high-grade published peer-reviewed data to support improved marginal functional outcomes for the device used in this case over home over-the-door cervical traction models for cervicalgia with or without radicular symptoms.  All told, the mechanized spinal distraction therapy for spinal decompression provided during the dates in question was not likely to be more efficacious than other treatment options.