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

A 54-year-old female enrollee has requested the use of a low load prolonged static ankle stretching device (DynaSplint) for treatment of her Guillain-Barre syndrome. Findings:  Two physician reviewers found that there are some published case reports and case series in the medical literature related to the use of low-load prolonged-duration dynamic orthoses (such as the DynaSplint) for various joints. There is, however, no high-grade data in the published peer-reviewed medical literature supporting the efficacy of the DynaSplint for ankle contractures or spasticity. Low-load prolonged-duration dynamic orthoses such as the Dynasplint remain unproven for patients with reduced range of motion at the ankles due to Guillain-Barre syndrome or other neurological conditions.  There is no compelling data establishing that the device is as effective or more effective than a rigorous exercise program combined with appropriate analgesics and palliative modalities.  Overall, the DynaSplint system is not likely to be as efficacious for treatment of the patients condition, as it is not proven to be effective for this condition. Moreover, the patients ankle range of motion did not improve significantly with DynaSplint therapy. All told, there is inadequate evidence supporting the use of the DynaSplint device in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested lumbar spine fusion for treatment of his chronic low back pain and radiculopathy of the left lower extremity.  Findings:  The physician reviewer found that there is no evidence of instability, angulation, significant scoliosis, spondylolysis, spondylolisthesis, trauma, or infection in this patients records, all of which would be considered criteria for spinal fusion. Thus, the proposed two level spinal fusion is not considered medically necessary and is not indicated in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Femara (letrozole) for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the process of epiphyseal fusion during puberty is regulated by estrogen, even in males. By delaying epiphyseal closure with the use of aromatase inhibitors in order to block the production of estrogen, preliminary studies have shown an improvement in final height. Anastrozole increases adult height potential of adolescent boys on growth hormone (GH) therapy, while maintaining normal pubertal progression after two to three years. Preliminary studies suggest that treatment of adolescent boys with aromatase inhibitors, with or without concomitant growth hormone, increases predicted adult height in these patients. Treatment with aromatase inhibitors offers an alternative in promoting growth in GH-deficient males in puberty. This particular patients growth potential is further compromised by his advanced bone age, which would allow premature epiphyseal bone closure leading to even shorter predicted adult height. Third generation aromatase inhibitors such as Femara have been used in circumstances similar to this patients. Thus, Femara would be expected to have similar effects to anastrozole and therefore is medically reasonable and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  group occupational therapy, once per week for treatment of the enrollees autism.   Findings:  The physician reviewer found that based on the available medical literature, the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends occupational therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The literature reveals that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. In support of the need for occupational therapy, studies have shown that this modality prevents deterioration and provides significant improvements in activities of daily living (Case-Smith and Arbesman). Thus, OT is within the standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism and progress with therapy thus far, there is sufficient evidence to support the medical necessity of group OT since the date in question and forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech delay and lisp. Findings:  The physician reviewer found that according to the medical literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior. In particular, speech sound disorder not only greatly reduces intelligibility it has also been associated with later reading disability (Smith, et al). Specifically, the authors noted 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 concern is that, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. In addition to persistent speech- and language-related underachievement, language-delayed children have also shown more behavior problems and impaired psychosocial adjustment (Nelson, et al). It is clear that speech disorders must be taken very seriously, and intervention should be timely and comprehensive. Given these factors, the speech therapy services provided to this patient have been proven to be medically necessary for management of his speech delay and lisp.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested an electric scooter (mobility chair for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that CMS (Medicare) regulations provide that power mobility devices are reasonable and necessary for individuals who have a personal mobility deficit sufficient to impair the performance of Mobility-Related Activities of Daily Living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. It must be established that the individual is unable to safely and timely complete MRADLS with a walker, cane or manual wheelchair. The medical records provided do not document sufficient findings to establish whether the patient meets criteria for a power mobility device. The physical therapy evaluation does not document lower extremity strength or distance ambulated with a walker. Additionally, the provider visit note dated on the said date does not document any objective exam of upper or lower extremity strength, gait or balance. Nor is there a clear cut need or medical necessity established for the power mobility device. The personal power mobility deficit is not clearly stated in the records, although the patient subjectively notes pain and weakness. Thus, the Health Plans recommendation that the patient be further evaluated by the Wheelchair Clinic is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  speech therapy for treatment of the enrollees developmental delay with a speech delay.  Findings:  The physician reviewer found that this patient is significantly delayed in the development of speech. A speech assessment by the Health Plans speech pathologist found the patient to be at least one year delayed in speech development. The effectiveness of speech therapy in the young child is emphasized in the available peer reviewed medical literature. Law et al. reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles. Gorhus-Brower specifically examines speech-delayed children who do not have cognitive deficits and points out that such patients are ideal candidates for successful speech therapy.   The patients condition has clearly been established, the Health Plans speech pathologist noted a speech delay of at least one year, and the patients developmental pediatrician has recommended an intensive speech program. In this patients case, speech therapy would be considered the standard of care in treating her speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 3-month-old female enrollee has requested physical therapy (PT) for 2 hours per week for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities occurring in greater frequency (Parker, et al). As a result, the prevention of secondary disability is important. The central hypotonia slows the acquisition of gross motor skills while the ligamentous laxity complicates the ability to acquire appropriate gross motor skills (Baum, et al). As recommended by the American Academy of Pediatrics (AAP), PT with early intervention services is needed for continued improvement in gross-motor skills in this patient population. The long-term benefit of PT includes prevention of compensatory movement patterns that patients with Down syndrome are prone to developing. Should these issues go untreated, this can lead to orthopedic and other functional problems (Rasmussen, et al). This patient has identified gross motor delays in all domains as documented by her provider during the most recent PT evaluation. As such, she will benefit from ongoing PT for two hours per week as it is medically necessary and within the standard of care for treatment of her Down syndrome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Microvolt T-wave Alternans testing for evaluation of his risk for coronary artery disease. Findings:  Three physician reviewers found that Microvolt T-wave alternans testing is a modality that examines the microscopic changes in the repolarization of the heart (T-wave) on an electrocardiogram (EKG). This testing has been investigated as a tool to refine the risk prediction of those that meet criteria for placement of an implantable cardioverter defibrillator (ICD). Thus far, there has been a paucity of data to support its role in predicting potentially fatal events in patients with systolic dysfunction. This patient presents with reportedly normal systolic function. In addition, due to lack of documentation from the treating provider as to the indication for the Microvolt T-wave alternans testing, there is insufficient justification for use of this testing over standard testing. In conclusion, from the available data it appears that there is no conclusive and evidence-based medical indication for the Microvolt T-wave alternans testing in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested group occupational therapy, once per week for treatment of the enrollees Aspergers disorder.  Findings:  The physician reviewer found that this patient has been diagnosed with Aspergers syndrome, an autism spectrum disorder (ASD). The standard of care adopted by the medical community as set forth by evidence based guidelines for treatment of patients with ASD by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends occupational therapy in this setting. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The literature reveals that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. Studies have shown that OT prevents deterioration and provides significant improvements in activities of daily living (Case-Smith and Arbesman). In sum, OT is a standard of care modality for patients with ASD. In the case of this patient, there is documentation of fine motor difficulties. In light of these deficits and given his progress with therapy thus far, there is sufficient evidence to support the medical necessity of group OT since the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested Nutropin growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests with a height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile, a growth velocity less than the 25th percentile for bone age, a bone age more than 2 SDs below the mean for age, low serum IGF-1 and/or IGFBP-3, or other clinical features suggestive of GH deficiency. This patient does not meet these criteria. Based on the delayed bone age radiograph of 13-years at a chronological age of 14-years, 3-months, and a concomitant height measurement of 146 cm, the estimated final adult height prediction is approximately 65 inches using the Bayley-Pinneau method and assuming a normal growth velocity. This adult predicted height falls within an appropriate range for the patients genetic potential. Further, as his predicted adult height is taller than 63 inches, he is not short enough to qualify for a trial of GH therapy on the basis of the FDA-approved indication of idiopathic short stature. Of import is that his height is not more than 2.25 SDs below normal for age and gender and there is no documentation of abnormally low growth velocity prior to GH treatment. In addition, his IGF-1 level is normal, he has not failed 2 provocative GH tests, and he has no known morphological abnormalities of his pituitary gland. As such, the requested Nutropin GH therapy has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a bilateral breast MRI for evaluation of her family history of breast cancer.  Findings:  The physician reviewer found that the guidelines for screening breast MRI studies are well established in the peer-reviewed medical literature. The American Cancer Society guidelines recommend a screening breast MRI if any of the following conditions are met: BRCA mutation; a first degree relative of a BRCA carrier, but untested; a lifetime risk of 2025% or greater, as defined by BRCAPRO or other models that are largely dependent on family history. The American Society of Breast Surgeons only recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of developing breast cancer of 19.4%.  The patient has not had a screening mammogram or breast ultrasound. She does not have a personal or family history of BRCA mutation. The patient does not have a history of radiation therapy to the chest wall.  Using well-accepted published guidelines, this patient does not meet the established criteria for a screening breast MRI. Therefore, the requested breast MRI procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested lumbar spinal fusion from L5-S1/Axial Lumbar Interbody Fusion for treatment of her lumbar degenerative disc disease and lumbar spondylosis. Findings:  Three physician reviewers found that in the medical literature, the efficacy of spinal fusion in the management of chronic low back pain has been evaluated by Brox and colleagues in a randomized patient population to a program of cognitive intervention and exercises versus fusion with posterior transpedicular screws. Overall, there was no advantage over instrumentation and fusion versus the conservative treatment method. Similarly, Fairbank and colleagues compared an exercise program with fusion and found no significant difference in outcomes between the two cohorts. An additional evaluation comparing lumbar spinal fusion against nonsurgical treatment by Kwon and colleagues suggests that spinal fusion surgery has modest effects at best. This patients records document that she has undergone standard conservative therapies including pain clinic needle intervention treatments, which would be expected to provide only short-term benefits. The chart does not include any treatment with neurocognitive methods and the physical therapy approaches are limited to one year. Taking these factors together with the general considerations from the peer reviewed literature it is likely that the requested spinal fusion surgery will not be more beneficial for this patient than conventional modalities for management of her back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested authorization and coverage for insertion of a portacath for treatment of her hypokalemia. Findings:  The physician reviewer found that clinical features of hypokalemia vary greatly, and their severity depends in part on the degree of hypokalemia. Fatigue, myalgias and muscle weakness or cramps of the lower extremities are common. Severe hypokalemia may result in complete paralysis, hypoventilation, or rhabdomyolysis.  Given the risk of infection and other complications, the use of portacath is standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested outpatient mental health sessions provided twice per week (rather than the approved frequency of once per week) for treatment of his behavioral health issues. Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) criteria for outpatient therapy, this patient did not present with a need for a higher frequency of sessions necessary to stabilize a crisis. In addition, there was no expectation of progress in treatment given that this patient has been in therapy for a prolonged time period at the same frequency. Further, the providers goals were described as primarily for providing support and were focused on addressing chronic symptoms and behaviors. All told, the therapy services provided twice per week for this patient have not been established as medically necessary for the management of his OCD, anxiety, and depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Actiq (fentanyl prescription 200mcg) for treatment of her pain.  Findings:  The physician reviewer found that Actiq is presently indicated for breakthrough cancer pain in patients who are opioid tolerant or otherwise with a limited life expectancy.  Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy. Short release/acting medication with a high-risk of dependence and tolerance, such as Actiq, is not recommended.   Baron and colleagues reported that high-dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High-dose opioids may cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high-dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. All told, in this patients case, Actiq (fentanyl prescription 200mcg) was not and is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this case concerns the medical necessity of speech therapy services twice a week for the treatment of this 2-year-old male with developmental delay with respect to speech and language. Given his delay and based on overall evaluation of the relevant peer reviewed medical literature, including positive and negative analyses, these services are clinically indicated. Key to this patients case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with speech delay. At issue is the notion 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 speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to speech delay.