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

A 23-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing level of care including physical, occupational, and speech therapy, from a specific date and forward.  Findings:  The physician reviewer found that based on review of the available records, the patient is at a custodial level of care and does not require SNF level of care services. The records indicate that the patient has shown some very modest but largely inconsistent signs of progress, and is essentially in a minimally conscious state. He has not been tracking consistently or consistently following commands. He has been dependent for all care and mobility. Some ongoing recovery and functional progress may occur over the next 12-18 months, but the extent of rate of recovery is likely to be very slow given the severity of his injuries and the minimal progress that has been demonstrated since the initial accident. As such, further rehabilitative efforts can be provided at a lower level of care as no marginally significant improvement in health or functional outcomes is expected with ongoing SNF level care.  In the peer reviewed publications, Lombardi and colleagues literature review reported that, there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Similarly, a review by Meyer and colleagues on evidence-based interventions used to promote patient arousal from coma concluded that although each of the interventions showed promise and warrant further study, More methodologically rigorous study is needed before any definitive conclusions can be drawn. In addition, Georgiopoulos and colleagues noted that no therapeutic treatments were proven to be efficacious in significantly improving the recovery course or functional outcomes in the setting of vegetative state or minimally conscious state. Therefore, the requested multidisciplinary rehabilitative interventions including occupational, physical, and speech therapy is not medically necessary in lieu of care provided at a less intensive level such as custodial care with intermittent therapy services.  Consistent with these findings, the requested continued SNF care from the date in question and forward has not been shown to be medically necessary in the treatment of this patients medical condition.
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 speech delay.  Findings:  The physician reviewer found that reviewing the patients medical records, the requested speech therapy is clinically indicated to address her speech and language deficits. The patient has delays in receptive and expressive language of approximately one year behind her peers. A pivotal point with regard to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with language delays. At issue is the notion that plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment 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 receptive and expressive speech delays. For these reasons, the requested therapy is medically necessary for treatment of this patients medical condition.
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 speech delay.  Findings:  The physician reviewer found that the patient has delays in receptive and expressive language of approximately one year behind his peers. A pivotal point with regard to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with language delays. At issue is the notion that plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment 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 receptive and expressive speech delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested continued outpatient psychotherapy, at a frequency of five times per week or any other frequency greater than two sessions per week, and for outpatient psychotherapy at a frequency of five times per week, or any other frequency greater than one session per week, for treatment of her dysthymic disorder.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those diagnosed with affective disorders, such as dysthymia. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. (Gelenberg, et al.)Considering that the mean duration of a properly completed psychoanalytic case is approximately 1,000 sessions, (American Psychoanalytic Association) 11 years of sessions at a rate of 5 per week would well exceed the benchmark for psychoanalysis, if that is indeed the therapeutic approach being utilized. There is no other evidence-based psychotherapy that recommends treatment at such a frequency. In the maintenance phase of this patients treatment, psychotherapy at a frequency of two hours per week would have been medically appropriate. Thus, as of the said date, outpatient psychotherapy at a frequency of two sessions per week was medically necessary for this patient. With regard to future treatment, standard of care in this setting would include revisiting the treatment plan with consideration given to time-limited therapies (Gelenberg, et al.), such as behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy and life review therapy (Fiske, et al.), and selective serotonin reuptake inhibitors (Cuijpers, et al.). Given that treatment thus far has failed to achieve sustainment in the maintenance phase, and while the treatment plan is revised to facilitate the desired end state of affective harmony and individual autonomy, continued outpatient visits twice a week are reasonable and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested authorization and coverage for occupational therapy at a frequency of one time per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested authorization and coverage for radiosurgery via CyberKnife for treatment of the enrollees acoustic neuroma. Findings:  The physician reviewer found that stereotactic radiosurgery has become a well-established treatment modality in the management of selected patients with acoustic neuromas. According to German, et al., among neurotologists, 42% perform stereotactic radiosurgery (approximately 58% of those use Gamma Knife, and 44% use CyberKnife) and 37% percent of patients seen by neurotologists receive radiation. Results are better than with those obtained using whole-brain radiotherapy and comparable to the best selected surgery-radiation series. However, review of the relevant peer-reviewed evidence does not reveal adequate data that CyberKnife is superior to conventional radiosurgery in this setting. Although this patient requires radiosurgery to treat this acoustic neuroma, the relevant scientific literature does not demonstrate that treatment with CyberKnife is superior to traditional radiosurgery in this setting. Conventional radiosurgery is medically appropriate and indicated to treat this patients condition. Therefore, while the patient should be treated with radiosurgery, the Health Plans denial for the use of CyberKnife is appropriate, as it is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male has requested coverage for a functional electrical stimulator (Bioness L300 neuromuscular electrical stimulation system) for treatment of his foot drop, secondary to multiple sclerosis.  Findings:  Two physician reviewers found that the patient has multiple sclerosis (MS). He has had difficulty with tingling, weakness, and gait. Foot drop has been observed. He has used an ankle foot orthosis (AFO), trekking poles, and a walker in the past. As a result of gait impairment, he has fallen, and sustained traumatic subdural hematomas requiring neurosurgical drainage. He has had treatment with Ampyra, Provigil, Keppra, and Neurontin. The provider notes show that the patient has had a trial with the Bioness L-300 neuromuscular electrical stimulator (NES), and his gait was reportedly much more stable than without it. He was noted to walk better than with his current AFOs, with more stable gait, and lower energy use. The Bioness L-300 was advised by his provider.This patient has had gait impairment with foot drop from multiple sclerosis, which has caused him to fall. The patients falls have resulted in traumatic brain injury in the past. The patients gait with his foot drop is noted to be insufficient, with notably increased fatigue and slowed walking speed. Research on the use of functional electrical stimulation (FES) devices has shown the potential benefits of walking speed, oxygen uptake and physiological cost in patients with spasticity from chronic central nervous system lesions, such as occurs in MS, brain injury or spinal injury (Paul, et al.). Studies have also shown the potential for neural plasticity, with functional gains maintained after discontinuation of FES devices (Sabut, et al.). This patient has had a trial with the Bioness L-300 and has been observed by his physical therapist to have improved gait stability and reduced energy use in walking when compared to his AFOs. Thus, the requested device is likely to be more beneficial for treatment of the patients medical condition than standard available therapy, including the use of AFOs and physical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female has requested past and future coverage for AlloMap testing for evaluation of her medical condition status post heart transplant.  Findings:  Three physician reviewers found that the patient underwent two heart transplants due to the development of sarcoid cardiomyopathy. There is concern that further endomyocardial biopsies will cause valvular induced damage and regurgitation. As a result, AlloMap testing has been ordered to evaluate the patient for cellular rejection in a non-invasive manner. AlloMap testing is a molecular expression test that assesses the gene expression of circulating white blood cells. It is intended to aid in the identification of rejection in stable heart transplant patients. To monitor the heart muscle for cellular rejection, right ventricular (RV) biopsies are typically obtained at decreasing frequency of intervals after transplantation, and are not without complications. In contrast, the AlloMap test avoids frequent RV biopsies, allows for medication changes and allows for screening of rejection when a patient has non-specific symptoms or poor vascular access. Further, the use of AlloMap for evaluation of cellular rejection has been incorporated into the International Society of Heart and Lung Transplantation (ISHLT) Guidelines for patients post-transplantation. This test has now become standard of care in the majority of transplant centers and is backed by substantial evidence in the literature. This patient followed her local transplant centers rejection protocol and underwent testing with the AlloMap test. She should also be a candidate for future testing with AlloMap. All told, this diagnostic testing was and is likely to be more beneficial for evaluation and treatment of this patients medical condition when compared to standard medical therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 35-month-old male enrollee has requested  for speech therapy for treatment of the enrollees expressive language impairment. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.Therefore, the requested therapy is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male has requested coverage for occupational therapy at a frequency of two sessions per week for 60 minutes per session for treatment of his sensory processing disorder.  Findings:  The physician reviewer found that although anecdotal support exists regarding treatment of sensory processing deficits with occupational therapy, there is a paucity of sound evidence regarding its effectiveness as there are few well-controlled studies that exist which examine the effectiveness of frequently used pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life (Polatajko and Cantin). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention, however, no firm conclusions can be made regarding specific approaches due to poor study quality and great variability in interventions and patient populations. The occupational therapy sessions the patient has received in the past have concentrated on sensory processing issues and decreased oral and fine motor coordination. The initial occupational evaluation did not quantify the functional limitations in daily living skills and fine motor skills. All told, there is a lack of documentation of standardized testing of fine motor and daily living skills (i.e., Vineland II or other appropriate fine motor testing) that describes the extent of the patients delays and demonstrates that occupational therapy has been beneficial. Given the lack of peer reviewed data supporting the requested modality as well as the limited documentation of the patients current deficits and/or progress, the requested occupational therapy is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested coverage for Welchol for treatment of her hypokalemia.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with several coronary risk factors and has a history of a myocardial infarction in 2007. In this circumstance, aggressive treatment of dyslipidemia to achieve a goal LDL less than 70mg/dl is recommended. However, there is no indication in the medical records provided that the patient has allergy or intolerance to formulary statin medications including cholestyramine, which is the preferred generic alternative to Welchol. Also, there is inadequate evidence based data that demonstrates improved cardiac outcomes by adding non-statin cholesterol medications to patients already on statins as compared to patients receiving statins alone. For example, the recent AIM-HIGH trial conducted by Boden and colleagues, did not demonstrate incremental outcome benefit by adding niacin to patients already receiving statin medication. Consistent with these findings, the requested medication has not been demonstrated to be medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested coverage for a bone density scan/dual energy x-ray absorptiometry (DEXA) scan for evaluation of her bone pain.  Findings:  The physician reviewer found that the record provided for review does not establish that this patient is at risk for osteoporosis. Pain alone is not an indication of osteoporosis or bone loss. The patient is 51-years-old and there is no documentation that she is in menopause or has any other form of estrogen deficiency. Her comprehensive metabolic panel, including calcium, kidney function, and complete blood count (CBC) are all normal. The patient has diabetes but this is reportedly well controlled. In addition, the patient has no history of fractures or history of glucocorticoid use. Entering this patients data into the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX), the 10-year risk for fracture in this patient is not elevated because she does not have any documented risk factors that increase this score. Thus, based on the information available, the patient does not meet the criteria established by the National Osteoporosis Foundation (NOF) and the International Society for Clinical Densitometry (ISCD) for a bone density study.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested coverage for an abdominal panniculectomy for treatment of her abdominal pannus.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  An abdominal panniculectomy may be medically necessary for patients with a documented history of recurrent infections.   However, in this patients case, there is no documentation of office visits for treatment of a skin condition related to the pannus.  Additionally, the submitted documentation does not demonstrate that the pannus interferes with function, such as ambulation. The presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  In this patients case, the condition does not constitute an abnormal structure of the body.  The standard medically indicated procedures for this patient are hernia repair and bariatric gastrointestinal weight loss surgery.  All told, the requested abdominal panniculectomy is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy, physical therapy and occupational therapy  for treatment of the enrollee, who has been diagnosed with developmental delay and seizure disorder. Findings:  The physician reviewer found that Speech and language therapy is particularly important for children with developmental delay to facilitate development of functional communication skills to express needs. Children with global developmental delay are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information.  It is important to thoroughly address these deficits to prevent further impact on growth and development.  This patient has made progress with speech and language therapy.   Additionally, occupational therapy is medically necessary in this patients case.  This patient has delays in fine motor skills, self-help skills, and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case.   Physical therapy is medically necessary to address this patients delays in gross motor skills.  This patient demonstrates gross motor delays in both stationary and locomotion skills, with challenges in standing, ambulation, and equilibrium reactions.  He has made gains in gross motor skills, but continues to require significant assistance.  The requested physical therapy will allow this patient to improve and safely navigate through his environment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested past and future coverage for acute inpatient psychiatric care for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of major depressive disorder, recurrent, severe and bulimia nervosa. The patient presented with symptoms of depression with suicidal ideation as noted in the psychiatrists notes starting at the date in question. For the dates in question beyond the original date, this patient continued to have suicidal ideation with a plan to drive her car over a hill or overdose. The provider described her mental state as very despondent. The patient was planning and dreaming of her own death. Utilizing the practice guidelines from the American Psychiatric Association (APA), this patient continues to be at imminent suicidal risk necessitating the medical care and supervision provided in the patients current facility. She meets the criteria for an acute inpatient hospitalization as she continues to show suicidal ideation and self-injurious behavior and therefore the services provided from the date at issue and forward have been demonstrated to be medically necessary for management of this patients medical condition.