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

The parent of a 29-month-old female enrollee has requested  for occupational therapy, physical therapy and speech therapy for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that it is the medical community standard to offer such children appropriate rehabilitative services. Even small verbal and motor gains can allow the patient significant improvement in controlling and adapting to her environment. It is a medical necessity that this patient receive speech, occupational, and physical therapy.  There is a significant and robust medical literature supporting the positive effect of these therapies in a child with delays similar to this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 20-month-old male enrollee has requested  for occupational therapy, physical therapy and speech therapy services for treatment of the enrollees developmental delay and speech disorder. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers (Shevell, et al). The main goal of treatment is to enhance the level of functioning. This patient has delays in fine motor, gross motor and adaptive skills of greater than 50% with cognitive delays of 40%.  Appropriate therapies including occupational and physical therapy are medically necessary in this setting and promote adaptive skill development and independence (Wolraich, et al). Therefore, the requested occupational and physical therapy services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested bariatric surgery for treatment of the enrollees obesity.  Findings:  The physician reviewer found that this denial is based upon the belief that compliance with a preoperative program is correlated with compliance with a postoperative program, as there is the need for dietary modification after restrictive bariatric operations.  However, recent studies have failed to document this correlation.  Recent studies have indicated that patients who did not participate in preoperative medically-supervised weight loss programs were just as likely to lose weight after bariatric procedures as patients who did participate in these programs.  The Health Plans preoperative requirement for bariatric surgery is not required to obtain optimal outcomes from surgery.  All told, the requested bariatric surgery is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested reimbursement for intensity modulated radiation therapy (IMRT). The Health Plan has denied this request indicating that the therapy at issue was and is considered investigational for treatment of the enrollees recurrent inflammatory carcinoma of the left breast.   Findings:  Three physician reviewers found that the patient is status post bilateral mastectomy and reconstruction for stage T1N0M0 ductal cancer. She was treated post-operatively with Femara. She was found to have recurrence of inflammatory breast cancer in the left breast with left arm edema. The patient was started on Taxol which improved the edema within one week. The radiation oncologist recommended intensity modulated radiation therapy (IMRT) to contain the aggressive tumor and its extensive presentation. The Health Plan has denied the patients request for coverage for IMRT on the basis that its use is considered investigational in the treatment of breast cancer. In the clinical literature, IMRT for post-operative breast cancer treatment is indicated when documentation establishes that the heart is in the field of radiation (Ahmed, et al). This patients situation requires radiation to the left breast region as well as to the left axilla. Moreover, the patients left arm edema may prevent her from further raising her arm out of the radiation path. Given these indications for IMRT and the overall support in the peer reviewed studies, the IMRT at issue in this case was likely to be more beneficial for treatment of this patients breast cancer and should effectively minimize the exposure of radiation to certain critical structures.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested reimbursement for out-of-network services provided on 2/22/11. The Health Plan has denied this request indicating the services at issue were not required on an emergent basis.  Findings:  The physician reviewer found that the patient presented to an out-of-network provider with complaints of sharp abdominal pain for one week and brown vaginal discharge for four days. The patient reported the pain had worsened in the past two days. Her last menstrual period occurred four weeks prior to this evaluation. She denied fever, nausea, vomiting, diarrhea or constipation. Her pain level was noted as 0/10 on the pain scale. On physical examination, she appeared well and her vital signs were normal. She had abdominal tenderness on physical examination. Pelvic examination revealed some left adnexal tenderness. The patient was diagnosed with a vaginal infection and discharged home in stable condition with a prescription for antibiotics.  At issue in this case is whether a prudent layperson would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation does not demonstrate that this patient had signs or symptoms that would cause a prudent layperson to seek immediate medical attention. The patient had been experiencing abdominal pain for four days. Her pain level was documented as 0/10 on the pain scale at the time she sought medical care. There was no serious dysfunction to any bodily organ or part. The patient was able to eat and her bowel and bladder were functioning normally. A prudent layperson in this situation would not believe her health was in serious jeopardy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested authorization and coverage for a speech evaluation and/or speech therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this five-year-old patient has significant behavioral problems, immaturity and unintelligible speech. He has received a limited amount of speech therapy in an early intervention school program. His speech therapist has recommended continued speech therapy and his provider, more than one year ago, recommended a speech evaluation and speech therapy, if indicated on evaluation. The Health Plan has denied speech evaluation and therapy based on the fact that the patients speech delay is neither acquired nor congenital. The patients symptoms are consistent with developmental aphasia, which is often congenital. Patients with developmental aphasias have abnormal brain development in regards to processing speech. This patient has been in a speech therapy program and his speech therapist states that he has made improvement, which indicates that his condition is treatable. The medical community has long recognized the value of speech therapy in children with developmental aphasia (Law, et al. and Goorhuis-Brower and Kniff). A speech evaluation and speech therapy are medically indicated for this patient. The medical community standard for a five-year-old unintelligibly speaking child is speech therapy.  The patient should receive a speech evaluation and at least one hour per week of individual speech therapy for six months, followed by speech re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech dysfunction, speech therapy should be continued for another six months, at which time the patient should be reassessed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested a rapid maxillary expansion device for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that a narrow tapered maxillary arch is considered to be a risk factor for obstructive sleep apnea and treatment for this is indicated in patients with obstructive sleep apnea. The patient has a RDI of 21.6 and studies do indicate that treatment is required when the RDI is greater than 5.The RDI, which in addition to apnea and hypopneas, includes other less evident respiratory events such as respiratory effortrelated arousals (RERAs). The RERA event is characterized by increasing respiratory effort for 10 or more seconds leading to an arousal from sleep but not meeting the criteria of an apnea or hypopnea (Fleisher, et al.). Given this patients physical findings on his maxillofacial exam, that were inclusive of a narrow maxilla with a transverse deficiency and his RDI score, treatment with palatal expansion is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested reimbursement for one day of hospitalization to treat back pain.  The Health Plan denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who is status post decompressive laminectomy L4-L5, bilateral foraminotomies.  Findings:  The physician reviewer found that the submitted documentation failed to establish the medical necessity of the services at issue.  The development of screening criteria for review of patient care has resulted in the use of several generally accepted systems for use as screening tools.  In this patients case, she did not meet InterQual criteria for acute inpatient level of care.  The medical records indicate that the patient was ambulatory and was on oral analgesic medications on the date of service at issue.  All drains and catheters had been removed.  The submitted clinical records do not demonstrate any clinical situation which would have required inpatient level of care.  All told, the one day of hospitalization was not medically indicated in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a radioactive iodine uptake test for evaluation of the enrollees history of multinodular goiter with bilateral thyroid nodules.  Findings:  The physician reviewer found that the algorithm for the evaluation of a multinodular goiter is well-established within the peer-reviewed literature.  Leenhardt noted that there is a systematic algorithm for the evaluation of thyroid nodules based on physical examination, clinical history, measurement of thyroid stimulating hormone, and neck ultrasound, which has become the preferred radiologic modality for imaging thyroid disease. Per Leenhardt, radionuclide thyroid scanning is reserved for the evaluation of patients with suppressed thyroid stimulating hormone levels.  The use of nuclear uptake and scan studies is limited to patients with abnormal thyroid function, to evaluate ectopic thyroid tissue, or to determine if a neck mass has active thyroid tissue.  When a patient has a dominant or solid thyroid nodule identified on thyroid ultrasound that needs further evaluation, the examination of choice is a fine needle aspiration of the thyroid nodule.  This is documented in multiple medical articles and is the recommendation of the American Thyroid Association. This patient had a known multinodular goiter with no documentation of abnormal thyroid function.  The patient has had a thyroid ultrasound and had a dominant solid thyroid nodule.  In this clinical situation, the requested testing is not medically necessary.  All told, the requested radioactive iodine uptake test is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested Avastin intravitreal injections for treatment of his retinopathy. Findings:  Two physician reviewers found that treatment with intravitreal bevacizumab for this patient is not more efficacious than standard therapy. There is no medical evidence from appropriate scientific studies that this patients disease would be helped by the treatment at issue.  In this case, the patient has cystoid macular edema likely related to either postoperative inflammation or Coats disease or a combination of the two.  Although bevacizumab has a proven role in treating other exudative retinal diseases, there are only case reports of beneficial treatment in the setting of Coats disease (Goel, et al.; Bohm and Uhlig). Further, there is stronger evidence that bevacizumab does not improve post-cataract surgery cystoid macular edema (Spitzer, et al.). There is also reason to be cautious when using bevacizumab in Coats disease as it may cause additional problems (Ramasubramanian and Shields). The available medical evidence suggests that bevacizumab use for Coats disease or post-cataract cystoid macular edema is not likely to be superior to standard treatment alternatives.
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 mixed receptive/expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Feldman & Messick). 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 & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than children who have no treatment. Review of the submitted documentation demonstrates that this patient was noted to have speech and language delay. A subsequent evaluation the following month did not reveal a delay; however, different tools were utilized to determine the patients abilities. The patient has an identified delay in receptive and expressive speech of greater than 50% per one evaluation and no identified delays in another evaluation. It is important to determine this patients current speech and language development. Given the discrepancy in the findings of the patients speech and language evaluations, he should undergo re-evaluation with an independent speech therapist to determine his current level of functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees mixed receptive/expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Feldman & Messick). 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 & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than children who have no treatment. The documentation demonstrates that this patient was noted to have speech and language delay at 24 and 28 months of age. A subsequent evaluation at 29 months of age did not reveal a delay; however, different tools were utilized to determine the patients abilities. It is important to determine this patients current speech and language development. Given the discrepancy in the findings of the patients speech and language evaluations, he should undergo re-evaluation with an independent speech therapist to determine his current level of functioning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested weekly outpatient mental health therapy for treatment of his generalized anxiety disorder. Findings:  The physician reviewer found that this patient is a typically high-functioning individual who has severe psychosocial stresses and is symptomatic with anxiety and dysphoria. He has been treated with a treatment regimen consisting of anxiolytic and outpatient therapy sessions. The patient finds weekly therapy helpful to his anxiety and feelings. At less frequent visits, he was more symptomatic. Consistent with the American Psychiatric Association (APA) treatment guidelines, weekly psychotherapy is within the standard of practice given this patients symptoms and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on review of the available records, although this patients pre-treatment height was 2.5 standard deviations (SDs) below normal for age and gender, there is no clear documentation of poor linear growth velocity or low pre-treatment growth factors. In addition, provocative GH testing revealed normal results. Thus, this patient does not meet standard criteria for GH deficiency. According to the recent Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity in less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet most of these criteria based on the information provided. Furthermore, given the arrest in weight gain that is notable on review of the patients growth chart, documentation that the patient has a normal erythrocyte sedimentation rate (ESR) and celiac antibody panel is warranted to rule out other causes of growth failure prior to consideration of GH therapy for this patient.Without documentation to support low pre-treatment growth factors, poor pre-treatment linear growth velocity, and laboratory testing to rule out occult systemic causes of poor growth, the requested GH therapy has not been established as medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested Lyrica 25 mg for treatment of his seizures. Findings:  The physician reviewer found that no comparative trials using gabapentin versus pregabalin (Lyrica) are identified in the literature. Comparison trials of pregabalin versus lamotrigine suggest that Pregabalin has similar tolerability but seems to have inferior efficacy to lamotrigine for the treatment of newly diagnosed partial seizures in adults. Inferior efficacy of pregabalin might have been attributable to limitations in the study design, as treatment doses might have not been optimized adequately or early enough. (Kwan, et al.) In a study comparing gabapentin versus pregabalin, Delahoy, et al. noted In patients with refractory partial epilepsy, pregabalin is likely to be more effective than gabapentin at comparable effective doses, based on clinical response and the number of seizure free days. In sum, while there are no direct comparison trials, the literature suggests that Lyrica is more likely to be effective in this setting than gabapentin. Therefore, Lyrica is medically necessary and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  speech therapy at a frequency of two sessions per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patients speech was at a 12 month receptive level and expressive language was at a 9 month level when tested 6 months ago. In a more recent evaluation, the patient was noted to have significant delays in his expressive speech, as well as articulation deficits. The etiology of his speech delay is due to a severe developmental delay in his maturation of speech. Regarding the medical necessity of speech therapy, it is the medical communitys standard practice to offer speech therapy to a two year-old whose speech is significantly delayed for his age.  There is robust medical literature supporting speech therapy in this speech delayed toddler population. According to Law and colleagues, children with speech delay can be readily treated. Two-year olds, who tested below the 10th percentile, as this patient did, require and did benefit from speech therapy in two different studies (Emmanuel, et al; and Buschman, et al).   All told, based upon the patients recent speech therapy evaluation, speech therapy is medically indicated for this patient, at a frequency of two hours per week.