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

A 49-year-old female has requested coverage for past transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has major depressive disorder and generalized anxiety disorder.  Per the submitted medical records, the patients symptoms included irritability, tearfulness, restlessness, fatigue and interpersonal withdrawal.  She has had prior outpatient psychotherapy.  The patients prior medications included Oleptro, Abilify, Cymbalta, Lamictal, Celexa, Paxil, Zoloft, buspirone, trazodone, and risperidone.  These psychopharmacologic agents have been poorly tolerated and have not achieved remission.  In this patients case, transcranial magnetic stimulation provided was likely to have been more efficacious than other treatment alternatives.  The current medical literature supports the services at issue in this patients case.  Schutter and Gross and colleagues suggest that the efficacy of transcranial magnetic stimulation may be greater than originally reported.  The American Psychiatric Association has endorsed the use of transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  There is sufficient evidence in the published, peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this patients case.  This has patient has tried multiple medications, with inadequate response or intolerable side effects.  All told, transcranial magnetic stimulation provided was likely to have been superior over other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for an MRI of the back for evaluation of his low back pain. Findings:  The physician reviewer found that there is no documentation of conservative therapy, including physical therapy.  There is no clinical concern of infection or metastatic disease.  There is no history of recent trauma.The current medical evidence does not support the requested diagnostic procedure in this patients case.  As there is no documentation of a recent trial of conservative therapy, and this patient has uncomplicated back pain, the requested MRI of the back is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for speech therapy twice per week for treatment of the enrollees dysfluency/stuttering.  Findings:  The physician reviewer found that stuttering affects the fluency of speech. It begins during childhood and, in some cases, lasts throughout life. Although most young children recover from stuttering, if the child is already older than 6 years of age, the spontaneous recovery will be less likely. In his preliminary study of case histories, Millards hypothesis was that early intervention with young dysfluent children is more successful over a shorter period of time than if speech and language therapy is delayed. The amount and duration of speech and language therapy along with the outcome was measured. The author concluded that preliminary findings indicate that early intervention is effective. Millard also looked into intensive therapy but looked at it in terms of group therapy. She looked at the effectiveness of a 2 week program and concluded that the results she obtained provided evidence supporting the effectiveness of intensive group therapy. Therefore, the requested speech therapy is medically necessary twice per week for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female has requested Betaseron 0.3mg for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication.  The patient has a reported history of relapsing-remitting multiple sclerosis.  Her prior therapies are unknown, as is the degree of disease activity.  Interferons and Copaxone are first-line therapies for the management of multiple sclerosis and are indicated for individuals with active disease.  In this patients case, details regarding her medical course were not provided.  The medical records do not demonstrate that the requested medication is indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male has requested a specific surgical procedure as recommended in a consultation report for treatment of his left lower back pain radiating to the left leg and foot.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure in this patients case.  In this case, CT myelogram showed medial placement of the L3 and L4 pedicle screws.  The immediate postoperative onset of this patients symptoms was consistent with nerve impingement from these screws.  Nerve impingement is a known complication of medial screw placement.  Lonstein and colleagues performed a retrospective review on pedicle screw procedures.  The authors reported 4790 screw placements during 915 operative procedures on 875 patients.  Nerve impingement occurred in 1% of these procedures.  Three patients had residual neurological weakness despite removal of the screws.  Thus, the utility of removing the screws was not demonstrated.  The current medical evidence does not support the requested procedure in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested reimbursement for services of an assistant surgeon during a bilateral brachioplasty and assistant surgeon services for abdominoplasty treatment of the enrollees excess skin. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue.  Surgeons call upon assistants to utilize problem-solving skills that are only developed through medical and surgical training.  The primary surgeons decision about who is most appropriate to serve as an assistant at surgery may be based on factors such as the nature of a specific operation, the unique medical circumstances of an individual patient, the availability of appropriately trained physicians or non-physician staff, or ready access to other appropriately trained specialists.  An assistant surgeon is medically necessary if the care provided or service rendered by the assistant requires the credentials and technical skills of the assistant.  Specifically, an assistant surgeon is indicated when the service provided could not be fulfilled by lesser trained providers employed in the operating room. Given the magnitude of this patients operation and amount of suturing required, an assistant surgeon was medically necessary for the services at issue.  All told, assistant surgeon services for bilateral brachioplasty and assistant surgeon services for abdominoplasty were medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested authorization and coverage for Provigil 100 mg for treatment her multiple sclerosis.  Findings:  The physician reviewer found that Provigil is used in clinical practice by neurologists in the treatment of patients with fatigue associated with multiple sclerosis. This is an off-label use of the medication, it is effective in reducing fatigue associated with multiple sclerosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested authorization and coverage for a PET/CT scan for evaluation of her breast cancer. Findings:  The physician reviewer found that PET/CT scans are mainly utilized in the evaluation of patients with stage III or IV breast cancer and for the evaluation of response to treatment in patients with known metastatic breast cancer. The National Comprehensive Cancer Network guidelines do not advocate for the use of PET/CT scans in patients with stage I or stage II breast cancer.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested  coverage for vision therapy for treatment of the enrollees multiple medical conditions.  Findings:  Two physician reviewers found that the efficacy of vision therapy in the treatment of dyslexia and learning disabilities is not supported by the peer-reviewed medical literature. Although studies support that visual/ocular defects are more prevalent in patients with learning disabilities, it is higher brain function that is responsible for the decoding of retinal images (American Academy of Ophthalmology, 1998). There is a great deal of controversy surrounding the extent to which visual problems are responsible for dyslexia. The available peer-reviewed medical literature indicates that the role of eye movements and visual perception are not critical factors in the reading impairment found in dyslexia (American Academy of Ophthalmology, 2007) and it continues to remain unclear whether visual deficits in children are linked to reading or learning difficulties (Barrett). In sum, there is inadequate scientific literature supporting the use of vision therapy in the treatment of learning disorders. Therefore, the denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested occupational therapy for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patient has multiple psychiatric, behavioral, educational, and social problems. Occupational therapy testing, utilizing the well-accepted Bruininks-Oseretsky Test of Motor Proficiency, indicated an acute need for occupational therapy intervention. The usual and customarily practice in the medical community would be to refer this patient for occupational therapy.  There is sufficient medical evidence of the efficacy of occupational therapy in children who demonstrate such deficiencies in formal testing. The purpose of occupational therapy is to improve the patients abilities to adapt and function in his/her activities of daily living.  With the degree of sensory processing and motor impairment that this patient has, it is medically necessary for him to receive occupational therapy services. Sensory integration techniques enable the occupational therapist to assist patients in developing the ability to integrate into normal motor and personal-social patterns, in order to function appropriately with their peers (Schaaf and Miller). The peer reviewed medical literature demonstrates that sensory integrative programs for improving sensory-motor function in developmentally delayed children have been successful (Miller, et al.). Additionally, patients who have been treated by an occupational therapist, utilizing sensory integration techniques, have shown improvements in behavioral patterns (Roberts, et al.). Therefore, it is medically necessary that the patient receive the requested occupational therapy services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement and continued authorization and coverage for skilled nursing care services for treatment of the his medical condition.Findings:  The physician reviewer found that the patient is medically stable and does not have skilled nursing needs beyond custodial care. Functionally, the patient requires moderate to maximum assistance with bed mobility, is dependent in transfers, is dependent and requires maximum assistance of five persons in ambulation with a front-wheeled walker. The patient did not demonstrate medical or rehabilitation issues consistent with SNF level of care services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year, eleven-month old female has requested PROMPT therapy, which includes speech therapy at a frequency of five hours per week and social skills training at a frequency of six hours per week for treatment of her childhood apraxia of speech.  Findings:  Two physician reviewers found that the patient has been diagnosed with severe apraxia of speech, as well as a mixed expressive/receptive language disorder and impaired communication skills. As a toddler, she was treated at an early childhood partial hospitalization program (PHP), which utilized a comprehensive and multidisciplinary program, including prompts for restructuring oral muscular phonetic targets (PROMPT) techniques. She was discharged from the PHP three years ago with a diagnosis of childhood apraxia of speech. Continued intervention utilizing the PROMPT method was recommended. The patient continued with speech therapy, with minimal improvement. She was then transferred to a private therapist with experience in childhood apraxia of speech, and who utilized the PROMPT therapy method. The patients parents report that the patient has made significant progress since beginning the PROMPT therapy method. Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and language-delayed children have also shown increased behavioral difficulties and impaired psychosocial adjustment (Nelson, et al.). Overall, children with speech delays who are treated with speech therapy have demonstrated positive gains in speech and language development in the areas of expressive phonological skills and expressive vocabulary skills (Law, et al.). Verbal apraxia or apraxia of speech is an impairment in planning and coordinating movements for speech production (Kleigman, et al.) which affects the ability to voluntarily initiate goal-directed speech or imitate speech. This is a deficit in motor programming and sensorimotor processing at the central level and is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, children with apraxia of speech communication at all levels may be ultimately impaired (Lewis, et al.). The PROMPT method of therapy has been used for a number of years to successfully treat children diagnosed with childhood apraxia of speech (Grigos, et al.). In this case, the patient has been treated with the PROMPT therapy method with gains in social skills. The patient continues to present with expressive and receptive language delays. Given the intensity of service offered by the PROMPT approach, it is likely to be more beneficial than standard therapies for treatment of the patients severe apraxia of speech and mixed expressive/receptive language delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested weekly ultrasounds and non-stress tests for evaluation of her hypothyroidism treated with levothyroxine while pregnant.  Findings:  The physician reviewer found that maternal and fetal thyroid abnormalities are related as thyroid function is dependent on adequate iodide intake, and its deficiency early in pregnancy can cause both maternal and fetal hypothyroidism. In addition, maternal TSH-receptor-blocking antibodies can cross the placenta and cause fetal thyroid dysfunction. However, the more common antithyroid peroxidase and antithyroglobulin antibodies have little or no effect on fetal thyroid function even though they too cross the placenta. Similarly, maternal Hashimoto thyroiditis is not typically associated with fetal thyroid dysfunction. In fact, the prevalence of fetal hypothyroidism in women with Hashimoto thyroiditis is estimated to be only 1 in 180,000 neonates. There is no evidence in this patients case that she has autoimmune hypothyroidism. As this patient is on thyroid therapy, she should have her serum TSH repeated every 4-6 weeks during the first 20 weeks, at 24-28 weeks, and at 32-34 weeks gestation. An increase in thyroid requirements is seen in about 20-30% of patients in the second half of pregnancy. Immediately after delivery, the patient should return to her pre-pregnancy dosage. All told, there is no support for serial ultrasound examinations and non-stress tests for the indication of hypothyroidism in pregnancy. Therefore, the requested services are not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested inpatient skilled nursing care, physical therapy, and occupational therapy for treatment of his multiple medical conditions. Findings:  The physician reviewer found that the submitted documentation demonstrates that by the date in question, the patient had reached a functional plateau. Therefore, he does not require daily skilled physical or occupational therapy to maintain or improve his functional status. Improvement in rehabilitation rests largely on neurological and/or muscle recovery following injury. The patients ongoing medical issues are preventing neurological recovery and he has therefore reached his maximal recovery potential in terms of daily skilled rehabilitation therapy. Furthermore, the patient no longer presented with daily skilled nursing needs. While the patient has ongoing medical issues, his conditions can be managed at a non-skilled custodial level of care with appropriate specialty follow-up, as proposed by the Health Plan. Thus, the denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested authorization and coverage for a PET/CT scan for evaluation of her breast cancer. Findings:  The physician reviewer found that the National Comprehensive Cancer Network guidelines do not advocate for the use of PET/CT scans in patients with stage I or stage II breast cancer.   Niikura and Ueno reported that there is limited evidence to support the use of PET/CT scans in the initial staging of primary breast cancer.  The authors noted that for cases in which conventional imaging techniques do not provide adequate information, PET/CT scans could be used to obtain more detailed anatomical information.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for Rituxan for treatment of his membranous nephropathy. Findings:  Two physician reviewers found that the current medical literature supports a trial of steroids and cyclophosphamide at the first-line of management in this clinical setting.   Fervenza and colleagues and Ruggenenti and colleagues have published studies indicating that rituximab (Rituxan) is useful in inducing remission of nephrotic syndrome and proteinuria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 30 hours per week for treatment of the enrollees global developmental delays with autistic features.   Findings:  The physician reviewer found that based on review of the available records, this patient has autistic features, but has not been definitively diagnosed as autistic, possibly due to her young age. In the medical literature, Myers and colleagues state that, there is a growing consensus that important principles and components of effective early childhood intervention for children with autism spectrum disorders (ASD) include the following: entry into intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made. Further, the authors recommend provision of intensive intervention with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives. In addition, ABA has been shown to be effective in improving behaviors in this patient population as reported by Sallows and Graupner. Consistent with these data, it is important to initiate ABA therapy for this patient without delay. However, it is unlikely that a child of this patients age would tolerate six hours per day in ABA therapy in addition to her time spent in speech and occupational therapies. Therefore, the patient should receive 10 hours per week of ABA therapy totaling 2 hours per day. Further, one hour per week of indirect supervision is adequate. As such, 10 hours of ABA therapy per week and 1 hour of indirect supervision have been demonstrated to be medically necessary for adequately addressing this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested for resumption of acute rehabilitation therapy for treatment of her status-post stroke. Findings:  The physician reviewer found that the peer reviewed medical literature indicates that patient outcomes are dependent upon the severity of the stroke rather than the location or degree of continued therapy. Therefore, the intensity or location of future rehabilitation therapy is not likely to influence the patients rate of brain recovery after the initial acute stroke period.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested authorization and coverage for Humira 20mg injections for treatment of the enrollees polyarticular juvenile idiopathic arthritis. Findings:  The physician reviewer found that the standard of care in pediatric rheumatology is to switch to a second anti-TNF agent in the event of failure of the first agent.  Although clinical trials involving Humira have been conducted in children over four years of age, younger children were not included in the trials due to the difficulty of recruiting a sufficient number of patients in this age group.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested authorization and coverage for computed tomography myelogram of the lumbar spine for evaluation of her lumbar spinal stenosis.  Findings:  The physician reviewer found that patient is not a candidate for the preferred method of evaluation of the lumbar spine with magnetic resonance imaging (MRI) due to the metallic artifacts which would be generated by the hardware. The American College of Radiology (ACR), CT myelogram is the next procedure of choice and is useful when there are contraindications or limitations to MRI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-month-old male enrollee has requested authorization and coverage for individualized physical therapy and individualized occupational therapy for treatment of the enrollees gross motor skills delay. Findings:  The physician reviewer found that individualized occupational therapy is medically necessary in this patients case.  This patient has delays in fine motor skills, visual motor skills, and self-help skills, in part due to asymmetries in trunk and upper extremity strength.  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 clinical setting.