Persius/hicric huggingface dataset:
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 mild receptive language impairment, severe expressive language impairment and severe impairment in feeding skills. Findings:  The physician reviewer found that in this patients case, the requested speech therapy is medically indicated. As noted by Nelson and colleagues, 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. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. This patient has severe expressive language delay and severe impairment in feeding, negatively impacting her ability to achieve age-appropriate functional skills and milestones. Studies have shown that speech and language therapy can result in significant improvement in speech and language development in such children. Additionally, it is another avenue from which to improve feeding skills. All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of her cecal cancer. Findings:  Two physician reviewers found that this patient is sensitive to various chemotherapies and has a tumor that is restricted to the pelvis that is amenable to surgery and HIPEC.  HIPEC has followed debulking surgery in the series that have been published, which is the proposed sequence in this patients case.  Importantly, most of the pathology shows moderate differentiation.  There is support in the current medical literature for the requested services in this clinical scenario. The report of Elias and colleagues excluded appendiceal adenocarcinomas and showed promising results with median survival approaching three years.  In this patients case, there is a lack of alternative treatment options, as she has failed multiple prior treatments. In sum, the requested cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is likely to be more effective than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested continued use of Xolair for treatment of his asthma.  Findings:  Two physician reviewers found that the patient has received steroid therapy and rescue inhaler prior to beginning Xolair.  Since starting Xolair, the patient no longer requires rescue albuterol or inhaled corticosteroids. On the said date, the medical records noted that patient continued to have occasional symptoms, although he had improved and was doing well on Xolair. The submitted documentation notes a reduction in the number of acute asthma exacerbations requiring oral corticosteroids, a reduction in the use of inhaled corticosteroids, a reduction in the use of beta agonists and an increase in quality of life.  The patient has requested coverage for continued use of Xolair.  In this patients case, continued use of Xolair is likely to be more beneficial than other available treatment options. The patient is now well-controlled on Xolair therapy. This patient has a persisting mild obstruction of flows, as noted in current pulmonary function testing. In this case, continued use of Xolair is consistent with standards of good medical practice. The submitted records indicate a good response to Xolair therapy, with improvement of all parameters and reduction in the use of medications.  Therefore, continued use of Xolair is likely to be superior over other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder. Findings:  Two physician reviewers found that this patient has been treated with various medications and has now been referred by his treating psychiatrist for TMS therapy. The Food and Drug Administration (FDA) approved TMS therapy in October 2008 for treatment resistant depression. The FDA requires documentation of failure of one pharmacologic agent. This patients records show that he has failed multiple psychopharmacologic agents. His symptoms clearly suggest the need for an alternative therapy as he has not responded to the conventional treatment. Given that his symptoms have persisted despite medical therapy, it is justified that this patient be tried on TMS therapy as a means to alleviate his severe depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A representative of a 23-year-old male enrollee has requested a referral to receive hypnotherapy for treatment of his intellectual disability and compulsive eating of non-food items.  Findings:  The physician reviewer found that based on review of the available records, this patient has a history of developmental disabilities and Pica and was referred for hypnotherapy to treat his eating disorder. The current medical literature on the treatment of eating disorders does show that hypnotherapy can be effective for weight loss. The confounding factor in this patient is that he suffers from mental deficits in addition to his eating disorder and the data is less clear in this patient subset. In fact, there is inadequate data demonstrating the effectiveness of hypnotherapy in a patient with cognitive impairment. There are many articles using various minerals including zinc and iron as well as pharmacotherapy for the treatment of Pica. This patient had been tried on medication but its use was discontinued secondary to side effects. Given the availability of conventional, proven treatment alternatives in treating this patients eating disorder, the medical necessity of the requested hypnotherapy has not been established in this patients care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested actinotherapy (therapeutic use of ultraviolet light) for treatment of her squamous cell carcinoma in situ and actinic keratosis. Findings:  Two physician reviewers found that in this patients case, the requested treatment has become an established treatment modality for squamous cell carcinoma in situ and actinic keratosis. Compared to other treatment methods, Levulan topical treatment plus blue light illumination offers an excellent outcome. This patient has a history of proven pre-cancers and skin cancers.  In this clinical situation, the requested actinotherapy (therapeutic use of ultraviolet light) is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested Adderall for treatment of his attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that based on review of the available records, this patients provider recommended Trazodone for insomnia and verapamil with Midrin for migraines. The patient indicated that he was only taking trazodone but declined other controlled medications including non-stimulants. Applying the recommendations from the American Society of Addiction Medicine (ASAM), the patient should first be given an adequate trial of medication as recommended by his provider. This is especially important as the patient has a prescription for cannabis and is therefore at a higher risk for abuse of stimulants. Thus, given this patients elevated risk he should first be given an adequate trial of medication pursuant to his providers recommendation. For these reasons, the medical necessity of the requested medication has not been established in this patients care at this time.
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 expressive speech delay. Findings:  The physician reviewer found that consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy intervention is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis of the knee. Findings:  The physician reviewer found that the efficacy of viscosupplementation in treating osteoarthritis of the knee is generally accepted in appropriate patients and as part of a comprehensive treatment strategy. It is most effective in patients with mild to moderate disease, and is not effective in patients with more severe involvement. The question of the efficacy of repeated series of injections remains unclear.  In patients with a previous beneficial course of therapy, there is evidence of response, and other reports have been encouraging. However, there are also reports of an increased frequency of problems associated with repeated series of injections. Studies of this question are in progress, but the results have not yet been published.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested Tenormin 100 mg for treatment of his hypertension.  Findings:  The physician reviewer found that based on the records provided the patient has essential hypertension that is being treated with a combination of Maxide and Tenormin. There are no documented blood pressure readings after the patient was started on the generic atenolol medication, no evidence of side effects, and no indication the patient was intolerant to the generic alternative. Further, there is no documented improved effectiveness of the name brand Tenormin relative to the generic alternative atenolol. All told, generic alternatives have been demonstrated to be of equal effectiveness in the treatment of medical conditions through rigorous studies prior to FDA approval. Generic alternatives contain the same active ingredients as their brand name counterparts and are identical or within an acceptable bioequivalent range to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties. For these reasons, the continuation of the brand name Tenormin is not medically necessary in this case based on the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year, seven-month-old male enrollee has requested authorization and coverage for circumcision for treatment of the enrollees physiologic phimosis.  Findings:  The physician reviewer found that McGregor and colleagues defined phimosis as the inability to retract the foreskin. The authors discussed the importance of distinguishing physiologic and pathologic phimosis, as the former is managed conservatively and the latter requires surgical intervention. The submitted documentation demonstrates that this patient has physiologic phimosis rather than pathologic phimosis. Review of the medical literature does not establish that there is a medical necessity for routine circumcision (Wang, et al.).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for bilateral canaloplasty procedures for treatment of his glaucoma.  Findings:  Three physician reviewers found that the current status of the scientific data, Cheng and colleagues concluded that, Viscocanalostomy and deep sclerectomy were less effective than trabeculectomy in the treatment of open-angle glaucoma. Thus, although some studies suggest that there were fewer documented complications with canaloplasty than trabeculectomy, Mosaed and colleagues concluded that, Trabeculectomy is still the most effective IOP-lowering procedure performed today despite the potential complications. Accordingly, the requested canaloplasty has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested bunionectomy procedures (28296 and 28310) and surgical shoes (L3260 x 2) for treatment of her bilateral hallux abductovalgus with bunion.  Findings:  The physician reviewer found that based on review of the available records, the patient has a bilateral moderate bunion deformity. Flex exam showed an increased intermetatarsal angle by 13 degrees, and a sesamoid position of 7 on the right, and 6 on the left. These radiographic findings are clinically consistent with the clinical findings of hallux abducto valgus. However, there is no documentation of failed conservative treatment options including alternative shoe gear, padding, anti-inflammatory treatments consisting of oral medications or local steroid injections, and orthotic therapy. A review of the literature indicates that when symptoms begin to interfere with a patients lifestyle, initial conservative treatment is often self-directed (i.e. lower heeled/wider shoes, bunion pads, ice, and over-the-counter analgesics). In addition, if the self-directed treatment fails and the patient is referred to a podiatrist, the patient should also undergo conservative treatment options before surgical correction is considered. Given the lack of documentation of adequate trials of self-directed treatment and provider recommended conservative measures, the requested services have not been established as medically necessary in this patients care at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old male enrollee has requested for proton beam radiotherapy for treatment of his prostate cancer. Findings:  The physician reviewer found that there is a lack of evidence in the literature demonstrating that the outcome after proton therapy, either with respect to PSA control, tumor control, or toxicity, is better than intensity modulated radiation therapy.  Of note, the bulk of data for proton therapy with prostate cancer is from patients with low-intermediate risk prostate cancer.  A recent review article by Mendenhall and colleagues addresses treatment of these high-risk patients, but makes no mention of the use of proton therapy.  All told, the requested proton beam radiotherapy is not medically indicated 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 speech therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive and receptive speech of approximately 40 to 50% per the Rossetti Infant-Toddler Language Scale and the Developmental Profile III.  Speech therapy is indicated with any delay greater than 25%. Extensive review of the literature, including the meta-analysis by Law and colleagues, noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately 50% of children delayed at two years of age catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who did not receive early intervention. Children who participate in speech-language treatment show better improvement as compared to children who have no treatment.  This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested mental health outpatient therapy at a frequency of five times per week for treatment of her bipolar II disorder.  Findings:  The physician reviewer found that the data reviewed do not support more than two psychotherapy sessions per week. There has been no appreciable change in her GAF score over the years, and there is no documented history of inpatient treatment or evidence that the patient is at risk for hospitalization. There is no indication that there has been an effort to link the patient to community support services. While the patient may have a contraindication to a rechallenge with lithium, medications with evidence-based thymoleptic action comprise many different classes, and there is no known medical contraindication to all of them.  American Psychiatric Association practice guidelines indicate that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention that addresses illness management and interpersonal difficulties. Although not adequately studied to provide evidence-based documentation, supportive and psychodynamic psychotherapy are widely used in addition to medication. These guidelines support therapy as an adjunct to medication management.  All told, based upon current evidence-based practice standards and expert consensus, mental health therapy at a frequency greater than two times per week was not and is not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested for emergency department services  indicating that her condition was  emergent or urgent in nature. Findings:  The physician reviewer found that the patient presented to the Emergency Department for evaluation of painful blisters with surrounding red skin at the end of her nose. Based on the documentation, her presentation appears consistent with a Herpes zoster infection (shingles) with Hutchinsons sign (lesions at the tip of the nose). The importance of Hutchinsons sign is that it signals the involvement of the ophthalmic branch of the 5th cranial nerve. A Herpes infection of the eye can be a serious problem. In light of the patients facial pain and appearance of the lesions, it was reasonable and prudent to go to the emergency department for further evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for anesthesia services for treatment of the her colonoscopy.  Findings:  The physician reviewer found that conscious sedation provided by the gastroenterologist is routinely utilized in uncomplicated colonoscopies. Review of the submitted records reveals no factors in this patients history that would place her at high risk for conscious sedation. Nor has any clinical evidence been provided which documents the reasons MAC was utilized for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested for excision (mastectomy) along with suction-assisted lipectomy for treatment of his bilateral gynecomastia. Findings:  Two physician reviewers found that treatment of gynecomastia has shifted from a purely open excisional treatment versus some type of lipectomy (suction-assisted versus ultrasonic) or some combination of both. Standard treatment as documented in the above references generally reserves severe cases for the solely open approach. Liposuction is not considered investigational and is standard of care.  It is well accepted in the plastic surgery field.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested for emergency services indicating that the services at issue were emergent in nature. Findings:  The physician reviewer found that the patient presented to the Emergency Department with an exudative infection of his throat (tonsils) that was obvious on visual inspection and was associated with significant pain, enlarged regional lymph nodes and a high pulse rate. These symptoms had been progressing over a two-day period and had reached the point where a prudent layperson would reasonably expect that he had developed an emergency medical condition which required immediate attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for a hearing aid replacement for treatment of his bilateral sensorineural hearing loss.  Findings:  The physician reviewer found that in the peer reviewed medical, Saunders and Cox noted that considerable counseling is required to create realistic expectations in patients regarding use of hearing aids. Further, Goggins and Day found that at three years minor interventions for the hearing aid are usually required, but does not indicate that the devices need replacement. Given that this patients hearing is stable and he currently has a functioning hearing aid, the request for a replacement device has not been established as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested for the Dynamic Adjustable Finger Extension Device for treatment of his post comminuted fracture of the proximal interphalangeal joint of the left hand.  Findings:  The physician reviewer found that there is a lack of consistent and quality evidence of the efficacy of splinting of the hand in the effort to gain or retain motion.  It is not clear whether stretching induces lasting motion increases in patients with functionally significant contracture. The use of stretching devices is considered medically necessary in appropriate patients undergoing physical therapy, who are less than four months from the surgery.