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

The parent of a two-year-old male enrollee has requested speech therapy for one hour, two times per week for treatment of the enrollees moderate expressive language impairment.  Findings:  The physician reviewer found that 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.  The authors noted that 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.  Speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that while most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  This patient has moderate to severe expressive language delay, as well as lesser delays in receptive language and play. These deficits are significantly impairing his ability to communicate effectively and function socially. He has shown progress with weekly therapy to date, and continued twice weekly therapy would facilitate optimal speech and language development. All told, speech therapy for one hour, two times per week, is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested authorization and coverage for radiofrequency ablation/rhizotomy. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees cervical spondylosis and occipital neuralgia.  Findings:  Two physician reviewers found that a review of the record indicates the patient has a history of cervical spondylosis. The providers notes indicate the patient is five months status post C2-T1 posterior cervical fusion and is still having difficulty with pain. The provider noted the patient had extension of 10 degrees, bilateral rotation of 20 degrees, and flexion of 20 degrees. An operative report documents neck pain radiating over bilateral occipital region, left greater than right, treated with facet joint injections. The provider performed bilateral C2-3 and C3-4 facet injections under fluoroscopy. Another provider noted that the patient had complete pain relief for three days after C2-3 facet injections bilaterally. The provider states in his letter that the patient has completed facet injections prior to consideration of the recommended rhizotomy procedure with temporary pain relief. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the patients cervical spondylosis and occipital neuralgia.This patient reportedly experienced pain relief from the first facet injection. However, given this patients previous surgical history including C2-T1 fusion, the benefit of cervical facet joint radiofrequency neurolysis at the level of fusion is not clearly established in the literature. Moreover, there is no documentation of benefit to the second diagnostic facet injection. The requested radiofrequency neurolysis is not likely to be more beneficial than available conventional treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that the literature demonstrates that children with autism benefit from intensive intervention that focuses on increasing the frequency, form and function of communicative acts. Yoder and McDuffle noted that past research has shown that object play, non verbal communication and useful speech are all influenced by various types of interventions in young children with autism, suggesting that therapy is indicated. The standard of care adopted by the medical community as set forth in the evidence based guidelines for autism developed by the American Academy of Neurology and Child Neurology Society includes speech therapy. Specifically, the guidelines state that the evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, including one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists. Given the available peer reviewed medical literature and the patients documented expressive and receptive language delay, the requested speech therapy is medically necessary for treatment of his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested  occupational therapy for treatment of her autism spectrum disorder and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that the effectiveness of occupational therapy (OT) in the treatment of autistic children is well-documented. Pfeiffer, et al. reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the problematic mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children and concluded that sensory integration was effective.  Therefore, it is medically necessary that this patient receive the requested individual occupational therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested authorization and coverage for a standing aid frame. The Health Plan has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee, who is status post spinal stabilization revision surgery.  Findings:  Three physician reviewers found that the patient has a history of muscular dystrophy, scoliosis, and spinal stenosis. She is status post lumbar decompression with fusion. She has subsequent paraparesis and requires a power wheelchair for mobility. She has been receiving physical therapy, but requires assistance with transfers. The patient has requested coverage for a standing aid frame for use at home.  The Health Plan has denied coverage for the requested standing aid frame and reported that the requested equipment is investigational in this patients case.  The patient is appealing this denial.  In this patients case, the current medical evidence has not demonstrated that the requested standing aid frame is likely to be more effective than other treatment options.  There are few studies which examine the efficacy of standing frames for improving strength, function and bone density in paraparetic patients.  There may be benefits in endurance and strength, but there is a lack of definitive evidence in the literature that justifies making a standing aid frame standard of care in this clinical situation. There is a lack of evidence of functional benefit from a standing aid frame.  Thus, the requested standing aid frame is not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for a heavy-duty power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for the enrollees mobility.  Findings:  The physician reviewer found that the records provided do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility related activities of daily living (MRADLs) in the home using an optimally configured manual wheelchair. The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude manual wheelchair use. Exams have shown that the patient is intact neurologically and musculoskeletally. Moreover, the patient has conditions such as obesity, diabetes, hypertension and generalized pains that would benefit from increased physical activity rather than disuse. (Keyser, et al.)Overall, a power mobility device is not medically necessary for this patient based on Medicare guidelines (Dicianno and Tovey). The records provided for review do not establish that the patient would be bed or chair confined without a power mobility device. There are no objective indications that a manual wheelchair would not meet her mobility needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested authorization and coverage for continued partial hospitalization program (PHP) services provided from a specific date and forward. The Health Plan denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that, based on review of the available records, this patient did not require the intensity of PHP treatment for his medical condition. The provider notes indicated that the treating team would like the patient to remain in treatment, but the patient was not comfortable with that. The provider also listed a treatment alternative which was to transfer the patient into a halfway house. The patient was not experiencing any psychotic episodes or intent to harm himself or others. He had been encouraged to go on passes and more passes have been requested. Thus, applying the American Psychiatric Association (APA) treatment guidelines, the records do not support the medical necessity for PHP treatment for this patient for the requested dates. The therapists weekly summary indicated that the patient continued to do fairly well and further supported the position that services at the PHP level of care were no longer medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested one on one speech therapy at the frequency of twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that children with speech delay can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefited from speech therapy (Emanuel, et al; Buschman, et al).   Speech therapy is medically indicated for this child.  The medical community standard for a near three year-old verbally delayed patient, who is functioning at approximately an 18-month level, is to continue speech therapy.  The requested two hours per week of speech therapy is medically necessary, with re-evaluation at six month intervals. If the child demonstrates improvement, but still has significant delays in expressive speech, therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of an 89-year-old male enrollee has requested for skilled nursing rehabilitation services including physical therapy for treatment of the enrollee status post right lower extremity fracture. Findings:  The physician reviewer found that there is no documentation of meaningful participation or potential for meaningful participation with formal therapy services. Further, with regard to medical/nursing care, while the patient has multiple chronic conditions, he has no documented active conditions requiring inpatient hospitalization. Therefore, skilled nursing rehabilitation services/physical therapy are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old female enrollee has requested magnetic resonance imaging (MRI) of the brain for evaluation of her left sided headaches.  Findings:  The physician reviewer found that based on review of the available records, this patient presented with a chronic unchanging headache. The CT  showed no evidence of sinus disease or any pathology and was reassuring such that no further imaging was indicated. According to the American College of Radiology (ACR) appropriateness criteria, the MRI imaging done on the date in question was not indicated as the patients condition was described as chronic, unchanging and there was no sudden onset, clinical evidence of neurological deficit, or suspicion of infection. As the CT scan of the said date was negative and the MRI was not expected to provide any novel information with regard to this patients diagnosis, the diagnostic procedure at issue has not been established as medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 73-year-old female enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the breasts. The Health Plan has denied this request indicating that the diagnostic procedure at issue was and is considered investigational for evaluation of the enrollees diffuse cystic mastopathy.  Findings:  Three physician reviewers found that the patient presents with complaints of breast pain status post reduction mammaplasty. The patient indicates that this pain inhibits adequate compression mammography, so her provider ordered a breast magnetic resonance imaging (MRI). The patients family history is significant for breast cancer in one aunt. The MRI was done as an alternative screening modality with benign findings. The patients request for reimbursement of the MRI has been denied by the Health Plan as investigational in this clinical setting. In this case, the patient underwent MRI of the breast with contrast for screening. The records state that screening mammogram could not be performed secondary to patients pain on compression, but there is no documentation that a screening mammogram was attempted, or that ultrasound was preformed. In the medical literature, the American College of Radiology (ACR) indicates that mammography is still recommended as the screening test of choice. The current guidelines for screening MRI do not include the diagnostic procedure for evaluation of pain (Saslow, et al). All told, MRI should not be used as a substitute for mammography, but as a supplement to mammography. MRI should not replace careful problem-solving mammographic views or ultrasound in the diagnostic setting. As this patient is not within the high risk category for developing breast cancer, the MRI was not indicated and therefore not likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 61-year-old female enrollee has requested acute rehabilitation care for treatment of her medical condition status post cerebrovascular accident (CVA).  Findings:  The physician reviewer found that the focus of acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time due to the natural recovery process but are also amenable to rehabilitation interventions (Turner-Stokes, et al). The role of inpatient rehabilitative care for persons with significant post-stroke functional deficits is relatively well-established in the medical literature (Langhorne, et al.).In the present case, the patient sustained an acute cerebral stroke with severe functional deficits. Despite a prolonged period of inpatient care and rehabilitation, she still had severe functional deficits at the time she was transferred to acute inpatient rehabilitation on the date in question. In addition, she continued to have severe cognitive impairments. She made some modest gains while in acute inpatient rehabilitation but less than a month later, the patient could have been treated in a less intense level of rehabilitative care. Without any expectation of significant improvement in health or functional outcomes with ongoing acute inpatient rehabilitation in comparison to services provided at a less intense level of care, the services provided during the timeframe were primarily for the convenience of the patient and family until transfer could be effectuated to a lower level of care in another state. For these reasons, the medical necessity of the services at issue has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy and occupational therapy for treatment of the enrollees global developmental delay. Findings:  The physician reviewer found that Schaaf and Miller report the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. A controlled study demonstrated the effectiveness of sensory motor therapy in a childhood population (Miller, et al).  Although the study by Robert, et al. is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques. Given this patients medical records and the available peer-reviewed medical literature, it is indicated that this patient will continue to benefit from both occupational and speech therapies. It is therefore, medically necessary that this patient receive both speech and occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that Schaaf and Miller report the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. A controlled study demonstrated the effectiveness of sensory motor therapy in a childhood population (Miller, et al).  Although the study by Robert, et al. is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques.Children with speech delays can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefitted from speech therapy (Emanuel, et al; Buschman, et al).   The medical community standard is to offer both occupational and speech therapy to children with this degree of speech and developmental delay.  Given this patients medical records and the available peer-reviewed medical literature, it is indicated that this patient will continue to benefit from both occupational and speech therapies. It is therefore, medically necessary that this patient receive both speech and occupational therapy. The recommendation is to continue his present combined program of both individual and group speech and occupational therapy for the next 12 months, with reassessment at six and twelve months.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a four-day-old male enrollee has requested reimbursement for emergency room services provided. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature. Findings:  The physician reviewer found that the patient, a then four-day-old male, was brought to the emergency room by his parents due to six hours of crying, decreased oral intake and concern that the patients skin looked yellow. The emergency room physician noted the patient looked very appropriate, interactive and otherwise well. Upon examination of the eyes, the physician indicated that he did not see any jaundice. The patient was not crying in the emergency room and was resting comfortably. His bilirubin was 9.3. The physicians impression was fussy baby. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. This patient met prudent layperson criteria for emergency care because it was reasonable for a parent in this situation to suspect that an infant was suffering from an emergency medical condition given the duration of the patients crying, the lack of feeding and the change in skin color, all of which were abnormal for this patient. Some of these symptoms are also symptoms of potentially life threatening illnesses including sepsis, jaundice, and gastrointestinal disorders of the newborn. The patients symptoms were of sufficient severity (including prolonged crying and refusal to feed) such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to health. For these reasons, the parents decision to seek treatment in the emergency room was reasonable and consistent with the response a prudent layperson would have under these circumstances.