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 for speech therapy for treatment of the enrollees expressive and receptive language delays. 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.   As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, school attainment, and behavior.  These reviewers noted 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-language therapy, particularly for children with primary expressive language disorder.  This patient has significant expressive language delay and mild receptive language delay that is significantly impairing his ability to communicate effectively.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested a new vacuum-assisted socket system leg prosthesis (L5981 and L5781) for treatment of his status post right below knee amputation.  Findings:  Three physician reviewers found that in this clinical situation, a portion of the requested device is likely to be more beneficial than other available treatment options.  Code L5981 (FlexWalk foot) is likely to be more efficacious than other treatment modalities, and code L5781 (vacuum pump suspension) is not likely to be superior over other treatment options.  A FlexWalk foot is standard equipment for a community ambulator.  In a review by Hofstad and colleagues, the authors noted functional benefits of feet such as the FlexWalk in trans-tibial amputees during decline and incline walking and increased walking speeds.  However, there is a lack of high-grade medical literature supporting the marginal efficacy of a vacuum pump assisted suspension over conventional suspension options with respect to functional or health outcomes in the setting of a trans-tibial amputation.  There are no indications in the available records that the patient has failed other appropriate conventional suspension options.  Therefore, a portion of the requested device (L5981) is likely to be more effective than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested authorization and coverage for sclerotherapy and echo guide for biopsy.  The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins.  Findings:  Three physician reviewers found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy at the frequency of two days per week for 30 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that an extensive review of the literature including meta-analysis by Law and colleagues noted positive effects of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. The authors noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Data further suggests that approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while those who participate in speech and language therapy show better improvement than those children who are untreated. Similarly, Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment and reported statistically significant improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. Consistent with these findings, the requested speech therapy in this case is medically necessary to address this patients speech and language delays. This patient should also undergo a follow-up speech and language evaluation given that the patients initial evaluation was performed more than one year ago.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees neck pain.  Findings:  Two physician reviewers found that cervical medial branch radiofrequency neurotomy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurotomy in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In reviewing the submitted medical records, this patient has had a spinal fusion in the area to be treated with radiofrequency ablation. The medical literature does not support the efficacy of radiofrequency ablation at levels in which the medial/lateral branches are already disrupted, that is, have been treated with spinal fusion.  This patient had two cervical spinal fusions. If there is disruption of the cervical medial branches, then there is nothing to ablate and it is less likely the patient will benefit from cervical medial branch radiofrequency. Further, a study by Cohen, et al. proposed that cervical facet denervation was less likely to be beneficial due to poor selection criteria. One of the variables affecting outcomes was prior surgery and the levels treated. Dreyfuss, et al. performed a prospective audit to establish the efficacy of medial branch neurotomy under optimum conditions. They determined that medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. They also determined that adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. If the anatomy were disrupted as possible in spinal fusion, it would be difficult to adequately coagulate targeted nerves if they are still present.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder.   Findings:  Three physician reviewers found that the data reviewed fail to indicate that the requested services are likely to be more beneficial than other available treatment alternatives.  Details of past trials of medications, such as dose, length, degree of compliance, tolerance, and degree of response, or lack thereof, have not been documented. Additionally, the American Psychiatric Association indicates that electroconvulsive therapy is the most effective treatment for depression.  The current research does not demonstrate the superiority of transcranial magnetic stimulation therapy over antidepressant medications. Thus, the requested transcranial magnetic stimulation therapy is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested chiropractic care (including intersegmental traction, massage, joint manipulation, or spinal manipulation) for treatment of his muscle rigidity secondary to Parkinsons disease.  Findings:  Three physician reviewers found that after careful review of all submitted documentation, there is insufficient clinical documentation that supports the clinical indication for the requested chiropractic services. The submitted notes from the provider are vague and lack all clinical/record keeping requirements for chiropractic care. The provider fails to establish that the patients treatment plan is beneficial for his diagnosis or that the services are more beneficial than standard alternatives. Specifically, the submitted documentation of the physical examination and subsequent visits lacks documentation of any evaluation of the patients musculoskeletal/nervous system, documentation of duration and frequency of visit, indication of treatment goals and objective measures evaluating the patients response. Moreover, there is no evidence of incremental improvement from visit to visit in terms of activities of daily living or functionality. According to the Council on Chiropractic Practices and the Centers for Medicare and Medicaid Services (CMS), the treating provider is expected to keep and maintain adequate case records showing progression of care, diagnosis, clinical impressions, assessment of the patients condition, and treatment effectiveness. However in this case, the provider has not shown that the treatments provided this patient with muscle rigidity caused by Parkinsons disease have been or are more likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested residential treatment center (RTC) level of care services for her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has a long history of bulimia nervosa. She was placed in the residential treatment facility due to apparent out of control eating behavior. Applying the American Psychiatric Association (APA) treatment guidelines for patients with eating disorders, as of the said date this patient was no longer showing signs or symptoms which would require the residential level of care. The treatment records indicate the patients eating disorder was much improved to the point where she required very little intervention and could have been transitioned to a less restrictive treatment environment. Overall, she did not require the supervision and direction provided in a residential treatment facility during the period under review and there is no documentation in the treatment notes that the patient was likely to relapse with a lesser level of care during this timeframe.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her back, shoulder and neck pain secondary to macromastia. Findings:  The physician reviewer found that this patients condition may constitute an abnormal structure of the body however the documentation fails to establish that the patient has attempted and failed adequate conservative care. The patients photographs depict large breasts, but first-line treatment includes non-invasive therapies with medications such as non-steroidal anti-inflammatory drugs (NSAIDs), PT and supportive garments. This patients provider noted one month of PT. In general at least three months of PT is considered appropriate in order to fully address the patients issues. In addition, there is no evidence that the patient has undergone an adequate trial of supportive garments without improvement of her back, neck and shoulder symptoms. For these reasons, the requested surgery has not been established as medically necessary at this time, or reconstructive in nature, as first-line modalities have not reportedly been exhausted in this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested a referral to pain management department and/or treatment with acupuncture for treatment of the enrollees ovarian cysts.  Findings:  The physician reviewer found that although there has also been a growth in acupuncture research, at this time the findings from numerous literature reviews indicate there is inconclusive evidence to support the use of acupuncture to treat reproductive health complaints. The symptoms of the menopause and dysmenorrhea have been subject to greater clinical evaluation through randomized clinical trials and the evidence summarized in systematic reviews than any other reproductive health complaint. Overall, the evidence for acupuncture to treat dysmenorrhea and menopause remains unclear, due to small study populations and the presence of methodological bias. Acupuncture to treat premenstrual syndrome, polycystic ovarian syndrome and other menstrual related symptoms has not been as widely studied, and the evidence for acupuncture to treat these conditions is frequently based on single reports. This patients provider states that the patient has painful and recurrent ovarian cysts. However, there are no peer-reviewed studies in the medical literature specifically evaluating the efficacy of acupuncture in the treatment of ovarian cyst pain. For these reasons, the requested acupuncture therapy has not been shown to be medically necessary for treatment of this patients pain related to ovarian cysts as it is not within the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested an open MRI of the lumbar spine for evaluation of her lumbar spine condition.  Findings:  The physician reviewer found that according to the American College of Radiology Guidelines, the appropriateness of MRI is based on an individuals clinical history and physical examination findings. The indications for an MRI include the evaluation of such problems as degenerative disc disease, suspected spinal stenosis or bone metastases, and suspected infections; however, there is need for appropriate clinical evaluation prior to pursing this modality. (InterQual criteria) Studies have not shown improvement in treatment outcomes with MRI when not supported by objective tests and physical examination findings. (Rondsari and Jarvik) In the case of this patient, there is a lack of detailed documentation of the history of the patients problem. There is no documentation of the physical findings identified, other than tenderness. Further, there is no documentation of conservative treatment or the patients response to such measures. In the absence of such documentation, the medical necessity of an open MRI of the lumbar spine is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a power operated vehicle (POV) scooter for treatment of her sciatica and degenerative arthritis.  Findings:  The physician reviewer found that based on review of the available records, the patient is independent in mobility within her home and is independent with all MRADLs including home management. The Centers for Medicare and Medicaid Services (CMS) state that a power mobility device such as a power wheelchair or scooter is medically indicated for patients who have a mobility related deficit that impairs their ability to safely perform MRADLs within the home. In addition, the condition is not able to be ameliorated by a walker, cane or manual wheelchair. This patients records indicate that she has a personal mobility deficit, but is independent in all MRADLs within the home with a wheeled walker. Thus, applying the CMS guidelines, the requested power operated scooter has not been shown to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested weekly marriage counseling for treatment of his relationship issues. Findings:  The physician reviewer found that the documentation indicates that the patient has been separated from his spouse.  The medical notes indicate that his spouse has reported that she wants a divorce. Furthermore, the couple is receiving counseling through their place of worship. Given that the spouse does not appear motivated, marital therapy is unlikely to be successful.  Additionally, this would be redundant to the services that they are already receiving. The data reviewed fail to establish that the requested weekly marriage counseling is necessary or would likely have a successful outcome. The submitted documentation does not establish that weekly marital therapy is indicated at the present time according to current-evidence based practice standards and expert consensus. The Health Plan has authorized coverage for marriage counseling at a frequency less than weekly.  The submitted documentation does not demonstrate that marriage counseling at a frequency greater than the authorized frequency is medically indicated.  All told, the requested weekly marriage counseling is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested occupational therapy for the enrollees developmental delay.  Findings:  The physician reviewer found that in this patients case, the therapy at issue was medically necessary.  This patient demonstrates deficits in fine motor skills, sensory processing, functional skills, self-help skills, and communication. Children with deficits in the complex handling of sensory information have sensory integration dysfunction, often in conjunction with other neurodevelopmental disorders.  These children are less able to successfully participate in and develop the occupations of childhood, such as play, social interaction, and learning. Research demonstrating the efficacy of sensory integration treatment based on sensory integration theory has been published.  Its theories provide a framework from which occupational therapists can generate treatment plans for children with sensory integration disorders and functional deficits that will allow them to successfully participate in the occupations of childhood.  This patient has deficits in fine motor skills and self-care skills, as well as performance of activities of daily living. With its focus on developing motor planning skills, teaching self-help skills, and developing fine motor skills, occupational therapy was well-suited to affect positive change in this patients case. All told, occupational therapy provided during the said timeframe was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested PET scan with CT attenuation for evaluation of her metastatic parosteal osteosarcoma. Findings:  Three physician reviewers found that in this case, the diagnostic procedure at issue was likely to have been more efficacious for evaluation for tumor recurrence or additional metastases as compared to other tools for evaluating this patient.  In this clinical scenario, the PET scan with CT attenuation would have impacted treatment planning.  The current medical evidence supports the diagnostic procedure in this clinical situation.  All told, the PET scan with CT attenuation provided was likely to have been of greater benefit than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested right peroneal nerve surgery for treatment of her peroneal nerve entrapment.  Findings:  The physician reviewer found that at issue is the medical necessity of surgery to release entrapment of the right peroneal nerve. There is limited relevant literature regarding peroneal nerve entrapment surgery. In a study by Fabre, et al. it was described that in the 60 patients who had entrapment of the peroneal nerve, electrophysiological studies were performed for all patients in order to confirm the diagnosis. The results were generally favorable and the authors recommended operative decompression when symptoms persist or recovery remains incomplete for three to four months, provided that the diagnosis has been confirmed with electrophysiological studies. In the case of this patient, there is no evidence of electrophysiological or imaging studies to objectively demonstrate entrapment of the right peroneal nerve. Further, based on the results of the patients previous left peroneal nerve procedure, surgery on her right peroneal nerve is unlikely to provide any significant benefit.  All told, the clinical evidence provided does not support the medical necessity of right peroneal nerve surgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a full body positron emission tomography (PET) scan for evaluation of her history of stage IV squamous cell carcinoma.  Findings:  Three physician reviewers found that PET/CT scanning is recognized by the Centers for Medicare and Medicaid Service (CMS) in the staging and follow-up treatment of head and neck cancer. The peer-reviewed medical literature demonstrates that PET/CT scan has been proven to detect head and neck tumor recurrence when it may be undetectable by other clinical methods. Additionally, fluorodeoxyglucose (FDG) permits highly accurate detection of head and neck cancer recurrence in the post-therapy period (Lowe, et al.). The early detection of head and neck cancer can improve survival rates. In this case, the patients provider states that the patient has no evidence of disease (NED) at this time, however, she continues to have pain in her neck on the right side. The provider indicates that this is likely fibrosis status post surgery and radiotherapy, however, the patients pain has not responded to physical therapy exercises. Therefore, this patient is not asymptomatic and given the sensitivity of PET/CT scans in detecting recurrence of head and neck cancer, it is reasonable for this patient to undergo another PET/CT diagnostic exam to rule out the recurrence of tumors.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested artificial disc replacement surgery for treatment of his back pain.   Findings:  Three physician reviewers found that the medical records noted low back pain due to degenerative L5-S1 disc.  The Health Plan has denied coverage for the requested procedure.  The patient has appealed this denial.  The superior efficacy of the requested procedure in this clinical situation has not been established.  There are insufficient long-term, randomized, controlled trials documenting the superior efficacy and safety of lumbar disc replacement over the standard treatment, one-level lumbar arthrodesis.  The long-term adverse effects of arthroplasty materials, specifically wear debris from metals and polymers, are not known at this time.  The current medical evidence does not support the requested procedure in this patients case.  All told, the requested artificial disc replacement surgery is not likely to be more efficacious than other available treatment options in this patients case.