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

A 64-year-old male enrollee has requested coverage for past hospital care for treatment of his bladder tumor, urinary tract infection and gastritis.  Findings:  The physician reviewer found that in this patients case, hospital care provided on the dates under review was not medically indicated.  During these dates of service, the patient could have been safely and effectively managed in an outpatient setting.  This patient presented with hematuria and was afebrile.  Urinary tract infection was suspected, although culture proved negative.  He also reported vague abdominal discomfort, without urinary retention.  In this clinical scenario, outpatient evaluation would have been appropriate.  Outpatient antibiotics and monitoring status of fever and abdominal pain was medically appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male has requested coverage for magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his chronic back pain.  Findings:  The physician reviewer found that this patient presents with chronic low back pain of uncertain duration. Plain films show degenerative disc space loss at L5-S1. There is no clinical sign of infection or history of tumor. There is no documentation of any neurological abnormality or radicular symptoms. In addition, the records do not describe attempts at conservative therapy such as physical therapy (PT).  In this particular case, there is no discussion of intended or contemplated intervention for this patients low back pain and no evidence of any neurological deficit or symptom to make this requested diagnostic procedure medically necessary. Based upon the given history and lack of red flags in the patients chart, the requested MRI of the lumbar spine is not medically necessary for evaluation of his condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for eye movement desensitization and reprocessing (EMDR)  for treatment of her anxiety and panic attacks. Findings:  The physician reviewer found that the American Psychiatric Association does not recommend EMDR for the treatment of panic disorder; however, it is an accepted treatment modality for select post-traumatic stress disorder (PTSD) patients. According to the Department of Veterans Affairs and Department of Defense practice guideline, EMDR possesses efficacy for treating patients with PTSDWhile the results of numerous controlled published studies found medium to large effect sizes for EMDR, there is no evidence that EMDR is more efficient or rapid than other forms of cognitive behavioral treatment. Similarly, suggestions that EMDR is more easily tolerated than other psychological treatments remain unsupported empirically. While EMDR may be a clinical option in this case, the documentation does not establish that it is medically necessary. EMDR would not be considered medically necessary unless the patient has failed other evidence based treatments for PTSD, as EMDR has been shown to have no significant advantage over other first-line therapies for PTSD such as prolonged exposure, cognitive processing therapy or stress management therapy. As such, the medical necessity of EMDR for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested umbilical artery echocardiography (ECHO), Doppler with color flow add-on, and ECHO of the fetal heart for evaluation of her high risk pregnancy. Findings:  The physician reviewer found that a follow-up ultrasound examination to evaluate fetal growth and anatomy is appropriate in this patient whose anatomic ultrasound was limited by maternal habitus. However, consistent with the Fetal Echocardiography Task Force and American College of Obstetricians and Gynecologists recommendations, there is no indication for fetal echocardiography in this patient without a documented family history of congenital heart disease, concern for fetal cardiac anomalies on prior scan, diabetes or medication exposures. In addition, with no documented risk factors for preeclampsia or fetal growth restriction, there is no medical indication for uterine artery Doppler studies (Sciscione, et al). Therefore, the requested diagnostic procedures are not medically necessary for evaluation and care of this patients pregnancy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male has requested past and future coverage for 50 additional physical therapy (PT) sessions for the dates under review for treatment of his C7 spinal cord lesion.  Findings:  The physician reviewer found that based on review of the available records, this patient has a neuroenteric cyst at the C7 level which is causing his neck and bilateral shoulder and upper extremity pain. The patients right shoulder pain and weakness can be partially attributed to his shoulder pathology. His history is consistent with chronic pain syndrome, given the fact that his pain issues have persisted for more than three months. He is being treated by a psychiatrist for anxiety and depression, both of which are components of chronic pain syndrome. His providers documented that the patient is not a good surgical candidate at this time. One provider described the patients symptoms as difficult to interpret in the context of the lesion. Although PT can help improve pain and function for patients with chronic neck pain, it is unclear how many sessions are adequate and optimal to help control symptoms and improve function. In the medical literature Chiu and colleagues evaluated the efficacy of a neck exercise program for patients with chronic neck pain and found that, At week 6, patients with chronic neck pain can benefit from the neck exercise program with significant improvement in disability, pain, and isometric neck muscle strength in different directions. Despite these findings however, the authors concluded that the effect of exercise was less favorable at 6 months. In one case study, Pastor reported that, Rehabilitation following spinal cord compression injuries often focuses on increasing muscle strength and improving functional gait, but unfortunately, there is no literature to support either of these conventional interventions. Based on these findings, the clinically indicated PT sessions that should be provided include 30 additionally sessions, in lieu of the requested 50 additional PT sessions, per year. Thus, 30 additional PT sessions for the dates under review are medically necessary for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female has requested coverage for a positron emission tomography (PET) scan, or PET scan with computed tomography (CT) attenuation for evaluation of her metastatic breast cancer.  Findings:  Two physician reviewers found that the patient has a remote history of breast cancer discovered and treated in 1995 with known prior axillary spread. She was told she was cured but developed hip and pelvic pain. She was discovered to have metastatic bone disease in 2008 and is being treated for skeletal metastases. Her treating oncologist has requested positron emission tomography/computed tomography (PET/CT) for follow-up of the skeletal lesions to assess treatment success and also to screen the entire body. This patient has evidence of recurrence of her original breast cancer even after 16 years since her initial diagnosis. The tumor has metastasized to bone and the oncologist has requested a PET/CT to assess treatment success. In this patients case, she has had success on most of the bone lesions but there is a spine lesion which has been increasing in metabolic activity suggestive of active metastasis. In addition, this single test (PET/CT) will permit the radiologist to screen the patients other organ systems for metastasis at the same time. Clearly these findings will be relevant in terms of treatment decision making. No other single test allows such multi-system evaluation. For these reasons, the requested PET/CT scan is likely to be more beneficial for evaluation and treatment of this patients medical condition when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female has requested coverage for Roux-en-Y gastric bypass with biliopancreatic diversion with duodenal switch (BPD/DS) for treatment of her obesity status post gastric bypass in 2005.  Findings:  The physician reviewer found that based on review of the available records, this patient is status post gastric bypass in 2005 and currently is morbidly obese. The records indicate that the procedure worked well for the patient with loss of over 170 pounds then regained the weight. On EGD, there was no obvious anatomical failure of the patients previous gastric bypass. The patients chart documents very little surgical follow-up since her prior procedure and no dietary or behavioral follow-up. To be considered for the requested revisional procedure, it is clinically reasonable to ensure the patient is likely to comply with the dietary and surgical follow-up required. Further, revisional surgery is associated with an increased risk of leak and complications, including protein malnutrition, which need to be reviewed with the patient. The records indicate the patient was able to lose weight with the procedure and yet weight regain occurred. For these reasons, the patient may be a candidate for revisional surgery in the future however without documentation of a thorough multidisciplinary evaluation, the requested revisional surgery is not medically necessary for management of her condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested coverage for a wireless capsule endoscopy for evaluation of his medical condition.  Findings:  Two physician reviewers found that the patient is under evaluation for his iron deficiency anemia. The patient has a history of hypertension and alcohol use. Because of suspected gastrointestinal (GI) blood loss or malabsorption of iron, the patient underwent an esophagogastroduodenoscopy (EGD) with small bowel biopsies, which was essentially normal and did not identify a source of bleeding. A subsequent colonoscopy showed a normal colon and there was a punctuate erosion in the terminal ileum which showed non-specific inflammation. He also underwent an MRI, which was within normal limits. His most recent hemoglobin was 12.4 gm/dl. In this patients case, there are no symptoms of malabsorption or inflammatory bowel disease such as diarrhea, abdominal pain, or unintended weight loss and the patients MRI was normal. Thus, there is insufficient data to suggest irritable bowel disease (IBD) based on the data provided. There is no suspicion of a small bowel GI lesion of significance, such as a polyp or neoplasm, based on the provided documentation. Additionally, there is no objective evidence provided to substantiate a diagnosis of anemia in this patient.  In the absence of evidence of an accepted indication for wireless capsule endoscopy, the performance of this study is of speculative benefit and is not likely to be of clinical value.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 1-year, 11-month-old female enrollee has requested coverage for 6 doses of Synagis injections for treatment of her asthma.  Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in infants born prematurely, up to 12 months of age. The most prominent of these factors is a birth weight less than 2500 grams as noted by Holman and colleagues. According to the American Academy of Pediatrics (AAP), older infants who are still less than 24 months of age are considered high-risk if they carry a diagnosis of chronic lung disease or hemodynamically significant heart disease. Thus, while this ex-premature female patient may have been an appropriate candidate for Synagis last RSV season, she currently does not meet the published criteria or fall within a high-risk population based on the scientific studies. Accordingly, the requested Synagis for RSV prophylaxis is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested for residential treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) treatment guidelines for residential treatment the patient meets the criteria for residential level of care during the period under review as she was unsafe to adequately care for her self within the community. Moreover, the patient reportedly experienced a disturbance in mood resulting in behavior that could not be safely managed in a less restrictive setting. Given the patients imminent risk of deterioration in functioning due to the presence of severe multiple and complex psychosocial stressors, treatment in a supervised 24-hour controlled setting was clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested for mole removal for treatment of his mole between his eyes. Findings:  The physician reviewer found that there is no evidence of irregular pigmentation, irritation or bleeding of the lesion. Additionally, there are no documented concerning features of malignancy with the lesion, as the mole is not inflamed, bleeding, or otherwise causing adverse symptoms which would necessitate removal of the benign lesion.  Removal of the mole would be considered cosmetic in this location.  All told, removal of the mole is not medically necessary and the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 10-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that as noted by Law and colleagues, children with speech delay can be successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. Further, one prospective study from Pennington and colleagues commented on the accuracy of speech testing in a two-year-old population. The authors evaluated patients who were diagnosed with speech delays when they tested below the 10th percentile in expressive language. The authors concluded that these patients were correctly diagnosed, which prompted treatment with speech therapy resulting in marked improvement. There is robust medical literature that supports the medical necessity of the requested speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male has requested coverage for intravenous (IV) administration of Ertapenem Sodium for treatment of the his Lyme disease and babesiosis.  Findings:  The physician reviewer found that the patient is reported to have a progressive neurological illness that began in 2005 and was diagnosed as ALS. The available records indicate that the patient was ventilator dependent in 2011. There is little objective data in the medical records to confirm reports that the patient improved while receiving IV antibiotics. The available objective evidence demonstrates that the patient was able to be off of his ventilator for only two to two and a half minutes at a time during the spring of 2011.There are limited diagnostic tools that provide support when diagnosing any tick-borne illness. Specifically, the Lyme IFA is not widely recognized as a valid test and the Borrelia IgM Western Blot test is often falsely positive. A positive Babesia test is reported by the provider in his letter, however there is no laboratory report indicating the type or titer that was provided for review. Given the above information, the reported findings are not diagnostically indicative of any disease. Multiple repetitive tests are required prior to a definitive diagnosis of Lyme disease in any patient. There is no indication that this was performed in this patients case. Additionally, there is a paucity of available peer-reviewed medical literature demonstrating the effectiveness of Ertapenem Sodium in the treatment of Lyme disease. In sum, there is no objective evidence to indicate that this patient has a tick borne disease, nor is there evidence that the antibiotic therapy is being ordered for any other documented infectious disease. Thus, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the standard of care in the medical community would be to continue to provide speech therapy in this setting. A report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. According to the authors, People with ASDs [autism spectrum disorders] have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Thus, the lack of success of the patients prior speech therapy should not be a barrier to further speech therapy. Additionally, the paper by Turner and colleagues is a controlled study comparing autistic children who did and did not receive speech therapy. Those children who did receive therapy by the age of 2 had far greater communication skills by the age of 9 than those who did not receive speech therapy. Further, the report, of the Speech and Language Association states that all autistic children can benefit from speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, nine-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that there is robust medical literature that supports the medical necessity of the requested speech therapy. As noted by Law and colleagues, children with speech delay can be successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. Further, one prospective study from Pennington and colleagues commented on the accuracy of speech testing in a two-year-old population. The authors evaluated patients who were diagnosed with speech delays when they tested below the 10th percentile in expressive language. The authors concluded that these patients were correctly diagnosed, which prompted treatment with speech therapy resulting in marked improvement. Given the support for the efficacy of speech therapy in young patients with delayed expressive language skills, it is medically necessary that she receive speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested speech therapy and occupational therapy services for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the scientific literature supports speech therapy in the treatment of autistic children. People with autism spectrum disorders often have deficits in communication and treatment by a speech therapist is usually appropriate, as most children with autism spectrum disorders can develop useful speech (Myers, et al.). Children who have received speech therapy had far greater communication skills than those that did not participate in speech therapy (Turner, et al.). However, the literature which supports speech therapy for autistic children is not applicable to this patient. There is strong scientific evidence supporting the use of occupational therapy in the treatment of autistic children. Occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis regarding the use of sensory integration techniques in the treatment of autistic children and concluded that sensory integration was effective. Therefore, occupational therapy could improve this patients self-help and play skills within a group setting. Based upon the documentation provided, occupational therapy is a medically necessary modality for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested physical therapy for treatment of her severe right shoulder injury and right hand crush injury in a motor vehicle accident.  Findings:  The physician reviewer found that the patient sustained multiple injuries involving her right upper limb, particularly the hand and digits.  She sustained open soft tissue, tendinous, bony and vascular injuries.  These types of injuries, particularly when affecting the proximal digits, are often complicated by residual pain, stiffness, and dysfunction.  Keys to therapy revolve around early intervention with prolonged, low-load stress to restore and maintain range of motion.  In this patients case, she has undergone extensive hand therapy following her injuries a few years ago.  Despite therapy, she has persistent significant stiffness and dysfunction, particularly at the distal right upper limb.  There is persistent atrophy.  In this case, a significant, sustained benefit with respect to outcomes (e.g., hand function) is not expected with more formal therapy over an independent program.  The patient has had a sufficient number of therapy visits to be able to continue an exercise and modality program independently.  All told, the requested physical therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-month-old male has requested coverage for palivizumab (Synagis) injections for treatment of this infant who was born at 32 weeks gestation.  Findings:  The physician reviewer found that Palivizumab injections are medically necessary in this clinical situation.  There are a number of risk factors that increase the chance of morbidity from respiratory syncytial virus (RSV) in infants born at 32 to 35 weeks gestation. The most striking of these is a birth weight less than 2500 grams.  An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams.  Simoes and colleagues have developed a model based on seven risk factors to predict which infants born between 32 and 35 weeks are at highest risk of severe RSV disease.  In this patients case, his risk factors include gestational age and birth weight less than 2500 grams.  Thus, there is a risk of significant morbidity from RSV disease. The Impact-RSV Study Group examined the effect of palivizumab prophylaxis on severity of illness in premature infants. The authors noted a significant decrease in hospitalization rate for all infants.  Of note, for infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness.  The current medical evidence supports the requested services in this patients case.