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

The parent of a 12-year-old male enrollee has requested coverage of Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The problem behaviors in this patient include poor self-regulation, aggression toward others, and inappropriate touching. In light of the patients ongoing maladaptive behaviors, ABA therapy was and is an appropriate and medically necessary modality. The patient should continue to receive 10 hours per week of ABA therapy with 1.5 hours per week of clinical supervision going forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested coverage for Tracleer for treatment of her pulmonary hypertension. Findings:  The physician reviewer found that there is a lack of scientific evidence suggesting that Tracleer is superior for the treatment of patients in this clinical setting.  In the patients case, Letairis is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested coverage for Pristiq 100mg for treatment of her fibromyalgia. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) for the treatment of fibromyalgia, there are only three medications that are approved for this indication (Lyrica, Cymbalta, and Savella). Pristiq is not FDA approved for the treatment of fibromyalgia, standard practice in the treatment of rheumatology supports the use of off-label medication in the treatment of this disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male enrollee has requested coverage for occupational therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. A diagnosis of global developmental delay involves a profile that is associated with age-specific deficits in adaptive and learning skills. These deficits are evident in comparison with the skills obtained by same-aged peers (Shevell, et al.).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested coverage for the Bioness (NESS) L300 foot drop system for treatment of her multiple sclerosis and chronic regional pain syndrome. Findings:  Two physician reviewers found that the available literature does not present evidence of long term functional change beyond what would be expected with standard care for the lower extremity (Stein, et al. 2006 and Everart, et al.). All told, the NESS L300 device has not been shown to be advantageous over standard care for foot drop secondary to multiple sclerosis with associated complex regional pain syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for partial hospitalization program level of care services for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that this patient indicate her motivation, self-care skills and recognition of the need for treatment are sufficient for the patient to reduce her eating disorder behaviors and gain weight with outpatient treatment. Applying the American Psychiatric Association (APA) practice guidelines, this patient was a candidate for treatment in a lesser restrictive environment such as intensive outpatient program (IOP).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male has requested electrical therapy, via implantation of neuroelectrodes (CPT 64575)/peripheral lead implantable nerve stimulator for treatment of his chronic back pain.  Findings:  Two physician reviewers found that the patient is status post an L2-3 interbody fusion. The patient also has undergone conservative treatment with epidural steroid injections (ESIs), physical therapy and chiropractic manipulation. The patient continues to have low back pain and a post operative MRI demonstrated facet arthropathy, disc dessication and an annular tear L1-2. The patient is currently receiving treatment with the following medications: Ultram, trazodone and gabapentin. Subsequent to a pain medicine consultation the patients provider recommended a trial of peripheral field stimulation, as the patients pain distribution is likely not amenable to spinal cord stimulation. There is considerable evidence that spinal cord stimulation is an effective treatment for low back and leg pain in properly selected patients. However, there is limited data available in the peer reviewed medical literature examining the effectiveness of peripheral nerve stimulation in patients having axial low back pain without a radicular component, as is the case with this patient. There is not yet sufficient evidence to conclude that peripheral nerve stimulation is likely to be more beneficial for treatment of the patients chronic low back pain than other standard therapies, such as spinal cord stimulation and other less invasive therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested a Pro-Disc cervical artificial disc (cervical intervertebral disc replacement  ProDisc C  code 22856) procedure for treatment of his neck pain and right upper extremity radiculopathy.   Findings:  Three physician reviewers found that the patient has chronic neck pain and is reported to have radiculopathy, however this has not been confirmed by his history nor his physical examination. The patient has not had any motor or sensory symptoms that would correspond with the C4-5 level. Although he has had some paresthesias in his ring and small finger, these symptoms are not consistent with C4-5 symptoms. Moreover, with regard to the overall efficacy of artificial cervical disc replacement utilizing the ProDisc C, there is no data available in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of the device. Although there are a number of published reports which indicate artificial disc replacement with the ProDisc C is promising, these studies are small in scale and of short duration. A study by the Food and Drug Administration (FDA) to determine the long-term safety and efficacy of the ProDisc C is still ongoing and no results have been published. Therefore, there is inadequate evidence demonstrating that the requested procedure is likely to result in a better clinical outcome for this patient as compared to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for a duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is a standard primary treatment for morbid obesity. The peer-reviewed medical literature indicates that this procedure is safe and efficacious in the treatment of morbidly obese patients and has produced durable long-term weight loss outcomes. The American Society for Metabolic and Bariatric Surgery and the American Medical Association based upon numerous published peer-reviewed articles documenting the safety, efficacy and durable long-term outcomes. All told, the requested duodenal switch procedure is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested coverage for inpatient detoxification and comprehensive residential treatment program services for treatment of her opioid dependence.  Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) placement criteria, the patient was not showing severe withdrawal risk which would require management in the acute inpatient detoxification. In addition, she did not require medical monitoring, and there is no documentation of any emotional or behavioral component complications which require the 24-hour structured setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested coverage for Norco for treatment of her chronic low back pain.  Findings:  The physician reviewer found that the patient has not been compliant with following the prescribed medication regimen. There have been inconsistencies, as the prescribed drug has not been present on drug tests. As noted throughout the medical literature, Norco is a potentially addictive medication and stringent controls are therefore in place to monitor its use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater 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. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female has requested Nutropin for treatment of her short stature.    Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of Nutropin in this patients case.  This patients height is 2.6 standard deviations below normal for age and gender, and her growth velocity is suboptimal for mid-puberty.  The patients bone age was 11 years at a chronological age of 11 years 5 months.  Based on her bone age assessments over a five-month period, the estimated final adult height prediction is approximately 57 inches.  This adult height prediction is 3 standard deviations below normal.  Although this patient had normal IGF-1 and IGFBP-3 levels and normal results on provocative growth hormone testing, a subtle defect in the growth hormone/IGF-1 axis is likely, and other causes of short stature have been ruled out.  In this clinical setting, a trial of growth hormone therapy is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested coverage for spinal fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that the patients pain has not been mechanical in nature and there is no evidence of standard indications for fusion such as spondylolysis, spondylolisthesis, instability, scoliosis, fracture, non-union from her previous fusion, or a tumor. Therefore, the patient does not meet accepted criteria, as established in the peer reviewed medical literature, for a lumbar fusion procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested coverage for intensity modulated radiation therapy (IMRT) for treatment of her esophageal cancer. Findings:  Three physician reviewers found that IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. There is a growing body of literature on the use of IMRT for esophageal cancer, with most studies suggesting a dosimetric advantage of IMRT versus conventional 3D radiation, however, there is currently a paucity of clinical outcome data available. IMRT is a tool that enables the reduction of dose to surrounding organs.  There is no literature that explicitly shows that IMRT for esophageal cancer results in superior outcomes versus conventional 3-dimensional radiation techniques.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-month-old female enrollee has requested coverage for speech therapy  for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy has been found to be efficacious in the treatment of speech delays in young children.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to 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, behavior, and school attainment.  Bernhardt and Major concluded that results suggest 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 91-year-old female enrollee has requested for Inderal for treatment of her migraines. Findings:  The physician reviewer found that a review of the peer reviewed medical literature regarding migraine preventives shows that a variety of agents, including beta blockers and neuro-modulators, can be beneficial. Beta blockers are known to be helpful in the prophylactic treatment of migraines and several clinical trials have confirmed that propranolol is effective in the treatment of migraines. Generic medications are required to have tolerances for bio-availability that are very close to that of the brand agent, though they may have a difference in binders and other inactive ingredients. They are generally acceptable for most patients, though for disorders such as epilepsy, where consequences of slight variance of blood levels may result in treatment failure, brand medications may be necessary. While there is no literature showing that brand name Inderal is materially different in migraine prevention than its active ingredient, propranolol, this patient has been treated effectively with Inderal.
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 speech delay. Findings:  The physician reviewer found that this patient has an identified delay in receptive speech of 30% and expressive speech of approximately 35%, with additional developmental delays in adaptive, social-emotional and overall development. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  coverage of speech therapy for treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that a recent controlled study of speech therapy in a large population of pragmatic and socially language delayed children, with and without autism, can be applied to this patient (Adams, et al.). The study reported that speech and language therapy in a population similar to this patient favorably improved language skills, as noted by teachers and parents, but did not significantly improve standardized testing of those children. The conclusion drawn by the authors is that applying standardized testing in autistic children is not a reliable test of improvement of pragmatic speech in this population. It is very difficult to meaningfully test this population of children for improvement or lack of improvement (Adams, et al.). In the case of this patient, while he has remained moderately language delayed over his two years of speech therapy, he did gain two years of language age equivalency during this therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested authorization and coverage for a myoelectric prosthesis and related accessories for treatment of the enrollees congenital absence of left hand.  Findings:  The physician reviewer found that prostheses that are initiated in the chronic stages post-amputation are frequently abandoned (Biddiss and Chau). In the patients case, however, she does appear motivated to learn and adapt to the use of a functional prosthesis given her recent experience following an injury to her intact distal upper limb. The patient has different prosthetic options, which would include a body-powered prosthesis and a conventional myoelectric prosthesis. A myoelectric prosthesiss advantages are primarily related to cosmesis and a greater grip force per unit of effort. The body-powered devices advantages are primarily related to lighter weight, greater fine tip prehension, greater reliability and greater durability. Given that the patient is in a sedentary occupation, a myoelectric prosthesis is not an unreasonable clinical option. There is no published, high-grade, disinterested clinical literature, however, supporting that a myoelectric prosthesis with a i-LIMB terminal device confers significant, marginal functional benefit in the setting of a distal upper limb amputation due to congenital limb deficiency or otherwise in comparison to a conventional myoelectrical prosthesis (or a non-myoelectrical prosthesis). The majority of patients with congenital distal unilateral upper limb deficiency are independent with all activities of daily living without prosthesis (Buffart, et al; Yigiter, et al). Prostheses assist in some bimanual tasks, but no significant, marginal functional benefit with respect to self-care or activities of daily living has been proven. Thus, the i-LIMB hand prosthesis is not medically indicated in lieu of a conventional myoelectrical or non-myoelectrical prosthesis. Overall, the device is expected to be less functional and less durable than a conventional body-powered or myoelectric prosthesis. Consistent with these findings, the requested equipment is not medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested repair of her scar tissue for treatment of her scar status post Cesarean-section.  Findings:  The physician reviewer found that cesarean deliveries are a common and safe operation, which carry a typical risk of wound complications. The patients emergency Cesarean delivery was appropriately carried out with excellent maternal and neonatal outcomes. The transverse (Pfannensteil) incision utilized in this case has a more appealing cosmetic effect and poses less risk of wound dehiscence (Duff). Women who undergo Cesarean-sections, stapled wounds and those closed with subcuticular sutures experience equivalent cosmetic appearance of the scar post operatively (Cromi, et al.). Though patients frequently seek cosmetic improvement for existing scars, this is not medically warranted (Batra). There is no documentation in the submitted medical records demonstrating that the patient has any functional impairment as a result of the scar. As such, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-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 Child and Adolescent Level of Care Utilization System (CALOCUS), this patient meets the criteria for this level of care. Specifically, the patient should be treated in a secure 24-hour residential facility with psychiatric monitoring. The records clearly document the patient to be at substantial risk of harm, have serious functional impairment, there was evidence that outpatient treatment and repeat acute hospitalizations had not resulted in optimal control of the patients symptoms. In addition, the residential level of care is consistent with community standards including the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters. Consistent with this support, the services provided this patient have been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested coverage for bilateral sacroiliac joint injections for treatment of his low back pain. Findings:  The physician reviewer found that the patient has a history of posterior lumbar spine fusion at L4-S1.  The joints below a fusion may become degenerated and serve as a major pain generator for some patients. Conservative therapy has failed to relieve the patients pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female enrollee has requested  for therapy with a mental health provider who specializes in adoption issues for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that a review of the peer-reviewed medical literature suggests that there is much disagreement about the diagnosis and treatment of RAD. Overall, there is no clear gold standard for the treatment of this disorder. The article by Hanson and Spratt noted that, in the recent years, there has been an increase in the number of children diagnosed with RAD. There is considerable disagreement about what this entity actually entails and, in particular, what types of assessments and interventions to use with these children and families. The author expressed concern regarding the consequences of the RAD diagnosis to be the emergence of novel treatments that lack a sound theoretical basis or empirical support, and may potentially be traumatizing and dangerous to the child. The article by Hardy states that, Although evidence for the effective treatment of children with attachment disorders is minimal and inconclusive, the two major perspectives, developmental psychology and neuropsychoanalysis, offer guidelines. There is a lack of support for treatment of this patient with a specialist in attachment disorders.