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 authorization and coverage for speech therapy at the frequency of two sessions per week for one hour per session.  The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Additionally, there is an 18% to 32% delay in pragmatics.  Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including a meta-analysis by Law, et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick also note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Therefore, speech therapy is medically necessary for this patient for two hourly sessions per week.
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 sessions at the frequency of twice per week for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patients speech is at a 13-month receptive level as tested by the In-Plan speech therapist. The etiology of his speech delay is due to a severe developmental delay in his maturation of speech. From the limited available information and his near normal receptive language, the patient is probably intellectually normal.  Regarding the medical necessity of speech and language therapy, it is the medical communitys standard practice to offer speech therapy to a 2-year-old whose speech is at the 3rd percentile for his age. There is a robust medical literature supporting the efficacy of speech therapy in this patient population (Law, et al). In addition to data supporting the efficacy of speech therapy, Goorhuis-Brouwer and Kniff found that cognitive delays did not prevent patients from benefitting from treatment. Further, Buschmann and colleagues concluded that although catch-up development is to be expected in a substantial proportion of late talkers, our data demonstrate that a general wait and see approach is not justified in young patients with language delay. Consistent with the support in the clinical studies and standards of practice, speech therapy is medically indicated for this patient with speech delay. The recommendation is for one hour per week of speech therapy for six months followed by speech re-evaluation. If the patient demonstrates improvement, but still has continues with significant expressive delay, speech therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male has requested speech therapy services at a frequency of three sessions per week for 30 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that the key to this members case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health.  Thus specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. I find the requested services to be medically necessary based on overall evaluation of the literature and this patients medical records.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Botox injections at a frequency of every 3 months for treatment of her chronic migraine and cervicalgia.  Findings:  Three physician reviewers found that on review of the available peer reviewed, published, medical literature, the requested Botox injections are not likely to be more beneficial for the treatment of the patients chronic daily headaches than any available standard therapy. Overall, there is a paucity of medical literature supporting the efficacy of Botox in this patient population. Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches and reported approximately seven more headache free days compared to baseline with Botox. However, the authors concluded that the primary time point difference for Botox when compared to placebo was not statistically significant. Similar results were achieved in the study from Silberstein and colleagues. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The researchers found that there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. Thus, Botox injections for episodic, chronic, tension-type headaches or migraines has not been established as likely to be more beneficial than conventional modalities for management of this patients condition.
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 speech delay.  Findings:  The physician reviewer found that in the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested continued lab testing utilizing CPT code 83701 (high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed) for evaluation of his hyperlipidemia.  Findings:  Two physician reviewers found that current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. Lipoprotein measures should improve patient management, particularly through more accurate risk classification and guiding choice of therapy. To date, the most useful measures obtained from lipoprotein tests relate to atherogenic particle number.  However, at this time, non-HDL cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength.  In this particular patients case, there would be no additional therapeutic intervention regardless of the apolipoprotein sub-fraction. It is unclear whether adding the lipoprotein sub-fraction test for further cardiovascular risk prediction is useful or whether there is any further relevant prognostic information to be gained with this test.  Therefore, the requested continued lab testing utilizing CPT code 83701 (high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed) is not likely to be more beneficial than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested magnetic resonance neurography for evaluation of her left upper extremity neurologic symptoms.  Findings:  Three physician reviewers found that magnetic resonance neurography is used to better delineate nerves which are not well-evaluated on conventional magnetic resonance imaging. Magnetic resonance neurography has been studied to supplement diagnostic evaluations by electromyography and nerve conduction studies in patients with suspected peripheral nerve tumors, chronic compression, traumatic injury, post-irradiation neuritis, and pain syndromes where an anatomic lesion is suspected.  At this time, there is a lack of support in the medical literature demonstrating the superior efficacy of the diagnostic procedure at issue.  Large-scale, well-conducted studies are warranted.  Magnetic resonance neurography is not a first-line technique and should be used to supplement other diagnostic evaluations.  In this patients case, there is no indication that the patient had additional nerve conduction studies, electromyography or conventional magnetic resonance imaging.  Thus, the magnetic resonance neurography provided on the said date was not likely to have been superior over other available modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Orthovisc injections for treatment of his shoulder pain. Findings:  Three physician reviewers found that in this patients case, the requested Orthovisc injections are not likely to be more efficacious than other available treatment options.  The long-term safety and efficacy of the use of intra-articular injections of viscosupplementation for joints other than the knee has not been demonstrated at this time.  There is a lack of randomized controlled trials supporting the use of Orthovisc injections for the shoulder. Guidelines from the American Academy of Orthopedic Surgeons for the treatment of shoulder arthritis do not recommend injectable viscosupplementation in this clinical situation. The current medical evidence does not support the requested Orthovisc injections in this patients case.  All told, Orthovisc injections are not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old male have requested  intensive reflex integration (Masgutova-based) therapy for treatment of his autism.  Findings:  The physician reviewer found that the literature does not support the use of an alternative treatment modality such as intensive reflex integration (Masgutova-based) therapy for the treatment of autism. Accepted therapies in this setting include speech therapy, occupational therapy, physical therapy, and applied behavioral analysis. These modalities have been shown to be effective in treating behaviors associated with autism spectrum disorders (Warren, et al.; Rogers, et al.; and Meyers, et al.). Methods that are based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. At this time, the benefit of intensive reflex integration has not been established in this patient population. There are no peer-reviewed, evidence-based studies that support this form of treatment for autism and therefore, the treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for psychotherapy and medication management for treatment of her depression and obsessive compulsive disorder. Findings:  The physician reviewer found that there is no evidence that a regular risk assessment has been completed despite a history of suicidality, and there is no indication of a plan for managing early warning signs of relapse.  There is no indication that frequent medication dose adjustments have been made, and the majority of notes do not make specific indications regarding what medications the patient is taking. American Psychiatric Association practice guidelines indicate that patients should be cared for in the least restrictive setting that is likely to be safe and effective.  The documentation fails to establish the medical necessity of the services at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested for physical therapy for treatment of the enrollees gross motor delays.  Findings:  The physician reviewer found that in the medical literature, one article suggests that the Peabody Developmental Motor Scale (PDMS) is accurate in evaluating patients over a 6 month period (Palisano, et al). This patient was evaluated with the PDMS on 12/22/10 with findings suggestive of a 31% delay in locomotion, 38% in stationary, and 50% in reflexes, but the patients fine motor skills were reportedly within normal limits. However, further studies indicate that physical therapy for gross motor skills in high risk infants is not clearly beneficial. Given the differences in outcomes of the PDMS and the Early Intervention Developmental Profile (EIDP), Maring and Elbaum concluded that, Developmental tests should not be the sole determinant of the clinical decision making processes. Consistent with the lack of scientific data supporting the efficacy of physical therapy in this patient population, the requested therapy has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-month-old male enrollee has requested for physical therapy and occupational therapy services for treatment of the enrollees hypotonia and developmental delay. 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. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers. (Shevell, et al.) The main goal of treatment is to enhance the level of functioning. This patient has noted delays of greater than 50% in his gross motor skills, fine motor skills, and adaptive skills. The patient has an underlying chromosomal abnormality with clinical impression of Beckwith Wiedemann Syndrome. Developmental delay is associated with paternally derived duplications of 11p15 detectable by cytogenetic analysis (Shuman, et al). Standard intervention such as infant stimulation programs, including occupational and physical therapies, are often utilized for children with significant functional deficits secondary to Beckwith Wiedemann Syndrome and developmental delay (Shuman, et al).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested manipulation of the spine under anesthesia for treatment of her back pain.  Findings:  Three physician reviewers found that manipulation under anesthesia (MUA) has no proven benefit on analgesic, health or functional outcomes in the management of spinal or musculoskeletal pain. As stated in the Chiropractic Quality Assurance and Practice Parameters (`The Mercy Document,`) the efficacy of MUA is equivocal, meaning that the benefits of the procedure are not clearly established. Further, there is no proven superior benefit of MUA with respect to health or functional outcomes in comparison to a conservative therapy program including pharmaceutical management, self-applied modalities and a committed self-directed exercise program. Thus, although there are anecdotal evidence including case reports and case series suggesting the functional benefits of MUA over standard treatments, there is inadequate scientific data demonstrating that the potential benefits of the procedure outweigh the risks of the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested a consultation with an orthopedic specialist for treatment of the enrollees mild to moderate bilateral foot pronation.  Findings:  The physician reviewer found that foot pronation involves turning the foot outward at the ankle, with preference for walking on the inner border of the foot. While most of these conditions resolve spontaneously, a small percentage will persist unless treated.  It is important to initiate treatment early to optimize treatment. While exercises and specialized orthotics may be helpful for very young children, as the child ages, the likelihood that these will help decreases.  At this point, a referral to an orthopedic surgeon would be appropriate to determine the nature of the problem and the most successful plan of care. In this patients case, the functional positioning of his feet negatively impacts his mobility. He has participated in physical therapy, yet continues to have this problem.  All told, the requested consultation with an orthopedic specialist is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested gastric bypass surgery (Lap-Band) for treatment of her morbid obesity and endometriosis. Findings:  The physician reviewer found that based on review of the available records, this patient is morbidly obese. However, the medical necessity of the requested bariatric surgery cannot be determined based on generally accepted guidelines given the information provided. Applying the National Institutes of Health (NIH) consensus guidelines, documentation of a thorough multidisciplinary evaluation that includes behavioral and dietary evaluations as well as ruling out treatable metabolic causes of obesity with a thyroid stimulating hormone (TSH) level needs to be provided for review. Thus, although the patient states that she has failed dietary efforts in the past, there is limited evidence in the records consisting of one note from the patients primary care provider and a program summary without specific details of the patients weight loss attempts. In the absence of this required information, the requested surgery cannot be approved at this time although it should be noted that the patients BMI meets the criteria for bariatric surgery should she complete the requisite multidisciplinary evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested magnetic resonance imaging enterography for evaluation of her history of pain in the lower right groin area and right lower extremity numbness and tingling.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure.  This patient has known malrotation of the intestines with prior surgical repair of a volvulus.  She has ongoing episodes of severe abdominal pain.  The requested diagnostic procedure is a new imaging study that is most useful in the serial follow-up imaging of patients with known Crohns disease.   Thus, the current medical literature does not support the requested magnetic resonance imaging enterography in this patients case. In this clinical situation, the requested imaging modality is not the standard tool for evaluation. All told, the requested magnetic resonance imaging enterography is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested psychotherapy treatments at a frequency of 2 times per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that this patients records are not entirely clear on the therapeutic process being used and there is little documentation of improvement in the patients condition. According to the practice guidelines published by the American Psychiatric Association (APA), therapy should enable the patient to eventually become independent of treatment. However, the therapy notes suggest that therapy is fostering dependency and does not help the patient eventually become independent. To attain this goal, the patient should receive therapy twice per month but the requested twice weekly psychotherapy has not been shown to be medically necessary for management of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-month-old male enrollee has physical therapy for treatment of the enrollees motor hypotonia. Findings:  The physician reviewer found that cerebral palsy is due to an insult to the brain that controls motor function and to the cerebellum that controls motor tone. The physical pathology is apparent and the anatomical dysfunction is the failure of normal muscle control and movement. Generally accepted standards of care support the use of PT for patients with cerebral palsy. Therefore, it is medically necessary for the patient to receive individual PT for a period of time.  If reassessment at the end of the approved period shows improvement, then PT should continue at the same frequency until the patients motor function is at an age equivalency.