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

The parent of a two-year-old female enrollee has requested authorization and coverage for speech therapy, at a frequency of two times per week, for one hour per session for treatment of the enrollees delayed expressive language skills.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  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.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  This patient demonstrates expressive language delay, and this is negatively impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, speech therapy, at a frequency of two times per week, for one hour per session, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-month-old male enrollee has requested authorization and coverage for TREX1 genetic testing for evaluation of the enrollee, who has a history of global developmental impairment with associated cerebral calcifications.  Findings:  The physician reviewer found that the submitted documentation supports the requested testing in this patients case.  This patient has clinical features of Aicardi-Goutieres syndrome, including low birth weight, nystagmus, strabismus, progressive microcephaly, spasticity, periventricular and basal ganglia calcifications, and severe global delays.  Per the submitted medical records, the patients TORCH titers were reportedly normal, making Aicardi-Goutieres syndrome a likely diagnosis.  This disorder results in significant health problems.  Thus, establishing the diagnosis is indicated in this patients case.  All told, the requested TREX1 genetic testing is medically necessary for the evaluation of this patient.
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 for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the patient has identified delays in his receptive speech of 44% and in his expressive speech of approximately 56%, with mild cognitive delays. 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. All told, in this patients case speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested coverage for Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has significant cognitive delays, deals with minimal frustration with tantrums and screaming and is a danger to himself, as he frequently runs away. The patient has participated in ABA therapy for at least the past two years and he has since achieved very slow, but definite behavioral improvements. Despite the patients slow improvement in response to ABA therapy, ABA therapy remains the standard of care for the treatment of autism.  The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, ABA therapy has been proven to be effective in multiple controlled studies. This patient has been diagnosed with autism and ABA therapy remains the documented therapy of choice. However, there is limited evidence regarding the age at which ABA therapy should be discontinued. Generally, ABA therapy is slowly tapered beginning at the age of eight. The recommendation by the patients provider for 1.5 hours daily of ABA therapy is medically appropriate for this patient, as are the recommended supervision and parental guidance sessions, with a cumulative total of 35 hours of ABA therapy per month. As such, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested coverage for hernia surgery for treatment of his bilateral inguinal hernias. Findings:  The physician reviewer found that there is no evidence that the inguinal hernia is causing his pain or contributing to any gastrointestinal symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male has requested Sculptra injections for treatment of his lipodystrophy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services at this time.  HIV lipoatrophy is a common complication of HIV retroviral therapy.  Sculptra is an established treatment for facial wasting directly related to this therapy.  In general, there is no functional deficit to facial wasting.  Current photographs were not provided in this case.  The most recent photographs provided were from two years ago.  Therefore, the medical necessity of the requested Sculptra injections has not been established at this time.  In this patients case, he has lipoatrophy, which is a known complication of medical treatment.  This is considered to be an abnormal structure of the body, and this is caused by HIV medication in this patients case.  However, because current photographs were not submitted, the degree of abnormality and the patients current condition cannot be assessed.  In this case, the submitted records do not allow for an assessment regarding whether Sculptra injections will offer more than a minimal improvement in the appearance of the patient.  Recent photographs and documentation of current degree of severity are needed to establish the patients current condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested coverage for an out-of-Plan referral for neurovascular assessment for treatment of her lightheadedness and near syncope.  Findings:  The physician reviewer found that the differential diagnosis for such symptoms is broad and includes hyperventilation, orthostasis, arrhythmia, metabolic disturbances, and anxiety. Della-Morte and Rundek reported that, vertigo, nausea, and vomiting, along with nystagmus, represent symptoms of stroke in posterior fossa due to arterial occlusion or rupture of the vertebrobasilar system. In addition, the literature shows a variety of presentations of carotid-jugular fistula, typically including pulsatile mass, or potentially with congestive heart failure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old female enrollee has requested authorization and coverage for a licensed nursing professional (registered nurse (RN), licensed vocational nurse (LVN), public health nurse, or licensed home health aide) performing home health care services for treatment of the enrollees premature birth.  Findings:  The physician reviewer found that based on review of the available records, this one-year-old patient now has a corrected age of approximately nine months. At 10 months of age, she was able to scoot and could tentatively sit. These developmental parameters, when adjusted for prematurity, indicate that the patient is developing normally. The problem is the unavailability of the patients mother as a caregiver secondary to severe diabetes with multiple complicating problems. The patients care is being shared by the patients paternal grandfather and a paternal step-aunt, both of whom cannot be continuously available. The patients medical needs are relatively simple. The patient requires frequent oral feedings supplemented by gastrostomy feedings during the day and a continuous gastrostomy feedings at night. However, this care does not require the services of a skilled caregiver such as a licensed vocational nurse or home health aide. The grandfather and aunt are under stress caring for this patient and her mother but have provided adequate care. The patients medications are relatively simple and can be given via gastrostomy if the patient refuses them orally. Given that this care does not require the services of a licensed nursing professional registered nurse, licensed vocational nurse, public health nurse, or licensed home health aide, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested coverage for continued acute in-patient adolescent level of care with discharge/step-down to a psychiatric residential treatment program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the American Academy for Child and Adolescent Psychiatry (AACAP) Practice Parameter for depression, states the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for continued speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. 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. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested coverage for past inpatient psychiatric treatment of her major depressive disorder and bulimia nervosa.   Findings:  The physician reviewer found that based on review of the available records, this patient was very disturbed and lived within the context of a dysfunctional family setting and had a volatile relationship with her boyfriend. While in the facility she gained little insight and few skills concerning her living back at home. Her thoughts of suicide and self harm continued through the last progress note. Almost no progress was documented to adequately transition her back home or to an alternative setting. Despite limited progress, the patient remained at severe risk for escalation of her behaviors and a re-hospitalization. Consistent with the American Psychiatric Association (APA) treatment guidelines, this patient was not a candidate for treatment at a less restrictive setting and required the intensive medical care provided at the inpatient psychiatric level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 76-year-old male enrollee has requested coverage for continued skilled nursing facility services for post stroke. Findings:  The physician reviewer found that the keys to acute stroke care include cerebral reperfusion interventions, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses.  Functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant post-stroke functional deficits is well-established in the medical literature.  In this case, the patient sustained an acute hypertensive stroke and has become severely debilitated.  He has undergone extensive inpatient care, but he has not made significant progress to date.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old female enrollee has requested authorization for speech therapy for treatment of the enrollees moderate expressive language impairment. Findings:  The physician reviewer found that 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. Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient appears to have made modest improvements in his speech and socialization skills while receiving 20 hours per week of ABA therapy over a 9-month period. Due to the patients slow progress, an increase to 25 hours per week of ABA therapy was recommended. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, ABA therapy has been proven to be effective in multiple controlled studies. This patient has been diagnosed with autism and ABA therapy remains the documented therapy of choice. However, there is limited evidence regarding the age at which ABA therapy should be discontinued. Generally, ABA therapy is slowly tapered beginning around the age of eight. In the case of this patient, it is medically necessary that ABA therapy be continued and all ABA therapy services provided from the date in question to the present should be reimbursed. However, due to the patients age, ABA therapy should begin to be tapered and therefore, continued ABA therapy at a frequency of 15 hours per week would be appropriate and medically necessary for a minimum of one year with re-evaluation at the end of that period. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested reimbursement for use of Alloderm acellular dermal matrix for complex fistula reconstruction repair for treatment of bronchopleural fistula.  Findings:  Two physician reviewers found that the patient has cystic fibrosis.  She developed a right bronchopleural fistula after right pneumonectomy.  This resulted in fungal empyema.  She has mixed connective tissue disease.  Her medical history is significant for pulmonary aspergillosis.  The patient underwent a combined thoracic and plastic surgery procedure which included placement of Alloderm acellular dermal matrix allograft to repair the bronchopleural fistula, with placement of a serratus anterior muscle flap and right latissimus dorsi muscle flap for coverage of the bronchopleural fistula and obliteration of the right pleural dead space.  The patient has requested reimbursement for use of Alloderm acellular dermal matrix for complex fistula reconstruction repair.  Alloderm is an acellular dermal matrix allograft used for repairs and reconstructions.  Alloderm is of particular use in infected or devitalized fields.  Its use has been documented in many applications, including tracheobronchial repairs and fistulas into the pleura and esophagus.  Tracheobronchial fistulas are difficult to manage, with life-threatening consequences if failure occurs.  The most common occurrence is after a right pneumonectomy.  This patient had a life-threatening bronchopleural fistula with fungal empyema.  The services provided were likely to have been more beneficial than other treatment alternatives in this clinical setting.  The use of Alloderm has been documented in multiple reports for use in complex tracheobronchial reconstruction.  In this patients case, use of Alloderm acellular dermal matrix for complex fistula reconstruction repair was likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested coverage for acute physical therapy and occupational therapy for treatment of his diabetic ketoacidosis status post fall.  Findings:  The physician reviewer found that the patients rehabilitative needs are not complex as he requires routine nursing care, basic therapy interventions, basic reconditioning exercise, instruction for self-care, and family training. Lower limb strengthening exercises would be appropriate given his diabetic polyneuropathy. The patient would also benefit from higher levels of physical activity in the long-term.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for inpatient mental health services for treatment of the enrollees autism, anxiety disorder and obsessive compulsive disorder. Findings:  The physician reviewer found that the patient demonstrated severe symptoms throughout his inpatient stay. The patient required a comprehensive multidisciplinary treatment plan applied by specialized staff under 24-hour supervision to achieve the general goal of symptom decompression with a seamless transition to the outpatient setting. The inpatient mental health services provided were consistent with good medical practice in the United States.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested authorization and coverage for Echocardiography, transthoracic, real-time with image documentation (2D), including M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography. The enrollee has also requested authorization and coverage for Holter monitoring/reporting for up to 48 hours for evaluation of the enrollees chest pain.  Findings:  The physician reviewer found that based on the records provided the patient is a 57-year-old female with a history of known coronary disease who presents with symptoms interpreted by her physician as palpitations but no documentation of chest discomfort, dyspnea, or abnormal cardiovascular physical exam. An electrocardiogram on was normal on review. In this circumstance of unexplained palpitations in a patient with known coronary disease and prior myocardial infarction, further evaluation with Holter monitoring is reasonable, appropriate, and considered standard accepted practice in the medical community. The American College of Cardiology (ACC) and American Heart Association (AHA) expert consensus guidelines consider unexplained palpitations a class I indication for Holter monitoring. However, there is record of a prior echocardiogram about one year ago and no current cardiac symptoms or abnormal cardiac physical exam findings that would warrant a repeat echocardiogram. The current expert consensus guidelines also do not consider repeat echocardiography appropriate in this setting. For these reasons, the requested Holter monitoring is medically necessary while the requested echocardiography is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested coverage for Tracleer for treatment of her right heart failure and pulmonary hypertension. Findings:  The physician reviewer found that Tracleer is indicated only for symptomatic patients with WHO Group I pulmonary hypertension (i.e. pulmonary hypertension that is idiopathic, familial, associated with HIV, associated with connective tissue diseases or associated with congenital systemic-to-pulmonary shunts).