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

The parent of a nine-year-old male has requested speech therapy services for treatment of his pervasive development disorder. Findings:  The physician reviewer found that the literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy 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. Therefore, speech therapy is medically appropriate and necessary for treatment of this patient who has a diagnosis of pervasive developmental disorder accompanied by speech and language delay with clear documentation of receptive and expressive language delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 74-year-old female enrollee has requested for Vertos minimally invasive lumbar decompression (MILD) procedure for treatment of her spinal stenosis.  Findings:  The physician reviewer found that review of the available scientific data on the procedure, one peer reviewed article evaluating this procedure from Deer and colleagues is a retrospective review of only 90 patients. Another study from Chopko and Caraway is also a small study of only 75 patients that lasted 18 months. In addition, both studies are flawed in that neither had controls or were randomized. Thus, there are no large, scientific, randomized, long-term studies that have established the safety and effectiveness of the MILD procedure. Further, there are alternative treatment options available to this patient proven to be effective.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for individual speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that research from Gallagher and Chiat provided data on 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 eight-month period when compared to patients who received no intervention or nursery-based intervention. This patient continues to display delays in expressive and receptive language skills. Based on the foregoing discussion, the requested speech therapy is therefore medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female has requested for residential treatment center services for treatment of her medical condition. Findings:  The physician reviewer found that the documentation contains no evidence that the patient was suicidal, homicidal or showing impaired reality. the facility records note that the patient did not have any suicidal, homicidal or psychotic symptoms upon admittance. In the absence of such evidence, the medical necessity for 24-hour structure, supervision, and treatment is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female has requested for residential treatment center services for treatment of her eating disorder. Findings:  The physician reviewer found that the documentation contains no evidence that the patient was suicidal, homicidal or showing impaired reality. Based upon the documentation provided, the patient is near or at 81% of her ideal body weight. The records do not document instability from a medical or psychiatric standpoint. All told, the patient has not exhibited signs and symptoms that demonstrate a clinical need for 24-hour structure, supervision, and treatment.
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 Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for Oxycontin for treatment of his chronic obstructive pulmonary disease (COPD) and degenerative disc disease (DDD).  Findings:  The physician reviewer found that the records do not document any medical indication for the patients present Oxycontin dosing. There are no imaging studies or documentation illustrating the severity of the patients DDD. The current standard of care for chronic pain is treatment in a multidisciplinary practice including physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy with the maximum recommended dose for Oxycontin of 80mg twice per day as indicated for cancer pain (Fishman).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested for an annual DXA bone density study for evaluation of his status post lung transplant. Findings:  The physician reviewer found that there were no adverse changes from previous bone density testing. There is no indication that the patients health status has changed. Further, there is no indication that the patients medication doseage has changed. Bone density testing every two years is medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for bioidentical hormone replacement therapy for treatment of her history of breast cancer. Findings:  Three physician reviewers found that women with breast cancer often experience early menopause due to adjuvant chemotherapy, and may have vasomotor symptoms, estrogen therapy should not be prescribed.  In this clinical situation, there is concern regarding increased risk of breast cancer recurrence with estrogen therapy.  The current medical evidence does not support the use of hormone replacement therapy for women with a personal history of breast cancer. This would apply to bioidentical or other female hormones.  All told, the requested bioidentical hormone replacement therapy is not likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested authorization and coverage for speech therapy, and occupational therapy for treatment of his medical condition. Findings:  The physician reviewer found that the medical literature supports both speech therapy and occupational therapy in the autistic population. Concerning the requested speech therapy, the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) 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 (Myers, et al.). Myers, et al. recommends the modality, although the authors also note there is a paucity of literature concerning occupational therapy in the treatment of autism. However, subsequent to this report, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. Further, Pfeiffer, et al. found that occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism.The patient appears to be an excellent candidate for both speech therapy and occupational therapy.
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 receptive/expressive language delay. Findings:  The physician reviewer found that 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. This patient has made significant progress in her receptive language skills with intervention and is likely to benefit from continued therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested for revision of the right breast lift for symmetry for treatment of her status post breast surgery. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested right breast lift for symmetry. Photographs show a reconstructed left breast with an indiscrete poorly defined inframammary fold that is lower than the right inframammary fold.  However, the right breast is normal in shape, with the nipple above the level of the inframammary fold, and normally positioned, with visible good quality breast reduction scars.  Per the submitted documentation, this patient does not have any right breast ptosis, and the right breast is normal in shape and size. Therefore, the requested right breast lift for symmetry is not reconstructive in nature and is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested speech therapy and occupational therapy for treatment of his autism. Findings:  The physician reviewer found that the use of speech therapy for patients with autism, the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) 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 (Myers, et al.).Regarding the effectiveness of occupational therapy for children with autism, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. A study by Pfeiffer, et al. found that occupational therapy utilizing sensory integration techniques is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-month-old male enrollee has requested for speech therapy for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the plasticity in the developing brain still exists, even in patients with underlying neurological disease such as cerebral palsy. This brain plasticity can be utilized to improve overall neurological health. 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 pathogenic processes that give rise to expressive and receptive speech delay. Given this patients diagnoses of cerebral palsy and speech and language delay and the consensus in the available peer reviewed literature, speech therapy is medically appropriate and necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for a Sara 3000 electric patient lift for treatment of his Beckers muscular dystrophy.  Findings:  The physician reviewer found that a Hoyer lift or other patient transfer system that supports the patients entire body during transfers would be appropriate for this patient and is consistent with the recommendations by the occupational therapist. For these reasons, the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested coverage for revision of Roux-en-Y gastric bypass for treatment of her obesity.  Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient has regained weight following Roux-en-Y gastric bypass.  She has an associated comorbidity of sleep apnea.  Although a reference to type II diabetes mellitus was made by her provider, the submitted laboratory data does not support this diagnosis.  An upper gastrointestinal study did not demonstrate any causes of failure of her prior gastric bypass surgery.  This patient does not meet the criteria for revision of prior gastric bypass surgery.  Although her body mass index was 35.69, she lacks associated comorbidities to support the requested procedure.  Additionally, there is insufficient documentation demonstrating that the patient has resumed medically supervised dietary interventions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested  coverage for Applied Behavioral Analysis (ABA) therapy treatment at the frequency of six hours per week for treatment of his reported autism spectrum disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient has many behaviors suggestive of Autism Spectrum Disorder (ASD) but a formal evaluation is needed to provide a diagnosis. As noted in the medical literature by Volkmar and colleagues, this confirmation of diagnosis is important to insure that other possible conditions are not the cause of the patients behaviors as they may require varied treatments. Certain behavioral features are required for a diagnosis of autism, although they are sometimes observed in other disorders by themselves. Once a diagnosis has been established, there is substantial support for the medical necessity of ABA therapy for children with ASD (Johnson, et al). The American Academy of Pediatrics (AAP) guidelines note that if a positive screen for ASD is noted, then the patient is referred for a comprehensive ASD evaluation and audiological evaluation. If indicated, early intervention/early childhood education services are then provided targeting the patients unique deficits with modifications in intervention strategies as needed. In this case, it is unclear what medical condition the proposed ABA therapy is targeting. In addition, the patient may require more than six hours per week of ABA therapy if ASD is in fact diagnosed. For these reasons, it is appropriate at this time to have the patient undergo a thorough work-up to determine the etiology of his delays as recommended by the Health Plan. In addition, the Health Plans approval of Autism Services Therapy (AST) under CPT code H0031 for up to 15 hours of ABA assessment services appears reasonable. Therefore, the requested ABA therapy for six hours per week has not been established as medically necessary for treatment of this patients medical condition at this time pending the outcome of a more thorough diagnostic evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested coverage for a past computed tomography angiography (CTA) of the coronary arteries for evaluation of his chest pain.  Findings:  Three physician reviewers found that the patient was evaluated with a coronary computed tomography angiogram (CTA) with documented indications of back discomfort, chest discomfort, abnormal electrocardiogram and dyspnea. The coronary CTA revealed coronary calcium but no significant obstructive coronary artery disease (CAD). No additional medical records are available for review. Initial standard evaluation for the indications mentioned in the report typically does not include coronary CTA. For example dyspnea, abnormal EKG and chest discomfort are usually initially evaluated more appropriately with other cardiac modalities such as stress testing or echocardiography (ECHO). Coronary CTA is medically indicated only in certain situations such as assessment of coronary anomaly or assessment of coronary anatomy in a low risk patient with equivocal stress test results. Without records to support the clinical necessity of coronary CTA, its use was not likely to provide novel and useful information relevant to this patients care beyond that attainable with standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female requested past and future coverage for partial hospitalization program services received for treatment of her pervasive developmental delay not otherwise specified (PDD-NOS), cerebral palsy and dyspraxia.  Findings:  The physician reviewer found that the patient is diagnosed with PDD-NOS, which is a disorder on the autism spectrum. There is an overwhelming consensus within both the treatment and research communities that early, intensive intervention is the integral component to managing these disorders and securing the best possible outcome. Foxx identifies the importance of intensive instructional programming, which is defined as equivalent to a full school day, 5 or more days a week, 25 hours per week, year-round, for 12 months per year. These reports are consistent with the recommendations of the American Academy of Child and Adolescent Psychiatry whose updated practice guideline on autism is in the final stages of review. While intensive behavioral services are essential in this setting, such services do not necessarily need to take place in the partial hospital setting. In the case of this patient, she was admitted to the partial hospital program for her severe behavioral dysregulation, characterized most notably by physically aggressive outbursts and self-injurious behaviors. Medication management, comprehensive behavior therapy and parent training have been at the core of her treatment in the partial hospital program. Although the patient remains symptomatic, the records provided document clinical improvement and demonstrate that the patient has made substantial gains in the program. While it is noted that the patients behavioral disturbances in the home have increased, such behavior is not atypical, as it is a response to the consistent application of limits and boundaries. All told, the submitted clinical records do not describe a symptom complex that would warrant continued partial hospitalization as of the date at issue. Based upon review of the documentation provided, transitioning the patient to the outpatient level of care such as an ABA program as of the date at issue would have been consistent with accepted standards of practice in the medical community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested speech therapy for treatment of his autistic disorder and childhood apraxia of speech. Findings:  The physician reviewer found that children on the autistic spectrum have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. While school services are essential, they are not sufficient for children with the severity of deficits as seen in this patient. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. The speech therapy at issue therefore was and is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male has requested coverage for Gilenya for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that this patient has multiple sclerosis, and he has been on disease-modifying therapy. Treatment with Avonex was limited by side effects and inadequate efficacy, and treatment with Tysabri was limited by increased progressive multifocal leukoencephalopathy risk associated with prolonged therapy and positive JC viral titers. Patient compliance is important in long-term therapeutics. In general, patients prefer oral treatments and are more likely to be compliant with oral treatment, when compared to injectable therapies.  Gilenya has been studied and found to be effective as oral therapy. The requested medication is an effective treatment for patients with relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations.  A comparison study by McDonagh showed that for patients with relapsing-remitting multiple sclerosis, Gilenya 0.5mg and 1.25mg once daily were superior to interferon beta-1a in improving relapse-related outcomes over a one-year period.  Patient preference for non-injection therapy is medically relevant, as adherence to treatment is likely to be better.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old female has requested coverage for speech therapy twice per week for 45 minute sessions for 6 months for treatment of her acquired auditory processing disorder.  Findings:  Three physician reviewers found that this patient has a diagnosis of central APD. The standard of care as reported by Musiek and Chermak in the treatment for patients with APD is speech therapy and modification of the listening environment. These modalities are also encouraged by Moore in his 2006 article who states that, the management of childhood APD has been mainly achieved through modifications to the acoustic environment and sound delivery to the ears, and through auditory and speech training. This patient has demonstrated improvement with speech therapy services already provided and it is important for this treatment to continue to address his individual issues. Accordingly, the requested speech therapy is likely to be more beneficial than any standard alternative and should be approved.