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 for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this young patient has an identified delay in expressive speech of greater than 50% and a delay in pragmatic skills of 25%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, 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 and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested reimbursement for Adolescent Mental Health Residential Treatment.  Findings:  The physician reviewer found that on review of the patients psychiatric evaluation on admission to the RTC, he was described on MSE as being cooperative, well groomed, and calm, with a good sense of humor, logical thoughts and no current or acute suicidal or homicidal ideation. The provider also noted that the patient was motivated for treatment. Progress notes dated four days later describe full affect, no auditory or visual hallucinations, and no suicidal or homicidal ideation. Six days from the progress notes referenced above, the patients mood was described as stable and on the next day the provider noted a bright affect with no suicidal or homicidal ideation. Five days from the previous entry, it was noted that the patient was socializing with peers and was compliant with treatment. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria and the American Academy of Child and Adolescent Psychiatry (AACAP) treatment guidelines, this patient was a candidate for a less restrictive level of care during the period under review. These guidelines recommend treatment in the least restrictive setting possible, and given this patients symptoms, he would have been safely and adequately managed in an intensive outpatient program (IOP). For these reasons, the medical necessity for residential level of care has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-eight-month-old male has requested speech therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS).  Findings:  The physician reviewer found that autism spectrum disorder (ASD), including pervasive developmental disorder, not otherwise specified (PDD-NOS) is a complex neurological disorder with characteristic deficits in speech/language and social interaction. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach and including speech therapy among other therapies. Children on the autistic spectrum often have significant deficits in speech and language, as well as with social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these patients, are most appropriate. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. All told, the requested speech therapy is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested coverage for artificial disc replacement surgery.  Findings:  Three physician reviewers found that the medical records for this patient note neck pain and cervical radiculopathy and weakness in the C6 nerve root, with biceps and wrist extension weakness.  The provider noted that MRI was consistent with single-level pathology at C5-6 with disc herniation.  In this patients case, the superior effectiveness of the requested artificial disc replacement surgery has not been established.  There is a lack of long-term evidence in the peer-reviewed literature concluding the superiority of cervical arthroplasty over fusion in terms of efficacy and safety.   At this time, randomized controlled trials involve short-term to intermediate-term follow-up.  The most touted advantage of arthroplasty over fusion, reduction of adjacent-level degeneration, has not been validated in randomized controlled trials to date.  Long-term adverse effects of arthroplasty materials, particularly polymer and metallic debris, are not known at this time.  In sum, the requested procedure is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  speech therapy for treatment of the enrollees developmental speech and language delay.  Findings:  The physician reviewer found that per 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.  As noted by 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, behavior, socialization, 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.  McLaughlin noted that there are good data available to support the effectiveness of speech therapy for children with primary expressive language disorder.  This patient has expressive language delay that significantly impairs his ability to communicate effectively and function socially. Based on the medical literature, speech and language therapy is medically necessary and appropriate to address his speech and language challenges.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 19-month-old male enrollee has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorders. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested occupational therapy, sensory integration, social cognitive speech and language therapy for treatment of his autism. Findings:  The physician reviewer found that occupational therapy has been shown to result in significant improvement in activities of daily living in this setting (Case-Smith and Arbesman). Occupational therapy has been requested in this case to address the patients tactile, vestibular and proprioceptive function and is a medically appropriate modality to address deficiencies in these areas (Zingerevich, et al). The requested sensory integration therapy, Fazlioglu and Baran evaluated children between 7 and 11 years of age with autism and the use of a sensory integration program and found statistically significant improvements in the group of patients receiving sensory integration therapy. Pfeiffer, et al. also studied the effectiveness of sensory integration intervention compared to a fine motor treatment group. The results identified significant positive changes in both groups, however, more significant changes occurred in the sensory integration group, and a significant decrease in autistic mannerisms also occurred in the sensory integration group. This would suggest that sensory integration is helpful in children with autism and is medically indicated to address this patients auditory, tactile and oral motor deficits.The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. On average, the children who received speech therapy showed a significant increase in expressive language skills. In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female requested authorization and coverage for lap band removal and revision to a duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure was not medically necessary for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that this patient with morbid obesity was status post bariatric surgery with a laparoscopic adjustable gastric band. The submitted documentation reveals no evidence of overt complications of the procedure. An upper gastrointestinal series was normal and an EGD showed no erosion or slippage of the band. It appears dietary compliance may be an issue in this case as a consistent restrictive diet high in protein is not well documented. Based upon the submitted documentation, there is no evidence to support removal of the lap band and revision to duodenal switch at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old male enrollee has requested group speech and language therapy 3 days per week, for 2 hours per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the request for speech and language therapy is medically necessary despite the absence of documentation of any laryngeal pathology or oromotor anatomical anomalies. The patients speech and language testing with the RITLS and DAYC revealed significant impairments in expressive and pragmatic skills as well as borderline delays in receptive language. As such, this patient presents with a diagnosis of speech and language delay supported by clear documentation of receptive and expressive language delay. As demonstrated in the medical literature, abnormal language development can be improved through speech therapy given the plasticity of the young patients developing brain. 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. In addition, the requested frequency of three sessions per week is clinically indicated as recommended by the treating provider. For these reasons, the requested speech therapy services are medically necessary based on an overall evaluation of the relevant medical literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old male enrollee has requested authorization and coverage for circumcision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee, who was born prematurely. Findings:  The physician reviewer found that there is significant debate regarding the necessity of neonatal circumcision.  According to a report published by the American Academy of Pediatrics, although the current scientific evidence demonstrates potential medical benefits of newborn male circumcision, these data are not sufficient to recommend routine neonatal circumcision.  As noted by Kleigman and colleagues, circumcision is often recommended for infants who are predisposed to urinary tract infections, such as those with congenital hydronephrosis and vesicoureteral reflux.  The submitted documentation fails to establish the medical necessity of the requested procedure in this case.  This patient does not have any urogenital abnormalities or history of infection. All told, circumcision is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested coverage for X-Stop (spinal distraction device) surgery. The Health Plan has denied this request indicating that the surgery at issue was and is considered investigational for treatment of the enrollees low back pain radiating to the bilateral extremities.  Findings:  Three physician reviewers found that the patient has a long history of back pain and neurogenic claudication. His symptoms are improved with rest or sitting. He has not had success with medications, physical therapy, osteopathic care, chiropractic care, acupuncture, or injections. His magnetic resonance imaging (MRI) shows a broad-based disc protrusion at L2-3 as well as stenosis at L3-4 and L4-5. There is also anterolisthesis at L3-4. The patients provider performed bilateral decompression at L2-S1, discectomy L2-3, and insertion of interspinous distraction device (X-Stop) at L2-3, 3-4, and 4-5. The patient has requested reimbursement for the X-Stop placement and the Health Plan has denied this request as investigational in this clinical setting. This patient clearly has symptomatic spinal stenosis at L3-4 and L4-5 with neurogenic claudication as demonstrated on MRI scan. At issue is the use of the X-Stop device. The FDA has approved and restricted its use in only two levels in well selected patients. However, the North American Spine Society (NASS) indicates that use of X-Stop is not supported in the peer reviewed medical literature as durable, safe, effective, and providing equivalent or superior outcomes when compared to standard therapies. Without large, long-term studies establishing the safety and effectiveness the X-Stop is not considered within the standard of care (Kondrashov, et al). Currently, the FDA requirements to determine the durability and potential side effects of the device include 5- and 7-year studies and these are ongoing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Lexapro 10mg for treatment of his anxiety.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the medication at issue. While the patient is noted to have anxiety, there have been various diagnoses, including post-traumatic stress disorder and generalized anxiety disorder. There is no psychiatric evaluation supplied in accordance with American Psychiatric Association standards which leads to a specific diagnosis for which the requested medication is indicated.  The American Psychiatric Association guidelines for post-traumatic stress disorder indicate SSRIs as the hallmark of treatment. However, there is no information in the record justifying why a formulary SSRI could not reasonably be tried for the purpose of mitigating the patients anxiety. Given the availability of potential alternatives which apparently have not been tried, this medication was not and is not medically necessary for this patients condition according to current evidence-based practice standards and expert consensus. All told, Lexapro 10mg was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for protective coating for her prosthesis for treatment of her status post below knee amputation. Findings:  The physician reviewer found that endoskeletal prostheses use foam coverings to provide bulk to the prosthesis (akin to muscle and fat on a biological limb) and protective outer coverings to protect the foam and internal componentry (akin to biological skin).  The protective outer covering in question is a basic component required for use of the prosthesis in conditions where exposure to moisture is expected.  This component is medically necessary for this patient for her use in routine activities of daily living and community activities.  All told, the requested protective coating is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Xifaxan for treatment of her irritable bowel syndrome (IBS).  Findings:  The physician reviewer found that the link between the patients symptoms and the presence of SIBO has not been clearly established based on the clinical findings presented in the records (Singh and Toskes). However, if her treatment plan included a course of antibiotics for 7-10 days there are several more standard alternatives. The proposed use in this patients care would be an off-label use of Xifaxan. Although the medication has a very favorable side-effect profile, its use is not considered standard of care in this clinical setting. Proven therapies include a quinolone or preferably metronidazole combined with trimethoprim/sulfamethoxazole (TMP/SMX). For these reasons, Xifaxan has not been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-month-old male requested authorization and coverage for Enteral formula (Enfacare 22 calories ready to feed formula). The Health Plan denied this request indicating that the requested formula is not medically necessary for treatment of the enrollees stated condition of pre-term birth and slow growth without nutritional supplementation. Findings:  The physician reviewer found that the requested Enfacare 22 calories per ounce (cal/oz) is not medically necessary for this patient. This patient was born late preterm, with a birth weight of 2695 grams, which is above the 50th percentile for his sex and gestational age. His discharge weight, of 3025 grams, was also above the 50th percentile. He was not considered to be failure to thrive, his feeding problems resolved and he was able to breastfeed. Additionally, the patient was not noted to have any chronic or debilitating conditions. The literature indicates that preterm infants should not be overfed in the attempt to promote catch-up growth (Merenstein and Gardner). Late preterm birth does not necessitate caloric supplementation, particularly in the absence of medical problems. At two months of age, the patient weighed 9 pounds 15 ounces almost double his birth weight of 5 pounds 15 ounces. The general rule of thumb is that a baby should double its birth weight by four months of age. This patients growth velocity demonstrates more than adequate growth and does not support the need for continued use of Enfacare 22 cal/oz at this time. The requested Enfacare 22 calories per ounce (cal/oz) is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested coverage for outpatient care at the frequency of 5 times per week for a past four-week period  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.   Findings:  The physician reviewer found that based on review of the available records, the provider states that the patient entered psychiatric crisis and subsequently required an increased frequency of outpatient sessions. The clinical notes do support the need for increased frequency of outpatient sessions for this patient during the period under review as recommended by the American Psychiatric Association (APA). However, there is inadequate justification to establish the medical necessity for all of the of outpatient treatment sessions provided. Therefore, as well as the sessions approved by the Health Plan, one additional session per week during the period under review was medically reasonable in order to safely manage this patients condition, and once per week thereafter through the end of the requested timeframe.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that IMRT is the technology used for delivering highly conformal external beam irradiation to solid tumors.  This technique results in a more conformal target coverage and normal tissue sparing as compared to three-dimensional conformal radiation therapy.  This is particularly useful for obtaining highly conformal dose distributions needed to irradiate complex targets positioned near or immediately adjacent to sensitive normal tissues.   IMRT requires an inverse plan with dose constraints for normal surrounding anatomy.In a letter from the date in question, the provider indicated that this patient received IMRT to give homogenous dose to the right breast to decrease skin toxicity, and reduce scatter dose to contralateral breast, which would reduce the likelihood of second cancer.  The provider further stated that multiple studies have shown that IMRT reduces scatter dose to contralateral breast and other parts of body.  In this patients case, the superior efficacy of IMRT has not been established.  In reviewing the dose-volume histogram (DVH) sheet, comparing IMRT to the three-dimensional conformal plan, there is no significant advantage of the IMRT plan. Furthermore, the papers that were submitted to support the use of IMRT do not pertain to this patients case.  All told, in this patients case, IMRT was not likely to have been more effective than other available treatment options.