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 speech and language therapy services for treatment of the enrollees delayed speech. Findings: The physician reviewer found that this patient has a significant delay in her speech development. Extensive testing by her speech therapist reported a 25 to 50% delay in speech development. The enrolle's speech is not due to a delay in intellectual development, as her tested intellect is slightly above normal.  She has an isolated speech developmental disorder which is due to delayed brain development and maturation. In the meta-analysis by Law and colleagues, the authors noted the success of speech therapy for children who fail to generate normal speech within the expected range. Cognitively normal children are excellent candidates for speech therapy (GoorhuisBrouwer and colleagues). There is sufficient support in the medical literature for the requested services in this clinical scenario. All told, the requested speech and language therapy services are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested Orthovisc injections for treatment of her left knee osteoarthritis. Findings:  The physician reviewer found that the requested third series of Orthovisc injections for this patient has not been proven medically necessary in this clinical setting. The rationale is that this patient has x-ray documented degenerative osteoarthritis with structural abnormalities, specifically, varus deformity. The medical literature does not suggest that Hyalgan intra-articular injections will effectively alter an arthritic process, which is advanced and determined by structural alignment (i.e. varus deformity). In the study by Jorgensen and colleagues, 337 patients were treated in a randomized multicenter placebo controlled double blind trial with either hyaluronan injection or saline injections. The study group consisted of 167 Hyalgan injected patients and 170 saline injected patients. The injections were performed weekly for five weeks. Both providers and patients were blinded as to whether saline or hyaluronan was administered. The patients had been selected as fulfilling the American College of Rheumatology criteria for knee osteoarthritis with both clinical and laboratory studies supporting the diagnosis. They were followed with patient questionnaires at 3, 6, 9 and 12 months after treatment. Overall, the researchers observed no significant improvement in pain, function, or anti-inflammatory consumption between patients treated with hyaluronan and those given saline. Although some studies report improved relief of pain and stiffness with intra-articular sodium hyaluronan injections, their methodological flaws cannot be ignored. One study published by Turajane and colleagues evaluated 183 patients with osteoarthritis of the knee. The patients were administered a series of three intra-articular sodium hyaluronate injections. The authors concluded that intra-articular sodium hyaluronate injections were effective in improving pain, stiffness, and function. However, the design was not double-blinded, lacked proper controls, and the results are vulnerable to a placebo effect. As there is insufficient scientific evidence to support a further series of Orthovisc injections for this patient, the requested therapy has not been demonstrated to be medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested laparoscopic duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that based on the records provided, this patient is morbidly obese. She has failed prior dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious metabolic, medical, dietary or behavioral barriers to surgery. The patient is requesting a standard primary treatment of morbid obesity that is covered by standard national guidelines including the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Centers for Medicare and Medicaid Services (CMS). The patient indicates that she has been preparing for bariatric surgery for two years and is committed to follow-up and dietary restrictions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested individual mental health therapy sessions for treatment of her anxiety disorder. Findings:  The physician reviewer found that the submitted documentation does not include an evaluation consistent with American Psychiatric Association standards or progress notes detailing a history and treatment plan which would warrant ongoing therapy. Specifically, there is no indication that the patient has ever been or is at risk for psychiatric hospitalization. Goals of treatment are not specific. There is no evidence that there is a plan to disengage the patient from therapy or otherwise taper the frequency by using patient support systems and community resources. American Psychiatric Association practice guidelines indicate that patients should be managed in the least restrictive setting which will meet their treatment needs. The data reviewed fail to establish that the patient requires ongoing therapy in order to safely and effectively manage her condition. All told, the requested individual mental health therapy sessions are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested Lyrica for treatment of his pain.  Findings:  The physician reviewer found that the treatment of neuropathic pain of any etiology can be managed with membrane stabilizing agents such as Lyrica and Neurontin. These medications are generally part of first-line therapy and are an integral part of a comprehensive management strategy for difficult to control neuralgia that can come from multiple underlying causes.  In many cases, Lyrica is used off-label if the patient fails to obtain relief from Neurontin.  The indications for Lyrica include neuropathy from post shingles pain, diabetes, pain from fibromyalgia, and seizure control for complex partial seizures.  However, it is common to see off-label uses for other chronic pain syndromes, especially neuropathic pain syndromes.  In this case, the patient has already failed Neurontin due to side effects.  Lyrica is very similar in mechanism of action, but is generally better tolerated.  In this patients case, due to the chronic refractory nature of the pain and good response to the medication at issue, Lyrica was and is medically indicated from the date in question forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested outpatient mental health sessions at a frequency of four times per week (rather than the approved two sessions per week) for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted information fails to establish the medical necessity for the requested level of service. The patient contends that his depression is mild, but the provider contends it is severe. A psychiatric evaluation in accordance with American Psychiatric Association practice standards was not submitted for review, and progress notes were not provided. Details regarding the patients history, condition and treatment plan are lacking. There is no evidence that the patient has been hospitalized or is at imminent risk for inpatient treatment. All told, outpatient mental health sessions at a frequency of four times per week during the dates in question and continued outpatient mental health sessions at a frequency of four times per week were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested continued skilled nursing facility (SNF) care including speech therapy, occupational therapy, and physical therapy for treatment of his primary lateral sclerosis.  Findings:  The physician reviewer found that primary lateral sclerosis is a progressive degenerative neurological condition resulting in severe chronic disability. Without an effective agent to halt destruction of the neurons, patients generally continue to decline (Ropper and Samuels). Skilled therapy cannot halt the degenerative process (Dalbello-Haas and colleagues). From a review of the patients records, although he did show some progress with high dose steroid therapy, he was unable to continue to improve functionally. The patients provider described the patient as dependent in activities of daily living but noted that he did improve in his ability to feed himself. However, he did not improve in swallowing and was down-graded to thickened liquids. Overall, the records demonstrate the patient has only made minimal gains with skilled therapy and has not progressed with skilled physical therapy as of the date in question. While he requires daily exercise to maintain his current function, exercise can be provided in a variety of ways outside of the SNF setting. Given the patients underlying diagnosis and functional status as of the date at issue, the medical necessity of continued skilled services beyond the last authorized date of service has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested right ovary removal (oophorectomy) for treatment of her ovarian cyst.  Findings:  The physician reviewer found that decisions regarding management of an ovarian cyst are made based on a combination of factors including the patients symptoms, age and menopausal status. Also considered are a patients personal and family history of ovarian or related cancers, findings on pelvic and ultrasound examination, and laboratory results. The primary issues are risk of malignancy or rupture, risk of torsion, and severity and persistence of pain. Management of the post-menopausal patient tends to be more aggressive since the risk of malignancy tends to be elevated. Despite these efforts, the data may still be insufficient to determine the etiology of an ovarian cyst. With regard to this patient, the work-up to date lacks specificity from the treating provider as to any factors that mitigate or exacerbate the patients pain. However, the persistence and severity of the patients pain is documented in terms of lack of control achieved with Dilaudid and reference to emergency room visits for uncontrolled pain. The provider also noted that the patients CA-125 was evaluated. Further, the patient is post-menopausal which increases the risk of malignancy. She has already undergone a total abdominal hysterectomy, which likely has left the ovary encased in adhesions from the previous surgery. Given the ultrasound confirmation of the ovarian cyst and the patients persistent symptoms, the requested surgery is medically necessary for treatment of this patients ovarian cyst.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested corrective surgery consisting of surgical removal of bone from femur toward the knee for treatment of his medical condition status post left hip replacement surgery. Findings:  The physician reviewer found that in the medical literature, Clark and colleagues indicate that leg length discrepancy after total hip arthroplasty can pose substantial problems to the orthopedic surgeon, and can be associated with nerve palsy, low back pain, and abnormal gait. In addition, Maloney and Keeney reported that discrepancies of 1 cm or less are common and can be a source of dissatisfaction to the patient. Corbett and colleagues found that uncemented implants may be associated with higher rates of revision regardless of age, although the risk of revision is higher in older arthroplasty recipients. Further, Hallan and colleagues stated that uncemented total hip arthroplasties have poor long-term results, and often times require regular radiographic evaluation to detect osteolysis. The evaluation of a discrepancy requires careful study, and functional problems may be present in the earlier stages of recovery after surgery (Bhave, et al). When a correctable cause of discrepancy can be identified, surgery may be appropriately indicated (Parvizi, et al).    In this case, there is a length discrepancy, but the radiologic evaluation is not detailed in the records provided for review. In addition, there is no documentation of the use of lifts or other conservative mechanical methods of adjusting the length discrepancy to evaluate the response. Overall, there is insufficient data supporting the requested surgical intervention for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

35-year-old female enrollee has requested mental health outpatient treatments at a frequency of three times per week for treatment of her post-traumatic stress disorder and depression. Findings:  The physician reviewer found current information from the therapist provides a GAF of 55, which indicates moderate impairment in functioning.  Goals of treatment appear longstanding, such as resolving past childhood abuse, resolving causes of depression, managing emotions constructively and building healthy social and intimate relationships.  The patient has contracted for safety.  Psychosocial and environmental problems were also identified as inhibiting the patients recovery, including inadequate social support.  Based on the identified treatment goals and a current GAF of 55, treatment goals could be accomplished within two sessions per week. Per the submitted records, mental health outpatient treatments at a frequency of two times per week from the date in question onward were and are medically indicated. However, mental health outpatient treatments at a frequency of three times per week during this time were not and are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested RAST testing for evaluation of her allergies. Findings: Three physician reviewers found that RAST testing for IgG was not likely to have been the most beneficial method of evaluating this patient. Food allergy is due to an IgE-mediated triggering of mediators from cells. Therefore, testing for IgE reactivity is the recommended method of testing. IgG RAST testing for food allergy has not been demonstrated to be beneficial in this clinical scenario.  Reliance on IgG testing may result in over-diagnosing patients with conditions they do not have. The American Academy of Allergy Asthma and Immunology does not support the testing at issue in this patients case. The nature of the tests is non-specific, and as a result, can be applied non-specifically to a wide variety of disorders. All told, RAST testing for IgG was not likely to have been of greater benefit than other available methods of evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested Pylera 125-125mg capsule for treatment of the her H. pylori bacterial infection.  Findings:  The physician reviewer found that the Health Plan has suggested the patient received individual components of H. pylori treatment. One alternative included combination therapy with omeprazole, amoxicillin and clarithromycin. However, the patient has an amoxicillin allergy. Another alternative included combination of metronidazole, tetracycline and bismuth subsalicylate. This alternative is appropriate for this patient. It is medically appropriate for the patient to take individual components of the regimen rather than Pylera. The suggested alternative combination therapy is efficacious for the treatment of H. pylori.  All told, the requested medication, Pylera 125-125mg, is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her diabetes and obesity.  Findings:  Three physician reviewers found that on review of the relevant medical literature, it becomes clear that laparoscopic sleeve gastrectomy is an appropriate primary treatment of morbid obesity (as defined by a BMI of 40 or greater). The laparoscopic vertical sleeve gastrectomy is also recommended for the well selected patient by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery (ASMBS). Further, the studies have established the long-term safety, efficacy with the availability of 5-year follow-up data. Moreover, the American Medical Association has approved a CPT code for the procedure. Given the plethora of support for laparoscopic sleeve gastrectomy collected from various reliable sources, this patients surgery should be covered as it was likely to be more beneficial than any standard available therapy for treatment of her morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested reimbursement for previous and authorization for prospective skilled nursing facility (SNF) services and/or skilled nursing facility rehabilitation services for treatment of his medical condition status post cerebral vascular accident (CVA). Findings: The physician reviewer found that in the medical literature there are limited studies on the outcomes for comprehensive programs in treating this patient population. The newer literature focuses on testing new techniques, but overall the data on patient outcome following a hemorrhagic stroke has been stable for over a decade. Essentially the research supports clear benefits of stroke rehabilitation with early intervention. There is little improvement with later treatment (Ronning and Guldvog). In addition, more than three months following a stroke, there were no substantial advancements in hospital versus settings (Anderson and colleagues). This patients stroke prevents him from clinically benefitting from daily skilled therapy. Therefore, the skilled nursing care at issue has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Orthovisc injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that Orthovisc injections are medically necessary for this patient.  She has failed conservative management and has confirmed localized inflammatory pain with osteoarthritis on MRI and radiographs.  The patient has failed treatment with NSAIDs, Tylenol, physical therapy and steroid injections.  The medical records noted that she is at an ideal weight.  The use of Orthovisc is an appropriate conservative modality before a surgical solution is considered.  The current medical literature supports the use of viscosupplementation in this clinical scenario. All told, in this patients case, the requested Orthovisc injections are medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested radiofrequency neurolysis for treatment of her pain.  Findings:  Three physician reviewers found that the current peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic back pain due to lumbar facet and sacral joint arthropathy. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation. They concluded in the study that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. This patient is a good candidate for this procedure. She reported reduction in her pain for four to five months following lumbar medial branch blocks.  Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Van Kleef and colleagues performed a randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. The study concluded that radiofrequency zygapophyseal joint denervation results in a significant alleviation of pain and functional disability in a select group of patients with chronic back pain. This patient has failed to receive any pain relief with anti-inflammatories and opiates. In addition, the patient reported a decrease in pain following the lumbar facet diagnostic blocks.  In this patients case, the requested radiofrequency neurolysis is likely to be superior over other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested speech and language therapy (once per week for six months) for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that this patients expressive language dysfunction stems from two etiologies. The first is that of brain maturation and organization.  Congenitally, the child has not developed language skills based on her cerebral development. Additionally, the speech pathologists evaluation indicated oral-pharyngeal motor difficulties, which again stem from a congenital dysfunction. Cognitively, the patients receptive skills are normal, which implies a normal intellect. Law and colleagues conducted a meta-analysis of the outcomes of speech therapy in intellectually normal children.  For the most part, such speech interventions are highly successful in developing expressive language in these children. Goorhius-Brouwer and colleagues also noted the success of developing expressive language in intellectually normal children.  There is adequate support in the medical literature demonstrating the efficacy of speech and language therapy in this clinical scenario.  All told, the requested speech and language therapy (once per week for six months) is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested audiology testingfor evaluation of the enrollee, who reportedly has difficulty hearing. Findings:  The physician reviewer found that the patient has modest inattention and impulsivity which would suggest some degree of attention deficit disorder.  CAPD is a diagnosis made by an audiologists electrophysiological tests.  There is a lack of medical evidence supporting the requested testing.  Research in this area has been marred by frequent design and descriptive flaws which suggest that validating CAPD is extremely difficult.  There are many etiologies that may be associated with CAPD, again clouding the ability to make the diagnosis (Bamiou and colleagues).  Ferguson and colleagues suggested that what is described as CAPD is actually a specific language disorder.  Thus, the limited peer-reviewed papers raise doubt as to the validity of the diagnosis and the value of therapy directed following the diagnosis.  All told, the requested diagnostic testing is not medically indicated for this patient.