Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage for magnetic resonance imaging (MRI) of the breast. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees stage IV non-small cell lung cancer.   Findings:  Three physician reviewers found that the patient has a history of stage IV adenocarcinoma of the left lung. She has a family history of breast cancer with an aunt and a grandmother succumbing due to this disease. There are no physical findings referable to a breast exam in the records and no mammogram or ultrasound reports describing equivocal findings. The oncologist requested an MRI of the breasts as a screening exam due to the patients family history. The Health Plan denied the request stating MRI of the breasts is not indicated without documented BRCA 1 or 2 genetic mutations and therefore the use of MRI in this instance is investigational. Although this patient has a diagnosis of stage IV lung cancer, the records provide little guidance as to the specific clinical indication for a breast MRI at this time. The patients oncologist does not outline reasoning for ordering this study as a screening tool in the absence of a first-degree or personal history of a BRCA genetic mutation. While this patient has a positive family history of breast cancer there are no first-degree relatives with the diagnosis to indicate a true genetic predisposition to the disease. Also, there is no equivocal imaging or clinical findings which provide an indication for MRI as a problem solving tool. As mammography is still the first-line of screening for breast cancer and the records do not provide any reason that technique should not be employed for this patient, the requested MRI has not been established as likely to provide novel and useful data relevant to this patients care at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested CT scan of the head for evaluation of the enrollees headache.  Findings:  The physician reviewer found that this patient presented with new onset of headache with associated nausea, vomiting and visual changes.  Neuroimaging for patients with headaches is medically appropriate when the headaches are of new onset, when the patient is over the age of 50 and when there is nausea and vomiting associated with a new headache.  This patient meets all of these criteria.  According to the International Headache Society Classification, a patient needs to have five headache episodes prior to a diagnosis of migraine-type headache.  Using this guideline, the patient cannot yet have a diagnosis of migraines, as this was her first episode.  The diagnostic procedure at issue was medically indicated in this clinical situation.  All told, the CT scan of the head performed on the said date was medically necessary for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested reimbursement and continued authorization and coverage for care with an out-of-network provider. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the patient underwent a specialty evaluation which noted the patient was receiving appropriate conventional therapies and management for autism. A gluten-free-casein-free diet, avoidance of food allergens and the addition of vitamin and mineral supplements was subsequently implemented. Such treatment measures do not require ongoing monitoring by a specialist. At this time, there is insufficient evidence for assessing outcomes of such biologic therapies and thus, they have not been found to be a validated treatment for autism (Warren, et al.). Appropriate vitamin and mineral supplements were added to minimize the restrictive effect of the gluten-free-casein-free diet with this patient. This type of diet is similar to the gluten free diet in Celiacs disease and does not require the assistance of another physician to monitor. All told, the efficacy of biologic therapies for the treatment of autism remains unproven. Patients who pursue this course of therapy can be adequately followed by  a primary care physician who can monitor their diet and assist with fortified foods and/or supplements to avoid nutritional deficiencies. (Meyers, et al.) Therefore, the medical necessity of the disputed services has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested reimbursement and prospective authorization and coverage for an intrathecal pump and medications. The Health Plan has denied this request indicating that the service at issue was not and is not medically necessary for treatment of the enrollees back pain.  Findings:  The physician reviewer found that the records indicate the patient has been stable for several years with an intrathecal (IT) pain pump with morphine, clonidine, and bupivacaine, with little fluctuation, the ability to still work and adequate pain control after several surgeries with recurring neurocompressive lesions in the lumbar spine. She has done well using little oral methadone and no other oral medications. She has followed up regularly to have her pump refilled on time with only small incremental changes in the dosages as needed and frequently no changes. An IT system runs on the premise of direct delivery of the medications to the spinal space with rapid transit to the cord and brainstem, sites of ascending pain pathways, and into the thalamus and cortex and higher processing centers (Belverud, et al). The presence of a catheter is compatible with MRI, spinal cord stimulation, and re-operation should it become needed. Further, the patient is able to manage with less medication and fewer systemic side effects as detailed by Cohen and Dragovich. Given that this patient has been in pain since the mid 1990s with failed back surgery syndrome and has done well for years with IT pain management, the service is clinically indicated for this patient (Tomycz, et al). At this time, cessation of the patients IT pump could precipitate extreme withdrawal and make her pain nearly impossible to control with equivalent oral medications The patient is productive, employed, and enjoys stable and reasonable pain control with no reported problems with her IT system. For these reasons, the requested coverage for past medication and IT pump refills and prospective approval for reasonable refills and medication as recommended by her pain physician has been established as medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-month-old female enrollee has requested for speech therapy, occupational therapy, and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome oftentimes have significant intellectual, motor, and speech delays for their chronological age secondary to this genetic diagnosis. There is ample medical literature advocating on the positive effects of speech, occupational, and physical therapy interventions for children with Down syndrome. LaForme and colleagues reported that sensorimotor occupational therapy resulted in improved motor skills when compared with an untreated control group. In addition, Ludlow and Allen reported that early intervention and a stimulation program, involving both occupational and physical therapy techniques in a variety of settings resulted in higher IQs and advanced development compared with an untreated Down syndrome population. Similarly, Angulo-Barroso and colleagues studied physical therapy utilizing treadmill intervention in infants and preschool children with Down syndrome and noted that treated children had higher levels of physical activity and walked earlier than children in an untreated control group. Further, van Bysterveldt and colleagues reported significant improvement in speech development in infants and toddlers with Down syndrome who received speech therapy integrated with letter recognition and phonological awareness.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested physical therapy, at a frequency of one 30 minute session per week, and occupational therapy services, at a frequency of one 60 minute consultation per month for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that occupational therapy (OT) and physical therapy (PT) are utilized to improve the patients abilities to adapt and function in activities of daily living and gross motor skills development. With this degree of fine and gross motor impairment, this patient has a medical necessity for OT and PT services.  Myers, et al., points out the success of rehabilitative therapies in preschool children, enabling transition into a school setting.  According to Schaaf, et al., sensory integration techniques utilized by the occupational therapist, aids the developmentally delayed child to develop the ability to integrate into normal feeding and personal-social patterns to function with his peers. Additionally, improvements in behavior patterns have been noted in patients who have been treated by OT, utilizing sensory integration techniques. In sum, the requested services are medically necessary for treatment of this patients medical condition. The patient should be reassessed at six month intervals to determine if continued treatment is indicated..
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee requested authorization and coverage for lock down residential treatment center services. The Health Plan denied this request indicating that the requested services are not medically necessary for treatment of the enrollees obsessive compulsive disorder (OCD), oppositional defiant disorder (ODD), anger issues and bipolar disorder.  Findings:  The physician reviewer found that the patients diagnosis includes bipolar disorder co-morbid with substance abuse/dependence. The patient has required two psychiatric hospitalizations within 12 months. Progress notes by the patients treating physician during a recent hospital stay indicate the patient remained anxious, angry, labile and intrusive. The progress notes indicate that due to the patients impulsivity, prior threats and history of running away, he would benefit from a locked unit in terms of residential treatment. Medical records indicate the patient was anxious, impulsive and unpredictable with no coping skills. The nursing notes consistently indicate a runaway (AWOL) risk during his hospital stay. Given the clinical factors described above, including the patients history of aggressive and assaultive behavior and concerns about him having a gun, along with a well documented history of repeat run away episodes, residential treatment in a secure locked unit is considered clinically appropriate and medically necessary.This finding is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria which indicates that Level 6 is defined as secure 24 hour service with psychiatric monitoring, this can occur in a highly programmed RTC. Factors supporting Level 6 placement include ambivalence toward treatment, poor resilience and response to treatment, severe functional impairment such as assaultive behavior, minimal control over impulses that may result in abusive behaviors, running away, and AWOL risk. Also, the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters note that for patients with bipolar disorder, disruptive behavior is often present and intervention strategies should be based on the specific symptom presentation of the patient including co-morbid conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested anterior endoscopic cervical foraminotomy, or in the alternative, artificial disc replacement for treatment of his cervical radiculopathy, low back pain, and lumbar facet arthropathy.  Findings:  The physician reviewer found that the first issue is the medical necessity of an anterior endoscopic cervical foraminotomy. Of the few case reviews, the only report on the anterior approach was a combined cadaver/case series study of 16 patients (Saringer, et al). Overall, the results of these 16 patients are insufficient to determine the safety or efficacy of this procedure. Therefore, the procedure should be considered not medically indicated. In an assessment of the safety and efficacy of cervical disc arthroplasty, Matz and colleagues performed a systematic review of the literature which yielded 280 references. After reviewing the abstracts and titles, the authors examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF). Of these 10 publications, there were no class I studies and only 4 class II studies. Overall, the authors concluded that total disc arthroplasty is still being evaluated for long-term outcomes in terms of durability and safety. Mummaneni and colleagues reported on their randomized, controlled trial of 541 patients, 276 of whom underwent arthroplasty, and 265 who underwent ACDF. When all criteria for success were used, the arthroplasty group had a superior outcome. However, multiple confounding factors such as the use of medications, cervical collar immobilization, and lack of blinding limit any conclusions from being drawn. More recently, published reports of randomized trials with longer term follow-up do suggest that artificial disc replacement may be beneficial, but the percentages of patients receiving 4-year and 5-year follow-up are exceedingly low and call into question the validity of the findings at this time (Burkus, et al). Given the lack of scientific data supporting the medical necessity of the requested procedures in this patients case, the denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 10-month-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive 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 and 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 varies with disorder type, severity, age, and the etiology of the condition. For this reason, a complete work-up to assess possible etiologies of the patients condition is essential. As speech therapy is the standard of care for patients with speech delay, the requested therapy is medically necessary for this patient at the frequency of two, one-hour sessions per week.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested bariatric surgery (Lap-Band) for treatment of her obesity.  Findings:  The physician reviewer found that standard national guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines define clinically severe or morbid obesity with a BMI of 40 or a BMI of at least 35 with one or more serious weight related co-morbid conditions. This patient has history of hypertension treated with medication and her actual BMI should be clarified by the provider. However, even if the patients BMI is proven to be at least 35, then the patient would still require evidence of supervised weight loss attempts. In addition, the patient also needs to undergo and provide documentation of a multidisciplinary evaluation with a dietary and behavioral evaluation before it could be determined whether this patient is a good candidate for bariatric surgery. All told, the requested surgery has not been established as medically necessary in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested residential treatment services for her chemical/chlorine toxicity.  Findings:  The physician reviewer found that there is no protocol for such testing found in the available scientific literature. Thus, there is no scientific evidence demonstrating the validity of the test that was performed to determine this patients chlorine toxicity. The additional problem with using chemical chlorine is the irritant or corrosive effect on the dermis. The skin testing is for assessment of IgE mediated reactions. While the sinusitis may indicate the need for aeroallergen testing, the patient did not appear to have any food related IgE mediated reactions. Even if there was an indication for food skin testing, the use of intradermal testing for foods (such as was done with avocado, wheat, etc.) is not recommended by the American College of Allergy, Asthma and Immunology (ACAAI) or the American Academy of Allergy, Asthma and Immunology (AAAAI), as listed in their practice parameters. These guidelines indicate that intracutaneous skin tests for foods are potentially dangerous, are overly sensitive, increase the chance of a false-positive test result, and are not recommended. (Bernstein, et al.) Additionally, immunotherapy using foods is not recommended by the ACAAI and AAAAI. The provider mentions in his letter that he makes his own vaccine from the purest substances available. It is unclear if these extracts are Food and Drug Administration (FDA) approved and they are not supported by the documentation provided. The metal assays that were performed were noted to have been developed and performance characteristics were determined by the diagnostic company who performed the test, which has not been cleared or approved by the FDA. Thus, this test would not be considered within the standard of care for determining toxicity in this patient.In review of the patients history and exams, the findings do not indicate an immune deficiency. Additionally, there is no laboratory results included that would corroborate the patients diagnosis. As this patients diagnosis was not confirmed by objective laboratory testing, the services at issue used to treat the patients chemical/chlorine toxicity are not considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested authorization and coverage for a transrectal ultrasound (TRUS) with color Doppler and CAPRA score determination to enable his providers to formulate a more comprehensive treatment plan for the enrollee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer.   Findings:  The physician reviewer found that this patient has a diagnosis of prostate cancer adenocarcinoma Gleason score of 7 (3+4) with one positive core of 7% involvement. The digital exam was normal and therefore his stage is T1c. A second ultrasound has been requested which is to include color Doppler. The medical literature shows that the color Doppler technique in this clinical setting has not been established to better diagnose tumor extension than the standard approach (Nelson, et al and Strigari, et al). The CAPRA score requires the age of the patient at diagnosis, PSA at diagnosis, Gleason score of the biopsy (primary/secondary), clinical score (T-stage), and percent of biopsy cores involved with cancer (May, et al). However, this patients record has the required information to calculate the CAPRA score. For these reasons, the requested prostate ultrasound with color Doppler has not been shown to be medically necessary in the management of this patients prostate cancer.
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 speech delay. Findings:  The physician reviewer found that an extensive review of the available peer reviewed medical literature, including a meta-analysis by Law, et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period when compared to no intervention or nursery-based intervention. Thus, speech therapy in this case is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested coverage for computed tomography (CT) myelogram for evaluation of the enrollees back pain. Findings:  The physician reviewer found that a study presenting the common causes of lumbar stenosis and on the routine use of imaging studies to evaluate these conditions. The modalities included CT, MRI and CT myelogram and the article concludes that any one of these modalities can adequately diagnose lumbar spinal stenosis. The overall accuracy of rate of CT, MRI and CT myelogram has been reported to be similar, even complimentary. In general, it is recommended that the least invasive modality be performed first. Thus, MRI should be the first choice because it does not require ionizing radiation or contrast injection.