Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient presented to an urgent care facility complaining of a one-week history of a non-productive cough, hoarse voice and chest discomfort associated with a sore throat, nasal congestion and fever. No specifics regarding the severity of the patients symptoms were recorded in the medical records provided other than chest discomfort and a sore throat. The physical examination revealed normal vital signs and pulse oximetry, normal pharynx and normal lung sounds. No laboratory or x-ray testing was completed. The patient was diagnosed with an upper respiratory infection, with fever, cough and throat pain. She was given a prescription for benzonatate (a cough suppressant) and Augmentin and was discharged with instructions to follow up with her primary care provider in two to three days. The patient reports that she did not have a cell phone or access to the internet to find out if there were any in-network urgent care facilities closer to her home.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation indicates that the patients symptoms had been ongoing for one week. In addition, she had no physical findings of a serious illness such as strep throat or pneumonia. Further, her pain level was not noted to be severe based on the descriptive language in the medical records. All told, a prudent layperson would not have sought immediate medical attention in this situation. The patients symptoms did not rise to a level of severity that would cause a reasonable layperson to believe that the absence of immediate medical attention would jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested for a power scooter for treatment of his multilevel degenerative disc disease and arthritis in the feet.  Findings:  The physician reviewer found that the standard of care indicates that a power mobility device should be utilized only if a patient is unable to effectively use a gait-aid or non-powered mobility devices, such as a wheelchair. The use of a power mobility device carries with it the substantial risk of iatrogenic deconditioning, which can cause a profound cycle of inactivity, weakness, and immobility. A power scooter is therefore only necessary when a patient is unable to ambulate in the community or otherwise with a less restricted device. This patients medical records do not include an evaluation establishing this type of mobility related deficit. Therefore, the medical necessity of a power scooter is not supported as clinically reasonable or medically necessary for treatment of this patients medical condition.
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 enrollee, who has Down syndrome. Findings:  The physician reviewer found that the current medical evidence supports the requested speech therapy in this clinical situation. Many children with Down syndrome have cognitive deficits, as well as difficulty with speech.  Speech intelligibility, in particular, is a significant and prominent problem.  As noted by Kumin, the factors that affect speech intelligibility for children with Down syndrome include difficulty with combining, organizing, and sequencing the movements necessary for speech. It is essential to facilitate development of communication skills in children with global disabilities, particularly when intelligibility is compromised, so that they can express their needs in a functional way.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested carotid intima-media thickness testing for heart disease risk screening for evaluation of her history of hypercholesterolemia.  Findings:  Two physician reviewers found that in this clinical situation, the testing at issue was not likely to have been superior over other available tools for evaluating this patient. Guidelines for assessing the likelihood of obstructive coronary disease and managing cardiac risk are published, periodically updated by expert national committees, and endorsed by several national organizations.  These guidelines currently do not recommend the routine use of measuring carotid intima-media thickness to help assess the prevalence of coronary disease or to assess the risk for developing coronary disease.   There is a lack of data indicating that a change in treatment based on the testing at issue favorably effects cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling alone.  Therefore, carotid intima-media thickness testing performed on the date in question was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested panniculectomy with lipectomy for treatment of her excess skin.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure.  A panniculectomy may be medically necessary for patients with a history of recurrent infections. The mere presence of a pannus does not automatically make its removal medically necessary.  There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy in this patients case. The documentation provided includes letters from the patients gynecologist and primary care physician in support of coverage for the requested surgery.  However, these letters lack objective data, such as dates of treatment of any skin condition related to the pannus or excess abdominal skin, or listing of any prescribed medications for such treatment. The proposed surgery will not improve function.  All told, the requested panniculectomy with lipectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female has requested occupational therapy for treatment of her autism. Findings:  The physician reviewer found that there is a significant body of medical literature that supports occupational therapy for autistic children. Myers, et al. recommends occupational therapy, however, it was also noted there is a paucity of literature concerning this modality in the treatment of autism. However, subsequent to the report by Myers, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. Pfeiffer and colleagues found that occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism. May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded that the therapy was effective. All told, there is ample literature support for the use of occupational therapy in the treatment of children with autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested speech therapy and occupational therapy services for treatment of his autism. 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.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. Occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded that the therapy was effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female has requested coverage for biofeedback therapy for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested biofeedback therapy.  Van Tulder and colleagues performed a systematic review of available randomized controlled trials to determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific neuromuscular pain and which type of behavioral treatment is most effective. They concluded that although behavioral therapy seems to be an effective treatment for patients with chronic low back pain, it is still unknown what type of patients benefit most from what type of behavioral treatment. Vlaeyen and Morley reported that there is relatively little known about the specific behavioral mechanisms that lead to chronic pain and pain disability.  At this time, the strength of evidence in the medical literature supporting biofeedback for chronic neuromuscular disorders is weak. The current medical evidence does not support the requested services in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has major depressive disorder.  In a letter the provider noted that the patients depression has not responded to pharmacotherapy or psychotherapy. The patients prior medications have included venlafaxine, paroxetine, nafazodone, escitalopram, bupropion, nortriptyline, and mirtazapine, and augmentation has been attempted with lamotrigine, olanzapine, quetiapine, aripiprazole and ziprasidone. The patient has requested coverage for transcranial magnetic stimulation.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patients treatment-resistant major depressive disorder is well-documented.  Her previous treatment has included mood stabilizers and augmentation strategies, including second-generation antipsychotics.  She had a prior psychiatric hospitalization.  There is support in the peer-reviewed literature regarding the efficacy and safety of transcranial magnetic stimulation in this clinical situation.  George and colleagues confirmed the benefit and safety of transcranial magnetic stimulation for adult patients with major depression.  In 2008, Janicak and colleagues noted that transcranial magnetic stimulation has demonstrated efficacy in the treatment of major depressive disorder.  Demitrack and Thase noted that transcranial magnetic stimulation is safer and better tolerated than many other pharmacotherapeutic options or electroconvulsive therapy.  All told, the requested transcranial magnetic stimulation is likely to be superior over other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested continued care with a pediatric cardiologist specialist (in lieu of an adult cardiologist) for treatment of his medical condition status post open heart surgery after birth.  Findings:  The physician reviewer found that this type of surgery was replaced more than 20 years ago with a superior procedure and therefore is rarely used. Patients who have undergone the Senning procedure can be stable for years, but are at risk for significant problems as adults including arrhythmias and right ventricular failure. Some patients may require arrhythmia treatment including pacemakers and radiofrequency ablation. In addition, some patients may require transplants when the right ventricle fails. All told, these patients require continuing care by a specialist in congenital heart disease as provided by a pediatric cardiologist. Adult cardiologists generally do not receive adequate training in complex congenital heart disease. It is common practice for congenital heart disease patients to continue to be cared for by their pediatric cardiologist in the absence of an adequately trained adult congenital cardiologist. For these reasons, the requested services have been demonstrated to be medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential level of care for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that according to American Psychiatric Association (APA) practice guidelines, this patient did not meet the requirements for residential detoxification services from during the said timeframe. Specifically, the records do not indicate that the patient demonstrated chemical substance withdrawal complications, a major medical complication, or persistence of severe neurological or psychological symptoms. Since none of these factors were present in the records provided for review, the patient could have adequately been treated in a less restrictive environment and the criteria for discharge were met. In addition, the Milliman Care Guidelines for hospital discharge includes lack of harm to self or others and lack of impairment in essential functions. The record available for review does not document any impairment in this area; therefore the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for neuroplasty/decompression of the greater and third occipital nerves for treatment of the enrollees headaches.   Findings:  Two physician reviewers found that the patient has a history of chronic headaches.  These headaches have failed to respond to various modalities of treatments.  The medical records noted that two series of forehead Botox injections only provided approximately 50% improvement for a few weeks, after which time her headaches returned to their baseline level. The patients symptoms include nausea, vomiting, diarrhea, photophobia and lightheadedness.  The patient has requested coverage for neuroplasty/decompression of the greater and third occipital nerves.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. The current medical literature has not demonstrated the superior efficacy of the requested services. The neurovascular compression of the greater occipital nerve and its implications for migraine headaches has been described. The study by Janis and colleagues showed that the greater occipital nerve and occipital artery have an anatomical intersection 54% of the time. Thus, migraine headaches may originate from the occipital region.  In a review of indications and outcomes for surgical treatment of patients with chronic migraine headaches caused by occipital neuralgia, Ducic and colleagues described 206 consecutive patients undergoing neurolysis of greater or, less commonly, excision of greater and/or lesser occipital nerves. In this retrospective evaluation, the authors found that over 80% of patients experienced at least 50% pain relief.  However, at this time, there is a lack of controlled studies or observational studies utilizing a large number of patients. All told, the requested neuroplasty/decompression of the greater and third occipital nerves is not likely to be more efficacious 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 for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested occupational therapy for treatment of his autism. Findings:  The physician reviewer found that Myers, et al. recommends this modality, although the authors also note there is limited 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. Pfeiffer and colleagues found that occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism. May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded that the therapy was effective. All told, there is ample literature support for the use of occupational therapy in the treatment of children with autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested speech therapy for treatment of his Aspergers syndrome. Findings:  The physician reviewer found that 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.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). Therefore, it is medically necessary and appropriate for this patient to undergo individual speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old male enrollee has requested lysis of penile post circumcision lesion for treatment of the enrollees status post circumcision.  Findings:  The physician reviewer found that based on the documentation submitted, the requested lysis of penile post circumcision lesion is not medically necessary for the treatment of this patient.  Per the submitted medical records, the patient has no difficulty with urination, no evidence of inflammation, no altered function, and no pain.  According to the literature, circumcision revision is relatively uncommon, given the number of circumcisions performed. The usual complaint is redundant foreskin, which typically does not have medical implications. Further, complications of re-circumcision may be significant and include bleeding and hematoma, so this procedure is not without risk.  This patients condition does not constitute an abnormal structure of the body. The medical records do not demonstrate abnormal anatomy of the penis, as the urologist documented normal penile anatomy.  All told, the requested procedure is not reconstructive in nature and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy.  ABA is an intensive behavioral intervention program that was first reported by Lovass in the 1970s.  ABA therapy has a documented 40 year history of substantially improving motor, verbal, and socially interactive skills in autistic children (Myers, et al.). ABA therapy has been proven effective in multiple controlled studies (Turner, et al.; Sallows and Graupner; and Remington, et al.). It is medically necessary and appropriate that the patient receive nine hours of ABA therapy.