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

The parent of a 13-year-old female has requested Mepron (750mg 300cc with two additional refills) for treatment of her diagnosis of Lyme disease.   Findings:  The physician reviewer found that based on review of the available records, there is inadequate documentation to support the presence of Babesia infection in this patient. Specifically, there is no clinical history that might indicate a reason to consider this diagnosis. In addition, the patients serological tests for Babesia have been either completely negative (the FISH) or at a borderline level of significance (the IFA). Given that the Babesia titer and IFA titers were the same on two dates a month apart, it is likely the results were falsely positive. There is also no support for the diagnosis of any other tick borne disease. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested 12 hours of direct applied behavioral analysis (ABA) therapy per week and 8 hours per month of supervision for treatment of his autism. The physician reviewer found that review of the submitted documentation demonstrates this six-yearold patient is autistic.  By specific Vineland Adaptive Scale scores, his age equivalency has shown only minimal improvement, but he achieved most of the behavioral goals outlined by his therapists over the past two years. This is typical of autistic children, as it is extremely difficult to test this patient population at a single setting. For test scores to be reliable, they generally have to be repeated over a short span of time.  However, since the patient has met most of the outlined behavioral goals, he has demonstrated positive improved behavior which is one of the major goals of ABA therapy. Despite the patients slow improvement in response to ABA therapy over the prior two years, ABA therapy remains the mainstay treatment in this setting. It is the medical communitys customary practice to provide ABA services to a child with autism. There is strong support in the medical literature establishing ABA therapy and Picture Exchange as the only peer-reviewed successful treatments for autism. ABA therapy has a well documented history of substantially improving motor, verbal, and interactive social skills in this population. Myers and Johnson state: The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. That ABA therapy is the treatment of choice for autistic children is confirmed in multiple controlled studies including the studies by Turner, Sallows and Remington cited above. These studies also emphasize that ABA intervention should be initiated and continued at an early age. This patient has been diagnosed as autistic and continued ABA therapy is medically appropriate and indicated.Based upon the relevant literature, as well as the progress and continued deficits documented in the patients clinical records, continued ABA services are medically necessary for this patient. However, after two years of therapy, a reduction in the frequency of services to 10 hours of direct 1:1 therapy per week and 4 hours per month of supervision is appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested approval for a past lumbar artificial disc replacement at L3-4 and L4-5 for treatment of his degenerative disc disease.  Findings:  Three physician reviewers found that the patient is has a history of severe right leg sciatica as well as low back pain. He has been treated with multiple therapies including epidurals, nerve root blocks, acupuncture, physical therapy, massage and medications, all without lasting relief. On neurological testing, he has 4+/5 strength in the right iliopsoas, tibialis anterior and extensor hallucis longus (EHL) but 5/5 elsewhere. His sensation is intact in both lower extremities. A discogram was unable to determine his primary pain generator. A post discogram computed tomography (CT) demonstrated multilevel disc and facet degenerative changes without significant central canal stenosis. An electromyography (EMG) was consistent with a right L4 radiculopathy with ongoing denervation. The patient underwent artificial disc replacement surgery at L3-4 and L4-5. The ProDisc-L total disc replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The main conclusions of the study were that at 24 months, the overall incidence of adverse events, number of device-related adverse events, and the overall success rate of the ProDisc-L group was no worse than that of the control group. In a case series published in a peer-reviewed journal, Shim and colleagues followed 24 patients for greater than three years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively), raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Given the lack of well designed studies with long-term outcome data supporting the superiority of the procedure under review, the surgery at issue was not likely to be more beneficial for treatment of the patients medical condition than any available alternative therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested BART testing for evaluation of her breast cancer.   Findings:  Two physician reviewers found that the records indicate the patient has a first-degree relative, her mother, who was diagnosed with breast cancer. The provider has recommended BRCA1 and BRCA2 testing as well as BART testing for evaluation of her condition and direction with potential treatment options.  As this patient has a personal history of breast cancer and a first-degree relative who was also diagnosed with breast cancer, she meets the criteria for BRCA1 and BRCA2 testing. However, in the absence of the BRCA1 and BRCA2 test results, the utility of the requested BART testing cannot be assessed. The peer-reviewed medical literature does not support an indication for the BART test until the BRCA1 and BRCA2 test results are available for review. Therefore, the requested BART testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard approach at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.   Findings:  Three physician reviewers found that the patient has a major depressive disorder, recurrent, severe.  She presents with depressed mood, lack of motivation, fatigue, problematic concentration and recent suicidal ideation. She has impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including fluoxetine, Celexa, Duloxetine, Abilify, Seroquel, and Lithium, which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.  According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorder. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for this patients depression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female has requested endovenous ablation therapy (36475), stab phlebectomies of varicose veins (37766) and post-operative duplex scan of the extremity veins, unilateral (93971) for treatment of her left saphenous vein reflux.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the requested services are medically necessary for this patient. The patient presents with chronic venous insufficiency with greater saphenous vein reflux and varicose veins (CEAP II). Symptomatic greater saphenous vein reflux treatments include medical therapy such as leg elevation and compression therapy progressing to ablation, ligation, phlebectomy, or stripping of the great saphenous vein or small saphenous vein. Endovenous ablation with stab phlebectomy is significantly less morbid and much better tolerated than ligation and stripping and is the treatment of choice in most young active individuals as recovery is significantly shorter. Venous duplex examination following endovenous ablation is recommended to rule out deep venous thrombosis and to check the completeness of the procedure. As such, the proposed services are medically appropriate and necessary for treatment of the patients greater saphenous vein reflux and varicose veins.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested spine nerve treatment consisting of radiofrequency neurolysis on the right side for treatment of his low back pain.   Findings:  Three physician reviewers found that this case involves a patient with a longstanding history of low back pain and who also underwent multiple surgical interventions. The provider has diagnosed him with post surgery syndrome, lumbar degenerative disc disease and lumbar facet joint arthropathy. The provider also performed facet joint nerve blocks on two occasions on the left side at L2, 3 and 4 levels. There was no L5 dorsal ramus block based on the available notes. Further, the first block involved injection of 1 mL of 0.25% bupivacaine at each level, whereas it appears that the second block involved injection of 2 mL with 0.25% bupivacaine and 40 mg of Kenalog with 1 cc each at each level. The provider has recommended right side nerve blocks consisting of neurolysis.  The records do not demonstrate that the patient has already undergone appropriate diagnostic medial branch injections on the right side, and if so, the patients response. Based on the available notes, it appears that a potential diagnostic nerve block was performed on the right side. However, the patient reportedly received 240mg of Kenalog, which is a high dose that is not clinically recommended. The medical literature suggests that diagnostic blocks are extremely important and they must be performed with very low volumes, preferably around 0.5 or 0.6 mL, or less (Manchikanti, et al). They should be controlled diagnostic blocks utilizing either controlled comparative local anesthetic blocks or placebo-control. Moreover, there was no quantification in the records of the patients relief. A positive block is defined as a predetermined criteria, either 50% or 80% relief, and with ability to perform previously painful movements. There was no such documentation included in the patients records provided for review. The response with radiofrequency neurotomy in patients who have not undergone diagnostic blocks was in the placebo range and reported to be less than 35% patients reporting improvement at three-month follow-up (Cohen, et al). Based on the available records and current literature, there is no indication for the requested right sided radiofrequency neurotomy without controlled diagnostic blocks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested coverage for weekly outpatient psychotherapy from a specific date and forward for treatment of his bipolar disorder.  Findings:  The physician reviewer found that Roman and Gillig concluded that a combination of psychotherapy and pharmacotherapy is superior to pharmacotherapy alone for patients with frequent relapses of Bipolar Disorder. Miklowitz also noted that adjunctive psychotherapy enhances the outcomes of Bipolar Disorder. The records indicate the patient is safe to be treated on an outpatient basis, treatment goals are clear, frequency and duration are appropriate for severity of illness and he cannot be managed at a lower level of care. The patients symptoms suggest a co-occurrence of both depressive and hypomanic symptoms. Psychotherapy has been shown to help reduce this patients symptoms, but like any other treatment, it does need to be continued for maintenance. In addition, the general standard for maintenance psychotherapy is weekly, not every other week. All told, weekly psychotherapy is appropriate to treat the patients condition, consistent with good medical practice, and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male has requested participation in Phase III Clinical Trial Evaluating DCVax-L, Autologous Dendritic Cells Pulsed with Tumor Lysate Antigen for the Treatment of Glioblastoma Multiforme.  Findings:  The  physician reviewer found that chemotherapy prolongs survival with modest gains in some patients with GBM. The standard of care is to resect the GBM maximally followed by treatment with temozolomide. The regimen of temozolomide treatment concomitant with radiation therapy was analyzed in a randomized clinical trial setting with 26.5% two-year survival, compared to 10.4% in the cohort receiving only radiation (Taphoorn, et al; Stupp, et al). Most GBM tumors recur and then the treatment options are limited. According to the Physicians Data Query, patients who have brain tumors that are either infrequently curable or unresectable should be considered candidates for clinical trials. Further, dendritic cell vaccination therapy is listed as a potential clinical protocol under the available treatment options (Fecci, et al; Luptrawan, et al). There are two major advantages to this patient receiving the next step of his treatment at UCLA. First, the facility is a National Cancer Institute (NCI) designated cancer center, where multidisciplinary care is readily available. Second, the surgery will enable him to enroll in a phase III clinical trial. The Health Plans providers agree that repeat resection is required. In addition, the literature indicates that patients with poor prognosis should have reasonable access to a reasonable clinical trial as part of the standard of care for treatment of cancer patients. All told, the requested services including participation in the Phase III Clinical Trial Evaluating DCVax-L, Autologous Dendritic Cells Pulsed with Tumor Lysate Antigen for the Treatment of Glioblastoma Multiforme are supported as medically necessary in treating this patients medical condition and should be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male has requested coverage for speech therapy services for treatment of the enrollees Down syndrome and oral phase dysphagia.  Findings: The physician reviewer found that speech and language therapy is noted as one of the most important parts of intervention services for children with Down syndrome (Buckley, et al.) The goals of speech therapy in this patient population include improving the quality and quantity of everyday communication and the need to work on specifically targeted activities for speech and language skills. Expressive (verbal) language in children with Down syndrome tends to be more delayed than cognitive and receptive language skills (Cohen). Appropriate communication techniques are recommended as part of a total communication approach to overcome problems with verbal expression and improve communication in general. A paper by Baum notes that ongoing speech therapy is advised as part of accepted health supervision guidelines for children and adolescents with Down syndrome. Some children continue to require weekly individual sessions with a therapist who has knowledge and skills to address the childs profile of difficulty for speech. In the case of this patient, therapy notes demonstrate that he has made some progress with speech therapy in the past. As such, additional speech therapy services are medically appropriate and necessary for treatment of the patients continued speech and language deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male has requested coverage for weekly mental health therapy treatment from a specific date and forward for treatment of his depression, anxiety, and panic disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient continues to meet the American Psychiatric Association (APA) criteria for ongoing treatment given his poor functioning. The records indicate the patient has not completed all of his treatment goals, and his symptoms have not resolved or responded well to medication. The patient should receive services on a weekly basis to continue to make progress. All told, weekly psychotherapy is appropriate to treat the patients condition, consistent with good medical practice, and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested resumption of in-home nursing care for treatment of the enrollees cerebral palsy, epilepsy, gastrostomy care, and failure to thrive.  Findings:  The physician reviewer found that based on review of the available records, the patients multiple and complex medical conditions are unstable and require the skills of a trained licensed nursing professional to provide intermittent care. The patients disorder necessitates ongoing collaborate care by different healthcare professionals (Turkelson, et al). According to the Centers for Medicare and Medicaid Services (CMS), skilled nursing care is considered medically necessary when the services could not be provided safely by non-medical personnel. Given the patients unstable medical condition, ongoing skilled nursing care is supported medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female has requested Rituxan therapy for treatment of her Sjogrens disease and neuromyelitis optica (Devics disease).    Findings:  Three physician reviewers found that the patient has a history of recurrent myelitis and optic neuritis in association with a connective tissue disorder most consistent with Sjogrens. She has had multiple severe attacks of myelitis leaving her with weakness and bladder issues, as well as recurrent loss of vision in both eyes with some residual optic neuropathy. Her disease has been characterized as neuromyelitis optica (Devics disease), but her neuromyelitis optica (NMO) antibody has been borderline. She has been treated with chronic oral Dexamethasone, high dose IV Solu-Medrol, intravenous immunoglobulin (IVIG), methotrexate, high dose CellCept, and most recently IV Cytoxan with control, but the medication had to be stopped due to congestive heart failure. She was hospitalized three weeks ago for recurrent bilateral loss of vision, and reportedly responded well to IVIG and her first course of Rituxan. It was requested that she finish the therapeutic protocol (1000mg IV for two courses separated by two weeks). She is now overdue for the second course as the Health Plan has denied the requested Rituxan treatment based on its status as an investigational therapy. This patient has a clinical syndrome consistent with NMO spectrum disorder. Approximately 35% of patients with this condition have negative antibody status. This is complicated by the patients underlying autoimmune disorder, which is likely contributing to her disease. The patient has recurrent disease despite highly aggressive therapy including three different immunosuppressant medications, IVIG, and high dose steroids with a variety of complications, including congestive heart failure. The literature regarding therapy with Rituxan supports its use in patients with refractory NMO, as this patient. The American Academy of Neurology (AAN) statement indicates that Rituxan may be considered for use, but they are unable to give a stronger recommendation based on the lack of placebo controlled studies. As NMO is a relatively rare disease, no large, double blinded, placebo controlled studies have been performed or are likely. Given the failure of multiple standard therapies to treat this patients autoimmune NMO spectrum disorder, the patients reported improvement after her first Rituxan dosing, and a literature supporting the use of this drug in this clinical setting, the requested Rituxan is more likely to be effective than standard therapy in treating this patients medical condition than standard alternatives.