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

A 67-year-old male enrollee has requested an electrical stimulator (CPT code E0745 for treatment of his left shoulder pain and limited range of motion.  Findings:  Three physician reviewers found that there is a lack of peer-reviewed medical literature supporting the use of neuromuscular electrical stimulation devices for shoulder pain.  In a 2010 meta-analysis, Fuentes and colleagues concluded that it is unknown whether the analgesic effect of interferential current is superior to that of the concomitant interventions.  They noted that interferential current alone was not significantly better than placebo or other therapy at discharge or follow-up. Although there may be some transient improvements in pain, sustained long-term analgesic and functional gains above that expected from the natural history of waxing and waning of pain symptoms have not been demonstrated in a scientifically rigorous manner.  There is a lack of published high-grade randomized controlled trials that have demonstrated the efficacy of neuromuscular electrical stimulation devices in musculoskeletal conditions or pain syndromes over placebo controls or basic conventional care consisting of analgesics, self-applied thermal modalities and a self-directed exercise program. Overall, the research in the area of physiotherapy interventions for shoulder pain is limited.  Thus, the electrical stimulator was not likely to be superior over all other treatment options for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested the remote heart monitor for evaluation of her heart palpitations.  Findings:  Two physician reviewers found that based on the records provided, the patient has a history of palpitations in the setting of a normal ECG, essentially normal ECHO, and no symptoms during Holter monitoring. In this circumstance, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording potential dysrhythmias during symptoms that are not frequent enough to be identified on continuous 24-48 hour Holter monitoring. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. This patients records offer no documentation to indicate that she is unable to effectively manage these standard monitoring devices and or that these have been previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias. Consistent with these guidelines, the continuous real-time monitoring with the CardioNet device was not medically indicated in this case since off-line analysis with a patient activated device should be sufficient to identify symptomatic dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by CardioNet real-time mobile telemetry remains investigational in this circumstance and has not been shown to improve health outcomes compared to standard monitoring techniques.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested Celebrex for treatment of her temporomandibular joint disorder (TMJ).  Findings:  The physician reviewer found that Celebrex is not medically necessary for the treatment of the patients condition. There is no documentation in the patients medical records that there was treatment failure with a second non-steroidal anti-inflammatory drug (NSAID) in order to qualify for treatment with Celebrex. In the medical literature, Mejersjo and Wenneberg concluded that there are several NSAIDs that may provide similar efficacy to Celebrex. The authors compared treatment with diclofenac sodium to occlusal splint therapy in a randomized, single-blind controlled trial of patients with TMJ and found that after one week, there was significant reductions in pain and discomfort in patients treated with diclofenac. Moreover, TMJ tenderness and joint pain was reduced following one week with diclofenac when compared with occlusal splint therapy. The authors concluded that diclofenac gave a more rapid improvement than occlusal splint therapy. In addition, Ta and Dionne compared the efficacy of Celebrex with naproxen and placebo in the treatment of TMJ in a randomized controlled trial and found that Celebrex showed slightly better pain reduction than placebo, but the difference was not statistically significant. In fact, the only clinically noteworthy improvement in mandibular range noted was with naproxen when compared to Celebrex and placebo. The scientific data also recommends conservative treatment with physical therapy for mild to moderate TMJ prior to instituting medications that potentially have adverse effects. Kirk Calabrese examined physical therapy in the management of TMJ in a clinical cross-sectional study and reported an 82% improvement in patients with mild to moderate disc dysfunction and pain associated with TMJ. For these reasons, it is appropriate for this patient to try at least one more of the Health Plans approved NSAIDs prior to Celebrex approval given that other NSAIDs may be more efficacious in the treatment of TMJ. Given that the literature supports the improved health outcomes with NSAIDs, the medical necessity for Celebrex has not been established in this patients case at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested shockwave therapy for treatment of his plantar fasciosis, left heel.  Findings:  Two physician reviewers found that the pain had not responded to NSAIDs, orthotics, cryotherapy or night splint usage.  The patient has been diagnosed with plantar fasciosis.  On the date in question, the patient underwent extracorporeal shockwave therapy of the left heel, without complications. Extracorporeal shockwave therapy has been an FDA approved viable treatment for painful proximal plantar fasciitis for many years.  Numerous studies have been done on this treatment modality.  The efficacy of this treatment is about 70%.  This falls below the 90% efficacy rate of a simple outpatient minimally invasive procedure, such as an endoscopic plantar fasciotomy.  Local cortisone injections as well as physical therapy also involve a 90% effective rate.  All told, extracorporeal shockwave therapy was not likely to be superior over all other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female has requested for 10 to 20 more sessions of occupational therapy for treatment of her spastic quadriplegia.  Findings:  The physician reviewer found that occupational therapy is medically indicated when the requested therapy is an effective treatment for the patient's condition. The services must require the skills of a therapist or supervision of a therapist. In addition, there must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services are needed to establish a maintenance program.  In this patients case, the evaluation by her occupational therapist determined she had weakness of her right thumb and was unable to hold a cup. Following therapy, the patient did have a decrease in her spasticity and also demonstrated functional change regarding her ability to feed herself.  The requested occupational therapy sessions are indicated due to the objective functional loss from her distant occupational therapy evaluations and progress noted with her more recent therapy sessions.  All told, the requested 10 to 20 more sessions of occupational therapy are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Zetia 10 mg. for treatment of his coronary artery disease.  Findings:  The physician reviewer found that it is a clinically reasonable treatment decision to attempt and reduce LDL cholesterol to less than 70 mg/dl in patients with known atherosclerotic coronary artery disease (CAD). In the medical literature, Taylor and colleagues conducted the HALTS trial to compare Zetia versus extended release niacin in patients with elevated Framingham risk scores, diabetes or known CAD. The authors concluded that the addition of Zetia did not meaningfully affect carotid intimal thickness. Likewise, other studies with Zetia have failed to demonstrate a change in outcomes. In addition, standard therapies are available (LaRosa and colleagues) who demonstrated a reduction in atherosclerotic events with high dose (80 mg) atrovastatin versus low dose (10 mg) atrovastatin. In this study, the target LDL in the high dose group was approximately 70 mg/dl, and 100 mg/dl in the low dose group. Although no difference in mortality was demonstrated, there was a difference in event rates. Moreover, the side effect profile in the high dose group was completely satisfactory. With regard to this patient, there is no stated compelling clinical reason not to try atrovastatin 80 mg before proceeding to combination therapy with Zetia. His records provide no specific indication for Zetia that could not otherwise be addressed with high dose monotherapy with a statin. Therefore, the requested medication has not been shown to be medically necessary for the management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested acute intensive psychiatric inpatient services and partial hospital program (PHP) care for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patients records document that she had been treated for severe, recurrent major depression with suicidal ideation for two years prior to the onset of her eating disorder. She also has had a history of self harm with cutting. Following the above described admission, the patient cycled into a manic episode while being treated on an antidepressant. She was readmitted as an inpatient, and subsequently discharged to the partial hospitalization program(PHP) on the date in question. Her team of treating providers indicated that the patient was thought to require this level of care as she was not safe to be at a lower level of care at that point. Clearly, with a new diagnosis of bipolar disorder, accompanied by a recent diagnosis of anorexia nervosa and a co-morbid diagnosis of PTSD, an adjustment period was necessary. It is important to achieve full resolution of symptoms of the current episode in an attempt to improve the patients behaviors (Thomas and colleagues). Given the patients recent history of purging anything consumed and loss of 12 pounds within 1 month prior to admission, both psychopharmacologically and psychologically, the medical necessity has been established for her treatment at the acute inpatient level of care and follow-up therapy in the PHP through the requested dates.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 3-year, 5-month-old male enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  Three physician reviewers found that a review of the records provided for this patient reveals features of autism and a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). His provider is considering use of intravenous immunoglobulin (IVIG) for treatment of PANDAS based upon a comprehensive microbiological/neuroimmunological (in particular a high titer of anti-neuronal antibodies) and nutritional laboratory analyses. The association of streptococcal infection with basal ganglia disease, in particular, obsessive compulsive disorder and movement disorders such as Tourettes syndrome, remains controversial and the clinical data does not support a cause-and-effect for diagnoses such as PANDAS without additionally, substantially larger and carefully controlled clinical studies. From a historical perspective, a similar error was made for other entities, including Kawasakis disease. This makes treatment with IVIG for obsessive compulsive disorder (OCD) difficult to sanction, given that this condition may be a chronic condition, and the efficacy and safety of long-term IVIG therapy may be problematic. While neuroimmune abnormalities may be present in children that carry a diagnosis of tic disorder, OCD and history of streptococcal infections, systematic studies offer no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. Thus, IVIG treatment is unwarranted in non-specifically correcting an underlying immunologic defect that might give rise to these conditions and it should be considered investigational in this circumstance.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 4-year, 9-month-old male enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  Three physician reviewers found that Swedo, a neuropsychiatrist, was one of the first to recognize the possibility of a new syndrome, PANDAS, by an autoimmune attack on the basal ganglia triggered by a streptococcal infection, which could result in motor tics and personality changes. The treatment of choice for these symptoms is IVIG, if the symptom complex meets the criteria of Swedo and colleagues. Despite its similarities to the bodys autoimmune response to beta-streptococcal infection resulting in Sydenhams chorea, the syndrome still continues to be controversial. However, Wolfe and Singer report that many advocates believe in its existence although its diagnosis remains clinical as there are no unequivocal specific confirming laboratory tests. Kirvan and colleagues suggest that the Kirvan/Cunningham test for antineuronal antibodies may be diagnostic of the disorder, but this has not been conclusively established. The reported antibodies returned from Cunninghams laboratory do not confirm the diagnosis of PANDAS in this patient. Overall, the existence of PANDAS is not well recognized by the neurological community. Further, the role for diagnostic testing, if any, has not been established in the medical literature. Thus, the use of IVIG is experimental and cannot be anticipated to benefit this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested revision of bilateral mastopexy for treatment of her breast pain.  Findings:  The physician reviewer found that the submitted documentation does not include photographs or measurements to document breast ptosis that would require mastopexy. Mastopexy is not a treatment for breast pain. There is no documentation that the scars from previous breast surgery are symptomatic, so there is no justification for scar revision. Based upon the submitted records, there is no documentation that a condition which constitutes an abnormal structure of the body exists. There is no indication that the requested surgery would be performed to either improve function or create a normal appearance to the extent possible, or even minimally improve appearance. The expanded concept of medically necessary reconstructive surgery defined in California law is not met.  All told, the requested procedure is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female has requested a bariatric consultation and Lap-Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not establish the medical necessity of the requested services.  The medical records indicate that the patient is 58 and weighed 197 pounds on the said date.  This equates to a body mass index (BMI) of 30. Based upon the National Institutes of Health guidelines, weight loss surgery is not indicated for patients with a BMI less than 35. Patients such as this patient are likely to achieve adequate results from conservative weight loss measures. In this patient population, the benefits of weight loss surgery are outweighed by the potential risks posed by surgical intervention. As such, the requested surgery is not medically indicated for this patient with a BMI of 30.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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. The patient had swelling and pain in his calf for one week prior and had no chronic medical conditions.  The patient was in no acute distress according to the Emergency Department records.  Vital signs and pulse oximetry were normal on arrival. The patient did not have any concerning signs, such as loss of sensation, deformity, dislocation, absence of pulse, bleeding or fever.  The patient had a basic muscle/tendon tear.  The patient had previously been evaluated by his family physician.  The patients symptoms on the date in question did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested surgery for treatment of the enrollees un-descended testicle.   Findings:  The physician reviewer found that the cause of cryptorchidism is multifactorial. An un-descended testis can be located anywhere between the abdominal cavity and just outside the anatomic scrotum. This patients medical records state that the testicle was by the external ring but could be linked to the upper scrotum. In the medical literature, Puri and Nixon described normal testicular descent as a testis that remains stationary within the dependent portion of the scrotum. Therefore, cryptorchidism is a developmental defect in which the testis fails to descend completely into the scrotum. A retractile testis withdraws spontaneously out of the scrotum toward the inguinal canal by an active cremasteric reflex but can easily be brought down into a dependent position within the scrotum and remains there after traction has been released. If a testis can be milked down to the bottom of the scrotum, it is probably retractile and does not require therapy, however, there is debate regarding whether retractile testes are a subtle variant of their un-descended counterpart. In cases of ascent, boys previously documented to have normally descended testes are found later in childhood to be cryptorchid. Ascent probably represents an un-descended testis that is almost completely descended. Oftentimes, the testis is located in a superficial inguinal pouch and is diagnosed as un-descended with somatic growth. Therefore, children with retractile testes should be monitored regularly, at least up to puberty, until the testes are no longer retractile and remain intrascrotal. Based on the published literature, the studies report higher than anticipated cumulative orchiopexy rates of 2% to 4%, with the mean age at surgery reported to be 7 years in the majority of series. The most common testicular position was observed to be distal to the external inguinal ring, and in about half the cases the processus vaginalis was patent. Although Puri and Nixon reported that children with retractile testes have normal testicular volume and a normal fertility rate in adulthood, testicular development has been reported to be abnormal in both retractile testes and ascending testes, with histology similar to that of un-descended testes. As this patients records demonstrate that he does not have a normal descended testicle the recommended orchiopexy is medically indicated and necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested 16 doses of Vivelle Dot per month for treatment of her medical condition status post surgical menopause. Findings:  Two physician reviewers found that there is a paucity of data to support the efficacy of increasing the dose of Vivelle Dot patch to every other day. Given the lack of scientific data establishing the long-term safety and efficacy of this increased dosage there may be additional risks and side effects that have not been determined. To date, the available medical publications do not show the increased dosage improves health outcomes. Further, the research does not suggest that replacing the Vivelle Dot patch every other day rather than twice per week is as good as, or better than standard alternative therapies. Since this elevated dose has not been established as safe and effective, its use in this instance remains investigational.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested an ambulatory cardiac event monitor for evaluation of her heart palpitations and rapid heart rate.  Findings:  Two physician reviewers found that based on the records provided, the patient has a history of shakiness and rapid heart rate in the setting of a normal cardiovascular physical exam and a normal ECG. In this circumstance, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording potential dysrhythmias during symptoms that are not frequent enough to be identified on continuous 24-48 hour Holter monitoring. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. This patients records offer no documentation to indicate that she is unable to effectively manage these standard monitoring devices and or that these have been previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias. Consistent with these guidelines, the continuous real-time monitoring with the CardioNet device was not medically indicated in this case since off-line analysis with a patient activated device should be sufficient to identify symptomatic dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by CardioNet real-time mobile telemetry remains investigational in this circumstance and has not been shown to improve health outcomes compared to standard monitoring techniques. Accordingly, I have determined the device at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.