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

The parent of a one-year-old female enrollee has requested a cranial orthosis (helmet) for treatment of the enrollees plagiocephaly. Findings:  Three physician reviewers found that Teichgraeber and colleagues studied 248 infants who were treated for posterior positional plagiocephaly. They found that molding helmet therapy is an effective treatment for position-induced head shape abnormalities. According to Vles and colleagues, helmet therapy produces a significantly faster response when compared to non-helmet treatment. In 2003, the American Academy of Pediatrics concluded that the best response for helmets occurs in the age range of 4 to 12 months due to the greater malleability of the infant skull bone and the normalizing effect of the rapid growth of the brain. There is less modification of the cranial configuration when used after 12 months of age. According to Persing and colleagues, the use of helmets and other related devices may be beneficial when there has been a lack of response to mechanical adjustments and exercises.  All told, the cranial orthosis (helmet) is likely to be the most beneficial treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eleven-year-old male enrollee has requested acute inpatient mental health services at two facilities and prospective mental health residential treatment center care, status-post discharge from the acute inpatient level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that acute inpatient mental health services provided at the first facility were medically necessary as the medical records indicate the patient was engaging in self-injurious behavior with numerous self-inflicted puncture marks on his arm. In addition, the patient continued to verbalize thoughts of wanting to hurt himself. He has a significant history of mood disturbance, self-harm ideation, impulsivity and aggression. Subsequently, the patient was admitted to an acute inpatient level of care at a second facility three days after his discharge from the initial acute inpatient facility. The submitted records establish the medical necessity of these services. The medical records indicate the patient had thoughts of wanting to cut himself and the patient verbalized thoughts of not liking himself. His history is positive for carrying out self-harm behavior, with impulsive behavior and mood instability. As noted in AACAP practice guidelines, a history of rapid mood shifts, depression and rage are all associated with a high rate of suicide attempts. Given this symptomatology, it is evident that the patient has required an intensity of care only available in an acute inpatient setting. This level of care should continue until it is determined that the patient is stable for step-down to a less intensive level of care. The request for residential treatment center (RTC) level of care post-discharge from acute psychiatric hospitalization is medically necessary and clinically indicated as this proposed level of care is consistent with CALOCUS guidelines and AACAP practice guidelines. CALOCUS recommendations for the RTC level of care include the presence of serious risk of harm, significant impulsivity, and physical aggression with poor judgment and insight. Self-harm ideation, impulsivity, poor judgment and aggression are well-documented in the medical records for this patient. The medical records indicate that the patient has been guarded and not engaged in treatment. The RTC level of care is also indicated when there is serious functional impairment such as impulsive and abusive behavior. The presence of serious functional impairment alone is an indicator for 24-hour services according to CALOCUS criteria. Additionally, this patient has demonstrated significant difficulty in maintaining therapeutic gains and previous treatment has not achieved optimal control of symptoms. There are also co-morbid conditions listed in the medical records which include attention deficit hyperactivity disorder (ADHD), fetal alcohol exposure, post-traumatic stress disorder, and reactive attachment disorder, all of which can significantly impact the course of treatment for his mood disorder diagnosis.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested emergency services for treatment of her 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.This patient presented with pain in her foot for several weeks after stepping on some glass. She denied fever, swelling, vomiting, or any other symptom associated with an infectious process. Her symptoms had not recently changed or worsened. Foreign bodies that have been present in the soft tissues for long periods of time do not generally pose an immediate threat to life or limb. They are usually cared for on a non-emergent basis and are seldom removed in the Emergency Department. Since this patient was not experiencing any sudden decompensation in her condition and was not suffering fever, swelling, or any other acute sign of infection, her symptoms do 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 her health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested physical therapy and occupational therapy for treatment of the enrollees cerebral palsy.  Findings:  Three physician reviewers found that the clinical and pre-clinical literature verifies the ability of the injured brain to retrain itself based on mechanisms of synaptic plasticity. Further, modern scientific data has demonstrated that cerebral palsy is not a static encephalopathy unresponsive to therapeutic modalities. For this reason, the skills training provided during PT and OT sessions can help re-pattern the nervous system with considerable benefit in patients with cerebral palsy. As numerous reliable studies have shown, the advantages of these treatment modalities are well documented in similar patient subsets with compromised normal brain function. Thus, the requested PT and OT sessions have been shown to be medically indicated for this patient and are not experimental or investigational.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Botox for treatment of her migraines. Findings:  Three physician reviewers found that this patients history is consistent with chronic migraine. She has been treated with three classes of standard migraine therapies without significant relief of symptoms or has experienced intolerable side effects. Her provider has recommended treatment with Botox, which has been shown in at least two large placebo-controlled, double blind, randomized studies to be effective in the management of migraines. At this time, Botox is becoming widely used by specialists for patients who fail treatment with multiple standard therapies and is likely to be more beneficial for treatment of this patients chronic migraine than standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-month-old female enrollee has requested speech therapy services for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this nearly two-year-old female patient has no speech. She was reported to have two words at 13 months by her mother, but when evaluated at the age of 17 months she had no language. The articles by Law and colleagues and Goorhuis-Brouwer and Kniff both report the effectiveness of language therapy in speech delayed children. Goorhaus-Brouwer, further reported that speech therapy aids the development of speech in patients who are developmentally delayed. Additionally, children with macrocephaly have a higher incidence of neurological delays than children who are normocephalic. All told, this patient will benefit medically from speech therapy. As she is nearly two-years-old, she is an appropriate candidate for initiation of speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested Enbrel for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that this patient has a history of psoriasis that has been unresponsive to topical therapies and ultraviolet B treatment.  He does not have documented psoriatic arthritis. The patient has not been treated with any systemic therapy, including methotrexate or cyclosporine.  There is a long history of treatment of pediatric psoriasis with methotrexate and cyclosporine with long-term safety data, as noted by Silverberg.  While the injectable biologics have shown to improve psoriatic lesions in pediatric patients, long-term safety data are not available.  The patient has not failed therapy with a prior systemic therapy, and treatment with Enbrel should be reserved for those treatment failures.  In this patients case, Enbrel is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested a WalkAide functional electrical stimulator for treatment of her hemiparalysis. Findings:  Two physician reviewers found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard ankle foot orthosis (AFO) for foot drop. Studies performed to date have involved small numbers of subjects. In order to demonstrate the clinical need for a neuroprosthesis for foot drop, it is necessary to demonstrate that the device significantly improves gait mechanics or is significantly better tolerated than standard bracing techniques in a given individual. In the case under review, the patients gait has not been fully assessed and it does not appear that standard therapies have been exhausted. For example, bracing alternatives such as an articulated plastic AFO or double metal upright AFO, both of which allow motion to occur at the ankle, have not been tried. A double metal upright AFO is also typically used in persons who do not tolerate a direct contact brace and are at increased risk of skin breakdown. Alternatively, there is no evidence that the patient has undergone a trial of physical therapy for gait training using her current AFO in order to optimize her functional mobility. Given the limited evidence supporting the advantages of functional electrical stimulation over bracing in general for management of foot drop and the absence of documented clinical benefit over standard therapeutic approaches in the case under review, the documentation does not support the need for the WalkAide device over standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Vfend for treatment as she is on immunosuppressive therapy. Findings:  The physician reviewer found that this patient had a prior diagnosis of non-invasive aspergilloma (fungus balls) of the maxillary sinus. This was surgically eradicated, and the pathology documented the absence of any vascular invasion or systemic invasion.  Common fungus balls of the paranasal sinuses are usually located within the maxillary sinus.  These are commonly treated with surgical extirpation without any need for antifungal therapy.  Secondary bacterial contamination is not unusual, but many of the bacterial species are very common to other forms of acute bacterial rhinosinusitis, as noted in the literature.  Although this patient has a prior history of lupus erythematosus, the laboratory evaluation performed did not demonstrate a significant immunocompromised state.  She had a normal white cell count and other normal laboratory values.  This patient did not show any evidence of systemic fungal infection based on the clinical records submitted for review.  Without further objective evidence and culture-based evaluation or objective clinical studies such as radiographic evaluations, Vfend is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested home infusion of lactated Ringer solution (2 liters per day) for treatment of her chronic fibromyalgia and immunoglobulin deficiency. Findings:  The physician reviewer found that the medical records do not show a clear definitive diagnosis of fibromyalgia or Lyme disease in this patient. There is also no documentation of clinical hypovolemia in this patient. There are no signs of hypovolemia on examination, or any orthostatic changes in blood pressure or pulse. In addition, red blood cell mass and volume deficit readings, based on red blood cell mass studies, have not been clinically validated. All told, there is insufficient evidence that the patient meets clinical indications for lactated Ringers solution. In the absence of clinical practice guidelines or randomized studies demonstrating the appropriateness of lactated Ringers solution in this setting, the medical necessity of the requested therapy is not established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested combination therapy of bevacizumab (Avastin) and paclitaxel (Taxol) for treatment of her recurrent refractory ovarian cancer. Findings:  Two physician reviewers found that this patients particular clinical situation makes her an appropriate candidate for the combination chemotherapy of Avastin and Taxol. According to nationally recognized treatment guidelines (National Comprehensive Cancer Network), the combination of Taxol and Avastin is a category one recommendation for the treatment of metastatic ovarian cancer. There is no evidence that there are other regimens that are likely to be more effective in this case than the proposed regimen of Taxol and Avastin. An article by Hurt, et al. showed sustained progression-free survival with Taxol and Avastin in patients with recurrent ovarian cancer. In sum, the combination of Taxol and Avastin is a medically reasonable option for this patient and should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested the VEST airway clearance system for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that overall, the scientific data suggests that airway clearance assistance is considered to be the standard of care for patients with cystic fibrosis. For patients who have failed treatment with manual chest physiotherapy, high-frequency chest wall oscillation (HFCWO) via the VEST system has been shown to be an effective alternative. This patient was receiving postural drainage with clapping initially, but still became infected with pseudomonas requiring treatment with a Tobi inhaler. Thus, a more effective airway clearance system was indicated to prevent recurrent infections, and the VEST airway clearance system was appropriately recommended for management of her condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee has requested emergency services on an emergent basis for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient 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 a history of right ear pain and cold symptoms for two days prior. The medical records noted a congested nonproductive cough. The patient was not toxic. He was well-appearing, well-nourished and in only mild discomfort according to the Emergency Department records. Vital signs and pulse oximetry were all normal on arrival. The patient did not have any concerning signs such as lethargy, vomiting, high grade fever, seizure activity or decreased responsiveness. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested a sleep study for evaluation of his seizure disorder. Findings:  The physician reviewer found that seizures are part of the differential diagnosis of abnormal motor behavior occurring during sleep. Optimal diagnosis of nocturnal seizures requires a polysomnogram with full electroencephalogram montage, with simultaneous video recording if possible. Additionally, there is significant evidence that there is a pathogenic link between sleep apnea and seizures (i.e., apnea can cause seizures and does exacerbate seizures). There has been a substantial amount of research done since the 1980s that provides evidence of this link. Given the patients history of nocturnal seizures, the proposed sleep study is likely to be clinically useful in this setting. As such, further evaluation with a sleep study is medically appropriate and necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested enhanced external counterpulsation for treatment of her microvascular angina.  Findings:  Two physician reviewers found that enhanced external counterpulsation (EECP) therapy has been shown to have significant effects on chest pain reduction and quality of life scores when used for treatment of un-revascularizable fixed coronary artery disease (CAD). However, there remains a group of patients, a majority of them women, who have persistent and life limiting anginal type symptoms without evidence of fixed obstructive CAD on coronary angiography. It is known that those who continue to have persistent symptoms despite medical therapy have worse long-term outcomes and more cardiovascular events based on the WISE study. Much of this angina is felt to be likely related to abnormal vasodilatory reserve due to both endothelial and non-endothelial depending factors in the coronary arteries, and recently, testing to assess this has become more prevalent. There is also increasing data that EECP therapy improves endothelial dysfunction in patients with symptomatic CAD.This patient has a history of a systemic inflammatory syndrome (SLE) which could be playing a role in the documented endothelial dysfunction, leading to lack of coronary vasodilatory reserve. This could be the cause of her persistent anginal symptoms. Based on the results of the WISE trial, this places the patient at higher risk for long-term cardiovascular events.  She has been maintained on proper medical therapy without relief and nitroglycerin is being utilized to its fullest extent with limited relief as well for her life limiting symptoms. The data regarding EECP suggests usefulness in these isolated cases of significant endothelial dysfunction. Given the failure of conventional medical therapy and the clinical documentation of significant coronary macro and microvascular dysfunction, a trial of EECP is a reasonable next course of action in this particular patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested BRCA1 and BRCA2 testing for evaluation of her cancer risk. Findings:  Three physician reviewers found that women found to have a mutation of the BRCA1 and BRCA2 genes have a high risk of developing breast and/or ovarian cancer. These mutations are particularly seen in women who have been diagnosed with breast cancer and in patients with a family history of certain cancers.  For women who have not had cancer, there are a variety of guidelines for the use of BRCA1 and BRCA2 testing. In this patients case, per National Comprehensive Cancer Network guidelines, testing is recommended if there are two or more close relatives with breast and/or ovarian cancer and at least one close blood relative diagnosed with breast cancer under the age of 50.  Thus, the requested BRCA1 and BRCA2 testing is indicated and is likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested Lyrica for treatment of his eye pain.Findings:  The physician reviewer found that there are other medications including antidepressants, topical anesthetics and anticonvulsants within the same class of Lyrica that are covered by the patients Health Plan. There are no reports that the patient has used these medications for treatment of his eye pain.  Gabapentin is an anticonvulsant sharing the same class of medication as Lyrica and is covered by the Health Plan. Gabapentin may be as equally effective as Lyrica in the treatment of neuropathic pain. Numerous clinical studies show that first-line therapy should include antidepressants, anticonvulsants and/or topical anesthetics. Collins and colleagues performed a review to determine the relative efficacy and adverse effects of antidepressants and anticonvulsants in the treatment of neuropathic pain. Overall, the review reported that antidepressants and anticonvulsants had the same efficacy and incidence of minor adverse effects in neuropathic pain conditions.  Thus, Lyrica is not medically indicated for this patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Remicade 15 mg/kg for treatment of Crohns disease. Findings:  The physician reviewer found that the Food and Drug Administration's (FDA) recommended dosage of Remicade for the treatment of patients with Crohns disease is 10 mg/kg every 8 weeks. The medical literature does not support the use of an increased dosage although it reports that some patients may become resistant to therapies justifying its off-label use. However, this patient has not been treated with alternative therapies such as Humira and Cimzia. Moreover, this patients documentation suggests that she is resistant to the effects of Remicade, likely due to the development of pre-formed antibodies. Thus, she would not be considered a candidate for treatment with Remicade at a dose higher than approved by the FDA and supported in the available scientific data. For these reasons, the requested dosage of Remicade is not clinically indicated for management of this patients Crohns disease.