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

A 52-year-old male enrollee has requested carotid angioplasty with stent to the left vertebral artery and magnetic resonance imaging and magnetic resonance angiography for the treatment of his high grade stenosis. Findings:  Two physician reviewers found that at issue is whether carotid angioplasty with vertebral artery stenting is likely to be more beneficial for treatment of the patients vertebral artery stenosis than standard alternative therapies. The literature on endovascular vertebral artery treatment is largely limited to case reports and case series. Mas and colleagues in their 2006 study conducted a multicenter, randomized, non-inferiority trial to compare stenting with endarterectomy in symptomatic patients with at least 60% carotid stenosis. The authors concluded that, The rates of death and stroke at one and six months were lower with endarterectomy than with stenting. On follow-up study in 2008, the authors reported that, Carotid stenting is as effective as carotid endarterectomy for middle-term prevention of ipsilateral stroke, but the safety of carotid stenting needs to be improved before it can be used as an alternative to carotid endarterectomy in patients with symptomatic carotid stenosis. Luebke and colleagues 2007 meta-analysis of the randomized studies available at the time suggested that, CEA [carotid endarterectomy] can be performed with more safety than CAS [carotid artery stenting]. As a result, CEA remains the gold standard treatment for suitable de novo carotid stenosis and CAS should only be performed within randomized trials of stenting versus surgery. Based on the available evidence, carotid artery stenting has not convincingly been shown to be superior to carotid endarterectomy in terms of safety and efficacy at this time. There is even less evidence in support of the safety and efficacy of vertebral artery stenting than carotid artery stenting and it should likewise be considered an unproven technique. With regard to the MRI and MRA, since their purpose is for pre-operative evaluation in preparation for vertebral artery stenting, they are not indicated at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Botox injections for the treatment of her hemiparetic migraine. Findings:  Two physician reviewers found that the use of botulinum toxin (Botox) for management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse and is helpful in managing refractory headache syndromes. In fact, this patient has been receiving Botox for many years with significant prophylactic effect which has resulted in a significant decrease in the number and intensity of her headaches as well as reduction in the episodes of hemiparesis. Given the excellent results the patient has achieved from Botox, and the suboptimal results she experienced with other prophylactic agents, Botox represents a superior treatment option in this particular case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested robot assisted laparoscopic prostatectomy (Da Vinci) for the treatment of his prostate cancer. Findings:  The physician reviewer found that radical prostatectomy can be performed through an open incision as has been routine for the last several decades. In the last few years however surgeons have learned to remove the prostate laparoscopically with robot assistance which has increased the facility, speed, and safety with which this operation can be performed. There are now multiple centers with extensive experience performing robot assisted radical prostatectomy and the frequency with which it is performed has increased rapidly in the last few years. The outcomes for cancer cure and continence appear to be equal to the open procedure, but the blood loss and preservation of erectile function are better than with open surgery. It is anticipated that the Da Vinci robot will be used to perform more than 60% of the radical prostatectomies in the United States in 2009. It has become the standard of care for laparoscopic radical prostatectomy. By comparison, straight laparoscopy is difficult, technically challenging, and simply not as precise as the surgery when performed with the assistance of the Da Vinci robot which offers 3D depth perception, increased dexterity with the special tools, and seven degrees of range of motion instead of only four as with straight laparoscopy. In addition, the improved instrumentation makes the procedure easier, more precise, and faster.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested Tarceva (to be used in conjunction with Gemzar) for the treatment of his metastatic pancreatic cancer. Findings:  The physician reviewer found that the provider has indicated that the treatment plan was to initially treat the patient with gemcitabine/oxaliplatin followed by gemcitabine/Tarceva. There is evidence supporting the use of the gemcitabine/oxaliplatin combination. Gemcitabine chemotherapy has been the standard of care for metastatic pancreatic cancer since it provides a survival benefit compared to best supportive care in clinical trials. The benefit is modest, with median survival of six months. Gemcitabine has been combined with other chemotherapeutic drugs with mixed results. Recently, the FDA approved Tarceva as first-line therapy in combination with gemcitabine based on a randomized clinical trial where 569 patients received either gemcitabine alone or in combination with Tarceva.  The latter treatment arm resulted in a modest improvement in survival that was statistically significant (6.24 versus 5.91 months). Although the clinical trial showed a statistically significant increase in overall survival, there is a debate among practicing oncologists regarding whether this is clinically meaningful in light of the toxicities of Tarceva. Furthermore, this trial involved the use of Tarceva and gemcitabine as first-line therapy, whereas this patient has been treated with gemcitabine/oxaliplatin. All told, there is inadequate support for the combination of Tarceva and gemcitabine in this previously treated patient to demonstrate its medical necessity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Tri-Luma cream for the treatment of his melasma. Findings:  The physician reviewer found that this patients symptoms constitute an abnormal condition of the body that is caused by disease. Melasma is an acquired disease that results in hyperpigmentation of the skin. It primarily occurs on the face although it can occur on other skin exposed to the sun. Men comprise only 10% of patients with this disorder and generally it affects dark skinned patients more often than those with light skin. There is a genetic component to the development of melasma and the condition is often a therapeutically challenging disease. Additionally, the requested medication is being used to create a normal appearance to the extent possible as pigmentary abnormalities, whether increased pigmentation as seen in melasma or loss of pigmentation as seen in vitiligo, are most debilitating in dark skinned races. As noted by Taylor and colleagues, pigmentary disorders pose significant negative impact on a persons health-related quality of life creating a need for effective treatments of pigmentary disorders based on their prevalence and effect on quality of life. The requested medication would be used to fade hyperpigmentation to produce as normal an appearance as possible in this patient. The requested medication will offer this patient more than minimal improvement in his appearance. As indicated by Grimes in his 1995 article, the bleaching agent Hydroquinone remains the most effective topically applied bleaching agent approved by the Food and Drug Administration for the treatment of melasma. This conclusion is reiterated by Grimes in his 2009 article in which he states that Hydroquinone remains the gold standard of topical agents for melasma.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested Botox injections for the treatment of his back pain. Findings:  Three physician reviewers found that there have been several scientific studies to evaluate the utility of Botox. Currently, there is a lack of sufficient scientific evidence from randomized, controlled studies to demonstrate that Botox is likely to be more effective than alternative standard treatments for myofascial low back pain. A publication from Jeynes and Gauci reviews the literature on Botox for a variety of conditions. The authors note there is conflicting evidence with regard to the use of Botox for myofascial pain, such as is present in this patient. All told, the superiority of Botox in this particular setting has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 24-year-old male enrollee has requested inpatient mental health facility treatment for the treatment of the enrollees bipolar affective disorder, manic with psychotic features. Findings:  The physician reviewer found that while the patient may have experienced elements of psychosis associated with drug use in the past, there was no suggestion that he was psychotic, suicidal, homicidal, overly aggressive or regressed and unable to care for himself at the time of admission. There was no mental status examination reported. The patients need for residential treatment was not clearly documented at the time of admission, nor was it documented at any other time throughout the admission. While it was stated that medications were not needed, there was very little description of the treatments given. Based on the information provided, the patient did not require 24/7 professional observation and care. This patients treatment needs could have been safely and effectively provided at a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested enhanced external counterpulsation for the treatment of his multiple cardiac problems. Findings:  Two physician reviewers found that the use of enhanced external counterpulsation (EECP) in chronic angina patients who cannot be safely re-vascularized and are refractory to medications is accepted as a medically appropriate treatment modality. The current American College of Cardiology (ACC) guidelines for the treatment of chronic angina specifically consider the use of EECP in this patient population. The ACC classification of this recommendation for EECP recognizes that the indications for the use of EECP are still being studied. Gibbons and colleagues found in their study that EECP was generally well tolerated and efficacious with approximately 75% to 80% of patients reporting improvement in symptoms. However, additional clinical trial data are necessary before this technology can be recommended definitively. Given this, the current recommendations for treatment of angina remain anti-anginal therapy or re-vascularization as first line therapy, with EECP reserved for those symptomatic patients who fail a reasonable trial of medications and cannot be re-vascularized. In this particular case, this patient is on several anti-anginal agents including one from each drug class. He was taking a beta blocker, long-acting nitrate, calcium channel blocker, and Ranexa, which amount to maximal medical therapy. Further, the documentation provided indicates that the patient, at that time, could not be re-vascularized. Specifically, the patient had a surgical consultation and the diagonal area was thought to be jailed. As such, this patient had refractory symptoms of chest pain or angina. EECP is normally considered in this subset of patient that experiences continued Class 3 to 4 angina despite maximal medical therapy, and is not a candidate for re-vascularization.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested continued physical therapy (64 visits) for the treatment of her high-grade sarcoma in the right brachial plexus. Findings:  The physician reviewer found that the records provided for review demonstrate the patient has shown slow but consistent progress with PT thus far. Although the patients increase in range of motion is only reported to be a few degrees and she has had only incremental improvement in overall motor strength, considering the extent of her injury, she is likely to continue to improve slowly over an extended period of time. According to Centers for Medicare and Medicaid Services (CMS) guidelines, which are consistent with the standard of care in this setting, PT services are medically necessary when they are reasonable for treatment of the patients condition, progress is expected, and the services are sought to improve function. This patient, whose range of motion is still quite limited, is likely to benefit from additional PT services once per week for at least two months to prevent regression and continue progress for her adhesive capsulitis. Since this patient has not plateaued in her progress and has not reached maintenance level, skilled PT should continue until the patient has received two consecutive months of therapy without improvement in any active range of motion (AROM), strength, or functional activity (at which time she will have plateaued). The majority of providers recommend several months of therapy for treatment of adhesive capsulitis and this patient should be provided services until she has achieved maintenance level such that she no longer requires the services of a skilled physical therapist.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested occupational therapy for the treatment of the enrollees pervasive developmental disorder and Aspergers syndrome. Findings:  The physician reviewer found that the literature examines the effectiveness of occupational therapy on developmentally disabled children.  Schaaf and colleagues reported the effectiveness of sensory integration techniques by occupational therapists in children similar to this patient. Miller and colleagues reported a controlled study demonstrating the efficacy of occupational therapy in this population. Additionally, although the report of Roberts and colleagues was a single case study, it documented a dramatic improvement in behavior and attention with occupational therapy. This patient has had significant documentation of his motor and sensory integration problems on at least three evaluations. He also has had reported improvement by his pediatrician and his occupational therapist. Continued occupational therapy is medically appropriate and indicated for this patient. He has previously benefitted from the therapy and is likely to experience additional functional gains from continued therapy. The patient should receive one hour per week of occupational therapy for a six-month period with re-assessment at that time to determine the need for continued therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that this patient weighs 215 pounds and has a height of 57 with a body mass index (BMI) of 33.7. As such, the patient does not meet criteria set by National Institutes of Health for weight loss surgery. She does not meet the criteria set by the FDA for lap band surgery. Any use of an implantable device that is outside the conditions set by the FDA guidelines is considered an off-label use. Per National Institutes of Health and FDA guidelines, bariatric surgery is not medically indicated for this patient. In this patients case, the risks associated with weight loss surgery outweigh the potential benefits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested Vyvanse 30mg for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD), inattentive type. Findings:  The physician reviewer found that Vyvanse is FDA approved for the treatment of ADHD in children and adults. Vyvanse is a prodrug of dextroamphetamine and offers certain advantages, such as longer duration of symptom control, and fewer side effects in some patients. Both efficacy and safety have been observed in the literature. This patient has tried three different strengths of Concerta. According to the submitted medical documentation, this patient is responding well to the current dosage of Vyvanse. A change in medication could significantly exacerbate his illness. Vyvanse was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested intensive outpatient therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that because of the patients dangerous behavior, deterioration and serious functional impairment, intensive outpatient treatment with the multiple therapeutic interventions described is medically indicated. Progress has been noted in the medical record since intensive outpatient therapy was initiated. The level of care at issue is consistent with CALOCUS level of care utilization system guidelines, which provide that intensive outpatient therapy is indicated when there is major comorbidity, serious risk of harm to self or others, moderate to serious functional impairment and a stressful environment. Based on the clinical documentation provided, this patient meets these criteria. The requested therapeutic services are also consistent with American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested use of a dynamic shoulder splint for the treatment of her shoulder stiffness and discomfort. Findings:  Three physician reviewers found that the scientific literature reveals inadequate peer-reviewed data to support the use of a dynamic shoulder splint to improve range of motion following proximal humerus fracture. If physical therapy is unsuccessful, surgical release is the preferred treatment in this setting. At this time, there is a lack of randomized, well-controlled, randomized studies demonstrating that the use of dynamic shoulder splinting results in an improved clinical outcome as compared to standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested vision therapy for the treatment of the enrollees ocular motor dysfunction. Findings:  Three physician reviewers found that this patient had a normal eye exam with no evidence of strabismus. The documents submitted do not demonstrate the presence of an ocular disorder that is likely to benefit from vision therapy. For this patient, vision therapy is of unproven value and lacks a sound scientific basis. There is no scientifically proven link between eye movement and reading difficulties. Furthermore, there is no scientific documentation that training in eye tracking and movement results in any long-term benefits. Thus, there is insufficient support for the efficacy of vision therapy to support its use in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a continuous passive motion (CPM) machine for the treatment of his medical condition status post anterior cruciate ligament replacement surgery. Findings:  The physician reviewer found that although the use of a CPM machine following arthroscopic surgery for ACL repair is not entirely uncommon, there is little support in the medical literature to support its use and further study is needed to prove its efficacy (Smith and Davies). Richmond and colleagues found that the prolonged use of CPM did not offer any additional benefit while Wright and colleagues stated that although a possible decrease in pain was noted in some studies, no substantial advantage was identified to justify the use of the device. Additionally, Engstrom and colleagues found no increased motion with use of CPM post-operatively.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested neuropsychological testing for an evaluation of the enrollees autism. Findings:  The physician reviewer found that this patient presents with symptoms of an autism spectrum disorder along with cerebral palsy. Neuropsychological testing is often indicated for both disorders to assist in developing or enhancing an appropriate treatment plan. The history also indicates the patient is regressing in school and additional testing could be helpful in the treatment process. Neuropsychological testing is likely to be of clinical value in this setting and is consistent with American Academy of Child and Adolescent Psychiatry guidelines for the Assessment and Treatment of Children, Adolescents and Adults with Autism and Pervasive Developmental Disorders. Neuropsychological testing in this setting is also supported by other standard clinical references such as Volkmars Handbook of Autism and Pervasive Developmental Disorder.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested an interferential stimulator device for the treatment of her incontinence and sacroiliac joint dysfunction. Findings:  Three physician reviewers found that interferential stimulation therapy utilizing effects of low frequency electrical stimulation was first conducted on the lower urinary tract in the treatment of urinary incontinence in 1975. Interferential stimulation therapy for overactive bladder has been described in the medical literature in sporadic reports. The proposed utility of this therapy for conditions such as urinary frequency, urge incontinence, and stress incontinence was subsequently reported in these studies. However, there are no controlled or randomized controlled trials to confirm the efficacy of this treatment for these indications. At this time, the evidence supporting the benefits of interferential stimulation is lacking in both quantity and quality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested narrowband UV treatments/Excimer Laser therapy for the treatment of the enrollees vitiligo. Findings:  The physician reviewer found that the use of phototherapy, in the form of narrow-band UV or Excimer Laser therapy, is a useful treatment for vitiligo. However, based on the clinical information provided, this patient has not yet pursued first-line treatment with topical corticosteroids in conjunction with tacrolimus ointment. Use of potent topical steroids (such as clobetasol) on the face can be considered contraindicated for extended periods of time due to side effects of skin thinning and the development of telangiectasias.  However, the use of intermittent breaks from steroid therapy, as with the use of tacrolimus, is a safer and no less effective therapy for this condition. A three-month course of topical therapies, including alternating clobetasol and tacrolimus ointment, is a reasonable and often effective approach to treatment prior to the institution of Excimer Laser therapy or other narrowband UV modalities.  If this patient fails to respond after a three-month course with topical therapies, then narrowband UV treatments/Excimer Laser therapy should be pursued.