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

The parent of a 10-year-old male enrollee has requested  past cognitive therapy for treatment of the patient's autism.  Findings:  Two physician reviewers found that the patient has been assessed with autism. The patient receives multiple therapies. His primary physician recommended speech therapy, occupational therapy and physical therapy one to two times per week. An evaluation was performed for hippotherapy (cognitive therapy) and a treatment plan included improvement of coordination, improvement of body awareness, improvement of motor planning, and improvement of balance among other goals. At issue is whether the patients hippotherapy was likely to be more beneficial than any standard available therapy. While hippotherapy does show some efficacy for certain diagnoses, there is no convincing scientific evidence of its utility in autism. In fact, there is no mention of hippotherapy in the evidence-based review of interventions for autism used in or of relevance to occupational therapy (Case-Smith and Arbesman). Autism is mentioned as a diagnosis for which hippotherapy is useful, but references from the Reports of the International Therapeutic Riding Congresses offer little scientific investigation or evidence to support this conclusion. Some studies have demonstrated mild improvements in terms of communication skills, imitation, and perceptual and motor adjustment but were not performed under strict scientific methodologies (Hameury, et al. and Taylor, et al.). Some of these effects were sustained for a short period of time.  While promising, these studies do not provide significant evidence of long-term improvement in individuals with autism. Another study investigated the effectiveness of a simulated horse riding program on the motor proficiency and sensory integrative functions in 60 children with autism (Wuang, et al.). Investigators demonstrated that children with autism showed improved motor proficiency and sensory integrative functions after a 20 week program; however, this study was not performed using live animals and as a result, there could be generalizability issues. While the use of hippotherapy for patients with autism shows some promise, at this time hippotherapy cannot be considered more effective than standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested past and future coverage for hormone replacement pellet therapy for treatment of her menopause-related vasomotor symptoms.  Findings:  Three physician reviewers found that during the transition from the reproductive years through menopause and beyond, a woman experiences many physical changes.  Most of these changes are normal consequences of both menopause and aging.  All women experience menopause, but each in a unique way.  Although for many women menopause is asymptomatic and associated with little disruption of normal life and well-being, many women experience symptoms that considerably impact their quality of life.  Several prescription drugs are available to help relieve menopause-related symptoms. Hormone therapy is the most effective intervention for management of these quality-of-life issues. Over the years, a number of research studies presented a complicated picture of the risks and benefits of hormone therapy, and its use for prevention of cardiovascular diseases was controversial. This led the National Institutes of Health (NIH) to conduct a large clinical trial of the risks and benefits of hormone therapy.  Results from the trial published in 2002 showed that the overall risks of estrogen plus progestin outweigh the benefits.  Compounded bioidentical hormones are plant-derived hormones that are prepared, mixed, assembled, packaged, and labeled as a drug by a pharmacist. These preparations can be custom made for patients according to a physician's specifications. Bioidentical hormones refer to hormones that are biochemically similar or identical to those produced by the ovaries or body.  According to a Committee Opinion released by the American Congress of Obstetricians and Gynecologists, there is a lack of scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens prepared by compounding pharmacies.  There is no evidence that bioidentical hormones have any advantage over conventional hormone therapies. Of note, the quality of compounded products may be substandard in some cases.  According to the American Congress of Obstetricians and Gynecologists, most compounded products, including bioidentical hormones, have not undergone rigorous clinical testing for either safety or efficacy. Also, there are concerns regarding the purity, potency, and quality of compounded products.  All told, hormone replacement pellet therapy was not and is not likely to be more efficacious than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested for skilled nursing facility level of care with physical therapy and occupational therapy for treatment of her Guillain-Barre syndrome. Findings:  The physician reviewer found that Guillain-Barre syndrome (GBS) has a generally favorable natural course and relatively good prognosis. There are standard treatment options that have demonstrated to be effective treatments for this condition (van Doorn, et al.). Despite the generally good prognosis and available therapeutic options, some patients continue to have significant functional impairments at six months or longer following the onset of symptoms. To date, highly intensive rehabilitation services have not been proven to effectuate better long-term functional outcomes in this setting (Khan, et al.). Further inpatient rehabilitation and skilled nursing facility level care including physical therapy and occupational therapy is not medically necessary. Rehabilitation services can be provided in the community setting. Further inpatient care would be custodial in nature based on the available records, and therefore not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested coverage for a past MRI of the breast including computer-aided detection (CAD)for evaluation of her stage IV lobular breast cancer.  Findings:  Three physician reviewers found that the patient has a family history positive for breast cancer. The patient was noted to have very dense breast tissue on mammography. She was found to have invasive lobular carcinoma in the left breast metastatic to the left axilla. She underwent a PET/CT scan and an MRI. The MRI revealed a suspicious area in the superior aspect of the right breast, which could not be biopsied due to difficulty in positioning the patient following her left mastectomy.  A follow-up MRI of the breasts utilizing computer-aided detection (CAD) was performed, which revealed two foci of abnormal enhancement in the right breast.Review of the submitted clinical documentation demonstrates that this patient has very dense breast tissue as reported on mammography. The proven diagnosis of invasive lobular carcinoma of the breast is a disease with at least 25% bilaterality. The very dense breast tissue on mammography virtually excludes that technique for adequate screening of such a patient. MRI is the most sensitive means of screening for breast cancer and in this patient who already had an abnormal MRI examination there is no other technique available to provide the necessary information. As such, the MRI with CAD was the best method by which to evaluate this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in autistic children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach. Fundamental to the diagnosis of autism spectrum disorder (ASD) are deficits in speech and language. Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Deficits in the use of language for social purposes are universally seen in this population. These deficits can serve as major impediments to successful social adaptation and research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum (Volkmar). Therefore, individual speech therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested coverage for Ampyra, 10 mg, one tablet twice per day for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that there is adequate medical literature demonstrating the safety and efficacy of Ampyra for multiple sclerosis (MS) patients. One phase 3, placebo controlled trial conducted by Goodman and colleagues reported class 1 evidence on the positive effects of Ampyra on ambulation in MS patients. In addition, Espejo and Montalban noted that Ampyra is a K+ channel blocker that was recently approved by FDA for the symptomatic treatment of ambulation hardship in MS. This patient has documented MS with associated symptoms including lower extremity and gait impairment. Inadequately treated MS would place the patient at risk of falls, functional limitation, and unnecessary morbidity (Miravalle, et al). Given that Ampyra has been shown to improve function in MS patients, the supervised used of this therapy is medically reasonable and necessary for management of this patients progressive MS.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for Far Infrared Radiant Heat therapy (FIRHT for treatment of her skin condition.  Findings:  The physician reviewer found that although FIRHT units do not provide any significant tissue penetration, they may still provide clinical benefits (Crinnion). There are reports that therapeutic use of this FIRHT for a variety of cardiovascular problems, improvement in lung function, and pain relief. However, currently there are no data in the medical literature regarding the use of FIRHT for skin diseases. In general, treatment of dermatophyte infection involves primarily oral and/or topical formulations of azoles or allylamines, particularly itraconazole and terbinafine. Topical medications applied once or twice daily are the primary treatment indicated for tinea corporis/cruris, and tinea pedis/manuum. Use of oral anti-fungals may be practical where the tinea involvement is extensive or chronic, or where application of a topical is not feasible. Recently, topical amorolfine and ciclopirox formulations have been approved for use in milder onychomycosis cases and relapse of infection remains a problem. Appropriate follow-up and education of patients on proper foot hygiene are also important components in providing effective therapy (Gupta, et al). Antibiotics are used for systemic and topical skin diseases treatment, taking advantage of their antiseptic, bacteriostatic and also their anti-inflammatory and immunomodulating properties. In cases of localized external skin layer infections, a topical treatment is adequate. In cases of widespread and deeper infections a systemic treatment is needed. The latter dermatological diseases are mostly treated by beta-lactam antibiotics macrolides and tetracycline. In topical treatment, mostly erythromycin, Clindamycin, mupirocyne and fusidic acid are used. The most common bacterial skin diseases where topical treatment is sufficient are: impetigo contagiosa; folliculitis; and erythrasma. Systemic treatment is required in cases of severe staphylococcal and streptococcal infections, secondary bacterial infections, acne vulgaris, rosacea, and dermatosis with bacterial antigens pathogenesis influence (McDonald, et al.)Anti-fungal and anti-microbial drugs are usually an effective treatment for the type of skin disease diagnosed in this patient. Failure may have been caused by development of drug resistance by the microorganisms on the patients skin, which could be addressed by performing antibiotic sensitivity tests. However, there is currently no persuasive data showing how FIRHT could improve skin infections with associated dermatitis. Alternative approaches with unpredictable outcomes, like FIRHT, are not medically necessary because the appropriately used standard methods of diagnosis and treatment are sufficient to resolve this common medical problem.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested five doses of Synagis for respiratory syncytial virus (RSV) prevention.  Findings:  The physician reviewer found that in a survey of pediatric specialists who care for children with chronic medical conditions that are technology dependent, almost 90% recommended RSV immunoprophylaxis, and over half recommended immunoprophylaxis for children older than two years (Panitch, et al). In another study of 282 hospitalized children, 22% were older than 12 months, and were more likely to have underlying chronic diseases. These authors concluded that children older than 12 months with underlying disease are at increased risk for serious or fatal RSV infections and are not always protected by previous RSV disease. Such older children should be considered candidates for passive or active immunoprophylaxis against RSV infection as such agents become available. (Groothuis, et al.)This patient is a young child at risk for severe RSV disease. He is technology dependent because of his hypoplastic left heart syndrome complicated by chronic lung disease and severe pulmonary hypertension. It is thus medically necessary and appropriate to administer Synagis for RSV prophylaxis to this patient for the duration of the 2011-12 RSV season. Synagis administration should begin immediately to avoid patient morbidity, and should continue for the full duration of the season as tracked by the Centers for Disease Control and Prevention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested medical therapy with Pegasys or Peginterferon alpha-2a and Ribavirin for treatment of his hepatitis C.  Findings:  The physician reviewer found that Hepatitis C virus (HCV)-related end-stage liver disease is the leading clinical indication of liver transplantation (LT) in the United States as reported by the Bureau of Health Resources Development. HCV recurrence after LT is almost universal and occurs early, with histological recurrence observed in up to 70% of patients during the first year after LT (Gane, 2003). Cirrhosis develops in up to 30% of transplant recipients after 5 years with persistent HCV viremia, and may be associated with graft failure and the need for re-transplantation (Gane, 1996). This leads to lower patient survival rates compared to non-HCV transplant recipients (Forman, et al). Eradicating HCV using antiviral therapy improves patient and graft survival (Veldt, et al). Regimens combining Ribavirin (RBV) with pegylated interferon (PEG) report rates of sustained virological response (SVR), ranging from 28% to 45% with up to 48 weeks of treatment (Bizollon, et al). Currently, there are no established guidelines to determine the timing and type of HCV treatment after LT. In general, the approach to the treatment of HCV after liver transplantation is similar to the pre-transplant protocol of 48 weeks of treatment with viral kinetic evaluation at 12 and 24 weeks. One study reported that patients with recurrent HCV after LT are likely to be slow virological responders due to immunosuppression (Hashemi, et al). Therefore, SVR after 48 weeks of antiviral therapy is expected to be lower than in immune-competent HCV patients. Overall, 73% experienced end of treatment of response and 60% had SVR. The conclusion of the study was that recurrent HCV after LT can be safely treated with extended virological response-guided therapy using PEG/RBV, but requires close monitoring for treatment-related adverse effects, particularly cytopenias (Schmidt, et al). Therefore, based upon the data from various studies using extended therapy in post-transplant HCV, it is appropriate and medically necessary to use extended therapy with pegylated interferon and Ribavirin to have a better chance of achieving SVR in these patients and thereby improve graft and patients survival, and prevents the patients from undergoing re-transplantation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan for evaluation of her status post ductal carcinoma in situ (DCIS) surgery.  Findings:  Two physician reviewers found that a follow-up MRI showed an additional mass in the upper inner quadrant 1.5 cm in diameter which also proved to be malignant. A PET scan performed on the date in question showed no evidence of metastatic disease. A repeat MRI of the breasts/chest and a PET scan were requested for follow-up. Additional information has been submitted which indicates that when the patient presented to her provider on the date in question, there were concerns regarding a hardened area under her scar, subsequent to radiation treatment. The provider noted that it was difficult to determine if there is a recurrence or whether the hardened area is fat necrosis. In addition, it has been noted that the patient is status post mantel radiation for Hodgkins lymphoma. The provider recommended authorization and coverage for an MRI and PET scan of the breasts. As previously indicated, the requested MRI is medically reasonable and appropriate in this patient who has biopsy proven multicentric disease. MRI is the most sensitive test for multicentric disease and would be of greater benefit than conventional mammographic imaging in this clinical setting. The requested PET scan is also medically reasonable. PET is the most sensitive means with which to evaluate the entire body for metastatic disease, particularly the axilla. The absence of hypermetabolic uptake on a prior PET scan should not preclude the future use of PET in this situation. All told, the requested diagnostic scans are likely to be more beneficial for evaluation of this particular patient than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested reimbursement for computed tomography (CT) scan of the heart.  Findings:  Two physician reviewers found that the patient is a 64-year-old male with a history of hyperlipidemia.  He presented with exertional dyspnea without chest pain.  Per the submitted documentation, prior examination was significant for an irregular heartbeat.  The cardiac physical examination was otherwise normal. Approximately two weeks later, an electrocardiogram revealed premature ventricular contractions. Computed tomography (CT) scan of the heart was performed that same day.  The Health Plan has denied reimbursement for the CT scan of the heart and reported that the diagnostic procedure at issue was investigational for the evaluation of this patient.  The patient is appealing this denial.  The submitted documentation noted exertional dyspnea symptoms thought possibly due to an ischemic equivalent, premature ventricular contractions, mitral regurgitation and no objective evidence of ischemia on electrocardiography or echocardiography.  Coronary CT angiography only provides an assessment of coronary anatomy and does not assess the functional significance of any potential stenosis identified.   Therefore, coronary CT angiography would not directly assess the cause of the patients symptoms.  Additionally, coronary CT angiography does not assess for ischemia from causes other than fixed obstructive coronary disease and does not assess for other potential causes of exertional dyspnea, such as exercise-induced dysrhythmias, diastolic dysfunction or exercise-induced worsening valvular regurgitation.  If an assessment of coronary anatomy is considered medically necessary, then invasive coronary angiography is generally preferred given improved accuracy relative to CT angiography and the ability to intervene with revascularization during the same procedure, if clinically indicated.  All told, CT scan of the heart provided on the date in question was not likely to have been more effective than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) with weekly maintenance therapy for up to one year for treatment of her major depression.  Findings:  Two physician reviewers found that this patient presents with a long history of major depressive disorder which has been refractory to numerous medication trials, psychotherapy, and ECT. In addition, she has a history of suicidality requiring hospitalization. She was treated with TMS by her treating psychiatrist with documented reduction in symptoms. TMS has been approved by the Food and Drug Administration (FDA) since 2008. Moreover, there are adequate studies showing the benefit of TMS with minimal, if any, negative side effects. This patient has shown an improvement with the NeuroStar TMS therapy for her sustained depression despite a lack of improvement with other therapies. Therefore, it is reasonable that this patient continue this technique which has been shown to improve patients with this disorder.