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

A 69-year-old male has requested coverage for a positron emission tomography (PET) scan for evaluation of his renal cancer.  Findings:  Three physician reviewers found that the patient has undergone right nephrectomy for renal cell cancer. Prior magnetic resonance imaging (MRI) and computed tomography (CT) scans showed liver metastases which have shrunken over time with treatment. The patient has a solitary kidney with impaired function. Laboratory testing reveals that his serum creatinine level is 1.6 and glomerular filtration rate (GFR) is 43. Previous imaging with positron emission tomography/computed tomography (PET/CT) demonstrated that the liver lesions are PET avid, thus his provider has recommended repeat PET/CT to evaluate the remaining liver lesions as well as other sites for potential treatment with radiofrequency ablation (RFA). The provider noted that in addition to screening the two liver lesions, evaluation of the rest of the body is necessary since if the other sites are positive, the patient will not be a good candidate for RFA. Further, the contrast enhanced CT or MRI is not advised due to the impaired renal function and the patients solitary kidney. This patient has known metastatic disease to the liver which has responded to therapy but may still be active. For evaluation, intravenous (IV) contrast enhancement for CT and MRI is not considered safe due to the impaired renal function of the patients solitary remaining kidney. However, in order for CT and MRI to be effective in the detection of metastatic disease, the use of IV contrast is essential. Many metastatic and even primary tumors are only evident with contrast enhancement on conventional CT and MRI scans. While PET/CT has some limited value in the evaluation of metastatic renal cell cancer (RCC) according to the American College of Radiology (ACR) Appropriateness Criteria, PET/CT is likely to be of more clinical value due to the metabolic properties of 18-FDG. In addition, the known PET avid nature of this patients tumor based upon prior PET results increases the probability of its utility for comparative purposes. For these reasons, the requested PET/CT is likely to be more beneficial for evaluation and treatment decision making in this patient than any other available diagnostic procedure or testing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female has requested coverage for radiofrequency ablation for treatment of her metastatic leiomyosarcoma.  Findings:  Two physician reviewers found that this patient has metastatic disease involving her lungs, bone and liver. While she has undergone radiofrequency ablation of the bony site of disease, it appears as though she has recurrence.  She has had stable disease over the period of 10 months in all sites and remains asymptomatic. Therefore, given that the hepatic lesion is asymptomatic, is not progressing in comparison to either the June 2011 or January 2011 study, and she has multiple other sites of metastatic disease, radiofrequency ablation is unlikely to provide any significant benefit compared to her current systemic therapy. Given the lack of treatment plan to specifically target the bone and pulmonary lesions, ablative therapy for a single site of metastasis is unlikely to provide any significant benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy and physical therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that there is robust medical literature supporting the value of speech therapy in this setting. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in their meta-analysis of multiple medical journal articles. Prelock, et al. discussed the evaluation and successful treatment of speech-delayed children with speech and language therapy. A study by Goorhuis-Brouwer and colleagues examined speech-delayed children, both those with and without developmental delay, and found that both of these categories of children are candidates for successful speech therapy. A study by Carboni and colleagues states that muscle stretching by physical therapists is essential for hypotonic children to experience improved motor function. Parush and colleagues found that hypotonia will continue to affect large motor groups throughout childhood and therefore continuous physical therapy is necessary to address these deficits. Given the available literature supporting the use of physical therapy in this setting, the requested physical therapy is medically necessary for the treatment of this patients documented motor skill deficits.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  Three physician reviewers found that ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Dawson, et al.; Rogers, et al.; and Warren, et al.).  The scientific literature supports the use of ABA. Treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. A recent 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism specific behaviors using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles (Dawson, et al.). Warren, et al. reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches, early intensive behavioral intervention variants and the Early Start Denver Model resulted in improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown treatment using ABA therapy to be efficacious (Rogers, et al.). ABA offers a program that is intensive, structured, and individualized with explicit teaching of social skills, communication and learning to learn skills (National Research Council). In sum, the ABA services at issue were and are likely to be more efficacious than any other therapy for treatment of the patients autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3 year old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the standard and customary practice in the medical community would be to arrange speech therapy for this patient whose expressive language is markedly delayed as there is a compelling medical literature that supports speech therapy in this young population. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. Similarly, Goorhuis-Brouwer and Kniff concluded that normal and developmentally delayed children with speech delay are candidates for successful speech therapy. In addition, Emanuel and colleagues noted that in prospective studies on patients in the 2-year-old population, who tested below the 10th percentile for age, benefit from speech therapy. Therefore, the recommendation is that this patient receives individual speech therapy sessions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that the literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.  Therefore, speech therapy is medically necessary for treatment of the patients severe speech and language delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees receptive and expressive language delay. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. .  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested coverage for Celebrex for treatment of her rheumatoid arthritis  Findings:  The physician reviewer found that based on review of the available records, this patient has severe, active rheumatoid arthritis and is on potent medications including methotrexate and rituximab, in spite of which she has persistent, active synovitis. The medical records document that her symptoms were improved while she has been treated with Celebrex. In addition, the records demonstrate that she has already failed at least 5 other NSAIDs. Celebrex is medically necessary for this patient and there is no medical reason to retreat her with medications that she has already tried and failed. Celebrex is FDA approved for the treatment of osteoarthritis and rheumatoid arthritis, and should be covered by the insurance company for treatment of this patients RA. As Ross noted in his 2009 article, pain [in arthritis] often is a significant problem and should be treated whenever it becomes a barrier to function. Consistent with these findings, the requested Celebrex has been shown to be medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his gastric cancer.  Findings:  Two physician reviewers found that three-dimensional conformal radiation therapy is the standard of care for radiation therapy treatment of gastric cancer. There are a few publications in the literature suggesting improved coverage of target and reducing radiation dose to nearby sensitive organs. However, these are small single institution studies with a few patients. In a paper by Minn, et al., IMRT was found to result in sparing of liver and possibly renal function. A study by Alani, et al. found that IMRT confers only a marginal benefit in the adjuvant treatment of gastric cancer and should be used in a small subset of patients with risk factors for kidney disease or those with a preexisting nephropathy. There are no randomized or large cohort trials suggesting improvement in clinical outcome with the use of IMRT versus 3D conformal radiation therapy. Thus, IMRT was not likely to be more beneficial than standard radiation therapy for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female has requested coverage for past monitored anesthesia care during an esophagogastroduodenoscopy with biopsy.  Findings:  The physician reviewer found that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients 12 years of age or younger, patients 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.  In this patients case, there was no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective procedure. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male has requested Tomatis Listening Therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS).  Findings:  Three physician reviewers found that Tomatis Listening Therapy falls into the category of auditory integration training. It uses electronically modified voice and music to ameliorate auditory processing deficits and improve concentration. According to the current literature, including a systematic review of existing studies, there is insufficient evidence to support the use of Tomatis Listening Therapy in this patient population (Sinha, et al.). One recent brief report stated, the results reflect a lack of improvement in language using the Tomatis Method for children with autism. (Corbett, et al.) In sum, the peer-reviewed literature does not currently support use of the Tomatis Listening Method as an efficacious treatment modality for children with autism spectrum disorders. Therefore, the proposed therapy is not likely to be more beneficial than other available therapies for treatment of this patients PDD-NOS.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested speech therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that there is substantial medical literature supporting speech therapy and reporting the effectiveness of speech therapy in similar children. Children with speech delay can be readily treated (Law, et al.) and cognitively delayed children, such as this patient, are candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). The standard of care in treating patients with a moderate speech delay, would be for treatment with speech therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

An 80-year-old female enrollee has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient presented to the emergency room with complaints of right thigh and hip pain for the previous two weeks. The patient described her pain to be worse at night and to have been worse for the previous two nights. The patients pain level was documented as mild. The patient denied a history of a fall or trauma to that hip and noted that she was able to walk up and down stairs without trouble. The physical examination revealed mild tenderness to palpation over the lateral right thigh/hip area with normal range of motion of the hip and no edema. X-rays showed mild osteoarthritis of the right hip, and did not show evidence of a fracture, dislocation or tumor. The patient was diagnosed with bursitis and discharged with instructions to follow-up with her primary care physician in two to three days.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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 patients thigh and hip discomfort had been present for approximately two weeks, there was no event to suggest that the hip had been broken, there was no evidence of infection and the patients pain was described as mild. Additionally, it was reported that the patients pain did not restrict activity, such as navigating stairs. All told, the patients symptoms 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 or her health and therefore would not have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested coverage for Lyrica 25mg for treatment of her burning mouth syndrome.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical situation.  The article by Schatton and Riechelmann noted that Lyrica is a potential treatment for burning mouth syndrome.  However, the authors noted that its value remains unproven at this time, and further study is required.  Patton and colleagues and Maltsman-Tseikhin and colleagues emphasized the need to investigate the underlying cause of burning mouth syndrome in each patient.  However, the authors noted that there is a lack of treatments that have proven to be effective for this condition.  There is a lack of support in the current medical literature for the requested medication in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male has requested coverage for a right sport knee brace for treatment of his status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment in this patients case.  This patient is status post right knee arthroscopy, anterior cruciate ligament reconstruction with patellar tendon autograft and removal of loose body and hardware.  Following which, his neurovascular functions were intact, and motion was from 5 degrees to 90 degrees.  The current medical evidence does not support the use of the requested knee brace in this clinical situation.  Although braces are often prescribed for use after anterior cruciate ligament reconstruction, evidence to support brace use is lacking.  There is a lack of evidence indicating that brace use affects pain, range of motion, graft stability or protection from subsequent injury.  The use of prophylactic braces to prevent injury in contact sports has not been shown to be of value.  Additionally, the use of prophylactic braces has not been shown to be effective in postoperative rehabilitation following anterior cruciate ligament surgery.  All told, the requested right sport knee brace is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested coverage for a MRI of the breasts for evaluation of her medical condition.  Findings:  Two physician reviewers found that this patient has a positive family history of breast cancer in her grandmother who was diagnosed at the age of 55. The patient underwent aspiration of a left breast cyst two years ago. Clinically, the patient had areas of palpable thickening within both breasts.  A diagnostic mammogram, performed a year later showed dense breast tissue with no evidence of malignancy.  A bilateral breast ultrasound performed in conjunction with the mammogram showed a benign finding within the right breast and no suspicious findings. A follow-up mammogram was recommended in one year.  The patients provider has requested a bilateral breast MRI which was denied by the Health Plan. In regards to a screening MRI of the breasts, this patient is not at high risk of developing breast cancer in her lifetime using the Gail Model (a breast cancer risk assessment tool).  Using the Gail Model, this patients lifetime risk for developing breast cancer is 8.6%.  It is well documented in the medical literature that yearly screening breast MRI is medically appropriate for patients with a calculated life time risk of greater than 20%. However, this patients calculated risk for developing breast cancer is significantly less than 20%. The American Society of Breast Surgeons recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. The patient has no history of a positive BRCA mutation in herself or in a first degree relative. The patient has no history of radiation to the chest wall. Therefore this patient does not meet the established guidelines for a screening MRI of the breasts. Additionally, this patient had an unremarkable diagnostic evaluation with mammogram and breast ultrasound.  The patient has no recent or prior diagnosis of breast cancer, no history of positive axillary nodes and the patient has no breast implants.  This patient does not meet the established criteria for a diagnostic breast MRI. The use of MRI as a screening modality in this clinical scenario is not supported by peer-reviewed scientific data. In the absence of scientific evidence demonstrating that a screening MRI is likely to be of clinical value in this setting, the proposed MRI remains of unproven efficacy.