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

A 65-year-old female enrollee has requested vertebral axial decompression, physical medicine, electrical stimulation and application of low level laser therapy services for treatment of her chronic low back pain and sciatica.  Findings:  Two physician reviewers found that overall, the use of muscle stimulation for back pain and/or spondylolisthesis has not been widely reported to result in improved health outcomes beyond that achievable through conventional treatment modalities. Although there may be some transient improvements in pain, sustained long-term analgesic and functional gains above that expected from the natural history of waxing and waning of pain symptoms and function during the course of a chronic pain syndrome state have not been demonstrated in a scientifically rigorous manner. Further, there is no proven clinical benefit of low level laser therapy, including in the infrared spectrum, in back pain syndromes with respect to analgesic effects or functional outcomes versus placebo.  As noted by Bingol and colleagues, there was no significant improvement in pain, active range, and algometric sensitivity in the laser treatment group compared to the control group in patients with shoulder pain. A meta-analysis by Chou and colleagues similarly revealed limited evidence from one randomized controlled trial for the use of infrared laser for the treatment of acute neck pain and chronic neck pain. The authors concluded that larger studies are required to confirm the positive findings and determine the most effective laser parameters, sites and modes of application. With respect to the chiropractic manipulation under review, there is notably no proven sustained benefit in the peer-reviewed clinical literature of prolonged chiropractic manipulation on health or functional outcomes in the setting of low back pain. There is also inadequate data to support the efficacy of whole body vibration therapy. To date, there are preliminary data suggesting possible improvements in strength and jumping ability in sedentary or elderly patients exposed to this type of treatment. However, without any high-grade support in the scientific literature proving the efficacy of this device in the setting of back pain, it is not likely to be more effective than standard therapies (Cardinale and Pope). Moreover, observations from occupational medicine have demonstrated that prolonged exposure to [whole body vibration] can have major negative effects on health. All told, none of the treatments rendered and documented in the records reviewed are of proven benefit for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a toe dorsiflexion Dynasplint for treatment of her medical condition, which is status post cheilectomy.  Findings:  Three physician reviewers found that treatment for hallux limitus or hallux rigidus in the medical literature includes options such as footwear modifications, non-steroidals or surgery.  There is a lack of published high-grade medical literature supporting the efficacy of dynamic splinting using devices such as the Dynasplint in the setting of hallux limitus or hallux rigidus, whether preoperatively or postoperatively.  In the present case, the submitted records do not indicate that a sufficiently rigorous program of self-directed range of motion exercise had been utilized prior to application of the Dynasplint.  Moreover, there is no documentation of significant range of motion or other clinical benefit with any intervention in the present case.  In this patients case, the toe dorsiflexion Dynasplint was not likely to be superior over other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested an MRI scan of the left breast for evaluation of her breast mass.  Findings:  Three physician reviewers found that this patient has a palpable breast mass with no corresponding findings on mammography or breast ultrasound.  For patients such as this, the next step is a biopsy of the palpable mass.  The peer-reviewed literature does not support the use of breast MRI for the evaluation of a palpable breast mass prior to biopsy.  The American College of Radiology guidelines note that a highly suspicious physical examination should prompt biopsy regardless of the imaging findings.  Stein and Chellman-Jeffers noted that MRI of the breast does not currently have a role in the workup of a palpable abnormality and should not be used in place of biopsy.  All told, the requested MRI is not likely to be more efficacious that other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Orthovisc injection to the left knee for treatment of her degenerative joint disease of the left knee. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates the medical necessity of Orthovisc injections (viscosupplementation) for this patients left knee arthritis. This treatment is specifically indicated for the patient in this case given that she is at risk from gastrointestinal complications of non-steroidal anti-inflammatory drug (NSAID) use with a prior history of ileocolectomy. Recent treatment records indicate the last injections to the left knee occurred two years ago and were followed by documented clinical improvement from the initial course of injection. For these patient specific reasons, it is considered to be medically necessary for this patient to receive the recommended Orthovisc injection. This decision is consistent with a Cochrane review performed by Bellamy and colleagues in 2006 which documents the efficacy of viscosupplementation in this setting. The authors reviewed 76 trials and concluded that viscosupplementation was useful in the treatment of knee osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested an MRI scan (CPT code 77058) for evaluation of her ductal carcinoma in situ.  Findings:  Two physician reviewers found that the patient had an MRI of the breast which demonstrated a questionable lymph node of the right axilla, which was enhancing.  A fine needle aspiration of the lymph node on the date in question was benign.  A few months later, the patients oncologist requested a six-month follow-up MRI.  Lymph nodes containing tumor cannot be reliably diagnosed at this time with the current contrast agents.  At this time, lymph node staging by MRI is not established in the medical literature.  MRI features of metastatic lymph nodes depends more on size and morphology than on enhancement criteria.  Further, in this patients case, sampling was performed and was determined to be negative.  In this patients case, conventional imaging, such as ultrasound, can be performed.  All told, the requested MRI scan is not likely to be the most efficacious method of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings: The physician reviewer found that from a review of the available records, it appears that there is no multidisciplinary team note determining that the patient is a suitable candidate for referral to a surgeon. Given this omission, the patient would not be considered an appropriate candidate for weight loss surgery at this time despite the presence of morbid obesity. In addition, no failed weight loss efforts are documented and it is unclear whether a longer course of behavioral therapy would be important for this patient prior to undergoing such a procedure. Regardless of weight, BMI or co-morbid conditions, bariatric surgery may not be suitable for all patients. A multidisciplinary evaluation is essential to ensure that each patient is an appropriate candidate and is able to make the life-long commitment necessary for success. At this time there is insufficient medical documentation to support the medical necessity of the requested surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested a bilateral breast reduction/mammoplasty for the treatment of her bilateral macromastia. Findings: The physician reviewer found that the medical records note that the patient has had an adequate trial of conservative therapy. Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, shoulder bra strap grooving and skin breakdown, if they are present. In this case, the patients symptoms have been present for more than one year and are due to macromastia. To further delineate this group of patients, the Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. As the amount of tissue removed is increased, the procedure changes from a cosmetic procedure to a medically necessary reconstructive procedure. For this patient, the removal of 550 grams of tissue or more meets these criteria. The patients provider has planned to remove 500 grams, which does not meet these criteria. Therefore, the requested bilateral breast reduction/mammoplasty is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a PET/CT, skull base to mid-thigh for evaluation of her history of breast cancer. Findings:  Three physician reviewers found that the patient currently has no symptoms or physical findings to suggest recurrent or metastatic breast cancer.  PET/CT scans are utilized as an adjunct to conventional imaging in select patients with a personal history of breast cancer.  This diagnostic procedure is mainly utilized for patients with suspected loco-regional recurrence or those patients with suspected distant metastatic disease. The National Comprehensive Cancer Network guidelines do not recommend the use of PET/CT scans for surveillance purposes in patients with a personal history of breast cancer.  As this patient does not have clinical evidence of suspected loco-regional recurrence or suspected distant metastatic disease and is not currently undergoing chemotherapy, the requested diagnostic procedure is not likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a CT scan of the thorax (71270), abdomen (74170) and pelvis (72194) for evaluation of her history of breast cancer.  Findings:  The physician reviewer found that guidelines for breast cancer surveillance have been well-studied and documented by the American Society for Clinical Oncology and are based on evidence-based and outcome-based data. The current medical evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination.   Examinations should be performed every three to six months for the first three years, every six to twelve months for years four and five, and annually thereafter. For those who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained one year after the initial mammogram and at least six months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling. CT scans are not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.  There is no reason to suspect recurrence in this patients case based on the clinical history provided.  Based upon the evidence-based literature, the requested diagnostic procedures are not likely to improve outcome.  All told, the requested CT scans of the thorax (71270), abdomen (74170) and pelvis (72194) are not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested Xolair injections (J2357) for treatment of the enrollees asthma.  Findings:  Two physician reviewers found that several, well-controlled, randomized clinical trials examining the efficacy of Xolair (omalizumab) in the treatment of poorly controlled allergic asthma in children six to 12 years of age have been published.  The study by Kulus and colleagues was a randomized controlled trial involving 246 patient who were six to 12 years of age. The authors noted that the addition of Xolair resulted in a statistically significant decrease in frequency of exacerbations and concluded that omalizumab was safe and well-tolerated in this patient population with severe persistent asthma treated with long-acting bronchodilators and inhaled corticosteroids.  An additional study by Lanier and colleagues enrolled 627 patients six to 12 years of age. This study demonstrated a decrease in frequency of exacerbations by 31% over 28 weeks and by 43% over 52 weeks.  This study also concluded that omalizumab was safe, well-tolerated and efficacious in this age group of asthmatics with poorly controlled symptoms despite available standard therapy. All told, is this patients case, Xolair injections are likely to be more efficacious than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested femoral head splitting/reshaping surgery (a head splitting osteotomy to be followed by application of an external fixator)for treatment of the enrollees Legg, Calve Perthes disease. Findings: Three physician reviewers found that the patient  has failed treatment with proximal femoral osteotomy and acetabular shelf procedures. A magnetic resonance imaging (MRI) arthrogram of the left hip on said date showed changes in the head and neck consistent with Perthes disease and secondary degenerative changes. In addition, labral hypertrophy was noted with a probable tear. On said date, the patient was evaluated by a non-plan provider who proposed femoral head reshaping for advanced Perthes disease. This would include a head splitting osteotomy with an external fixator. An x-ray report from the date in question notes flattening of the left hip, with irregularity of the acetabulum and thickening of the femoral neck. An x-ray report in said dates described the flattening and widening of the left femoral head, adequately covered, as well as the healed osteotomy sites, as unchanged from the prior study of the date in question. The requested femoral head splitting osteotomy procedure remains an unproven procedure for the care of patients with Calve Perthes disease. The medical literature suggests that arthroscopic or open surgery for hip pincer and CAM impingement is more likely to provide a beneficial outcome in this setting. The peer-reviewed literature also supports hip replacement as an option in this setting once patients become skeletally mature. The available scientific data on head splitting procedures in this clinical setting are sparse and the procedure remains unproven in terms of incremental health benefits over conventional alternative treatments. Thus, in light of the available scientific data, there is insufficient evidence to support the contention that femoral head reshaping including head splitting osteotomy is likely to be more effective for the treatment of this patients condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation does not substantiate the presence of impairments that would preclude the patient from accomplishing his mobility-related activities of daily living within the home with the aid of a manual wheelchair.  The records do not document any neurological or musculoskeletal impairment or pathology affecting the upper limbs.  He does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish his mobility-related activities of daily living.  The power mobility device form signed by the patients primary care physician on the said date specifically endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.  With respect to falls, there is no evidence in the present case that would support that there would be a significant additional risk of falling when comparing a manual versus a power wheelchair.  All told, the requested motorized wheelchair (power-operated vehicle) is not medically necessary this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested rituximab (Rituxan) for treatment of her vasculitis.  Findings:  Three physician reviewers found that the patient has severe Sjogrens syndrome with an associated vasculitis. She has been treated with multiple immunosuppressive medications in the past but has been unable to tolerate them due to infectious and allergic complications. Long-term steroid therapy, although effective at reducing symptoms, is not practical due to significant cushingoid and other side effects.  The patients reported history of pancytopenia obviates the use of Cytoxan therapy, which would otherwise be considered standard therapy in a case such as this.  The RAVE trial (NEJM 2010) established the non-inferiority of Rituxan to Cytoxan for the induction of remission in ANCA-associated vasculitides. Although Sjogrens related vasculitis is not an ANCA-associated disease, case series and review articles published recently (Ramos-Casals and colleagues) establish anecdotal evidence for its efficacy in this condition. No large clinical trials exist for this specific condition (nor will they ever likely exist), so reliance on case series, anecdotal evidence, and extrapolation from large trials conducted in related diseases is important in making therapeutic decisions. Based upon the patients failed treatment history and the available evidence, Rituxan therapy is reasonable and indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male enrollee has requested the VEST Airway Clearance System (CPT E0483) for treatment of the enrollees chronic congestion and hypotonia.  Findings:  The physician reviewer found that high-frequency chest wall oscillation (HFCWO) systems such as the VEST System were developed to improve airway clearance in those patients in whom the normal mucociliary transport system has failed (e.g., chronic bronchitis, bronchiectasis, cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. In stable outpatients with cystic fibrosis, high-frequency oscillation and chest physiotherapy were found to have comparable augmenting effects on expectorated sputum weight without changing PFTs or oxygen saturation. In a different study of cystic fibrosis patients, both wet and dry expectorated secretion weights were greater with HFCWO compared to CPT, suggesting HFCWO is at least as effective as manual CPT/PD (postural drainage) in clearing secretions from the airways in patients with cystic fibrosis. VEST therapy has also been studied in children with quadriplegic cerebral palsy. In one study, VEST therapy resulted in more effective suctioning of pulmonary secretions, reduced incidence of pneumonia, and reduced number of hospitalizations for pneumonia. In another study of 28 patients with cerebral palsy and neuromuscular diseases, compliance with treatment was higher with high-frequency chest wall oscillation than with standard CPT. Furthermore, in patients with familial dysautonomia, available data demonstrates HFCWO resulted in significant improvements in all health outcomes and oxygen saturation. In summary, VEST therapy has been shown to be at least as effective as manual CPT when manual CPT can be done appropriately. For this patient, manual CPT is not a reasonable option; proper positioning places him at risk for aspiration due to gastroesophageal reflux and difficulty handling secretions. He cannot use other devices (e.g., Flutter device) because he does not have the cognitive ability necessary to complete the therapy. The VEST System has been studied in multiple populations with airway clearance issues and has been found to be an effective means of clearing airway secretions, decreasing the need for hospitalization from pneumonia. Use of VEST therapy is medically necessary and appropriate for this patient to improve airway clearance and prevent unnecessary complications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested electrical stimulation therapy for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that overall, there is insufficient medical literature supporting the use of electrical stimulation for management of neck and shoulder pain despite its use in practice. There is a lack of high-grade clinical trials published in the medical literature demonstrating that electrical stimulation therapy confers a clinically or statistically significant sustained functional effect above that which would be achieved with conventional therapy in this setting. More research is needed to further evaluate and substantiate the claims that electrical stimulation is an effective modality for this condition. The electrical stimulation therapy provided on the date in question was not likely to be more beneficial for treatment of the patients medical condition than standard treatments including medication, epidural injections and physical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested physical therapy for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that while exercise therapy is beneficial for neck and shoulder pain, this patients condition is chronic and recurrent. Further, the patient was already independent on a HEP during her previous physical therapy sessions. Although manipulation is known to provide short-term relief, the physical therapy at issue was not medically necessary given the chronicity and recurrent nature of the patients neck and shoulder pain and her ability to manage her condition through the HEP.