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

A 60-year-old female enrollee has requested for Botox injections for treatment of her low back pain.   Findings:  Two physician reviewers found that a variety of studies of Botox treatment have shown pain relief due to anti-nociceptive effects directly as well as by reducing muscle spasm. Clinical study results have shown that injecting Botox into trigger points is not a very effective strategy. However, treatment of muscle groups to correct abnormal tone, dystonic contractions, or biomechanical dysfunction, can be beneficial. The safety of Botox treatment is well established through the medical literature. Studies of treatment of back pain have found benefit with doses in the range of 200-300 U. Standard treatment for myofascial back pain includes trigger injections. Trigger injections were performed in this patient with transient relief. Botox therapy provided more sustained relief. Thus, the use of Botox in this case was medically reasonable and appropriate in light of the scientific data available.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for ProDisc-C artificial disc replacement surgery for treatment of her C5-C6 disc herniation.  Findings:  Three physician reviewers found that there are no long-term recorded, randomized scientific studies supporting the efficacy and safety of artificial disc replacement. Nor are there medical studies comparing cervical disc replacement to anterior cervical discectomy and fusion (ACDF). Thus, the superiority of artificial disc replacement over standard surgical interventions has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for the medication Fentora for treatment of her intractable headaches.  Findings:  The physician reviewer found that opioids are controversial for headaches and much of the medical literature does not support the use of opioids for treatment of chronic daily headaches. The evidence is particularly lacking for use of short-acting opioids such as Fentora. In fact, the manufacturers prescribing information indicates that Fentora is used to treat breakthrough pain in adult patients with cancer and must not be used for short-term pain from injuries, surgery, and headaches.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested for occupational therapy for treatment of his fine motor delay. Findings:  The physician reviewer found that with its focus on developing motor planning skills, teaching self-help skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this child. Occupational therapy is therefore medically necessary and appropriate for the full duration in question (6 months).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested for Meridia 10 mg for treatment of her asthma and obesity.  Findings:  The physician reviewer found that Sibutramine (Meridia) has been approved by the FDA which states that, Meridia is indicated for the management of obesity, including weight loss and maintenance of weight loss, and should be used in conjunction with a reduced calorie diet. Meridia is recommended for obese patients with an initial body mass index  30 kg/m2, or  27 kg/m2 in the presence of other risk factors (e.g., diabetes, dyslipidemia, controlled hypertension). The American Association of Clinical Endocrinologists (AACE) indicates that, Pharmacotherapy, in conjunction with a basic weight management program, is suitable for patients with a BMI > 30 or for patients with a BMI of 27 to 29 and at least one major comorbidity. The Obesity Society considers pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for Botox therapy for treatment of her bilateral cervical dystonia.   Findings:  Two physician reviewers found that Botox is investigational, and not an FDA approved or standard treatment. Multiple studies performed for cervical myofascial pain have shown no significant improvement over placebo. This includes a Cochrane Database Systemic Review (Peloso, et al.). Thus, there is no persuasive evidence that Botox is likely to be more efficacious in this setting than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for the use of a continuous passive motion (CPM) machine and cold compression unit for treatment of her post-op (total knee replacement) left knee condition. Findings:  The physician reviewer found that there is no significant increase in range of motion in the long-term from the use of a CPM machine following uni-compartmental knee arthroplasty. Objective evidence that CPM results in improved clinical outcomes is lacking at this time. There is no literature to substantiate the need for continuous passive motion in the uni-compartmental knee arthroplasty perioperative period.  There is no peer-reviewed literature that suggests that this is more advantageous than standard available treatment (i.e., ice wraps/packs with ace bandage for compression) in the perioperative period.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for speech therapy, cognitive rehabilitation, and sensory integration therapy for treatment of her mild traumatic brain injury/post concussive syndrome. Findings:  Two physician reviewers found that speech therapy for cognition and integration studies has been documented since 1985, if not earlier. A study by Kennedy, et al. showed improvement in cognition and organizational skills for work and daily functioning with appropriate therapy. Hence, the services at issue are well-accepted for patients with traumatic brain injuries. Such methods are implemented routinely in acute and sub-acute conditions with periodic short-term therapy. As this patient was experiencing decreased functional capacity due to increased demands, it was reasonable and appropriate to employ a short course of therapy to return her to her previous level of functioning.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for an osteochondral knee allograft for treatment of her right knee pain and chondromalacia.    Findings:  Two physician reviewers found that an article by Bugbee and Convery as well as an article by Gross, et al. attest to the effectiveness of osteochondral grafting. The patients age and her failure to respond to all available conservative treatment options to date (except joint replacement) support the conclusion that the requested osteochondral allograft is appropriate and likely to be more efficacious than standard therapy in this particular case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested the OmniPod External Insulin Pump and monthly supplies for the treatment of his type I diabetes. Findings:  The physician reviewer found that the OmniPod pump at issue has a single insertion system requiring only the use of one hand/arm and thus improves the effectiveness of the equipment for patients such as this patient who have limited use of an upper extremity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for daily Cialis (5 mg) for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the effectiveness of Cialis, Levitra and Viagra are very similar, as seen in the above references. Results vary from one study to another, but a few have shown better results with Cialis. The medication is enhancing a receptor by acting as a PDE-5 inhibitor. It has not been shown to improve the problem if taken on a daily basis. Although a daily dosage does allow the patient to take a lower dose and have the receptor inhibitor present on a continual basis, the medical need for a daily dose has not been documented in peer-reviewed literature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested for Botox injections for treatment of her refractory migraine.   Findings:  Two physician reviewers found that literature  shows that Botox can be beneficial for individuals with chronic headache including those with medication overuse. This patient has reportedly had benefit with prior Botox therapy, and worsening headaches when the Botox has worn off. As she has failed multiple standard preventive regimens, and has had benefit in the past with Botox,
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for chemical dependency partial hospital/day treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient does have a significant chemical dependency issue and requires treatment. He has not had any substantive outpatient treatment in the recent past. The evidence does not demonstrate that the patients overall functioning is overtly impaired; he was able to attend school prior to entering detoxification. However, there is valid concern over the substances the patient has been using and the danger in which he has placed himself by the use of intravenous OxyContin and heroin.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for biofeedback therapy for treatment of her pelvic floor tension myalgia.   Findings:  Three physician reviewers found that the study by Cornel, et al. regarding the effect of biofeedback physical therapy in men with chronic pelvic pain syndrome concluded that biofeedback physical therapy had a significant effect on pelvic floor muscles. All told, there is sufficient evidence supporting the efficacy of biofeedback for treatment of pelvic floor tension myalgia to support its use by this patient, particularly since standard therapies have been ineffective.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for uro-gynecology services and uro-physical therapy services for treatment of her pelvic floor tension myalgia.   Findings:  The physician reviewer found that Rosenbaum and Owens concluded that physical therapy treatment of pelvic pain is an integral component of the multidisciplinary approach to chronic pelvic pain and associated sexual dysfunction. Criscuolo also concludes that interventional therapies are a valuable addition to treatment of myofascial pain syndromes.Furthermore, with regard to the uro-gynecology services at issue, Montenegro concluded that trigger point injections can be effective in the management of chronic pelvic pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for PET/CT scan  for evaluation of her breast cancer. Findings:  The physician reviewer found that it has been proven to be a useful tool in the evaluation of distant metastases. This is particularly important following this patients prior lymphadenectomy. PET/CT has proven valuable in the evaluation of distant metastases in breast cancer including the skeleton. This study is also useful in the restaging of patients with known malignancy after the completion of therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested for Lyrica for treatment of his painful paresthesias. Findings:  The physician reviewer found that there are two randomized controlled trials that have demonstrated statistically significant improvement in pain levels with the use of Lyrica in patients with central pain syndromes. An article by Gray states that Lyrica has been shown to be efficacious in the management of peripheral neuropathic pain of various causes.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for biofeedback therapy for treatment of his attention deficit hyperactivity disorder.   Findings:  Three physician reviewers found that the peer-reviewed literature does not support the efficacy of biofeedback for ADHD. A study by Drechsler, et al. found that there is skepticism due to the methodological issues in studies published so far. According to the authors, Two major methodological challenges are to prove convincingly that specific aspects of neurofeedback therapy mediate positive effects and that these effects are comparable or superior to appropriate control treatments. According to certain critics it is questionable whether positive effects after neurofeedback training can be related to the improved cortical regulation or rather to unspecific treatment effects. As principles of behavio[u]ral therapy, such as systematic reinforcement and a positive relationship to a therapist, are integrated parts of the neurofeedback training especially with children, selective effects of the EEG feedback are difficult to isolate. The authors also note that there are concerns that other feedback mechanisms such as respiratory or muscular feedback may be involuntarily involved and may contribute to improved behavior control or serve as relaxation training.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a panniculectomy for the treatment of her abdominal fold/bulge. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. There is no documentation of the patients abdominal pannus nor of her excess fat and skin. There is no evidence of skin infections, intertrigo or rashes. While the provider mentions a budge in the abdomen, there is no evidence of a hernia due to defects created by utilization of the rectus abdominis. Thus, there is no evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. As such, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. With regard to general concepts of medical necessity, again there is no evidence documenting the patients abdominal pannus. There is no documentation of excess fat and skin with pictorial documentation of skin infections, intertrigo or rashes. The patient had a computed tomography (CT) scan, which according to her physicians note, showed that she may have fat necrosis along the lower portion of her TRAM reconstruction and there appears to be a very limited abdominal wall recon. No loss of functioning was documented which would necessitate a panniculectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old female enrollee has requested  for speech therapy for treatment of the enrollees speech/language condition. Findings:  The physician reviewer found that the evidence suggests that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors state, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. The authors conclude overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded the following: results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a 2-level lumbar disc replacement arthroplasty for treatment of her low back pain. Findings:  The physician reviewer found that lumbar artificial disc replacement is still an unproven procedure for the treatment of lumbar degenerative disc condition. Though early studies remain encouraging, there are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well-defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long-term. Fusion remains the gold standard treatment. Furthermore, outcomes with respect to two-level artificial disc replacement in the long-term are not known.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for intensity-modulated radiation therapy (IMRT) for treatment of her stage I right breast infiltrating ductal carcinoma. Findings:  Two physician reviewers found that IMRT is a better form of conformal radiation treatment. There are randomized and single institution studies which show improved dose distribution as well as reduced dose to lung and heart. The study of Pignol and colleagues showed that breast IMRT significantly improved the dose distribution compared with standard radiation. This translated into a lower proportion of patients experiencing moist desquamation. The study by Donovan and colleagues demonstrated a statistically significant improvement in the breast appearance at five years. The study by Harsolia and colleagues showed that use of IMRT in the treatment of the whole breast results in significant decrease in acute dermatitis, edema and hyperpigmentation. The study by Bhatnagar and colleagues showed that primary breast irradiation with the IMRT technique significantly reduces the dose to the contralateral breast when compared with conventional tangential technique.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for Ketamine infusions for treatment of her complex regional pain syndrome (CRPS).  Findings:  Three physician reviewers found that Kiefer and colleagues conducted an open-label trial which suggested a benefit in pain reduction and associated CRPS symptoms, improved quality of life and ability to work following anesthetic Ketamine in previously refractory CRPS patients. However, a randomized controlled trial will be necessary to prove its efficacy as well as its safety. Goldberg and colleagues conducted an open label, prospective, evaluation of a 10-day infusion of intravenous Ketamine in the CRPS patient. While their results were positive, there is no control group to prove that this treatment was better than placebo. Hocking and colleagues concluded that for complex regional pain syndromes, there is only Level IV evidence of efficacy of epidural Ketamine. In conclusion, the evidence for efficacy of Ketamine for treatment of chronic pain is moderate to weak. Further controlled studies are needed to support the contention that Ketamine infusions as treatment for CRPS is more efficacious than standard interventions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested for his inpatient stay for treatment of his acute substance abuse. Findings:  The physician reviewer found that there is no evidence that the patient had prior treatment for substance abuse and he was without any suicidal or dangerous ideation on admission. There was no indication of his inability to care for himself and he had no evidence of failed outpatient services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested Actiq for treatment of her migraine headaches.  Findings:  The physician reviewer found that literature yielded a study by Landy discussing the treatment of breakthrough migraine headaches with immediate release Fentanyl in the form of an oral transmucosal Fentanyl citrate (OTFC) (i.e., Actiq).The author concluded that transmucosal Fentanyl rapidly and effectively relieved acute, refractory migraine in outpatients and was associated with high patient satisfaction ratings. He adds that this medication was well tolerated by this group of patients that had already been treated with opioids in the past.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for psychiatric residential treatment for treatment of her generalized anxiety disorder, depressive disorder, not otherwise specified, and non-verbal learning disorder. Findings:  The physician reviewer found that that the patient has several psychiatric issues, including anxiety, a learning disorder and limited depression, it does not suggest that she was homicidal, overtly suicidal or psychotic at any time. At the time of the psychiatric evaluation, she was not manifesting behaviors indicating a current deterioration in mental functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for decompression therapy or an epidural for treatment of his low back pain and neck pain. Findings:  The physician reviewer found that there is insufficient evidence regarding the efficacy of decompression. A literature review was performed by Macario and Pergolizzi to assess the efficacy of non-surgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain. The authors concluded that the efficacy of spinal decompression for chronic discogenic low back pain remains unproven. They opined that more scientifically rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for Avastin (bevacizumab) for treatment of her breast cancer. Findings:  The physician reviewer found that Avastin is one of a new class of drugs that act generally as adjuncts to chemotherapy as inhibitors to tumor angiogenesis. It has been approved for use in metastatic breast cancer, when given as first-line therapy with Taxol. Even as first-line therapy, its benefits were not dramatic in that it did not improved overall survival of patients, but did improve their progression-free survival.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested  for high intensity focused ultrasound (HIFU) for treatment of his prostate cancer.   Findings:  Three physician reviewers found that studies show short-term results measuring 1-2 years at the most, which is inadequate to determine the safety and efficacy of the procedure as treatment for prostate cancer. There are standard therapies in this setting that are supported by peer-reviewed, long-term data. Such therapies are more appropriate for this patient than HIFU, the benefit of which remains speculative at this time.