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

The parent of a two-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that the literature on the subject of ABA is clear that this treatment is not considered experimental and is rapidly becoming the treatment of choice for young patients with autism spectrum disorders. Moreover, numerous studies have established that ABA has a role in the treatment of autistic patients with documentation of improved health outcomes. This patient has been diagnosed with autism and is almost 3 years of age. Thus, he is an appropriately identified patient to receive the requested ABA service. The articles referenced consistently show that ABA is an effective intervention for autism in early childhood such that it is expected to provide this patient with better results than alternative treatment modalities. Given the patients level of deficits and the recommendations by his providers for 25 hours of ABA therapy per week, the requested services should be provided at the requested frequency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Xifaxan (duration of 10 days) for treatment of her intestinal bacteria. Findings:  The physician reviewer found that this patient has had several breath tests documenting small intestinal bacterial overgrowth.  Her symptoms include nausea, abdominal pain and bloating, and these symptoms are consistent with this diagnosis. She has failed three antibiotics. Up to 1600mg of Xifaxan (rifaximin) over a 7 to 10 day time period is medically appropriate for the treatment of this patients condition(Vanderhoof and colleagues). The patients provider has recommended Xifaxan 550mg, twice daily, over a ten day period.  Thus, the requested medication amount is within recommended total dosage and is standard of care.  All told, in this patients case, the requested Xifaxan (duration of 10 days) is medically indicated for her treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requestedmicrodecompression nerve release surgery and follow-up treatment for treatment of her occipital neuralgia.  Findings:  Three physician reviewers found that occipital neuralgia is a condition characterized by frequent and severe headaches.  The pain is located in the occipital area and may spread toward the vertex.  It is usually unilateral, but may be bilateral. The attacks can last for days, making even routine daily tasks difficult to accomplish.  The treatment plan for occipital neuralgia/occipital headache depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as patients age, ongoing medical conditions, and ability to tolerate other medical therapies. Standard therapy may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage.       Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes.  Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation.  At this time, the superior efficacy of occipital release surgery has not been proven.  All told, the requested microdecompression nerve release surgery and follow-up treatment are not likely to be the most efficacious treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a physical movement therapy device for treatment of her muscle atrophy and spasticity.  Findings:  The physician reviewer found that the requested device (Flexiciser) is an exercise device that utilizes upper body ergometry and provides passive leg movements.  There is a lack of published high-grade studies to substantiate that the device is effective in treating anoxic brain injury or tetraparesis, or is effective in treating or preventing adverse sequelae related to anoxic brain injury or tetraparesis.  There are very minimal high-grade data related to this specific type of therapy (active upper body ergometry with passive leg cycling) that is published in the literature.  In 2007, Ballaz and colleagues studied the acute vascular responses to this type of therapy in 15 volunteers with spinal cord injury.  The authors concluded that acute passive leg cycle exercise increases vascular blood flow velocity in paralyzed legs of people with paraplegia. This was followed up by a pilot study in 2008 that did not demonstrate sustained clinical effects following training.  The 17 subjects in the study had paraplegia and underwent 36 passive cycling sessions at home.  After training, however, mean blood flow velocity at rest did not differ from pre-training values.  The authors concluded that six weeks of home-based passive cycling training have no significant effect on the rest hemodynamic values.Astorino and colleagues published a small study related to the Flexiciser device in 2008.  This case series only involved eight subjects.  The authors concluded that this rehabilitative device has promise for individuals with acute spinal cord injury and those with chronic spinal cord injury who are attempting to initiate a rehabilitation program. However, the authors noted that the device may be ineffective for regular exercisers due to an inadequate exercise stimulus.  Overall, there are insufficient data in the prevailing peer-reviewed published medical literature to conclude that the requested device is effective for the treatment or prevention of complications related to anoxic brain injury or tetraparesis.  All told, the requested physical movement therapy device is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested epidermal growth factor receptor (EGFR) testing for evaluation of her stage IV lung cancer.  Findings:  Two physician reviewers found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked.  Even if stage IV disease is present, therapy targeted to the EGFR results in prolonged survival when compared with standard chemotherapy regimens, as noted by Mok and colleagues.  The National Cancer Institutes Physicians Data Query includes EGFR testing in the recommendations for stage IV disease. Additionally, the American Society of Clinical Oncology issued guidelines that include EGFR testing, as noted by Azzoli and colleagues.  All told, EGFR testing is likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested a bronchial thermoplasty for treatment of his asthma.  Findings:  Two physician reviewers found that to date, three trials of bronchial thermoplasty have been completed and each demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderate to severe asthma and demonstrated improved control over the course of the one year follow-up (Pavord, et al.). The RISA study examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma (Cox, et al.). Finally, the AIR2 trial compared thermoplasty with a sham procedure and followed the patients for one year (Castro, et al.). The patients in this study differed from earlier studies because the patients had milder asthma symptoms with fewer patients on oral corticosteroids. The thermoplasty group in AIR2 had fewer exacerbations and improved quality of life when compared to the sham group. However, neither the AIR nor RISA trial demographics indicate whether patients were on medications other than steroids and bronchodilators. By contrast, in the AIR2 trial, 30% of the patients in the thermoplasty group were concurrently being treated with other controlling agents with fewer patients on oral corticosteroids. While there is increasing evidence suggesting bronchial thermoplasty can be beneficial for patients with severe and uncontrolled asthma, the procedure is only indicated for patients who have failed to respond to adequate attempts at conservative therapies. Prior to consideration of bronchial thermoplasty, there should be objective documentation of trial and failure of an aggressive medication regimen including such agents as leukotriene receptor antagonists, methylxanthines, omalizumab or anticholinergics. In this case, although there is evidence the patient has severe asthma, the medical records provided do not document adequate attempts at an aggressive and closely monitored outpatient regimen. As such, there is insufficient clinical evidence demonstrating the patient is an appropriate candidate for bronchial thermoplasty to warrant performance of the procedure at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested continued acupuncture treatments for treatment of her pain associated with Kearns Sayre Syndrome.  Findings:  The physician reviewer found that the patient is an excellent candidate for continued acupuncture. She has chronic myofascial pain and intractable intercostal neuralgia. She has received excellent relief with physical modalities, including physical therapy and acupuncture. The submitted medical documentation demonstrated a high level of efficacy of these services, and the patient experienced increased pain when acupuncture was discontinued. There is sufficient medical evidence demonstrating the benefits of acupuncture in myofascial pain and a variety of neuropathic pain disorders. In this patients case, she has responded to prior treatment and is unable to tolerate traditional pain medications.  All told, in this patients case, continued acupuncture is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism typically have deficits in speech and language, as well as social communication. The more aggressively these deficits are targeted, the better chance young children have for developing adequate skills to function in the community. Thus, speech therapy is medically necessary for the management of this patients speech and language delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Sculptra injections for treatment of his lipoatrophy. Findings:  The physician reviewer found that HIV lipoatrophy is a common complication of HIV retroviral therapy. Sculptra has been approved by the Food and Drug Administration for use in cases of facial wasting directly related to this therapy. In this patients case, he has been diagnosed with lipoatrophy. Based upon the evidence provided, the patients HIV associated lipoatrophy has not resulted in a functional impairment and therefore the requested Sculptra injections are not medically necessary. With regard to whether the requested services meet criteria for reconstructive surgery, lipoatrophy is considered to be an abnormal structure of the body. This abnormal structure of the body is caused by treatment of disease or infection (HIV). The side effect of HIV treatment includes facial wasting. The requested services will not improve function, however, they are being performed to create a normal appearance to the extent possible. Based upon the photographs submitted, the requested services will offer more than a minimal improvement in the appearance of the patient. This patient has moderate lipoatrophy on the left side and mild lipoatrophy on the right side. All told, the requested Sculptra injections meet the criteria for reconstructive surgery under California law.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested a circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that phimosis is defined as the inability to retract the penile foreskin. Initially, in the uncircumcised infant, this is physiologic. Over time, if it persists, it may become pathologic in the presence of inflammation or scar tissue. Initial treatment involves application of corticosteroid cream. In the event of phimosis beyond age 10 years of age, failure of steroid treatment, or ballooning of the foreskin with urination, circumcision is indicated.  According to a recent study by Zavras and colleagues of 1185 boys with a diagnosis of phimosis (some with mild balanitis), treatment with topical steroids was successful in 91% of cases.  This patient has symptomatic phimosis, and the literature supports the safety and efficacy of a course of topical steroids prior to surgical intervention. Thus, circumcision is not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested ongoing occupational therapy for two, one-hour sessions per week for treatment of the enrollees autism. Findings:  The physician reviewer found that according to the Guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. Thus, occupational therapy in this patient population is standard of care in the community. In the case of this patient, indications for medically necessary occupational therapy are met by this patient in that the requested therapy is aimed at improving and adapting function and the patient has shown evidence of practical improvement with prior therapy based on the progress notes provided. Given this patients ongoing functional deficits, the requested occupational therapy is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested an MRI for evaluation of her low back pain. Findings:  The physician reviewer found that this patient presented with first-time sudden onset of low back pain.  At the time of presentation, she reported that her pain began two weeks prior. This patient has been evaluated with lumbar spine x-ray, and the results noted mild degenerative disc disease. At this time, the requested MRI is not medically indicated. Conservative therapy, including physical therapy, is appropriate and is standard of care in this clinical scenario.  The submitted documentation does not indicate that the patient has had an adequate trial of conservative therapy. Evaluation with an MRI would be indicated in the event that the patient has continued pain and radiculopathy following conservative management. All told, the requested MRI is not medically indicated for the evaluation of this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested the Exogen Bone Healing System for treatment of her ankle pain. Findings:  The physician reviewer found that despite frequent clinical usage of ultrasonic bone stimulation for promoting bone healing, including in delayed post-operative union, this treatment has not yet been proven to be efficacious. In this patients case, where the etiology of her symptomatology has been unclear and no bony fracture has been demonstrated, the expectations of significant, sustained benefit with this treatment would not have been significant.  All told, the Exogen Bone Healing System was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested weight management classes for treatment of her obesity.  Findings:  The physician reviewer found that the patient has demonstrated progress with the structured diet program with documented weight loss. Nutritional counseling is appropriate and medically indicated for the management of conditions for which nutritional intervention has been demonstrated to result in positive net health outcomes. These conditions include pre-diabetes, diabetes, eating disorders, cardiovascular disease and renal disease. The United States Preventive Services Task Force recommends dietary counseling for individuals with known risk factors for diet-related chronic diseases and concludes that such counseling is likely to improve health outcomes. This patient has conditions of hypertension, hyperlipidemia, impaired glucose tolerance and possible sleep apnea.  Structured medical nutrition therapy and lifestyle counseling serve as an essential component of the medical treatment of these specific disease states and should be the initial step in the management of these conditions.  All told, weight management classes from the date in question forward were and are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested physical therapy (PT) sessions for treatment of her right shoulder status post arthroscopic rotator cuff repair surgery. Findings:  The physician reviewer found that it is often necessary to continue stretching, exercises and modalities for a prolonged period of time after rotator cuff repair surgery, especially following open repair of severe tendon tears. These exercises and treatments, however, do not necessarily require a formal outpatient setting indefinitely.  Diverse types of shoulder dysfunction demonstrated improvement in both clinical and functional measures at the conclusion of physical therapy, although it is not possible to determine whether these changes were due to the interventions or due to time(Millar and colleagues). Similarly, in 2010, Seida and colleagues commented on the paucity of publications in support for PT in the management of patients following rotator cuff injury, concluding that, Evidence on the comparative effectiveness and harms of various operative and non-operative treatments for rotator cuff tears is limited and inconclusive. Overall, the clinical necessity of long-term formal PT for this patients condition has not been established in the scientific data. In the present case, the patient underwent an arthroscopic right rotator cuff repair on the said date. A few months later, the patient had attended 20 PT visits and should have been well versed in a self-directed exercise and modality program. She had functional ROM and good to good plus strength. There were no indications that she was not independent with her activities of daily living (ADLs) and further gains in strength and ROM could have been gained through an independent program. Notably, the records suggest the patient had plateaued after the said date, with 155 degrees of active flexion and 50-55 degrees of active external rotation. There is no documentation of therapeutic or passive exercises that required ongoing supervision or that could not have been substituted with independently performed exercises. As such, no significant difference in functional outcome would have been expected with ongoing passive modalities and manual therapy in the formal setting as of the date in question. Thus, the services at issue have not been shown to be medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  Three physician reviewers found that the medical community has determined that OT is indicated for young patients with autism as evidenced by the American Academy of Neurology (AAN) practice guidelines. Specifically, the AAN recommends immediate and long-term evaluation and monitoring with a comprehensive multidisciplinary approach performed by a qualified experienced professional trained in the array of challenges associated with this condition. An OT evaluation should focus on gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the autistic patients life. OT is indicated when deficits exist in functional skills in the areas of play or leisure, self-maintenance through ADLs, or productive school and work tasks. Sensory integration techniques are appropriate for patients such as this patient with deficits in sensory processing skills. Based on existing data including practice parameter guidelines accepted by the medical community, the requested OT services are likely to be of greater benefit for this patient than any standard alternative treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a PET scan for evaluation of her fever of unknown origin and lung nodules seen on CT scan. Findings:  Three physician reviewers found that in this patients case, PET scan was not likely to have been a more beneficial method for evaluating her condition than standard modalities. The pulmonary nodules in the right lower lung were not large enough for resolution with PET scan. Additionally, fever of unknown origin is not an indication for PET scanning. This technology can show increased uptake in cases of infection/inflammation and neoplasm. As such, its use in the setting of fever of unknown origin has the potential for a false positive result, which undermines the diagnostic value of the procedure. All told, the PET scan performed was not likely to yield more accurate clinical information than standard methods of evaluation.