Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy two times per week (one hour each session) and occupational therapy two times per week (one hour each session) for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on the available medical literature, the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. In support of the need for occupational therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy and occupational therapy are standard of care modalities for patients with autism. Given the documented deficits associated with his diagnosis of autism, it is medically necessary for this patient to receive speech therapy and occupational therapy at the requested frequency.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old male enrollee has requested  Femara 2.5mg for treatment of the enrollees Russell-Silver syndrome.  Findings:  Three physician reviewers found that Russell-Silver syndrome is characterized by intrauterine growth restriction, poor postnatal growth, relative macrocephaly, asymmetry and feeding difficulties.  Because of accelerated bone maturation due to atypical puberty in individuals with this condition, often height growth is terminated at a far younger than normal age.  Unfortunately, there are limited treatments available to help promote growth velocity in affected individuals, and there can be shortcomings with use of growth hormone, including lower limb asymmetry.  Aromatase inhibitors are a class of drugs that block the synthesis of estrogen. Recent data suggests that aromatase inhibitors may be a very promising treatment for boys with short stature due to precocious puberty.   Aromatase inhibitors hold promise of delaying the acceleration of bone age and increasing predicted adult height in adolescent boys with growth hormone deficiency. Femara, a potent third-generation aromatase inhibitor, has shown significant efficacy with a good safety profile.  In this patients case, Femara 2.5mg is likely to be superior over other available treatments.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested cryoablation for treatment of her left breast fibroadenoma.  Findings:  Three physician reviewers found that this patient presents with a presumed benign left breast tumor. Her alternatives for treatment include observation or removal. Observation is not necessarily an option in this case because the tumor is painful. For this reason, the patients options include excision versus cryoablation. The patient has requested authorization to proceed with the ablation and her surgeon states that she is an excellent candidate for the procedure. The patient reports that cryoablation is preferable as this is an office-based procedure using local anesthetic and is reported to be a very well tolerated procedure with excellent cosmetic outcomes and minimal underlying scar tissue. Each of these reasons are somewhat contradictory to open surgical excision, thus cryoablation is likely to be more beneficial than other available standard therapy for this patient. In 2008 the American Society of Breast Surgeons (ASBS) consensus statement on management of fibroadenomas of the breast states that the results of cryoablation have been reported with 4-year follow-up and demonstrate the procedure to be safe, efficacious and durable. The ASBS also set guidelines for patient selection in order to determine ideal candidates for cryoablation, and this patient fulfills these criteria. Given these findings, cryoablation is likely to be more beneficial than open surgical excision in this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a third series of Synvisc injections in the left and right knees for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the hyaluronan viscosupplements (Hyalgan, Synvisc or Synvisc One, Euflexxa, Supartz, and Orthovisc) have been approved by the Food and Drug Administration to treat the pain associated with osteoarthritis of the knee. Hyaluronan is a major component of synovial fluid. The goal of hyaluronan viscosupplementation is to restore the visco-elasticity of synovial hyaluronan. Viscosupplementation has been approved for patients who have failed to respond to conservative non-pharmacologic therapy and simple analgesics. There is medical justification for viscosupplementation treatment and even one-time retreatment if specific criteria are met. However, there is insufficient scientific evidence in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of multiple retreatments with viscosupplementation for osteoarthritic knees. Given the lack of prospective, multi-center, randomized clinical trial data documenting the benefits of multiple retreatments (more than two courses) of viscosupplementation, the medical necessity of the requested Synvisc injections for this patient has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested NeuroStar Transcranial Magnetic Stimulation (TMS) therapy for treatment of her major depressive disorder. Findings: Two physician reviewers found that the records show that her depression is treatment resistant since multiple anti-depressant medications from various classes have not successfully brought on remission. In the clinical studies, Schutter and colleagues reported that TMS had a moderate effect on treatment resistant depression (Schutter, et al). In addition, George and colleagues demonstrated that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Moreover, Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, although relatively new, TMS is effective treatment for patients with treatment resistant MDD. As it is FDA approved for the treatment of treatment-resistant MDD, consistent with standards of good medical practice, I have concluded that TMS is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested hip arthroscopy surgery for treatment of her left hip impingement and labrum tear.  Findings:  Two physician reviewers found that this patient has a positive crossover sign, which is a reliable clinical finding in the documentation of a relative acetabular retroversion. She has an alpha angle of approximately 90 degrees.  Physical examination noted findings of pain on internal rotation at 90 degrees flexion. There are additional physical findings which help to establish and support the diagnosis proposed of femoral acetabular impingement. The presence of either cam or pincer type acetabular impingement is likely to be associated with early development of degenerative osteoarthritis of the hip. The use of extra-articular approaches in the management of femoroacetabular impingement syndrome is likely to either delay or in some cases obviate the need for joint replacement by reason of an early and progressive osteoarthritis. The importance of delaying total joint replacement in the relatively young patients who experience this condition is very important because there are predictable problems of response to wear debris with loosening and subsidence after joint replacement. In the article published by Sink and colleagues, the typical clinical presentations of femoroacetabular impingement syndrome were noted. Findings of decreased flexion and limited internal rotation were noted on physical examination. In article by Bredella and Stoller, the basic types of femoroacetabular impingement are discussed. The authors noted that repetitive mechanical trauma to the hip joint causes mechanical wear of the labrum and to the anterior articular cartilage. In this patients case, she has positive MRI findings and positive crossover sign. The authors feel that the presence of these changes will lead to progressive osteoarthritis of the hip if untreated. Thus, in this patients case, the requested procedure is likely to be of greater benefit than other methods of treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested abdominoplasty for treatment of her stated condition of pain in his abdomen, hip and rib areas.   Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. The result is frequently improved by liposuction performed at the same operation. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, etc. The pannus would have to be quite large to cause lower back pain. In this case, the patient is complaining of pain in his abdomen, hip and rib areas. It is highly unlikely that removal of the pannus would affect the patients symptoms. The mere presence of a pannus and/or its physical burden on the patient does not automatically make its removal medically necessary. There is no evidence in the reviewed materials that would support the medical necessity of either an abdominoplasty or panniculectomy in this case.Furthermore, the proposed abdominoplasty does not meet the requirements of reconstructive surgery as defined by California law. The submitted documentation does not demonstrate the patients abdominal pannus is an abnormal structure of the body caused by infection, trauma, tumor or disease. The excess tissue is not so great as to be considered a structural abnormality. In addition, the submitted records do not include evidence that the excess abdominal tissue is infected or compromised in any way. Thus, the requested abdominoplasty is not considered reconstructive surgery pursuant to California Health and Safety Code 1367.63.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Orthovisc x3 injection series for treatment of his degenerative joint disease. Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of degenerative joint disease of the knee is generally accepted (Strauss). With regard to the benefit of repeat courses of viscosupplementation, the evidence remains mixed. Some reports have indicated that repeat courses of viscosupplementation are safe and effective (Pagnano and Westrich). However, a study by Jergensen, et al. indicated that the efficacy of this treatment is questionable, as there was no noted reduction of pain, function or pharmacological consumption as measured at 3, 6, 9 and 12 months post treatment. In addition, an increased frequency of adverse events has been reported in patients receiving more than one course of treatment (Morton, et al.). As Johnson and colleagues reported, overall there is limited scientific evidence addressing the efficacy of multiple series of viscosupplementation. While there are current clinical studies in progress to determine the long-term efficacy and safety of repeat courses of viscosupplementation in patients with knee pain, at this time the benefits of this therapy has not been sufficiently established. For these reasons, the requested third series of Orthovisc x3 injections has not been shown to be medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment level of care for treatment of the enrollees Aspergers disorder, anxiety disorder and type I diabetes. Findings: The physician reviewer found that this patient's diagnoses present severe disruption to his own ability to function independently as well as to the functioning of his family. The enrollee cannot regulate the basic functions of sleep and hygiene, and is not adequately managing his diabetes, placing him at severe risk of health consequences.  Furthermore, his lack of diabetic control is most likely further contributing to his emotional lability. His condition has not been controlled as an outpatient, despite significant and prolonged attempts at intervention on many levels. The residential treatment facility has provided a valid diagnosis and treatment plan, and there is evidence that he is making progress with his treatment. All told, residential treatment level of care from the said date and forward was and is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested Nexium, 40 mg for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that based on the records provided, the medical necessity of the requested Nexium medication has been established in this patients clinical situation. Nexium has been approved by the Food and Drug Administration (FDA) for treatment of symptomatic GERD. In addition, this patients provider has exercised due diligence in treating the patient with multiple acid blocker alternatives however these medications failed to provide the patient with relief. The patient noted that she had previously been covered for Nexium with good results. Further, she has numerous contradictions to other medications including NSAIDs, while Nexium was well tolerated and a proven benefit for her. All told, the use of Nexium in the management of this patients chronic condition has been shown to be beneficial in the past and without adverse effects. Accordingly, the patients request for Nexium should be approved as medically necessary for treatment of her GERD and gastritis symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his post-operative torn anterior cruciate ligament (ACL) of his the left knee.   Findings:  The physician reviewer found that in the medical literature, Richmond and colleagues reported on their comparison of 4-day versus 14-day use of CPM in the post-operative care of 20 patients following ACL reconstruction surgery with patellar bone autograft. At 42-day follow-up, the patients with measurements of ROM and other parameters confirmed that there were no statistically significant differences in those patients using the CPM for the 4-day period versus those using the CPM for the 14-day period. In addition, Gaspar and colleagues documented a significantly greater flexion extension ROM at time of discharge from the hospital, but reported that by 6-month follow-up, the differences were negligible. Consistent with the lack of scientific data supporting improved health outcomes with the use of CPM for post-operative care of patients after ACL surgery, the use of CPM in this patient was not medically necessary or beneficial. This decision is based upon a lack of evidence in the controlled studies and case reports. There is no evidence in this patient of any complications such as arthrofibrosis, which might provide an indication for the use of CPM. As such, the equipment at issue was not medically necessary for treatment of this patient following ACL reconstruction surgery, and therefore the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested combination chemotherapy with Avastin and Tarceva for treatment of his hepatocellular carcinoma.  Findings:  The physician reviewer found that hepatocellular carcinoma (HCC) is generally is not responsive to chemotherapy. One drug, Nexavar, has demonstrated a survival benefit and has been approved for use in this cancer. This particular young patient has been treated with a variety of past treatments including Nexavar and now has progressive disease, for which there is no known standard treatment likely to be of benefit. Two studies have been published demonstrating some degree of efficacy of Avastin. The first, by Cid and colleagues, studied 12 patients with Avastin who had previously received Nexavar and found a 50% rate of clinical benefit and median overall survival of 9.5 months. This study is applicable to this patient, but is a very small study that needs corroboration in other studies. The second published trial from Siegel and colleagues reported on 46 non-metastatic patients treated with Avastin. Overall, the authors concluded that patients treated with Avastin demonstrated a 13% response rate with a median progression-free survival of 6.9 months. However, the patients in the Siegel study are not comparable to the patient in this care, in that he has metastatic disease. With regard to the requested combination chemotherapy at issue in this case, Thomas and colleagues treated 40 patients with the combination of Tarceva and Avastin. All patients had advanced disease and had not received Nexavar. The researchers documented a 25% response rate, and 37% additionally had stable disease. In addition, the median survival was noted to be longer than observed in Nexavar trials. However, the authors concluded that the Tarceva and Avastin combination needed to be compared to Nexavar directly to confirm its superiority. Thus, the data supporting the use of the requested Tarceva and Avastin combination in this patients advanced HCC already treated with Nexavar, is fairly minimal. One must conclude that there is insufficient evidence to suggest that such treatment is likely to be beneficial. Moreover, it is noted that the patient was already tried on Tarceva and could not tolerate it due to toxicity. Ultimately, it is unlikely he would be able to tolerate it any better at this point in time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested chemotherapy regimen for treatment of her breast cancer. Findings:  The physician reviewer found that the issue in this case is whether additional cycles of Taxotere and Cytoxan (more than 4) are warranted given this patients initial characteristics. To date, there is a paucity of data to support the safety and effectiveness of treating patients with breast cancer with more than four cycles of Taxotere and Cytoxan. Thus, the patient should complete her systematic treatment with anti-hormonal therapy and is expected to complete local treatment. There is reported positive health outcomes with Taxotere and Cytoxan,  with researchers only administered four cycles of therapy and offered results based upon those cycles (Jones and colleagues). Therefore, at this juncture, there is inadequate evidence to support additional cycles of Taxotere and Cytoxan in the treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested Cialis 5mg daily for treatment of his prostate cancer. Findings: Three physician reviewers found that erectile dysfunction is a condition whose origin can be often multifactorial. The patients history includes hypertension, which can result in erectile dysfunction. The patients prostatectomy is also a known cause of temporary or permanent erectile dysfunction. The patient was also placed on Lupron postoperatively, and received a course of radiation therapy, which are also factors that can result in erectile dysfunction. The treatment of erectile dysfunction can be addressed with oral agents, including Cialis. However, the superior efficacy of the use of Cialis for penile rehabilitation after radical surgery remains unproven, as the results of rehabilitation studies in peer-reviewed journals are inconclusive at this time. Therefore, the requested Cialis 5mg is not likely to be more efficacious than other available treatment options for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old female enrollee has requested speech therapy once per week for 30 minutes for treatment of the enrollees Aspergers syndrome. Findings: The physician reviewer found that Aspergers syndrome includes significant social skills deficits with fair communication skills and marked circumscribed interests. Children with Aspergers syndrome are typically severely socially impaired especially when exposed to peers. Language deficits are often one of the core aspects of Aspergers syndrome and speech therapy provides professional help and guidance in appropriate communication development. Goldstein reviewed communication interventions in peer-reviewed research articles published over the past 20 years and found that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism spectrum disorder. Language skills can make a significant difference in the ability of autistic children to control their environment and has a profound impact on their functional abilities function on a daily basis. The guidelines established by the National Research Council (2001) include building spontaneous functional communication skills as a core aspect of effective treatment for children with autism at all ages and levels of disability. Given this patients level of disability within pragmatics and socialization, the requested speech therapy is medically necessary.