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

A 48-year-old male enrollee has requested a canaloplasty for treatment of his pigmentary glaucoma.   Findings:  Three physician reviewers found that canaloplasty has been shown to be effective in reducing intraocular pressure in a non-invasive manner (Godfrey, et al.). While the pressure lowering effect is greater in traditional filtering and shunt procedures, they are more complication-prone. Lewis and colleagues stated that while traditional filtering surgery is very effective in lowering pressure, there are several potential complications including some that can affect visual acuity. Results of studies on canaloplasty surgery show results comparable to those of more traditional surgical treatments. However, the safety profile of canaloplasty is more favorable when compared to traditional surgery. Canaloplasty appears to effectively lower pressure with fewer complications.In a younger patient with good visual acuity, it could be deemed preferable to perform a pressure lowering surgical procedure where the probability of vision-threatening complication is greatly reduced. Canaloplasty has a low complication rate, and is effective in lowering intraocular pressure. The available peer-reviewed medical literature demonstrates that canaloplasty is a safe and effective surgical procedure for lowering intraocular pressure. When examining this patients age, visual acuity, lens and optic nerve status, it is evident that canaloplasty was likely to be superior for treatment of his condition than standard surgical alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a mammogram without radiation (i.e. ultrasound, magnetic resonance imaging, thermography, or electrical impedance scanning) for evaluation of her cluster of microcalcifications in the left breast.  Findings:  The physician reviewer found that this patient has microcalcifications detected on screening mammography. The next procedure of choice will be to magnify the calcifications using traditional digital mammography. This additional technique will allow the radiologist to determine if the calcifications are suspicious enough to warrant biopsy. If so, the next technique will be to perform a stereotactic biopsy using mammographic technique. Thus, at this time, MRI is not suitable in this case due to the less than perfect negative predictive value of the imaging study in this setting. In addition, ultrasound is inadequate since microcalcifications often are not seen with this technique. The primary concern in this case is whether the microcalcifications seen on mammography represent ductal carcinoma in situ (DCIS). To acquire this data, the only reliable means with which to evaluate the breast is traditional mammographic magnification views and if necessary following this evaluation with core biopsy using stereotactic mammographic guidance. The other options suggested by the patient are not endorsed by the scientific community and are not supported by the relevant medical literature as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested magnetic resonance angiography (MRA) for evaluation of her pseudotumor cerebri. Findings: The physician reviewer found that the patients history of pulsatile tinnitus (swishing sound in the ear) raised concerns regarding the presence of a dural arteriovenous fistula. MRA was therefore ordered for diagnostic purposes.  In one of the largest studies on this topic, the sensitivity of MRA was determined compared to the gold standard, conventional carotid angiography, in the diagnosis of dural arteriovenous fistula (Cohen and colleagues). They examined a total of 46 patients with 51 fistulas, of whom 42 patients (46 fistulas) had complete follow-up data. Using conventional angiography as the gold standard, they found that MRA had a sensitivity of only 50%.  The current medical evidence does not support evaluation with MRA in this clinical scenario. All told, the MRA provided on said date was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested  speech therapy twice per week and occupational therapy for 10 hours per month for treatment of the enrollees autism. Findings:  The physician reviewer found that language deficits are one of the core aspects of autism, and speech therapy provides professional help and guidance in communication development for individuals with autism (Volmar and Weisner). Further, Stone and Yoder evaluated 34 children with autism at 2 years of age with re-evaluation 2 years later to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, patients treated with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions in peer-review research articles published over the past 20 years and found that the evidence supports the efficacy of interventions to teach communication skills to children with autism. The authors reported that language skills can make a tremendous difference in the ability of children to control their environment. Similarly, language skills have been found to be an adaptive alternative to highly disrupted forms of communication such as self-injury or aggression. This patients speech and language evaluation indicates significant impairment for which speech therapy, twice per week, is medically indicated. With regard to the requested occupational therapy, an evaluation performed on said date did not identify any gross motor or fine motor deficits. The issues noted by the therapist consisted of sensory abnormalities, i.e., deficits involving the tactile sense and taste/smell sense. Although anecdotal evidence exists in support of occupational therapy for patients with sensory processing deficiencies, the treatment does not have sound evidence for effectiveness. To date, there are few well-controlled studies examining occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life. At this time, no firm conclusions can be made regarding specific approaches due to poor study quality and great variability in interventions. Given that this patients occupational therapy evaluation failed to identify any gross or fine motor deficits with regard to functional activities as well as the lack of evidence supporting occupational therapy for sensory processing deficits, the requested occupational therapy is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollees non-specific pervasive developmental disorder with autistic features, or mild autism. Findings:  The physician reviewer found that this patient has a definitive speech delay and a diagnosis of pervasive development disorder (PDD) based on testing by clinical psychologists. Of import, is that the speech pathologist based an assessment of speech development through a play session. The patient could not be tested by the Pre-Language Scale or the Goldman-Fristoe test, because of a lack of cooperation. In the clinical studies, it reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles(Law and colleagues). In addition, Goorhuis-Brouwer and Kniff specifically addressed speech-delayed children who did not have cognitive deficits (as may be the case with this patient), and pointed out that these children are ideal candidates for successful speech therapy. Additionally, basing a denial on the inability of a speech therapist to administer age specific tests to this patient would be overlooking the fact that this patients failure to interact with the tests demonstrates his inability to comprehend language. The patient could not be tested by the Pre-Language Scale or the Goldman-Fristoe test, because of a lack of cooperation, which would suggest that the patient had significant speech delay, as these tests are specifically designed for this age group. As such, speech therapy is medically indicated in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested occupational therapy for treatment of the enrollees poor sensory processing and modulation issues. Findings:  Two physician reviewers found that this patient has had multiple symptoms of attention deficit/hyperactivity disorder.  Stimulant medication has exacerbated a tic disorder. Occupation therapy evaluation indicated avoidance to environmental factors such as wearing underwear and fear of brushing his teeth.  It is medically appropriate to attempt to modify these behaviors, utilizing a sensory modulation technique to slowly desensitize these fears.  There is adequate support in the medical literature demonstrating the efficacy of the requested therapy. Schaaf and Miller reported on the effectiveness of sensory integration therapy for children with multiple presentations.  Miller and colleagues conducted a controlled study of the effectiveness of this therapy.   Although the study by Robert and colleagues is a single case study, in this one studied patient, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing the requested techniques.  All told, in this patients case, occupational therapy is likely to be more efficacious than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a DynaSplint System ankle device for treatment of his ankle pain status post left peroneal reconstruction. Findings:  Three physician reviewers found that the available peer reviewed medical literature indicates that candidates for usage of the DynaSplint System include those patients who are recovering from injury or surgery, ideally during the early phases of healing or within 100 days from date of injury, trauma, or surgery. Based on the documentation provided, this patient has had chronic ankle pain for quite some time and underwent surgery more than 100 days ago. Further, there is a paucity of available peer reviewed medical literature documenting the efficacy of the DynaSplint System for treatment of peroneal tendonopathy of the ankle. Most of the studies published to date involve use of the device in other parts of the body. Given the paucity of available literature and that the patient is more than 100 days post surgery, there is no evidence that the DynaSplint System would be as or more effective for treatment of his peroneal tendonopathy than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested cytokine inflammatory profile and immune profile testing for evaluation of her chronic fatigue syndrome. Findings:  Three physician reviewers found that Chronic fatigue syndrome can present with a constellation of symptoms, but the hallmark is fatigue.  The symptoms should be present for a period of least six months and can be associated with muscle pain, headaches, pain in multiple joints, sleep disorders, sore throat and tender cervical adenopathy.  To date, there is no specific testing protocol to specifically identify a causative agent.  At this time, there is a lack of specific data that indicates that increased cytokines are a direct cause of the syndrome. In addition, there is no specific approved medical treatment for increased cytokine levels in patient with chronic fatigue syndrome. There has also been evidence that the Murine Leukemia Virus (MLV) and Xenotropic Murine Leukemia Virus Related Virus (XMRV) can be present in a significant number of chronic fatigue patients. There is no direct evidence that MLV or XMRV are direct causative agents for the syndrome. Further studies are necessary to determine if these viruses are reproducibly associated with chronic fatigue syndrome and if so whether these viruses are causative agents.   Thus, the testing at issue was not likely to be superior over other available options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested cervical radiofrequency facet joint ablations and medial branch blocks for treatment of her neck and bilateral shoulder pain.  Findings:  The physician reviewer found that this patient has recently undergone several cervical spine interventions and her treating physician has not recommended additional blocks/ablation procedures at this time. If it is documented by the patients physician that the previous techniques are no longer providing adequate relief or that untreated levels have failed to respond to conservative therapies, additional spinal procedures may then be indicated. At that time, cervical medial branch blocks may be appropriate to determine prognosticate response.  Sehgal, et al. reported that medial branch blocks are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. The authors performed a literature review of clinical studies on efficacy and utility of facet joint blocks in diagnosing facet joint pain. From the evidence obtained, they concluded that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. Thus, cervical medial branch blocks are performed to determine potential response to therapeutic facet joint interventions such as radiofrequency ablations. Cervical facet joint ablations are not medically necessary if cervical medial branch blocks have not been performed prior to ablation procedures. Therefore, if objective documentation from the patients physician is provided which indicates that the patients cervical spine pain is no longer responding to prior/conservative measures, then cervical medial branch blocks may be medically necessary prior to cervical facet radiofrequency ablation and the patients request should be reconsidered at that time. However, cervical facet radiofrequency ablation is not appropriate without documentation of response to diagnostic blocks.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a CT scan of the abdomen for evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scan of the abdomen performed on the date in question was not medically indicated for this patient. This patient presented with abdominal pain, chest and back tightness and dysphagia with solids.  These symptoms did not warrant evaluation with a CT scan of the abdomen.  This patients symptoms were suggestive of gastroesophageal reflux disease, esophagitis or a stricture.  The submitted documentation does not provide a differential diagnosis.  The medical records do not demonstrate the medical necessity of the diagnostic procedure at issue in this patients case.  The current medical evidence does not support this method of evaluation in this clinical scenario.  All told, the CT scan of the abdomen was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch is an appropriate standard treatment for morbid obesity in the well-selected patient. It has been shown through numerous published papers to be safe, effective and durable. It has a morbidity and mortality that is comparable to other restrictive type procedures with its own risk benefit profile. Like any procedure for weight loss, long-term follow-up is essential to success.  It has been shown to have the best resolution of diabetes of any weight loss procedure.  Although the requested procedure is a standard treatment for morbid obesity, the medical necessity of a duodenal switch for this patient has not been established.  The submitted documentation does not include a dietary evaluation that shows the patient to have appropriate understanding and ability to comply with a post bariatric diet.  All patients should complete a thorough multidisciplinary evaluation that includes a dietary evaluation in addition to other components such as medical clearance, behavioral clearance and surgical evaluation. The submitted dietary evaluation from June 2010 did not document that the patient was ready for surgery.  It is well within standard guidelines that documented dietary readiness be obtained before proceeding with duodenal switch.  All told, the requested duodenal switch is not medically indicated for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that this patient has very early stage prostate cancer, and he was presented with several treatment options. The superior efficacy of proton beam treatment in this clinical situation has not been established by randomized trials.  Slater and colleagues showed that proton beam therapy yielded disease-free survival rates comparable with other forms of local therapy, with minimal morbidity.  The treatment was well-tolerated and was capable of producing biochemical disease-free survival rates equivalent to those achieved with other treatment methods.  However, at this time, the current medical evidence has not proven that the requested proton beam therapy is likely to be of greater benefit than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested genetic testing for evaluation of his symptoms of Kearns-Sayre syndrome.  Findings:  Two physician reviewers found that Kearns-Sayre syndrome is a progressive and debilitating disorder which can result in progressive cardiomyopathy and fatal arrhythmias, progressive ophthalmoplegia and progressive retinopathy resulting in blindness, hearing loss, progressive muscle weakness, ataxia, and bone marrow suppression.  The diagnosis of Kearns-Sayre syndrome requires the identification of a mitochondrial DNA mutation or deletion detected through molecular testing including mitochondrial DNA sequencing.  If the diagnosis is confirmed by detection of mitochondrial DNA deletions, then the patient is at high risk for all of these complications and should be monitored closely.  If the diagnosis is confirmed in this patient, her clinical management and outcome will change. All told, the requested genetic testing is likely to be more efficacious than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested a Prodisc-C procedure (artificial disc replacement) for treatment of his chronic cervical radiculopathy involving C5-C6.  Findings:  Three physician reviewers found that in an assessment of the safety and efficacy of cervical disc arthroplasty (replacement), Matz et al. performed a systematic review of the literature in which they examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF).  Mummaneni et al. reported that when all criteria for success were used, the arthroplasty group had a superior outcome; however, multiple confounding factors, such as the use of medications, cervical collar immobilization, patient expectations, and lack of blinding, prevented any conclusions from being drawn. This study was downgraded to Class II evidence. Studies by Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric et al. (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or ACDF. These individual reports were subgroups of patients included in a larger randomized controlled trial. In these studies, both the arthroplasty and ACDF groups showed clinical improvement without significant differences between groups at 24-months postoperatively on the Neck Disability Index (NDI) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). More recently, published reports of randomized trials with longer term follow-up do suggest that artificial disc replacement may be beneficial; however, the percentages of patients receiving 4 year and 5 year follow-up are exceedingly low and call into question the overall validity of the findings at this time (Delamarter et al. and Burkus et al.). As such, artificial disc replacement is still considered inferior to other proven modalities in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 76-year-old male enrollee has requested X-Stop surgery for treatment of his spinal stenosis.  Findings:  Three physician reviewers found that the X-Stop procedure has been granted marketing approval by the FDA; however, the FDA has required a post marketing approval study for seven years to determine its long-term safety and effectiveness. This study is currently underway and has not been reported or concluded, with a closing date of 11/21/12. The study reported by Kondrashov, et al. reported on only a small number of patients, over a short period of time, and therefore the results of this study cannot be generalized to a large population. There is insufficient evidence of any long-term benefits with the use of X-Stop (Chou and colleagues). Additionally, other studies demonstrated concern regarding the safety of this product, noting a high complication and failure rate. Thus, based on the literature published to date, there is a lack of high-quality data from large, randomized, well-controlled studies supporting the use of X-Stop in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested Ilaris (canakinumab) injections for treatment of his bilateral chronic uveitis. Findings:  Two physician reviewers found that the current literature does not reveal that the safety and effectiveness of canakinumab in treating anterior uveitis has been adequately established.  The use of canakinumab in treating anterior uveitis must then be considered off-label and of unproven efficacy in this setting. At this time, the scientific data does not establish that canakinumab is likely to be more beneficial than any of the currently available standard treatments in this setting.  As such, the Health Plans denial of authorization for use of canakinumab was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested ultrasound guided chemical vein treatment (sclerotherapy) and its associated services for treatment of her varicose veins.  Findings:  Three physician reviewers found that ultrasound-guided foam sclerotherapy shows success rates varying from 82% to 100% and can eradicate reflux in the above knee and below knee greater saphenous vein in over 95% of patients with symptomatic primary great saphenous varicose veins. This treatment leads to significant improvement in health related quality of life for at least 12 months after treatment.  Given the studies published to date, there is sufficient medical evidence supporting the requested services in this clinical scenario.  In this patients case, the requested ultrasound guided chemical vein treatment (sclerotherapy) and its associated services are likely to be more beneficial than other available treatments.