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

A 57-year-old female enrollee has requested for right total ankle replacement with the STAR ankle arthroplasty device for treatment of her advanced end-stage arthritis.  Findings:  Two physician reviewers found that the STAR total ankle replacement is relatively new in the U.S., it has been used in Europe for over 10 years with sufficient long-term follow-up studies reporting favorable results. Additionally, the medical literature and the U.S. Food and Drug Administration (FDA) support the utility and durability of the STAR total ankle replacement. Saltzman and colleagues concluded that, By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Considering the scientific data proving the long-term safety and efficacy of the STAR total ankle replacement, this procedure should no longer be considered investigational or experimental.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for a hysteroscopic myomectomy with simultaneous laparoscopic myomectomies for treatment of her uterine fibroids.  Findings:  The physician reviewer found that the advantages of laparoscopic myomectomy over abdominal myomectomy include less post-operative pain and recovery period, shorter hospitalization, and cosmetically smaller abdominal scars. Also reported are fewer post-operative adhesions peripheral to the site of surgery. However, laparoscopic myomectomy is not without limitation as it is associated with a longer operative time and requires advanced endoscopic skills. Further, laparoscopic removal of large myomas (greater than 8 cm) increases the risks of hemorrhage and possibility for conversion to laparotomy. As this patient is under the treatment of a skilled provider, the requested surgery is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female has requested Aciphex 20mg (1 per day) for the treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that the relationship between acid reflux and dental erosions remains the subject of debate. Many patients with documented acid reflux do not have dental abnormalities such as erosions or periodontal disease. If there is a connection in this patients case, Nexium (one of the Health Plans formulary alternatives) is appropriate to prevent this problem. Its ability to heal erosive esophagitis and other complications of gastroesophageal reflux disease is superior to other PPIs. As such, the alternative medication offered by the Health Plan is medically reasonable and appropriate in this setting. The medical necessity of Aciphex 20mg (1 per day) has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested biofeedback therapy for the treatment of the enrollees attention deficit hyperactivity disorder. Findings:  Two physician reviewers found that this patient has a history consistent with ADHD but the records do not document use of pharmacologic therapy for management of his condition. A review of the relevant medical literature demonstrates that stimulants, such as methylphenidate, are considered first-line therapy for young patients with ADHD. In trials of medications with or without behavioral therapy, patients with ADHD who received treatment with stimulant medications showed the greatest improvement in behavior when compared to other interventions such as behavior therapy or family counseling. Research in prospective controlled studies show potential improvements in patients with ADHD treated with neurofeedback in attention, anxiety, and impulsivity and indicate a combination of both stimulant medication and behavior therapy demonstrate synergistic efficacy. Neurofeedback alone has not been shown to be more effective than standard therapies for ADHD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested physical therapy and occupational therapy for the treatment of the enrollees developmental delay. Findings:  The physician reviewer found that this patient has a number of dysmorphic features consistent with Goldenhar syndrome, but the CGH array did not demonstrate the typical chromosomal abnormalities. In addition, he demonstrates hypotonia, with delayed acquisition of fine and gross motor skills.  He has been receiving physical therapy services, with documented improvement. The patient has not yet undergone occupational therapy evaluation. Children with genetic disorders such as this patient frequently have hypotonia, delays in fine and gross motor skill development, sensory processing problems and oral-motor difficulties. Continued physical therapy is medically indicated for this patient to facilitate skill acquisition and to optimize functional development and mobility. With its focus on fine motor skill acquisition, processing of sensory information, and motor planning, occupational therapy, starting with a comprehensive evaluation, is also appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  coverage for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in general, patients with autistic spectrum disorders (ASD) experience similar deficits in terms of speech, language and social interaction. ASD is a complex neurological disorder of unknown etiology. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in young patients with ASD. Typically, interventions in multiple areas provided using a team approach consisting of speech therapy, occupational therapy, and behavioral therapy are employed for maximum functional improvement. As noted by Volkmar and colleagues, fundamental to the diagnosis of ASD are deficits in speech and language. The authors indicated that, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions, which is necessary as deficits in the use of language for social purposes are universally seen in this population. As these delays may impede social adaptation and acceptance, the authors concluded that, Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. This patient exhibits deficits in expressive and receptive language as well as socialization as a result of her neurologic disorder. The sooner and more aggressively her deficits are targeted, the better chance she has of developing adequate skills to function in the community. Accordingly, I have concluded that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for a DynaSplint device for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that the use of the DynaSplint for the treatment of plantar fasciitis is not supported by the medical literature. There is no evidence to suggest that it is likely to be more effective for this patient than a properly adjusted night splint. Given the lack of data supporting the efficacy of the DynaSplint for plantar fasciitis, the medical necessity of the device has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested right hip arthroscopy with anterior labral repair and femoral neck and acetabular osteoplasty for treatment of his right hip labral tear.  Findings:  Two physician reviewers found that the medical literature suggests that there is growing support for hip arthroscopy as a treatment modality for select young patients with labral pathology. However, hip arthroscopy is still an evolving area with regard to its use for patients such as this patient. A study indicates that patients over 45 years of age are at risk for poor outcome after hip arthroscopy(Philippon and colleagues). The procedure should not be considered until conservative options have been exhausted. This patients records do not demonstrate that he attempted adequate, conventional treatments prior to surgery. While there was a need for cardiac rehabilitation in this case, the patients exercise regimen could have been adjusted to decrease the impact on his hip.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that, as noted by and Pickett and colleagues, early studies of patients with autistic spectrum disorder (ASD) initially reported a poor prognosis for the future development of speech in nonverbal patients, but there is newer evidence that these patients may develop useful speech with appropriate therapy. In patients with ASD, laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors to persist. The scientific data suggests that the plasticity of the developing brain enables the retraining of neural circuitry not compromised by the underlying pathogenetic processes that give rise to ASD including speech and language delay. Thus, despite the presence of an underlying neurologic disease in patients with ASD, there is evidence demonstrating that speech therapy in an individualized setting can have a positive outcome on development of useful speech.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that, as noted by and Pickett and colleagues, early studies of patients with autistic spectrum disorder (ASD) initially reported a poor prognosis for the future development of speech in nonverbal patients, but there is newer evidence that these patients may develop useful speech with appropriate therapy. In regards to the medical necessity of speech therapy services for the treatment of this patient, laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with ASD. At issue is the notion that plasticity in the developing brain still exists, even in individuals with underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including speech therapy in an individualized setting is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for rituximab (Rituxan) for treatment of her neuromyelitis optica.  Findings:  The physician reviewer found that Rituxan is widely used in the management of patients with NMO at MS centers throughout the country. As NMO is a rare disorder, there will not likely ever be an adequate double blinded trial, thus the available scientific data is not in the form of randomized, double-blinded controlled trials. The discovery alone of the Antiaquaporin 4 antibody as the etiologic cause of NMO enabling differentiation from MS is itself a recent event. The largest trial of Rituxan in 2008 did suggest a very high efficacy with positive outcomes. Jacob and colleagues concluded that, In NMO, treatment with rituximab appears to reduce the frequency of attacks, with subsequent stabilization or improvement in disability. Since NMO is an autoimmune disorder, it requires treatment with immunosuppressive therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a PET scan for an evaluation of her breast cancer. Findings:  Three physician reviewers found that according to the Medicare guidelines, a PET scan is medically indicated for staging of patients with distant metastasis, or restaging patients with locoregional recurrence or metastasis as an adjunct to standard imaging modalities. PET is also indicated for monitoring response to treatment of locally advanced and metastatic breast cancer when a change in therapy is contemplated as an adjunct to standard imaging modalities. This patient has locally advanced disease, with 18 out of 19 lymph nodes positive. She has had abnormal laboratory values, including an elevated tumor marker. Conventional imaging has been negative. In this patients case, a PET scan is likely to be more clinically useful for evaluation of this patient than alternative methods of evaluation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient presented to the emergency room with a two-day history of fever, cough, sore throat and body aches. Although he had some shortness of breath, he was ambulatory upon presentation. The records reflect that he was in no apparent distress. The patient was febrile, but other vital signs were normal. The only laboratory data ordered was a strep screen. The patient did not require blood tests, a chest x-ray, or any intravenous fluids or medications in the emergency room. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms were not severe or sudden in onset. A prudent layperson in the patients circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her breast cancer.   Findings:  Two physician reviewers found that she has multiple risk factors including atypical ductal hyperplasia and LCIS. She also has dense breasts and a family history of breast cancer. Based on these factors, this patient meets the recommendations for breast MRI screening as defined by the American Cancer Society (see Saslow). According to the current literature, BI-RADS category 3 mammogram results (probably benign with short interval follow-up) is an approved assessment category for MRI (see Erguvan-Dogan, et al.). Since the abnormality described as probably benign was only apparent on an MRI, it is appropriate and reasonable to allow for such follow-up utilizing this same modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for a gastrointestinal tract wireless capsule endoscopy for evaluation of her Crohns disease.  Findings:  Two physician reviewers found that small bowel WCE is not a recognized diagnostic test to assess activity of previously diagnosed Crohns disease. Small bowel WCE is indicated for suspected Crohns disease that cannot be diagnosed by colonoscopy, upper gastrointestinal endoscopy, small bowel endoscopy, or radiographic studies, after a small bowel stenosis or stricture has been excluded, the terminal ileum appears endoscopically normal, and biopsies exclude Crohns granulomas. The small bowel WCE also has diagnostic value if the terminal ileum or neoterminal ileum cannot be intubated endoscopically. As noted by Benchimol and colleagues, Entocort is indicated for active ileocolonic Crohns disease, but its use beyond 12 months does not appear beneficial. Goldstein and colleagues recommend that if a patient has corticosteroid dependent Crohns disease, the next therapeutic option includes a thiopurine immunomodulator such as Imuran or mercaptopurine, or an anti-tumor necrosis factor (TNF) agent such as Remicade, Humira, or Cimzia. If the treating providers clinical impression is active Crohns disease, the next decision is to treat with one of the corticosteroid-sparing agents regardless of whether active Crohns disease is identified during WCE. Thus, a negative small bowel WCE would not likely change the therapeutic options for treatment of the patients condition. While the long-term use of corticosteroids, including prednisone and Entocort should be avoided due to potential side effects, if the patient is thought to have bile salt diarrhea, then Cholestyramine should be used and her response monitored.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested injections for spine disc x-ray (CPT code 62291), office consultation (CPT code 99243) and x-ray/CT spine disc (CPT code 72285) for an evaluation of his pain. Findings:  Two physician reviewers found that according to the articles by Manchikanti and colleagues, the major obstacle confronting proponents of cervical discography is the lack of consensus as to what constitutes a positive response. Widespread variations in criteria exist not only for pain provocation, but also for morphological classification. The authors note that while some investigators have interpreted certain patterns of contrast dispersion as being indicative of disc pathology, others have found a lack of correlation between morphology and pain reproduction. They also indicate that multiple questions have been raised regarding the utility of cervical discography, including the high reported false-positive rate, the lack of standardization, and the discrepancies regarding the need for control levels, pain concordance, pain intensity threshold and utilization. Another issue in this patients case is determining the validity of the results in a patient with an artificial disc in an adjacent level. There is a lack of published literature addressing this specific concern.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for a FES (functional electrical stimulation) ergometer cycle (RT 300 FES bike) for treatment of her quadriplegia status post spinal cord injury. Findings:  The physician reviewer found that the patients level of injury is at the C6 spinal level, she has voluntary control over some muscles in her arms, and can exercise those for general health benefits. The long-term benefits of FES cycling, in terms of whether the reduction in spasticity and increased circulation translates into reduced morbidity and/or mortality in cardiovascular events, are not clear. Moreover, the short-term benefits of increased circulation in muscles that cannot be voluntarily controlled do not appear to result in an increase in muscles that can be voluntarily controlled.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested cryotherapy for treatment of the enrollees acne vulgaris and verucca vulgaris. Findings:  The physician reviewer found that Cryotherapy induces superficial peeling due to epidermal necrosis, which causes desquamation of comedones, resolution of inflammatory papules, pustules, nodules and cysts. Ultraviolet therapy and cryotherapy/cryoslush therapy can be used in combination to treat acne when other methods have failed and/or caused untoward side effects. The use of cryotherapy for treatment of warts is the standard of care and consistent with generally accepted dermatologic practice. Additionally, the use of cryotherapy for the treatment of acne vulgaris is medically appropriate and indicated for patients such as this patient who have tried and failed multiple other treatment methods.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested ultraviolet light therapy for treatment of the enrollees acne.   Findings:  Two physician reviewers found that ultraviolet light therapy has been approved by the U.S. Food and Drug Administration and is considered medically appropriate in the treatment of acne vulgaris. In the case of this patient, standard therapies were tried and did not effectively remedy the patients condition. Numerous studies have been published that demonstrate the effectiveness of ultraviolet light therapy in the treatment of acne vulgaris. It has been shown to significantly reduce lesion counts. An article found that ultraviolet light therapy provides a safe and effective treatment for acne vulgaris(Lloyd and Mirkov). In light of the failure of other topical and systemic treatment modalities, the use of ultraviolet light for treatment of this patients acne was and is likely to be more beneficial than any other standard therapies for the treatment of her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested magnetic resonance imaging of the shoulder for evaluation of her left shoulder impingement.  Findings:  The physician reviewer found that this clinical entity is often accompanied by rotator cuff pathology and MRI is the most appropriate imaging test for evaluation of these findings. Despite a negative exam approximately four years ago, the patient has had increasing symptoms, which is an indication for a repeat MRI scan. The physical findings described in this patients case may also be attributed to partial or complete rotator cuff tear, and therapy would depend on an accurate diagnosis. The requested diagnostic procedure is medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested radioembolization with selective internal radiation therapy (SIRT) with yttrium-90 TheraSpheres for the treatment of his pancreatic cancer with liver metastasis. Findings:  Two physician reviewers found that SIRT with yttrium-90 TheraSpheres has been approved by the U.S. Food and Drug Administration (FDA) for treatment of hepatocellular cancer and has been utilized  with  safety and efficacy for this disease. While it is well-established that SIRT is useful for primary liver tumors, this case involves a patient with metastatic disease to the liver. There is no published literature supporting the use of SIRT in the management of patients with metastatic pancreatic cancer. As indicated by the patients provider, the primary pancreatic tumor site was unresectable so the patient was treated with chemotherapy with some response. The submitted evidence does not demonstrate that this patient has exhausted all systemic treatment. The requested therapy will treat disease in the liver only, and as such, is not likely to result in superior benefit over systemic therapy such as chemotherapy.