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

A 53-year-old female enrollee has requested extracorporeal shock wave therapy for treatment of her plantar fasciitis.  Findings:  Two physician reviewers found that review of the relevant scientific literature reveals some evidence that extracorporeal shock wave therapy can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined and there is a lack of information regarding the durability of treatment effect or long-term adverse effects of this treatment. In addition, there have been some conflicting results among the randomized controlled studies, thus raising concerns about the effectiveness of extracorporeal shock wave therapy for patients with plantar fasciitis. At this time, the peer-reviewed literature has not established that the services at issue are more beneficial than available standard therapy for the treatment of this patients condition.  Thus, extracorporeal shock wave therapy was not likely to be more beneficial than other treatment modalities for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Botox injections.  for treatment of her post-traumatic headache and neck and face pain.  Findings:  Three physician reviewers found that trigeminal neuralgia is a neuropathic disorder characterized by episodes of intense pain in the face, originating from one of the branches of the trigeminal nerve. Carbamezapine and oxcarbazepine are first-line treatments. For patients with medically refractory trigeminal neuralgia, gamma knife or microvascular decompression can be considered.  Botox has been the subject of small, non-randomized trials for treatment of trigeminal neuralgia.  However, large, randomized clinical trials with long-term follow-up are required to demonstrate that Botox provides health benefits, to define the clinical role of botulinum toxin, and to establish patient selection criteria.  Ho and colleagues published a systematic review of the literature regarding the use of Botox for the treatment of myofascial pain. The authors concluded that the current evidence does not support the use of Botox injections for treatment of myofascial pain.  Botox injections were not and are not likely to be the most beneficial treatment for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of 1-year, 10-month-old male enrollee has requested speech therapy for treatment of the enrollees coloboma, heart defects, choanal atresia, retarded growth and development, genital abnormalities, and ear anomalies (CHARGE) syndrome.  Findings:  The physician reviewer found that based on the findings of Blake and colleagues, laryngeal, oropharyngeal or craniofacial anatomical abnormalities are not essential for abnormal language development to exist as seen in children with CHARGE syndrome. Thelin and Fussner suggest that although the patients developing brain has an underlying neurologic disease, the plasticity of the brain can still be utilized to improve overall neurologic health. Thus specific treatment, including speech therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to CHARGE syndrome and their co-morbidities including speech delay. Moreover, with specific regard to this patient with a diagnosis of CHARGE syndrome is the diagnosis, by definition, includes some degree of anatomic abnormality of the craniofacial structures. Thus, it is even more likely that this patient will benefit from the individualized sessions with a skilled speech therapist as requested.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her behavioral health issues.  Findings:  The physician reviewer found that there are several factors in this case that deserve attention and make transcranial magnetic stimulation (TMS) inappropriate for this patient. The first issue is that she suffers from severe flashbacks and much of her symptomatology is related to her PTSD. In addition, she has a history of eating disorder symptoms that have included binging and purging. Further, her diagnoses of PTSD, GAD and insomnia do not appear to have changed in several years and none are currently recognized diagnoses that are being treated by TMS. The medical literature suggests that the FDA indication for TMS is for depression. In addition, an overwhelming majority of the literature in support of TMS has been published on its use in patients with depression and not anxiety, possible eating disorder, or trauma-based diagnoses. In summary the medical necessity of the requested TMS therapy has not been demonstrated in the instant case. While there is data to support the use of TMS for depression, the above-discussed reasons do not support the use of TMS in this patient over conventional treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested pelvic floor biofeedback therapy for treatment of her postpartum urge incontinence.  Findings:  Three physician reviewers found that incontinence can be stress which is primarily an anatomic problem, or in can be urgency which is either sensory and or neurogenic which is based on neurologic dysfunction, or can be a combination of stress and an unstable bladder. The volume ranges from a few drops to more, requiring major padding. This patients records are unclear as to the extent of severity of the incontinence and her pelvic exam is described as normal. There is no additional documentation describing the actual type, frequency, or severity of the patients problem. In addition, there is no indication that a complete work-up including urodynamics, Marshall Test and cystoscopy have been performed. The provider also fails to mention previous treatment programs and the results. The current consensus in the literature is that biofeedback does not add to pelvic floor exercises which remain the mainstay of treatment as well as medical therapy. As the studies do not show an increase in relief of symptoms with the use of biofeedback for treatment of urge incontinence, its use in this case is not likely to result in a superior outcome and was appropriately denied.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Botox injections and prospective future Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that chronic migraine is diagnosed in individuals with history of migraine, and headache more days than not, once secondary causes have been evaluated and excluded. The submitted documentation notes a diagnosis of chronic migraine, but there is no evidence submitted that she has been evaluated by a practitioner familiar with headache diagnosis and management. There is no evidence of prior preventive management efforts or baseline headache frequency, severity, disability, or impact on quality of life.  Botox is FDA approved for management of chronic migraine, and Botox has been confirmed in clinical trials to be effective and safe for this purpose.  However, based upon the submitted records, Botox cannot be said to be more beneficial than other treatments.  In this patients case, Botox injections were not and are not likely to be superior over all other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a C-Leg ABLE II prosthetic microprocessor controlled knee for treatment of his above the knee amputation.  Findings:  The physician reviewer found that a microprocessor controlled knee is considered safe and energy efficient for appropriate candidates. Per the Centers for Medicare and Medicaid (CMS) guidelines, a patient with a K3 or above function is considered such a candidate. From a review of the available records, it appears that this patient was not yet walking at the time the microprocessor controlled knee was requested. Thus, despite being very active previously, there is insufficient documentation that the patient will achieve a functional level of K3 or above given the extensive right leg trauma. In order to be considered for the requested prosthetic equipment, the patient must demonstrate K3 or above ambulation. Therefore, the requested microprocessor controlled knee has not been demonstrated to be medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the paper by Myers and colleagues is frequently cited in the autistic literature as a definitive source of the evaluation and treatment of autistic children. The authors report their findings suggest patients with ASD can develop useful speech. The authors cautioned that patients can benefit from therapy despite chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores. In addition, Turner and colleagues conducted a controlled study and concluded that autistic children who received speech therapy had far greater communication skills than similar patients who were untreated. Similarly, the American Speech-Language Hearing Association (ASHA) Ad Hoc Committee on Autism Spectrum Disorders found that children with autism can benefit from speech therapy. In sum, speech therapy is medically indicated and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested ablation surgery for treatment of his history of palpitations.   Findings:  The physician reviewer found that while paroxysmal atrial fibrillation by nature occurs randomly and may last for brief periods of time, this is not a valid basis for not having a current/past EKG which clearly shows the arrhythmia. Ablation therapy is a procedure during which the pulmonary veins are ablated from a percutaneous approach by various techniques, with success rates approaching 70% after one attempt. It is typically reserved for patients who have failed medical therapy or remain severely symptomatic with their arrhythmia.  In this case, the Health Plan appropriately offered a 30-day event monitor in order to increase the yield that an episode of atrial fibrillation is detected.  Based upon the submitted documentation, the requested ablation surgery is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested real-time cardiac monitoring for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that this patient had recurrent symptomatic atrial dysrhythmias treated with two prior ablation procedures. In this circumstance, serial continuous 24 to 48 hour Holter monitoring should be able to effectively identify dysrhythmias during recurrent intermittent symptoms of palpitations.  Likewise, self-activated non-real-time and non-continuous monitoring devices (event recorders) should be effective at recording dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient.  There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the patients symptoms.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias.  Thus, real-time cardiac monitoring was not likely to have been the most beneficial method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her invasive ductal carcinoma of the right breast.  Findings:  Two physician reviewers found that the Centers for Medicare and Medicaid Services (CMS) suggest that FDG-PET is only indicated as an adjunct to other imaging studies for staging, restaging in breast cancer patients or monitoring tumor response to treatment for patients when a change of therapy is being considered. Similarly, Kelloff and colleagues do not recommend FDG-PET in the routine surveillance of patients with a history of breast cancer. With regard to this patient, there is no indication that her provider is contemplating a change in her course of treatment depending on the results of the PET scans. Further, there are no findings in the records suspicious for recurrence to warrant a PET scan at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested the Flexi-Touch programmable pneumatic compression system for treatment of her lymphedema.  Findings:  The physician reviewer found that there is a paucity of quality studies that compare Flexi-Touch pneumatic compression device to other single or multi-chamber non-programmable or programmable pneumatic compression devices. The effectiveness of a Flexi-Touch pneumatic compression device has been demonstrated in case studies and a couple of small trials to have better efficacy on select patients when trunk drainage is especially a concern. There is one study that compares the pressure applied by Flexi-Touch to a standard pneumatic compression device and the authors report the pressure patterns and magnitudes on treated limbs depend on the device and the differences should be considered in selecting a specific device for each individual patient (Mayrovitz). Per the documentation, the patient is unable to use knee-high stockings and a Bio-Compression Sequential Circulator pump due to progression of the lymphedema in her hips as well as distal legs. She is also unable to tolerate the pressure used in a Bio-Compression Sequential Circulator pump. Since the patient continues to have swelling and pain despite having undergone the other standard treatments, the Flexi-Touch pneumatic compression device has been demonstrated to be medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested alendronate, 70 mg tablet for treatment of her history of osteoporosis.  Findings:  The physician reviewer found that the patient in this case was diagnosed with osteoporosis based on an x-ray of left knee that was read as consistent with mild osteoporosis. An x-ray can make the diagnosis of osteoporosis with the finding and assessment of fractures according to the National Osteoporosis Foundation. The patients x-rays of lumbar spine from the date in question indicated a limbus defect vs avulsion fracture anterosuperior L4 and disco-vertebral height of L3-L4 is slightly reduced. With these findings, this patient should have a follow-up imaging study, such as a magnetic resonance imaging (MRI) of lumbar spine, to determine whether this is a fracture. This recommendation is consistent with the International Society for Bone Densitometry, which considers an equivocal bone fracture to be sufficient indication for additional imaging. In this patient, the DEXA scan showed normal average bone density, with normal T-scores of hip and spine, -0.2 and 0.1 respectively. The T-score of the right femoral neck was 0.4, which is also normal. These normal average scores, however, could be masking low scores in any individual vertebra, so a full DEXA report would be helpful in establishing this patients diagnosis. Fosamax can have potentially serious side effects. Therefore, a diagnosis of osteoporosis must be confirmed in order for its use to be clinically justified. Had additional clinical and radiological information been provided in this case in support of the diagnosis of osteoporosis, showing that the findings in the patients spine are indeed due to fracture, and that any individual vertebral body has a T score below -2.5, then the diagnosis of osteoporosis could be sustained. However, in the absence of this information, the requested Fosamax therapy has not been demonstrated to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested a 4-wheeled walker with a seat for treatment of her sacroiliac joint dysfunction.  Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) guidelines indicate that multiple aids are available to assist patients with mobility difficulty. Depending on the severity of the patients limitation, one type of assistive device may be more beneficial than another (Braddom, et al). Since this patient is able to safely ambulate using a cane or a walker while at home, she can be expected to use one of these assistive devices to ameliorate her personal deficits that may impair her participation in mobility-related activities of daily living within her home. The practice guidelines do not support the medical necessity of a four-wheeled walker with a seat in this clinical setting as the patient does not require the use of the requested device within the home. Thus, the requested four-wheeled walker with a seat has not been shown to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that the patient has been diagnosed with chronic migraine, and tried and failed prior preventives. To date, the use of Botox for treatment of patients with chronic migraine has been evaluated in phase 3 studies. The patients were treated with 155-195 Units and showed definitive statistical and clinical benefits in terms of reduction in of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives even in patients who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients. Moreover, based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox as a chronic migraine preventive therapy, at dosing of 155 Units. Of import is that there are no other FDA approved medications for chronic migraine. As Botox is FDA approved for the indication of chronic migraine, it is not experimental. Therefore, Botox should be approved as per FDA indication.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that the guidelines for the use of breast MRI are well documented in the peer-reviewed literature. For patients with breast pain, the standard of care is a diagnostic mammogram and/or breast ultrasound. The utilization of breast MRI in patients with breast pain and a normal mammogram, physical exam and breast ultrasound is not medically indicated. Screening breast MRI is used only for patients with a calculated risk of developing breast cancer of greater than 25%, patients with personal or family history of BRCA mutation or patients with history of radiation therapy to the chest region. Diagnostic breast MRI is used for patients where diagnosis is inconclusive, even after standard work-up; evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors; patients with positive axillary nodes but no known primary; patients with rupture of a breast implant; and for determination of the extent of disease in patients with known malignancy, prior to treatment. This patient is not at high risk for developing breast cancer as there is no documented family history of breast cancer or BRCA mutation. Moreover, the patient does not have a history of radiation therapy to the chest wall, or inconclusive diagnosis on mammogram or breast ultrasound. Further, there is no evidence of an implant rupture. As this patient does not meet the established criteria for screening or diagnostic breast MRI, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested an MRI of both knees and a cortisol test for evaluation of her medical condition.  Findings:  The physician reviewer found that in this clinical scenario, an MRI of both knees is not medically indicated at this time. She has had an MRI of the right knee which demonstrated meniscal degeneration, but no evidence of internal derangement.  She had no new clinical findings related to the right knee. The issues involving the left knee recently developed and required a MRI for full evaluation. The patient underwent a MRI of the left knee on the said date. There is no clinical indication for further imaging of the knees with MRI at this time and therefore this service is not medically necessary. Further, based upon the submitted documentation, there is no indication for the requested cortisol test. This test has been requested for evaluation of possible fibromyalgia. There is no clinical suspicion on review of the medical documentation to support the requested study. The patient has no evidence of any endocrinologic or metabolic abnormality. The patient has no history of recent corticosteroid use, and there is no clinical suspicion of any adrenal abnormalities by examination or standard comprehensive laboratory studies. All told, the requested cortisol test is not medically indicated or necessary for the evaluation of this patient.