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

A 45-year-old female enrollee has requested pulsed radiofrequency denervation of the left suprascapular nerve for treatment of her chronic pain, left shoulder, and adhesive capsulitis, left shoulder.  Findings:  Two physician reviewers found that the patient failed to receive benefit with minimally invasive surgery.  A more invasive surgery is not appropriate for treatment of chronic pain unless there is an involved mechanical disruption. The next logical step after failed conservative therapy would be pulsed radiofrequency denervation of the left suprascapular nerve for long-term improvement of the patients shoulder pain. More recently published medical literature have shown support for pulsed radiofrequency denervation in improving health outcomes associated with chronic pain Luleci and colleagues established a prospective study on the application of pulsed radiofrequency denervation to the suprascapular nerve for 480 seconds. The aim of the study was to evaluate patient satisfaction, efficacy and safety of the pulsed radiofrequency technique applied to the suprascapular nerve for treatment of refractory shoulder pain. Following the study, they concluded that pulsed radiofrequency technique application to the suprascapular nerve for 480 seconds showed remarkable improvement for individuals with chronic shoulder pain.Chua and colleagues published a prospective study to evaluate the efficacy of pulsed radiofrequency denervation treatment of chronic pain. They obtained their data from randomized clinical trials and well-designed observational studies. From the available evidence, they concluded that pulsed radiofrequency denervation of the suprascapular nerve was found to be as efficacious as intra-articular corticosteroid injections in patients with chronic shoulder pain.Liliang and colleagues performed a study in the clinical setting to evaluate pulsed mode radiofrequency lesioning of the suprascapular nerve for treating chronic shoulder pain. The cohorts of the study performed 13 procedures using pulsed radiofrequency lesioning of the suprascapular nerve under fluoroscopic guidance in 11 patients with chronic shoulder pain for at least three months. The authors found that pulsed radiofrequency lesioning to the suprascapular nerve is a potential treatment options for patients suffering chronic shoulder pain, as it provided long-term pain relief and decreased pain medication requirements in the participants of the study. Therefore, pulsed radiofrequency denervation of the left suprascapular nerve was likely to have been of greater benefit than any available standard therapy in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 23-month-old male enrollee has requested  speech therapy for treatment of the enrollees delayed speech.  Findings:  The physician reviewer found that this 23-month-old patients speech is at a one-year level.  His speech is significantly delayed, both by parental description and formal testing.  The etiology is due to a severe developmental delay in the maturation of speech. It was noted that the patient does not demonstrate a developmental speech and language delay, however an in-plan speech pathologist, after testing the patient, diagnosed him as developmentally delayed in speech.  Regarding medical necessity, it is the medical communitys standard practice to offer speech therapy to a two-year-old whose speech is at a one-year level.  There is robust medical literature supporting speech therapy in this speech delayed population. Law, et al. reported that children with speech delay can be readily treated. Goorhuis-Brower, et al. specifically deals with speech-delayed children and points out that such children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, do require and benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).  In sum, speech therapy is medically indicated in this patient, with reevaluation after six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested oral surgery and follow-up services for treatment of his class III malocclusion.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services.  This patient has been diagnosed with a maxillofacial skeletal deformity. This deformity cannot be corrected by non-surgical means, and the patient will require orthognathic surgery. As a result of the surgery, the patient is likely to have improved occlusion and improved musculoskeletal and dento-osseous relationships. Additionally, improved mastication and swallowing are likely to occur following surgery.  The American Association of Oral and Maxillofacial Surgeons and current literature support the requested services in this clinical situation.  All told, the requested oral surgery and follow-up services are medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested two 30-minute sessions per week of speech therapy for treatment of the enrollees severe expressive language impairment and moderate receptive language impairment.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient has significant delays in receptive and expressive speech/language skills that negatively impact his ability to express his needs and interact with peers and adults.  At 19 months of age, objective testing demonstrated language comprehension at the 12-month level and language expression at the nine-month level. The literature supports therapeutic intervention for children such as this patient. All told, two 30-minute sessions per week of speech therapy is medically indicated in this patients case.
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 speech delay. Findings:  The physician reviewer found that this patients speech is below the level of a one-year-old peer, thus this patients speech is significantly delayed as well documented by formal testing. The etiology is due to a severe developmental delay in the maturation of speech due to motor apraxia. His brain development has been delayed altering and disrupting cerebral input to the muscles of the jaws and oral pharyngeal musculature. Speech apraxia is a well-known neurological disorder as acquired phenomena in adult stroke patients. In this particular patient, the apraxia is congenital, not acquired. Overall, the patients score on the Kauffman subtest was -1.5 standard deviations below the 7th percentile. From the available information, the patient is likely intellectually normal, but presents with an expressive speech delay due to apraxia, as there is no history of any prior developmental evaluations when his speech was evaluated. Given that this patient is two-years of age and currently exhibiting the skills of a one-year-old peer and there is robust medical literature supporting speech therapy in this speech delayed population, the requested therapy should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a bilateral or unilateral breast reconstruction for treatment of her stated condition of breast deformity secondary to lumpectomies.  Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate that the requested procedure is medically necessary or reconstructive in nature. Overall, the patient appears to have mild changes as a result of previous breast biopsies and aspirations. The photographs and exam documentations are consistent with mild or minor deformities. As was stated in the evaluation by the plastic surgeon providing the second opinion, augmentation is not indicated due to the small amount of volume loss. A lumpectomy/partial mastectomy that requires breast reconstruction generally has created a moderate to significantly sized defect. A paper by Levine and colleagues discusses the treatment of partial mastectomy defects and possible options. Their discussion is based on cases with greater deformities than are present with this patient. In the case of this patient, the amount of deformity is less than that associated with typical breast reconstruction of partial mastectomy defects. The treatment of partial mastectomy defects depends upon an algorithm based on amount of resected tissue, size of the breast and anticipated type of treatment. In accordance with this algorithm, this patients deformities are not to the degree to warrant reconstruction of a partial mastectomy defect.  The severity of deformity that is present in this patient does not support augmentation.  Although this patient has had multiple biopsies as a result of tumors or disease that have resulted in mild deformities, the requested surgery would not improve the patients level of functioning or create a normal appearance, as a breast augmentation would be overtreatment of the patients mild deformities. All told, the requested procedure is not medically necessary or reconstructive in nature in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested left side neurotomy for treatment of his lumbar facet arthropathy and radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, the facet block on the left L3-4, 4-5 and L5-S1 joints under fluoroscopy as well as the fluoroscopically guided rhizotomy of the left L3, 4, 5 and S1 medial and lateral branches done on the said date was medically necessary as part of an appropriate work-up consistent with the standard of care. In addition, the epidural injection CPT 62311 (with fluoroscopy 77003) on the date in question was done for what appeared to be reasonable suspicion of radicular impingement. Applying the American Society of Interventional Pain Physicians (ASIPP) national interventional guidelines and current medical literature, the facet block, initial left sided rhizotomy both with fluoroscopy, and the epidural with fluoroscopy, as well as the said date services including the epidural 62311 and fluoroscopy 77003 should be covered as medically necessary procedures. However, the Health Plans denial should be upheld for the bilateral rhizotomy and any related services performed with the rhizotomy on the said date as no symptoms were noted prior to the procedure. To summarize, the rhizotomy on the said date of the left L3, 4, 5, and S1 medial and lateral branches should be reimbursed as medically necessary. However, the rhizotomies performed on the date in question were not clinically indicated. Thus, the only medically necessary services provided the patient on the date in question were the fluoroscopy and the epidural injection.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested acupuncture, two times per week for eight weeks for treatment of his stated condition of severe neck and upper back pain.  Findings:  The physician reviewer found that this patient presents with a chronic pain condition for which surgical procedures were recommended by four different specialists six years ago. The patient previously underwent acupuncture, which benefitted his condition with frank symptom reduction, and for several years thereafter he did not need any additional care. The patients condition recently deteriorated and under the recommendation of his primary care provider, acupuncture was rendered again with symptom reduction. Based on the patients previous response to treatment, the records reviewed, and the peer reviewed medical literature, a modified treatment plan of six acupuncture sessions would be appropriate and beneficial to help the patient improve from the recent flare-up. Evidence of objective, significant and functional improvement is essential to establish the reasonableness and necessity of care and should be documented in future exams, if additional care beyond the six sessions herein recommended, is requested. Self management strategies like an independent exercise program (HEP), self-imposed restrictions, proper biomechanics and work modifications (if available and needed) are supported by peer review literature to avoid unnecessary passive care and to stimulate self reliance. In sum, after reviewing the medical reports and other documentation submitted for the treatment request, I find that a modified treatment plan of six sessions is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested chemotherapy regimen consisting of Herceptin and sodium phenybutyrate in combination with Torisel for treatment of her ovarian cancer.   Findings:  Two physician reviewers found that use of Herceptin has not been extensively tested in ovarian cancer, and is not listed in the National Comprehensive Cancer Network (NCCN) practice guidelines as an evidence-supported treatment in this disease. Herceptin is known to be active in breast cancer, and likely other cancers, where the tumor expresses the HER2 antigen. In this patients case, immunohistochemical staining for HER2 of the primary tumor was not available in the provided records but the provider reports that the patients tumor overexpressed HER2. A Gynecologic Oncology Group (GOG) study noted that single agent Herceptin in HER2 expressing ovarian cancer was minimally effective with only a 7% response rate (Bookman, et al). However, in the GINECO phase II study, the similar patient population was treated with Herceptin combined with chemotherapy (Carboplatin/Taxol) and resulted in an impressive complete response in 4 of 7 patients, and stable disease in 2 additional patients (Ray-Coquard, et al). Thus, while use of Herceptin has been denied, given that this patients tumor overexpresses HER2, it is reasonable to allow coverage for use of Herceptin in combination with cytotoxic chemotherapy, as per the GINECO trial. Despite the likelihood that Herceptin will provide this patient a more beneficial outcome than standard therapies, there is still inadequate support for the effectiveness and safety of sodium phenylbutyrate in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) programs have been shown to be effective in treating behaviors associated with autism spectrum disorder (ASD). Most recently, a 5-year randomized controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model (ESDM) interaction based on developmental and applied behavior analysis principles (Dawson, et al). In addition, a systematic review by Warren and colleagues found that Lovaas-based approaches and early intensive ABA intervention variants of the ESDM resulted in improvements in cognitive performance, language skills, and adaptive behavior skills. Further studies have shown treatments using the ABA approach to be efficacious (Rogers and Vismara). Current developmental trajectories note that behaviors in autistic children change over time and goals for intervention vary depending on the specific clinical context and age of the child. As noted by the National Research Council, ABA offers a program that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills. Given this patients autistic behaviors and his level of progress in ABA treatment thus far, the ABA services provided since the date in question and forward are medically appropriate at the requested frequency of 10 hours per week.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his lower esophageal cancer.  Findings:  Three physician reviewers found that based upon the large field of radiation and the surrounding critical structures such as the heart and lungs, the IMRT plan provides the best coverage with the least risk of long-term toxicity to the lungs and heart. The peer reviewed medical literature has established the effectiveness of IMRT as well as the reduction in exposure to adjacent critical structures including the heart, which is of concern in this patients case. The National Comprehensive Cancer Network (NCCN) supports IMRT as indicated when there are critical structures such as the heart adjacent to the target volume. For these reasons, the requested IMRT approach is likely to result in an improved health outcome when compared to 3D conformal radiation or any other standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy services, one hour per day, two times per week for treatment of the enrollees receptive/expressive language delay.  Findings:  The physician reviewer found that in this patients case, the requested services are medically necessary.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Per the current medical evidence, speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient demonstrates significant delays in expressive speech/language skills that negatively impact her ability to express her needs and interact with peers and adults.  According to her therapist, she has made slow but steady progress as the therapeutic relationship has grown. The literature supports therapeutic intervention for children such as this patient as long as progress can be demonstrated.  All told, the requested speech therapy services, one hour per day, two times per week, are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested authorization and coverage for stereotactic body radiation treatment (SBRT). The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees prostate cancer.  Findings:  Three physician reviewers found that the patient presented with rising PSA. The patient underwent a prostate biopsy, which established a diagnosis adenocarcinoma of the prostate, with a Gleason score of six. The patient was offered several treatment options and stereotactic body radiation therapy (SBRT) treatment was discussed. The patient requested authorization and coverage for SBRT. The Health Plan has denied coverage of SBRT on the basis that it is considered experimental/investigational.This patient has early stage localized prostate cancer. He can be treated with several standard options of treatments including surgery, 3D conformal radiation therapy, intensity-modulated radiation therapy (IMRT) or brachytherapy. All these options are listed in the current National Comprehensive Cancer Networks (NCCN) guidelines. SBRT is an emerging technology which has been used in the last few years to treat several malignancies including prostate cancer. Currently, there are only a few publications in the peer-reviewed literature examining the role of SBRT in prostate cancer. These published studies are single institution studies with a small number of patients and short follow up. There are no large scale studies published supporting the efficacy and safety of SBRT with long term follow up. At the  present time, there are three phase II trials being conducted to evaluate the role of SBRT for prostate cancer. Until the results of such large scale trials are available, SBRT is still considered to be of unproven efficacy in this setting. Additionally, the NCCN guidelines for prostate cancer do not consider SBRT an accepted treatment for prostate cancer. Thus, SBRT is not likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested authorization and coverage for chemotherapy with Vectibix.  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees stage IV colon cancer with liver metastasis.  Findings:  Three physician reviewers found that the patient is status post hemicolectomy.  He received Avastin/FOLFOX and Avastin/FOLFIRI.  The patients tumor has wild type K-RAS sequence.  He has also been treated with cetuximab.  He has requested authorization and coverage for chemotherapy with Vectibix.  The Health Plan has denied this request and reported that Vectibix is investigational for the treatment of this patient.  In this patients case, the requested medication is likely to be superior over other available treatment options.  Vectibix (panitumumab) is approved for use in metastatic colon cancer that has progressed through 5-FU or oxaliplatin chemotherapy.  There is no mention on the label regarding cetuximab prior therapy.  Both drugs are monoclonal antibodies that target the epithelial growth factor (EGFR) and appear to have similar mechanisms of action.  Additionally, both have shown efficacy in clinical trials.  The study by Metges and colleagues directly tested whether patients that had progressed on cetuximab would benefit with panitumumab. The studys preliminary results demonstrate a benefit for panitumumab in this setting.  There is sufficient evidence supporting the use of panitumumab in this patients case.  In sum, the requested chemotherapy with Vectibix is likely to be of greater benefit than other available treatment options.