Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for 40 hours per week of Applied Behavioral Analysis (ABA) Services for the enrollee who has autism spectrum disorder.  He has received early intervention services, home visitation, therapeutic services, and developmental specialist services. He has stereotypic/repetitive movements, echolalia, and is bothered by loud noises.  During the evaluation, he presented as withdrawn and difficult to engage.  He was observed to rarely use words for communication, to have inconsistent eye contact, and a strong preference for independent play.  He responded to his name inconsistently, but was able to follow some one-step directives given gestures.  His Childhood Autism Rating Scale result indicated that he is demonstrating significant impairments in social interaction and communication, as well as restricted, repetitive patterns of behavior that interfere with his functioning.  The psychologist noted that these results along with clinical observations and developmental history indicate the enrollee meets diagnostic criteria for autism spectrum disorder.  In this enrollee, several challenging behaviors were targeted with associated goals for improvement.  Early intensive ABA-based interventions are well-documented throughout the past five decades to show substantial and sustained gains in IQ, language, academic performance, and adaptive behavior, as well as some improvement as it relates to social behavior, with outcomes that are significantly above those of children who do not receive this level of treatment.  Consensus guidelines in non-medical  interventions address cognitive function and core deficits in children  with autism as based upon a systematic overview  of research findings and concluded that children with ASD should have comprehensive intervention, such as ABA to address social communication, language, play skills, and maladaptive behavior.  Forty hours per week of ABA is typically required when patients are in the severe range in all domains and with full clinical presentation of ASD, Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified  psychologist and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nelarabine infusions. Dunsmore and colleagues reported that the addition of nelarabine to an augmented Berlin-Frankfurt-Muenster regimen improved disease-free survival rates for children and young adults with newly diagnosed T-cell acute lymphoblastic leukemia without increased toxicity. Abaza and colleagues concluded that a hyper-CVAD chemotherapy regimen plus nelarabine was well tolerated and in the frontline treatment of adult patients with T-cell acute lymphoblastic leukemia. In this case, the patient has a history of T-cell lymphoblastic lymphoma. Given current medical literature, the requested service is standard of care and medically indicated. Therefore, Nelarabine infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine or chronic headaches, there is ample literature supporting its use in refractory cases.  In this particular case, the patient has failed multiple first-line therapies for headache and now has frequent disabling symptoms. Furthermore, the patient may now also have medication-induced rebound headaches and has responded to treatment with Botox in the past. Thus, a trial of Botox is a reasonable treatment strategy for this particular patient and may provide a bridge to minimize the overuse of other medications.  A reassessment of the necessity of Botox use after 12 months should be implemented to ensure that the therapy continues to be beneficial for reduction in the frequency and severity of her headaches.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old male enrollee has requested power wheelchair repairs for treatment of his arthrogryposis multiplex congenita (AMC).  Findings:  The physician reviewer found that wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario (Cherubini and Melchiorri; Dicianno and Tovey; Johnson and Fitzsimmons). In the current case, the patient was assessed in the community by a physical therapist and noted to be able to use a manual wheelchair for all of his home mobility needs. He was assessed to have the capacity to self-propel a manual wheelchair. His power wheelchair was being used for community mobility only. The homes entry/egress was not accessible to a power mobility device. Overall, the records from the specialized mobility evaluation do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living in the home. The current manual wheelchair was in excellent condition. Therefore, the requested repairs of this patients current wheelchair are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested the Vest Airway Clearance System for treatment of the enrollees asthma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  High-frequency chest wall oscillation was developed to improve airway clearance in patients in whom normal mucociliary transport system has failed. Medication management of secretions has been achieved with mucolytic agents such as hypertonic saline. This patient has persistent asthma despite adequate medication management, as well as difficulty clearing secretions.  Vest therapy has provided significant clinical relief of symptoms and he has failed treatment with standard therapies.  All told, the Vest Airway Clearance System is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for bilateral custom solid ankle foot orthoses (AFOs). Researchers concluded that an AFO immediately improves the dropped foot in the stance and swing phases. Medical literature states that their results suggest that bilateral custom-made AFOs plus walking shoes is effective in improving balance compared to walking shoes alone. This patient presents with bilateral foot drop and knee hyperextension. He has tried two off-the-shelf AFOs, which provided inadequate hyperextension control of the knee during the midstance phase of gait. He has finished physical therapy with an increase in his stamina and minimized use of a wheelchair. He is using a rolling walker and is ambulating approximately 100 feet. Bilateral custom solid AFOs with hyperextension control, dorsiflexion assist, three-point varus control, and lateral containment have been recommended to achieve maximize function and normalize gait. Current evidence-based medical literature supports the requested bilateral custom solid AFOs in this patients clinical scenario to improve his stance phase and improve balance. All told, the requested bilateral custom solid AFOs are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for procedures provided by Encino Surgical Center for treatment of her back pain. Findings:  The physician reviewer found that there is no documentation to substantiate a rationale for the various, multiple procedures and no documentation to establish the response to each intervention. Multiple procedures were done at the same time, invalidating the assessment of the diagnostic procedures. Studies have shown intravenous sedation obscures assessment of diagnostic medial branch blocks. Not only was intravenous sedation given each time that diagnostic medial branch blocks were done, but other procedures were done concurrently, obfuscating any assessment of benefit. There is insufficient documentation to substantiate that the patient was adequately assessed for benefit after the diagnostic medial branch blocks. Rhizotomy of the facet joints is not indicated unless there is a clear, substantial benefit from diagnostic medial branch blocks. Again, there was not adequate documentation to assess pain and function after diagnostic medial branch blocks.
Appeal type: Medical Necessity
Decision: Overturned

The daughter of a 91-year-old female enrollee has requested continued stay at a skilled nursing facility (SNF) for treatment of a fracture of the humeral head and neck and two strokes.   Findings:  The physician reviewer found that the patient had a gastrostomy tube and received all of her nutritional support via the tube feedings. Her feedings were managed by the nursing staff and gastric residuals were checked each shift. This was a skilled nursing service. However, a gastrostomy tube and gastrostomy tube feedings are not part of usual and customary hospice care. As of the date in question, the patient was admitted to the hospice program and her skilled nursing care was managed by the hospice agency. The care provided by the SNF was custodial and more directed toward comfort than symptom management.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition.  There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In addition, clinical exam findings did not evidence a neurologic deficit correlated with imaging evidence of grade 1 spondylolisthesis at L4-5 with canal narrowing. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the requested services did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met on the dates in dispute.  There was no documentation of spinal segmental instability on flexion and extension x-rays. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested reimbursement for cognitive FX concussion treatment services. There is limited evidence in current medical literature regarding cognitive, sensory, and related therapies for the treatment of post-concussion syndrome. Current guidelines do not provide guidance on the use of these types of therapies for treatment of post-concussion syndrome due to a lack of supporting data. In a meta-analysis and review of randomized controlled studies of cognitive behavioral therapy in adults with post-concussion syndrome, Chen and colleagues found no benefit from cognitive behavioral therapy for the symptoms of the post-concussion syndrome, although noting that such therapy may provide help for symptoms of depression, anxiety, and social integration. McNally and colleagues reported low level evidence supporting the use of cognitive behavioral therapy in providing improvement for post-concussion syndrome in children and adolescents. However, this was a non-randomized uncontrolled study, so it was not possible to determine if this effect was due to the therapy, placebo, or other bias. Therefore, cognitive FX concussion treatment services were not likely to have been more beneficial for treatment of the patients condition than any available standard therapyFindings:  Two of the three physician reviewers found the cognitive FX concussion treatment services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee has requested magnetic resonance spectroscopy (MRS) for treatment of his prostate cancer. Findings:  Two physician reviewers found that the MRS uses a strong magnetic field to obtain metabolic information as there are metabolic differences in normal prostate tissue, benign hypertrophic prostate tissue, and cancerous prostate tissue. This patients clinical situation (localized prostate cancer with a Gleason score of six, a PSA of 8.2, and a normal feeling prostate) carries a high probability of his disease being organ confined. In this case, radical prostatectomy is indicated as the treatment of choice. With standard radical prostatectomy, his five and ten-year probability of being progression free is between 89 and 97 percent. There is no evidence that a MRS would add clinically significant information that would alter the treatment of this patients condition. An MRS may be indicated in patients with high-risk/high-grade cancer. Accurate localization of cancer is of increasing value when focal therapies evolve (e.g., localized cryosurgery or high-intensity focused ultrasound), which is not the case with prostate cancer. A radical prostatectomy is planned for this patient regardless of any small subtle findings that may be revealed by the requested MRS. The proposed exam is not routinely used for preoperative evaluation in this setting and is not likely to confer additional benefit in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for neuropsychological testing. This patient has a long history of academic underperformance, difficulty with various executive functioning tasks, and impairments in overall organization and attention. However, there is no report of organic brain component to support neuropsychological testing following his assessment to support an indication for the neuropsychological testing performed. At present, diagnosis of ADHD and adjustment disorder can be adequately performed through psychiatric evaluation and do not require a full battery of neuropsychological testing. As noted in the medical literature, neuropsychological testing is useful to differentiate psychiatric illness from organic brain dysfunction that may be caused by dementia or traumatic brain injury. However, this patients records do not document concern for any of these organic brain components to support an indication for the testing performed. Additionally, there are no records to indicate that there was diagnostic confusion regarding the patient requiring clarification of diagnosis through this extensive testing. For these reasons, the neuropsychological testing was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a seven-year-old male who has been diagnosed with idiopathic short stature. The submitted records indicate the patients stature is well below the third percentile and is inappropriate for mid-parental height. The patients growth velocity over the most recent 15 months is less than 4cm/year (3.8). The patients evaluation was otherwise non-diagnostic. It appears that a genetics consultation has been requested to rule out syndromal etiology for the patients short stature/slow growth. A request has been made for Humatrope therapy. The Health Plan has denied the request on the basis that Humatrope is not medically necessary for treatment of the patients short stature.The patients history, physical examinations, and growth records support a diagnosis of idiopathic short stature. The patients abnormal growth velocity attests to the need for growth hormone therapy. Stimulation testing is not indicated or necessary prior to starting Humatrope as most children with idiopathic short stature test normal. Furthermore, abnormal stimulation tests are not required by the Food and Drug Administration in order to initiate therapy in patients with idiopathic short stature once diagnosis is established as long as other possible etiologies are ruled out and the patients stature and growth velocity support initiation of treatment.Based upon the information set forth above, I have determined 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha 140 mg/ml for treatment of his hyperlipidemia. Findings:  The physician reviewer found that the patient has documented coronary disease and persistently high LDL cholesterol despite maximally tolerated statin dose in combination with both Zetia and fenofibrate.  Repatha is a proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient fits the latter criteria.  There are randomized clinical trials that document significant LDL lowering with PCSK9 inhibitors in patients with the above criteria in addition to cardiac outcome improvement in post-hoc analyses.  The medical evidence supports the requested medication in this clinical setting.  Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee requested extracorporeal shockwave therapy for medical treatment of her plantar fasciitis and Achilles tendonitis. Findings:  Two physician reviewers found that in the peer-reviewed medical literature on the use of extracorporeal shockwave therapy for the treatment of chronic heel pain, there is a paucity of scientific data demonstrating improved health outcomes when compared to standard therapies. Many studies have small numbers of patients evaluated and the strength of the extracorporeal shockwave therapy is poorly defined. All told, the patient is likely to benefit from a comprehensive, well documented physical therapy approach, combined with splinting and orthotics. For these reasons, extracorporeal shockwave therapy is not likely to be more beneficial for treatment of this patients medical condition than any available conventional therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 25-year-old female enrollee has requested osteochondral allograft of the right knee for treatment of her knee pain. Findings:  Two physician reviewers found that the requested services are likely to be superior over other available treatment options.  At age 25, absent a carefully planned attempt at reconstruction, there is likely to be further progression in the deterioration of the knee joint.  By correcting the malalignment and addressing the major lesion on the tibial side of the lateral compartment, the patient will likely experience a positive benefit.  There is sufficient support for the proposed treatment in this clinical setting.  All told, the requested osteochondral allograft of the right knee is likely to be more effective than other available treatment options.