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

The parent of a 13-year-old male has requested circumcision for treatment of his medical condition.  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently issued a revision to its policy on circumcision. This 2012 AAP statement indicates that given the limited risks of mechanical neonatal circumcision methods, circumcision is a reasonable choice in newborns although it is not a medical necessity. The AAP policy does not specifically recommend or advocate for circumcision later in life. While Morris, et al. and Weiss, et al. note there can be risks associated with an intact prepuce, based upon the documentation provided, there is nothing in the patients medical history to demonstrate he is at risk. Further, there is no barrier to normal hygiene in the patients physical or developmental progress. Moreover, according to Weiss and colleagues, circumcision beyond the neonatal period is not without risk. In this case, there is no clear clinical benefit to performing circumcision in a 13-year-old individual who has no history of adverse impact secondary to his uncircumcised status. As such, the medical necessity of the requested circumcision has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old male enrollee has requested coverage for past treatments with transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  Two physician reviewers found that the patient has a long-standing history of depression. The patient was treated for his depression with the following medications: Wellbutrin, Zoloft, Serzone, Emsam, Pristiq, clomipramine, and Remeron. Additionally, augmentation therapy of antidepressants with the addition of atypical antipsychotic medication was tried. None of these trials proved successful in providing sufficient relief of the patients depression. The patients psychiatrist has reported improvement in the patients depression with TMS treatment.Scientific evidence has established TMS to be a safe and efficacious treatment for major depressive disorder (Janicak, et al.; George, et al.; and OReardon, et al.). Review of the scientific literature reveals that TMS avoids the complications associated with anesthesia, cardiac risks, and memory disturbances as reported with electroconvulsive therapy (ECT) in the treatment of depression and has a mild side effect profile. TMS was a scientifically established treatment for depressive disorder at the time of service and was likely to result in greater benefit to the patient than further trials of pharmacologic agents, as multiple medications had already been tried without adequate improvement.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested decompression with fusion at the L4-5 level for treatment of her stenosis at L4-5.  Findings:  The physician reviewer found that based on review of the available records, this patient has chronic back pain both from age related degeneration and from hook pullout from her scoliosis surgery. She has abnormalities on her CT and MRI scan at multiple levels but there is no convincing medical evidence that the L4-5 level is her pain generator. Her provider reports that the patient has retrolisthesis at L4-5. However, applying the criteria for fusion as reported in the Milliman Care Guidelines for lumbar fusion and from Bambakidis and colleagues, there has no evidence of significant instability, scoliosis, angulation, spondylolysis, infection, fracture or tumor to warrant surgical fusion at L4-5. Consistent with these recommended indications for fusion surgery this patient does not meet the medical necessity criteria and therefore the requested surgery was appropriately denied.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with an autism spectrum disorder. He has reportedly been receiving applied behavioral analysis (ABA) therapy. The patient has requested authorization and coverage for 36 hours of ABA therapy per month. Findings:  The physician reviewer found that the Behavior Analyst Certification Board (BACB) guidelines indicate that discharge will be reviewed when the patient has achieved treatment goals, no longer meets diagnostic criteria, does not demonstrate progress, the family does not want to continue services, or the family and provider are not able to reconcile important issues. The provider indicates that discharge criteria will be discussed when the patient has met all treatment goals. This patient meets the diagnostic criteria of autism and is still making progress on treatment goals. Based on this information, he does not meet discharge criteria.  It is premature to begin discussing discharge, including reducing an already low number of requested service hours. The Vineland 3 is a normative based assessment that compares adaptive functioning skills to individuals of the same age. Based on the patients Vineland score, he is functioning in all areas at the level of a six-year-old or younger and obtained scores that are 4 or more standard deviations from the mean. This information suggests that the patient is performing significantly discrepant from their same-aged peers and needs significant support. Given the level of deficits displayed and the need for improvement in several domains, reduction in service intensity is not medically appropriate.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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of the enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy and 12 hours per month of family treatment for treatment of the enrollee's autism spectrum disorder.Findings: The physician reviewer found that ABA is a medically necessary evidence based intervention for the treatment of autism spectrum disorders. In this case, the patients parents are requesting ABA therapy at the requested frequency of 40 hours per week of direct therapy and 12 hours per month of family treatment to address vocal stereotypies, non-compliance/non-responsiveness, elopement, and self-injury. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Based on the clinical documentation submitted for review and the support in evidence-based guidelines, the request for 40 hours per week of direct ABA therapy and 12 hours per month of family treatment has been established as medically necessary and should be approved. Final Result: The reviewers 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: Physician reviewer number is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 62-year-old female enrollee has requested posterior tibial nerve stimulation (PTNS) treatments and  resumption of weekly PTNS treatments (up to 12 weeks) and/or monthly maintenance of PTNS for treatment of her urinary incontinence.  Findings:  Two physician reviewers found that lower urinary tract symptoms make up a large percentage of the complaints encountered by urologists.  These complaints include urinary frequency, urgency with and without incontinence and occasionally nocturia.  Patients are initially instructed in lifestyle changes that may improve their symptoms.   If these techniques fail, second-line, non-invasive treatment options include pelvic floor muscle therapy, bladder retraining and anticholinergic therapy.  Although there are numerous medical therapy options available, not all patients are candidates secondary to other concomitant medical conditions.  In these instances, more invasive techniques may be required.  However, there is a lack of support for PTNS in this clinical setting.  In this case, there are multiple anticholinergics that are still available for trial by this patient.  Additionally, there is a lack of documentation regarding behavioral techniques trialed such as eliminating caffeine, timed voiding and fluid restriction.  The records do not indicate that pelvic floor muscle therapy has been trialed.  In sum, the superior efficacy of PTNS has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female, who has a history of right shoulder pain, has requested authorization for physical therapy services.Reviewer's Findings:The reviewing physician found that the patient showed steady gains in her right shoulder range of motion, strength and functional activities. Without supervised, consistent physical therapy it is doubtful the patient would have achieved such results.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for trastuzumab (Herceptin) chemotherapy for treatment of the enrollees basal cell carcinoma. Findings: The physician reviewer found that Herceptin is a human monoclonal antibody against the HER2 cell surface protein. It is commonly used in breast cancer that has HER2 amplification but its use has expanded to gastric cancer and gastroesophageal junction cancer. HER2 amplification is rare in small bowel adenocarcinomas. Herceptin was tested in ovarian cancer in a phase II trial performed by the Gynecologic Oncology Group (GOG) showing one complete response and two partial responses among 41 assessable patients with an overall 7.3% response rate. Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The use of targeted therapy in this patient is medically necessary and appropriate. Given this support, the requested Herceptin is supported as medically necessary for treatment of this patients small bowel adenocarcinoma. Final Result: The reviewer 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 medical oncology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for food allergy lab work (CPT codes 82784 x 1 unit, 82787 x 4 units, 83520 x 4 units, 86001 x 11 units, 86003 x 37 units, 86008 x 46 units, 88184 x 1 unit, 88185 x 2 units). The peer-reviewed medical literature supports the measurement of IgE levels to specific foods concerning for allergens as part of a food allergy evaluation for a patient. However, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing has not been demonstrated to provide benefit in the evaluation of food allergies. Sicherer and Sampson noted that, Current management relies heavily on avoidance and emergency preparedness, and recent studies, guidelines, and resources provide insight into improving the safety and well-being of patients and their families. The available data does not endorse the utility of the additional food allergy lab work studies requested in this patients evaluation and treatment. Therefore, the requested food allergy lab work (CPT codes 82784 x 1 unit, 82787 x 4 units, 83520 x 4 units, 86001 x 11 units, 86003 x 37 units, 86008 x 46 units, 88184 x 1 unit, 88185 x 2 units) is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy. Findings:  The physician reviewer found that the submitted documentation and medical literature support the requested services in this clinical setting. TMS is a noninvasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The medical literature supports that TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy, which was reportedly considered in this case.  Further, the American Psychiatric Association (APA) investigated this treatment option and the available literature. The outcome of the investigation in 2010 was an APA endorsement of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Prior treatment for this patient have included cognitive behavioral therapy and pharmacotherapy. The standard of care does not require multiple medication trials prior to TMS therapy, which was a rationale for denial asserted by the Health Plan in this case.  The APA endorsement is a compelling determination supporting the use of TMS in this clinical setting. As such, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represents a safe and appropriate treatment that is reasonably expected to improve this patients condition and prevent a more serious episode of illness. Therefore, the requested TMS therapy is medically necessary for treatment of the enrollees behavioral health condition.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 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

A 39-year-old female enrollee has requested inpatient chemical dependency treatment services for treatment of her alcohol abuse. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Per the American Psychiatric Association (APA) Clinical Practice Guideline on substance use, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this particular case, the patient has failed community programming and treatment in a less restrictive clinical setting.  Her alcohol consumption has been dominating all functional domains and her current social setting is unable to support her sobriety.  Considering the patients presentation, difficulty with outpatient detoxification and history of alcohol consumption, she is at risk for significant morbidity from alcohol withdrawal and treatment non-adherence outside a 24-hour supervised setting.  Thus, the submitted medical records support the medical necessity of an inpatient chemical dependency treatment program.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested cell function assay testing (Immune Cell Function Assay) for evaluation of his skin cancer status post heart transplant.  Findings:  Two physician reviewers found that the utility of the Immune Cell Function Assay for assessing the immunosuppressive status of patients who have received a heart transplant has not been accepted as the standard of care. The existing studies do not support a sufficient diagnostic accuracy to identify individuals at risk of rejection or infection. There remains significant heterogeneity across studies such that the International Society of Heart and Lung Transplantation guidelines do not recommend this test for routine clinical use. Therefore, the Immune Cell Function Assay testing is not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Medtronic 670G insulin pump for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that the request for Medtronic 670G insulin pump is medically necessary for treatment of the patients medical condition. The Medtronic 670G system is U.S. Food and Drug Administration (FDA) approved for patients with type 1 diabetes 14 years of age and older. The Medtronic 670G system includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor (CGM) sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. Medical studies show that the closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes. This feature is of importance to this patient given that the patient has documented hypoglycemia unawareness and hypoglycemic seizures. The Medtronic 670G system will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. This system will allow the patient to remain within the recommended target range most of the time. With this system, the patient will be able to keep his hemoglobin A1c (HbA1c) closer to goal and while minimizing hypoglycemic events. The ability of this pump to minimize hypoglycemic reactions by decreasing or stopping insulin delivery before hypoglycemia occurs is the most important feature that makes this system medical necessary for the proper management of this patients diabetes type 1. Final Result: The reviewer determined that the requested device 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 endocrinology, diabetes and metabolism 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 61-year-old female enrollee has requested for a computed tomography (CT) scan of the heart with coronary calcium evaluation for evaluation of her coronary calcification. Findings:  Two physician reviewers found that there are published consensus guidelines (see Greenland, et al.) regarding the appropriate use of coronary artery calcium (CAC) scoring. While the guidelines find that there are subsets of patients in which CAC may be reasonable, (such as low risk patients with atypical symptoms, or intermediate risk patients that are asymptomatic), this patient does not appear to fall into these subgroups.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested hyaluronan injections for treatment of the enrollees hip pain.  Findings: Three physician reviewers found that this patient is requesting authorization and coverage for hyaluronic acid injection for treatment of left hip pain attributed to osteoarthrosis. Viscosupplementation with hyaluronan is performed frequently for painful knee osteoarthritis, but the benefits are limited. The hyaluronan injection treatment proposed is approved by the Food and Drug Administration for treatment of painful osteoarthritis of the knee and injection in the hip is an off label usage. However, there have been very limited studies as to the superior efficacy of hyaluronic injections for treatment of hip pain related to hip osteoarthritis. The study by Qvistgaard and colleagues compared the effects of corticosteroid, hyaluronic acid and saline (placebo control) injections for hip osteoarthritis and no beneficial effects of the hyaluronic acid injection were shown. Most studies for treatment of hip symptoms include small numbers of patients and are uncontrolled with no comparison to more established treatment options such as corticosteroid injection. Therefore, the requested hyaluronic injections are not likely to be more effective than other available standard options for the treatment of this patient.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery 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.