Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene testing. This patients provider has recommended whole exome sequencing to assist in this patients diagnosis and treatment given his history of autism, intellectual disability, syncope, hallucinations, and arachnoid cyst. Whole exome sequencing is a comprehensive test, which identifies changes in a patients DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing analyzes the exons or coding regions of over 20,000 genes. Neurodevelopmental disorders are often complex clinical scenarios attributed to single-gene mutations that may be detected through exome sequencing. In a recent study, 100 families with 119 patients affected by neurodevelopmental disorders underwent diagnostic whole exome sequencing. The authors found that 40% of the patients tested received a molecular diagnosis, which led to a change in clinical care or impression of the pathophysiology in 49% of newly diagnosed families. In a retrospective cohort study, 78 patients with various neurodevelopmental disabilities and unrevealing work-up were selected to undergo whole exome sequencing. The authors found that the results yielded a presumptive diagnostic rate of 41% and the results affected management for all patients with a presumptive diagnosis. Furthermore, the use of whole exome sequencing has been endorsed by the American College of Medical Genetics and Genomics (ACMGG), which noted that whole exome sequencing should be considered when specific genetic tests available for that phenotype have failed to arrive at a diagnosis. For these reasons, the requested gene testing (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested gene testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 3 is board certified in genetics and is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested a special wheelchair for treatment of her cerebral palsy.  Findings:  The physician reviewer found that the medical records document the patient has spastic quadriplegia with progressive problems attributed to positioning issues with her existing custom wheelchair. The nature of cerebral palsy suggests that changes in posture due to altered spasticity are reasonably expected. Based upon the diagnoses provided and the current use of a custom wheelchair, a custom wheelchair is medically necessary. There are notes which indicate that a vendor for the wheelchair reportedly told the patients parent that a new wheelchair is needed and that the existing wheelchair cannot be adjusted. Based upon the presence of spastic quadriplegia and the information provided by the vendor concerning the need for a new wheelchair, this request for a new custom wheelchair is appropriate. Thus, the requested special wheelchair is supported as medically necessary for treatment of this 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 physical medicine and rehabilitation with sub-specialty certification in in pain medicine 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 60-year-old female enrollee has requested total left knee replacement for treatment of her left knee pain. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The American Academy of Orthopaedic Surgeons recommend patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low impact aerobic exercises, neuromuscular education and physical activity. In this patients case the there is a lack of documentation indicating that physical therapy has been tried and failed. The documentation submitted also indicates that this patient has a lumbosacral condition with abnormal nerve root morphology suggesting that there may be an overlapping radicular component to her knee pain. In sum, further attempts with conservative treatments are required before the medical necessity of total joint replacement is established. As such, the requested procedure is not considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested partial hospitalization program services for the treatment of her eating disorder. Findings:  The physician reviewer found that although her vital signs were stabilized following admission, she continued to ruminate daily about excessive weight and exercise. Additionally, the presence of a significant psychiatric comorbidity was well-documented in the medical records and impacted her level of motivation. Blunted affect, significant anxiety and poor eye contact were noted. Psychotropic medications were adjusted, resulting in an increase in certain medications. Family stressors were also present. All of these were impacting her recovery environment. The level of care received is also consistent with the American Psychiatric Association guidelines for the treatment of patients with eating disorders, and its effectiveness has been noted.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with a history of Cushings disease status post one-third partial hypophysectomy. She reports current symptoms of decreased energy, poor sleep and exercise intolerance. Physical findings of central obesity, and decreased lean body mass have been noted. A consulting endocrinologist indicated the patient is now growth hormone (GH) deficient based on a minimally decreased IGF-1 (100 with N1 greater than 106) and a barely positive argentine/GHRH (10 mg GH deficiency less than or equal to 9) stimulation test. It is noted that her weight increased from 125 pounds in 2000 to her current weight of 178 pounds. Additional reported signs and symptoms include fatigue, fibromyalgia like pain, panic attacks, irritability, and decreased memory. The patients provider indicates the patient has hypothyroidism for which she is on replacement medication.Medications include 10 different psychotropic drugs. It is unknown what medications were/are taken concurrently. Laboratory studies reveal elevated PRL, normal thyroid studies, and equivocal androgen and estrogen levels. An imaging study revealed normal pituitary gland. Pathology revealed no definitive findings of Cushings disease. The patients provider has recommended GH therapy for the patient. The Health Plan has denied the request indicating GH therapy is not medically necessary.Review of the submitted documentation reveals findings of a normal MRI, normal ACTH, and minimally elevated 24hr UFC on a single occasion (which can occur with obesity and/or depression). In light of these findings, the initial diagnosis of Cushings disease is questionable.Though the patient is status post one-third partial hypophysectomy, most people can function normally with two-thirds of their pituitary. The patients minimally decreased IGF-1 could be due to her excess weight. It is not likely the reported hypothyroidism is due to pituitary disease. The patients physical findings and galactorrhea can be ascribed to possible polycystic ovary syndrome with an elevated PRL. The pituitary pathology report does not support a diagnosis of Cushings disease. Given the evidence provided, it appears a full pituitary hormone evaluation should be performed including repeat PRL, plus LH, FSH and ITT for growth hormone stimulation. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for catheter ablation. Findings: Two of the three physician reviewers found that this patient has frequent symptomatic right ventricular outflow tract premature ventricular beats refractory to beta-blockers, calcium channel blockers and lifestyle modification. In this circumstance, therapeutic options include additional trials of alternative antiarrhythmic medications or radiofrequency catheter ablation. Catheter ablation is a reasonable approach in this patients case and is likely to be more successful if accurate mapping can take place. Additionally, very frequent ventricular beats may lead to left ventricular dysfunction and ventricular premature beat-related cardiomyopathy. Ablation has been shown to be helpful in prevention and treatment of this process as well. Therefore, catheter ablation is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld

The parent of a 9-year-old male enrollee has requested 30 hours per week of applied behavioral analysis (ABA) therapy  for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. However, when reviewing ABA as effectively applied to autistic older children, teenagers and adults, there is limited literature substantiating its favorable effect on these populations. In this patients case, his progress with ABA therapy has been limited. It has been documented that he only responds to his name being called one-third of the time. The available progress reports indicate behavioral improvement, but at a relatively slow pace. The requested frequency of 30 hours per week of ABA therapy is usually directed toward younger children who are just initiating therapy. Other than developing social skills, there is a lack of significant ABA literature guidance applicable to older children. Typically, rather than continue ABA therapy exclusively, the tendency is to expand social and behavioral skills in groups and school settings. The patients school is starting to place him into groups as he is now in group speech therapy. Thus, the Health Plans authorization of 20 hours of direct ABA services is sufficient for the continuance of ABA services. The requested 30 hours per week of ABA therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-three year-old female with a cystic bone lesion of the proximal humerus involving the proximal diaphysis, metaphysis and a portion of the humeral head is requesting treatment with an out-of-network orthopedic specialist.Reviewers Findings:  The reviewing physician found that the patients request for a referral to an orthopedic surgeon who specializes in the treatment of bone tumors is medically appropriate.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-seven year-old female who underwent left ACL reconstruction and partial meniscectomy is requesting reimbursement for the rental cost of a continuous passive motion (CPM) machine.  Reviewers Findings:  The reviewing physician found that a CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction.  Many surgeons find that patients regain their range of motion faster and have better pain control with the device.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the Afrezza titration pack, 3 boxes for 30 day supply (270 of the 4 unit cartridges and 270 of the 8 unit cartridges). The patient was diagnosed with type I diabetes at an early age. The provider reports the patient had quick correction of hyperglycemic and lower risk of hypoglycemia while on Afrezza. In order for Afrezza to be considered for treatment, it is important that clinicians perform a detailed medical history, physical examination, and testing of forced expiratory volume in all patients to identify preexisting lung disease. While the prior authorization form states the patient does not have lung disease and forced expiratory volume testing has been done, the medical records do not support this statement. Literature reports Afrezza should not be recommended for patients with asthma, chronic obstructive pulmonary disease or who smoke. Literature indicates Afrezza is contraindicated in patients with chronic lung disease because of the potential for acute bronchospasm.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology 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:  An enrollee has requested residential treatment center services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, without the complication of addictive illness, are notoriously difficult to treat and in general have poorer outcomes.  The patients alcohol use dominated his daily routine, generated distress and caused significant impairment across multiple domains of functionality.  He had strained relationships and occupational problems due to his drinking.  In this clinical setting, limiting the number of days of residential treatment would have been inadequate in consolidating the issues that prompted admission or generating the therapeutic momentum necessary for the patient to succeed in a less restrictive treatment setting.  Based on the alcohol use history, social environment and psychiatric comorbidity, it is likely that the patient would have promptly relapsed and required re-admission if he was discharged prematurely.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  All told, the residential treatment center services at issue were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested radiofrequency neurolysis for medical treatment of her back pain. Findings:  Three physician reviewers found that there is a lack of support for the requested radiofrequency neurolysis in this patients case.  There is a lack of documentation demonstrating that the patient underwent recent physical therapy prior to the current request.   Given the above, the requested radiofrequency neurolysis is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lumakras tablet 120 mg. Blair describes sotorasib (brand name Lumakras) as a RAS GTPase family inhibitor developed to treat solid tumors with KRAS mutations, including non-small cell lung cancer (NSCLC) and colorectal cancer. The author further notes that the U.S. Food and Drug Administration (FDA) approves the use of sotorasib for the treatment of adult patients with KRAS G12C-mutated locally advanced or metastatic NSCLC who have received at least one prior systemic therapy. Hong and colleagues note that the KRAS G12C  mutation occurs in 13% of NSCLCs and in 1% to 3% of colorectal and other cancers. The authors noted that in a study of the efficacy of sotorasib on a subgroup of 42 patients with colorectal cancer, 7.1% (or 3 patients) had a confirmed response, and 73.8% (or 31 patients) had disease control. While studies are ongoing, a response rate of 7% does not suggest a significant clinical response to sotorasib in the context of colorectal cancer. Therefore, Lumakras tablet 120 mg is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Lumakras tablet 120 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified internal medicine with sub-specialty certification in medical oncology and is 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: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested Genotropin growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that this patients records document a normal IGF-1 level, normal response to provocative GH testing, and no known abnormalities of the pituitary gland. Thus, the patient does not have classic GH deficiency. His height, when plotted for bone age, is at the expected channel for his genetic potential. He is receiving a dose of prednisone which is significantly above what is considered a maintenance dose, and this treatment may be contributing to growth suppression. Given the patients underlying chronic disease and history of chronic steroid administration, the diagnosis of idiopathic short stature is not supported at this time. Therefore, the requested Genotropin GH treatment is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a procedure to repair cartilage to the ankle, juvenile cartilage transplant (DeNovo) for treatment of the enrollees osteochondral lesion. Findings:  Two physician reviewers found that the request for a procedure to repair cartilage to the ankle, juvenile cartilage transplant (DeNovo) has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus (DeNovo) is well-known to be an effective method for management of focal chondral defects. This method relies on the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect. Studies have demonstrated that it is a rapid, safe, and effective treatment for cartilage defects. According to the study by Farr and colleagues involving the articular cartilage of the knee, the clinical outcomes showed a significant improvement over the baseline with histologically favorable repair tissue two years postoperatively. In light of the foregoing, the request for particulated juvenile articular cartilage (DeNovo) is medically appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. 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.