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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy (CPT Codes 77523, 77525 and 77522) for treatment of the enrollees osteosarcoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested service. The patient presents with osteosarcoma that cannot be resected. Given the size of the tumor a high dose of radiation is needed in order to control the gross disease. In this case, proton beam radiation therapy can improve local control of the tumor while sparing the surrounding normal structures including the small bowel. The plan dose volume histogram provided for review illustrates this point. Proton beam radiation therapy in similar tumors such as chordoma or chondrosarcoma indicate that proton therapy is more beneficial than therapy with photon techniques. Based on these reasons, proton beam radiation therapy is medically necessary for treatment of the patients medical condition. All told, the request for proton beam radiation therapy (CPT Codes 77523, 77525 and 77522) has been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 radiation 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Synvisc-One injections for both knees. The enrollee has primary osteoarthritis of both knees. She had cortisone injections to the left knee, with reported benefit duration of about two weeks. The enrollee received cortisone injections to her bilateral knees due to intense pain. The enrollee reported significant pain relief from Synvisc-One injections. She contacted the provider one month later with complaints of throbbing in both knees and requested another cortisone injection. The provider advised the enrollee that she needs to wait at least three months between cortisone injections. The enrollee was prescribed voltaren gel. A professional societys guidelines indicate intra-articular hyaluronic acid injections (Synvisc) have been suggested as a treatment for those with symptomatic osteoarthritis of the knee who have failed all other treatments. The requested intra-articular hyaluronic acid injections (Synvisc) are indicated for those who have knee arthritis with clinical symptoms of crepitus and pain. The enrollee has trialed conservative treatment and an invasive course without resolution of symptoms. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee requested 40 hours per week of licensed vocational nurse (LVN) services and two hours per month of registered nurse (RN) supervisory services for medical treatment of the enrollees feeding difficulties, gastrostomy tube (G-tube), and failure to thrive.   Findings:  The physician reviewer found that this patient has multiple medical and developmental problems including feeding intolerance and reliance on gastrostomy tube feedings for nutrition. He is not on home monitoring, there is no indication that he has uncontrolled seizures, his respiratory status appears to be stable, and his gastrostomy tube feedings appear to be stable. Although he has been under evaluation for failure to ambulate, there is no indication that this introduces skilled nursing needs. There is no indication that the patients parent is not competent or is not available to provide for his care for the requested 40 hours per week.  Based on the submitted documentation, the request for 40 hours per week of LVN services and two hours per month of RN supervisory services is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested twice weekly psychotherapy sessions for treatment of her generalized anxiety disorder. Findings:  The physician reviewer found that A diagnosis of generalized anxiety disorder was noted in the medical records. On the said date, the provider noted that the patient was receiving psychodynamic psychotherapy.  Progress notes indicated that the patient was doing better, and she was coping. Ongoing anxiety and stressors related to work, children and finances were noted in the twice weekly progress notes. Overall, the submitted documentation does not demonstrate that twice weekly therapy sessions from the said date forward would result in outcomes significantly different from weekly therapy. Additionally, cognitive behavioral therapy has been demonstrated in the literature as an effective therapeutic approach for generalized anxiety disorder.  All told, twice weekly psychotherapy session from the said date forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment program from 1/3/18 through 1/9/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.The documentation provided does not support the medical necessity of the services at issue from 1/3/18 through 1/9/18. The patient participated in her treatment and responded well to the psychotherapy, group therapy, medication management and denied any suicidal or homicidal ideations, intent or plan. Based on the records, the patients treatment in the residential facility was clinically indicated until 1/2/18. At which time, the patients symptoms had stabilized, and the need for 24-hour nursing support was no longer medically indicated. She responded well to treatment and developed more insight into her behaviors. The records indicate that her body weight normalized with time. Per the progress report dated 1/3/18, the patients weight was 116 pounds with a BMI of 18.57. In addition, it was noted that she completed meals without hesitation. Per the progress report dated 1/5/18, the patients recorded weight was 118 pounds and on 1/8/18, she weighed 119 pounds. As such, continued residential treatment services from 1/3/18 through 1/9/18 were not medically necessary for treatment of this patients medical condition.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 with expertise in eating disorders 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

An enrollee has requested reimbursement for air ambulance services provided. Findings:  The physician reviewer found that the air ambulance services provided was medically necessary for treatment of the patients medical condition. GBS is an acute progressive sensory-motor polyneuropathy. It is an autoimmune condition which if untreated can progress to respiratory failure, and can be fatal. It is standard of care for an acute GBS patient to have access to neurology and critical care expertise. IVIG is standard of care for GBS. In this case, air ambulance services from Arcata to Sacramento is estimated to be less than two hours. In addition, the hospital is an estimated 3-4 hours by ground transport lists two neurologists within a 10 mile radius. Driving 3-4 hours with a worsening GBS patient could have put the patient at further risk of decline, without certainty that a neurologist would have been available upon arrival. Prolonged transport times may be dangerous to a critically ill neurologic patient, and air transport is appropriate to reduce patient risk and improve potential for good therapeutic outcomes. As such, the services at issue were medically necessary for treatment of the patients worsening medical condition. 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 neurology 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

The parent of an enrollee has requested reimbursement for the inpatient psychiatric treatment program level of care services.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. The patient had a composite score which corresponds with a Level 4: Medically Monitored Community Based Services level of care, the patient scores for both his risk of harm and his functional status constitute independent criteria that would require admission to Level Five: Medically Monitored Residence-Based Services. Neither the patients composite score nor his individual dimension scores; however, correspond with the necessary scoring to qualify for an inpatient psychiatric treatment program level of care, Level Six, during the period at issue. Accordingly, the inpatient psychiatric treatment program level of care provided during the period at issue was not medically necessary to treat the patients medical condition.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, with subspecialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ADA diagnostic test. Findings:  Two of three physician reviewers found there is insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management of ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. A study showed that patients with loss of response may actually have high, rather than low, serum levels. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, ADA diagnostic test was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined the services at issue were not likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni 90-400 mg tablet for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for eight weeks. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks, as in this case. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  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  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: An enrollee has requested reimbursement for advanced lipoprotein blood test (CPT 83704). This patient presents with hyperlipidemia and an elevated coronary calcium score. The provider noted that the patient was already being treated with active lifestyle modification and high dose statin therapy to lower his low density lipoprotein (LDL) cholesterol to goal per American Heart Association (AHA) and American College of Cardiology (ACC) guidelines (Grundy, et al.). Advanced lipoprotein measurements may be useful in patients with a borderline or intermediate 10-year risk of cardiovascular disease as part of a shared decision making regarding the need to start statin therapy (Arnett, et al.). In this case, the patient has known hyperlipidemia and elevated coronary calcium score. He was already being treated with a high dose statin per existing guidelines to appropriate treatment goals (Grundy, et al.). Further refinement of risk with advanced lipoprotein testing will not change the current management of active risk factor reduction with statin and lifestyle modifications (Arnett, et al.). All told, the advanced lipoprotein blood test (CPT 83704) was not 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 advanced lipoprotein blood test (CPT 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 internal medicine with subspecialty 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

A 44-year-old male enrollee has requested Orthovisc injections (for his left knee) for the treatment of his condition status-post anterior cruciate ligament (ACL) reconstruction and left knee arthritis. Findings:  The physician reviewer found that evidenced-based medicine supports the use of an intra-articular injection of cortisone prior to under going viscosupplementation (Orthovisc) injection.  In the absence of evidence that the patient has tried and failed a full course of conservative management, the request for Orthovisc cannot be supported as being medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee, who is morbidly obese, has diabetes mellitus type 2, chronic kidney disease, hypertension and obstructive sleep apnea, has requested coverage for the medication Byetta.  Findings:  The physician reviewer found that the patient has already experienced significant benefit from Byetta with a decrease in his weight, A1C and insulin dose. As such, the continued use of Byetta is medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested for electro stimulation therapy for treatment of her pain. Findings:  Two physician reviewers found that Nnoaham and colleagues noted that in 13 of 22 inactive control studies, there was a positive analgesic outcome in favor of active transcutaneous electro stimulation treatment. They also noted that for multiple dose treatment comparison studies, 8 of 15 were considered to be in favor of this therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for neurofeedback therapy. This patient presents with a history of attention-deficit/hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), and sensory processing disorder. The provider reports that some of the patient demonstrates some autistic features and symptoms of depression. His provider has recommended neurofeedback after the patient failed to improve with maximally dosed amantadine and occupational therapy. Neurofeedback is a specific form of biofeedback that involves electroencephalography (EEG) to improve brainwave activity, particularly in patients with anxiety disorder. In the peer-reviewed medical literature, Studies found that changes in mean abnormal anxiety were significantly higher in the neurofeedback group than in the control group. For the ADHD portion of this patients impairment, Researchers noted that based on the results and methodologies of published studies, this review concludes that (neurofeedback) for pediatric ADHD can be currently considered as probably efficacious. Based on this support, treatment with neurofeedback is appropriate to treat this patients behavioral health conditions. All told, the neurofeedback therapy twice per week was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the services at issue were and are likely to be 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 and 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 reviewers 1, 2, and 3 are board certified in psychiatry with subspecialty certification in child and adolescent psychiatry 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: Overturned

A 52-year-old female enrollee has requested Zofran 8mg for treatment of her nausea and vomiting.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested medication quantity. The patient has chronic idiopathic nausea and vomiting.  It appears that the patients gastrojejunal ulcer may be contributing to her symptoms, although proton pump inhibitor therapy is not helping.  Per the medical records, the patient is having some improvement with Zofran.  However, Zofran should not be used more often than three times daily.  All told, Zofran 8mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the medication Saxenda, 3 mg/0.5 mL (18 mg/3 mL). This enrollee has an elevated body mass index. She has a medical history of hypertension, hyperlipidemia, and impaired fasting glucose. Her internal medicine physician reports the enrollee has been trying diet and exercise since, but has gained weight. Her physician indicated the enrollee has lost a few pounds since starting Saxenda, and was motivated for her exercise program. A governmental body reports Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with an initial body mass index of 30, or a body mass index of 27 if the person has at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus, or dyslipidemia. A study showed 3.0 milligrams of liraglutide (Saxenda), in addition to diet and exercise, was associated with reduced body weight. This enrollee has tried diet and exercise. She has a history of hypertension, hyperlipidemia and impaired glucose tolerance. The enrollees body mass index is above 30; therefore, she qualifies for Saxenda.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.