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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together seamlessly. Findings:  The physician reviewer found that there is a lack of studies supporting speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together for children with dysarthria or receptive-expressive speech/language impairment. Furthermore, there is a lack of studies showing the utility or supporting the biomechanical method utilized. In this case, speech therapy is indicated, however integrated aural habilitation, hearing therapy, and audio therapy is not clinically indicated. In sum, aural therapy or aural rehabilitation with speech training and audiology training has not been demonstrated to be effective in the medical literature. Therefore, the request for speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together seamlessly was not and is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Upheld

The patient is a 15-year-old male with several years of difficulty in organization and attention, who was referred for SPECT and CT scans. The scans were proposed for further evaluation and determination of his diagnoses and to devise a recommended treatment plan. The patient was described as carrying everything in his backpack, avoiding things he did not like, forgetting to write down assignments or turn in his homework, frequently feeling bored, and having difficulty finishing tasks. It was also noted he had problems with listening, requiring his mother having to repeat things several times before he hears her. The patient reportedly struggled with writing and getting his thoughts onto paper at times. Alternatively, he was also noted to hyper focus and to become an expert in the things he enjoyed doing. He was characterized as set in his ways, liking routine, and focusing on cleanliness. The patient was previously diagnosed with ADHD and in the spring of 2003, began taking Ritalin and was later switched to Adderall. The medications were initially thought to be beneficial, but his parents later determined them to be the cause of a subsequent lethargy and therefore discontinued the medications completely. Notably, the patients energy level did not improve until sometime later. As part of his psychiatric evaluation, the patient underwent SPECT and CT scans and findings consistent with ADHD, mood disorder  not otherwise specified, and generalized anxiety disorder were identified by his provider. The patients provider recommended that the parents consider treatments involving Trileptal, Omega 3 fatty acids, Neurontin, and Adderall or Strattera. The patients parents are requesting reimbursement for the SPECT and CT scans. The Health Plan denied this request based upon a determination that the diagnostic procedures were not medically necessary.The patients prior history was unquestionably clear about his diagnosis of ADHD. He could also be suffering from a depressive syndrome given his lethargy. However, one does not need a scan of any sort, SPECT or CT, in order to make this psychiatric diagnosis and recommend appropriate treatment. The SPECT and CT scans did not add any clinical value in this setting. Therefore, I have determined the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old female enrollee has requested genetic cancer sequencing (BreastNext Hereditary breast cancer panel) for evaluation of her medical condition. Findings:  Two physician reviewers found that BreastNext Hereditary breast cancer panel is not likely to be more effective for this patient than other available options. According to the National Comprehensive Cancer Network (NCCN) Guidelines, gene panels are intended for individuals who are negative for high penetrance genes, such as BRCA 1 and 2, and whose family history is suggestive of more than one syndrome. In this case, the patient has not yet had testing for BRCA 1 and 2, thus gene panels cannot be recommended at this time. All told, the requested services are not likely to be more beneficial for this patient than other surveillance modalities.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male enrollee requested continued pediatric psychotherapy from a specialist experienced in severe early childhood trauma utilizing eye movement desensitization and reprocessing (EMDR) treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a diagnosis of post-traumatic stress disorder (PTSD) and behavioral issues due to trauma. According to the American Academy of Child and Adolescent Psychiatry, Among the trauma-focused psychotherapies, [trauma focused-cognitive behavioral therapy] TF-CBT has received the most empirical support for the treatment of childhood PTSD.  A review of the therapy progress notes submitted for review does not demonstrate that the patients therapist is performing TF-CBT. The progress notes demonstrate active listening and validation as the therapeutic techniques being used in the patients sessions. Moreover, the requested therapy of eye movement desensitization and reprocessing (EMDR) is not mentioned in the therapy notes as a therapy technique that is being used in the patients therapy sessions. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested Cialis (for 16 20 mg tablets/month) for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction after a radical prostatectomy (performed with or without robotic-assisted laparoscopic techniques) is not uncommon. The treatment of this problem is being investigated in many centers. The role of the early use of phosphodiesterase inhibitors (such as Cialis) is still not proven. The dosage, frequency of dosing and duration of dosing are still being investigated. The need for a mechanical device, in addition to use of this class of drug is also being investigated. The Health Plan did allow six months of every other day dosing of a phosphodiesterase inhibitor post-surgery, but after six months the allowance of six tablets of Cialis (20 mg) per month is appropriate in this clinical situation and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male has requested anal fissure surgery for treatment of his anal fissure.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  There is no indication that topical therapy has been exhausted for the treatment of this patients anal fissure.  The records indicate that sigmoidoscopy only revealed external hemorrhoids.  The clinical notes do not show that surgical treatment is the recommended treatment in this clinical setting.  The current medical evidence does not support the requested procedure in this case.  All told, the requested anal fissure surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female, with complex regional pain syndrome (CRPS), has requested authorization for the prescription medication Lyrica. Reviewers Findings:The reviewing physician found that the safety of Lyrica has been sufficiently tested in other clinical applications and the medication was found to be safe in the prescribed dosage range. Treatment with Lyrica has been beneficial for this patient and without untoward side effects.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) with Gammagard 45 grams intravenous (IV) every three weeks. Findings:  The physician reviewer found that patients with IgG subclass deficiency require more extensive diagnostic evaluation including the demonstration of a poor antibody response to vaccine challenge to support a diagnosis of a clinically significant IgG subclass deficiency. Subclass deficiencies need to be carefully interpreted taking into account the clinical status of the patient as well as the patients ability to produce specific antibodies in response to vaccines. A patient is considered to have a selective IgG subclass deficiency if blood levels of one or more of the IgG subclasses are below the normal range based on age, and the levels of other immunoglobulins (total IgG, IgA, and IgM) are normal or near normal. An additional subset of patients have normal levels of immunoglobulin and normal IgG subclasses, yet fail to develop protective antibody levels in response to infections with streptococcus pneumoniae or vaccines against the bacteria. Overall, this patients medical records do not support a diagnosis of specific antibody deficiency. The patient has tried and failed multiple antibiotics but there is a lack of documentation of an adequate vaccine challenge. There is insufficient medical documentation by the provider indicating the date of the Pneumovax vaccine and proper timing of pre- and post-vaccination titers following vaccine administration. There were two dates for pneumococcal antibody titers which were one year apart but there were no repeat antibody titers three to four weeks following vaccine. All told, the requested IVIG with Gammagard 45 grams IV every three weeks is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is 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 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

The parent of a 17-year-old male enrollee has requested Femara (letrozole) for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the process of epiphyseal fusion during puberty is regulated by estrogen, even in males. By delaying epiphyseal closure with the use of aromatase inhibitors in order to block the production of estrogen, preliminary studies have shown an improvement in final height. Anastrozole increases adult height potential of adolescent boys on growth hormone (GH) therapy, while maintaining normal pubertal progression after two to three years. Preliminary studies suggest that treatment of adolescent boys with aromatase inhibitors, with or without concomitant growth hormone, increases predicted adult height in these patients. Treatment with aromatase inhibitors offers an alternative in promoting growth in GH-deficient males in puberty. This particular patients growth potential is further compromised by his advanced bone age, which would allow premature epiphyseal bone closure leading to even shorter predicted adult height. Third generation aromatase inhibitors such as Femara have been used in circumstances similar to this patients. Thus, Femara would be expected to have similar effects to anastrozole and therefore is medically reasonable and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy in a social setting with peers for 10 weeks, then 15 hours per week at home thereafter. To determine the medical necessity of ABA, researchers provide guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the patient has been receiving treatment at home and in school for the previous three years. The patient continues to make progress toward treatment goals and problem behavior has diminished. An area of concern continues to be the generalization of skills to natural settings. Guidelines suggest that service intensity be based on patient needs. The patients needs outlined in the progress report suggest that while needs exist, it is less intense than what was once required. Therefore, a focused level of intervention as approved by the Health Plan including 27 hours per week of direct ABA services for the 10 week period and 12 hours per week of ABA services at the onset of the school year should be sufficient for generalization and maintenance of skills. Thus, the 30 hours per week of ABA therapy in a social setting with peers for 10 weeks, then 15 hours per week at home thereafter were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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 psychology and is a board certified behavior analyst 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: An enrollee has requested reimbursement for substance abuse residential treatment center services rendered at Hoag Neurobehavioral Health, LLC. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records did not show that the patient was in withdrawals. There was no evidence of suicidality, homicidality, violence or aggression towards others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would have supported the level of care at issue.  By the first date of service in question, he was medically stable to the point where he did not require 24/7 monitoring.  He was also psychiatrically stable.  There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptoms that would interfere with his care. His home environment was supportive and conducive to his recovery. He had no prior treatment at a lower level of care, and there was no indication that treatment at a lower level of care would lead to decompensation or deterioration. He could have continued treatment and recovery on an ambulatory basis such as partial hospitalization program or intensive outpatient program. For the reasons stated above, substance abuse residential treatment center services rendered at Hoag Neurobehavioral Health, LLC during the dates of service in question were not medically necessary for treatment of 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: Upheld

The parent of a 14-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 14-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: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested continued skilled nursing facility (SNF) services including physical therapy and occupational therapy for treatment of the his cerebral palsy.  Findings:  The physician reviewer found that the duration of therapy and interdisciplinary inpatient care for patients with tetraplegia has not been scientifically established (Teeter, et al). This patient has been unable to make any gains with two weeks of skilled therapy and has minimal residual function. Overall, a two week trial is a reasonable period of time to assess a patients response to rehabilitation (Albert, et al). While it is reasonable for the patient to continue a rehabilitation course, it is not medically necessary for him to have continued daily inpatient stay. The intensity of rehabilitation has not changed the patients outcome in a clinically significant way and intense therapy is not the method for addressing the patients spasticity (Kheder and Nair). All told, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Skyrizi. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve sufficient control of disease, particularly for psoriasis in the scalp or hands or other difficult to treat areas with topical medications. The U.S. Food and Drug Administration approves the use of several systemic options including methotrexate, cyclosporine, acitretin, cyclosporine,  apremilast, and biologics including tumor necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 pathway inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors, such as Skyrizi. Kridin and colleagues note that in a study of 3,151 patients with psoriasis who tested positive for COVID-19, the use of oral methotrexate was associated with increased hospitalization. Fagni and colleagues reported that the immune response to vaccination may be somewhat reduced in groups taking methotrexate. In this case, treatment with the immunosuppressives cyclosporine and methotrexate are not recommended due to the risk of increased COVID-19 morbidity. Given that this patient has failed topical therapies and light therapy and the current COVID-19 pandemic, treatment with a systemic biologic agent is medically indicated. Therefore, Skyrizi is medically necessary for the treatment of this patient.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 dermatology 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 patient has requested authorization and coverage for a Synvisc One injection of the right knee (CPT-J7325). Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc One injection of the right knee (CPT-J7325) is medically necessary for the treatment of this patient. 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 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.