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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Functional Electric Stimulation Cycle Rehabilitation System (FES). The enrollee has spastic cerebral palsy. He was an active individual who was able to ambulate, work, and remain independent. He was diagnosed with C4 amyotrophic lateral sclerosis (ALS) cervical tetraplegia due to transverse myelitis. The enrollee has lost volitional motor function below C4 in his bilateral upper and lower extremities. His light touch sensation and proprioception is absent bilaterally below C4. The enrollee utilizes a standing frame weekly to maintain leg and trunk flexibility. He requires an alternative form of activity therapy since he cannot do this volitionally. Upper and lower extremity mobilization can be achieved in stable transverse myelitis enrollees with a cycle ergometer; powered by an enrollees own muscle strength, evoked by Functional Electric Stimulation (FES). His rehabilitation physician prescribed the FES. Literature describes electrical stimulation as a modality used for the rehabilitation of persons with neurological damage, effective in improving muscle strength and blood flow, decreasing atrophy, healing tissue, and decreasing pain. However, even though electrical stimulation has the capacity to produce movement in enervated, paralyzed, or spastic muscles, literature does not show a significant benefit over conventional exercise. The enrollees diagnosis would support that he would have partial or total loss of use of his limbs. The standard of care for enrollees with complete cervical spinal cord injuries is physical therapy; including range of motion exercises to prevent contractures, improve muscle tone, and to prevent skin breakdown. Further study is required to delineate which individuals are   appropriate for treatment and which symptoms FES can help alleviate. FES is approved for use in spinal cord injury and stroke enrollees. It is not approved for ALS. FES is used for traumatic spinal cord rehabilitation but the data for its use is limited and it has not been shown to improve function or outcome in ALS individuals.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in physical medicine and rehabilitation and are actively practicing.  All three 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

The parent of a three-year-old male enrollee has requested a custom power wheelchair for treatment of the enrollee, who has been diagnosed with X-linked myotubular myopathy. Findings:  The physician reviewer found that this patient has a severe congenital myopathy. However, he has satisfactorily demonstrated that he can manipulate his ground movements in a motorized wheelchair, which does gain him a minimal degree of freedom as long as he remains within the sight of his caregiver.  Quality of life is now factored into virtually all studies involving drug trials, medical mechanical devices, and implantable medical devices.  Jain and colleagues studied non-ambulatory patients with spinal cord disability, and reported that increased mobility with a motorized wheelchair had a dramatic improvement in the patients quality of life. Bottos and colleagues reported on the marked improvement in independence with the introduction of a motorized wheelchair for young children with tetraplegia.  Wiart and Darrah noted that the medical community standard is to supply non-ambulatory children with motorized wheelchairs. All told, the requested custom power wheelchair is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested acute psychiatric inpatient services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patient presented with suicidal ideation described as 3.5/10 with plan to overdose on prescription medication. He had no prior history of suicide attempts at the time of the admission under review. The records indicate that patient was not a danger to himself or others. He also presented with a current and past history of self harm, apparently associated with a personal relationship. His major depressive disorder was single episode, moderate. Although the patient engaged in self harm behaviors, he attested that these injurious behaviors were not suicidal in nature. During the course of his hospitalization the patient participated in all available services. He was described as insightful and utilized healthy coping mechanisms. Medication changes were not of a nature that required 24-hour nursing supervision on an acute inpatient psychiatric setting. He steadily gained weight each week and his eating disorder was not described to be of a severity that required 24-hour nursing supervision on an acute psychiatric setting. For these reasons, the patient did not require continued stay in an acute psychiatric inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the services at issue were not likely to have been more effective than other available modalities.  Per the submitted documentation, the available blood and imaging records gave no indication for advanced liver disease or tumor.  Contemporary measurement of liver fibrosis is made serologically and/or by elastography.  The systematic review and meta-analysis by Singh and colleagues noted that the degree of liver stiffness, using elastography, can predict outcomes in patients with chronic liver diseases.  Per the authors, liver stiffness measurement may be used in risk stratification.  Thus, the superior efficacy of SPECT scan has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee requested the WalkAide functional electrical stimulator (FES) for medical treatment of her foot drop secondary to multiple sclerosis.  Findings:  Three physician reviewers found that  in this patients situation, she has documented foot drop secondary to multiple sclerosis. In the past, she has failed a trial of an AFO with over 100 falls. Given the provided literature and the fact that the patient had a sub-optimal response to an AFO, the WalkAide FES is a reasonable treatment alternative. The requested device could increase the patients independence, function, and prevent future falls. As such, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy (twice weekly for six months)for treatment of the enrollees speech and language disorder.  Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of the requested therapy. This patient has expressive language delay. The current medical evidence supports the requested speech therapy in this clinical scenario. Law and colleagues noted that speech and language therapy may be effective for children with phonological or expressive vocabulary difficulties.  The medical literature demonstrates an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The current state of medical evidence suggests this patient would benefit from speech and language therapy.   All told, the requested speech therapy (twice weekly for six months) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested percutaneous vertebroplasty/kyphoplasty for treatment of his back pain. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  Per the submitted records, imaging demonstrated retropulsion at the T12-L1 level.  There is a lack of support for the requested services in this clinical setting. The integrity of the posterior vertebral body is in question, and the risk of cement migration has not been adequately addressed.  Based upon the presence of retropulsion and multilevel possible foci of pain generators, the requested services are not likely to be more efficacious than other options in this case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 21-year-old male who underwent an ACL reconstruction. Postoperatively he utilized a CPM device as prescribed by his orthopedic surgeon.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device.  The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the device postoperatively is medically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation (bilateral sacroiliac (SI) joint rhizotomy) for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that the patient is a presents with neck and low back pain, however his back pain is very bothersome particularly on the right side. He denied leg pain and indicated his back pain is increased with movement and decreased with rest. He reported that the pain is constant and aching. He was diagnosed with degenerative disc disease of the lumbosacral spine. The patient received bilateral sacroiliac joint injections and reported three days of complete pain resolution following the procedure. The patients physical exam a month later was significant for sacroiliac joint pain to palpation bilaterally, right more than left. The provider has recommended bilateral sacroiliac (SI) joint rhizotomy (radiofrequency ablation). The Health Plan has denied this request as investigational, stating that medical studies have not shown that radiofrequency ablation works well for pain in the sacroiliac joint.The majority of the peer-reviewed medical literature supports the use of sacroiliac joint rhizotomy for pain due to lumbosacral degenerative disc disease. Ferrante and colleagues indicated that radiofrequency denervation (rhizotomy/ablation) of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome. Another study concluded that sensory stimulation-guided radiofrequency ablation for the treatment of recalcitrant sacroiliac joint pain appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain (Yin, et al.). Cohen and Abdi also concluded that radiofrequency ablation in the treatment of patients with SI joint pain appears to be an effective treatment. All told, the peer-reviewed medical literature and the patients positive results with bilateral sacroiliac joint injections indicate that requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested psychiatric evaluation and NeuroStar Transcranial Magnetic Stimulation (TMS) therapy for treatment of her major depression. Findings: Two physician reviewers found that based on the information provided, it appears the patient had a response to Effexor, but the antidepressant was not maximized prior to the trial of TMS. Further, the record does not substantiate the trial and failure of an adequate course of electroconvulsive therapy (ECT). Per American Psychiatric Association guidelines, ECT would have been the most effective treatment for this patients condition. TMS has not been shown to be superior to ECT (Eranti and colleagues). There is insufficient evidence supporting the use of TMS in this clinical scenario (Martin and colleagues). All told, the psychiatric evaluation and NeuroStar Transcranial Magnetic Stimulation (TMS) therapy provided during the dates in question were not likely to have been the most efficacious treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: Clinical examination findings have been consistent with mild to moderate medial joint space narrowing in the left knee. Reasonable conservative treatment, including NSAIDs, activity modification, and corticosteroid injections have failed to provide adequate symptom relief. Records documented short-term pain relief for less than one month with prior viscosupplementation injections in March and April 2017 as well as October 2017. The evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Current evidence based medical guidelines recommend repeat injections when there is documented significant improvement in symptoms or six months or more. In this patients case, given the previous short-term response, repeat viscosupplement injections are not indicated. Therefore, the request for Orthovisc injections have not been demonstrated as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 41-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. A prudent layperson would reasonably believe that he or she was experiencing an emergent medical condition given the signs and symptoms (headache, numbness, visual changes) that this patient was experiencing.  It is well documented in the literature that headache, migraines, and stroke are inter-related. The patient was warned by her neurologist that she might be at risk for stroke given her history of migraine. She was suffering from increased frequency of headaches leading up to the Emergency Department visit. Given the occurrence of the patients visual and sensory neurologic deficits in association with her acute headache, it was reasonable for her to be concerned that she might be suffering from a stroke, an emergency medical condition.  As such, it was reasonable for the patient to seek emergency medical attention.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested percutaneous tibial nerve stimulation/percutaneous implantation of neurostimulator electrodes for treatment of his prostatitis.  Findings:  Three physician reviewers found that in this case, the symptoms are described as lower urinary tract symptoms.  The etiology of these symptoms may be secondary to prerenal conditions, bladder and/or prostate problems. The bladder dysfunction may be secondary to intravesical pathology and/or neurologic reasons. The evaluation of his symptoms is limited by the reported inability to undergo cystoscopy and urodynamic evaluation of the bladder. Uroflow to evaluate the stream of the patient, a measurement of post void residual, and a voiding diary have not been documented.  In this clinical scenario, the current medical evidence does not support the requested services. There is limited published data supporting these services for patients with this clinical presentation. All told, the superior efficacy of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for 40 hours per week of direct one-on-one applied behavior analysis (ABA) therapy. Medical literature define medically necessary ABA services as (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. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the specific dosage of treatment, the Behavior Analyst Certification Board (BACB) support treatment recommendations made by a BCBA, as these providers have expertise and formal training in the provision of ABA for the treatment of autism. In this case, the patients BCBA recommended 40 hours per week of ABA services as clinically indicated for the treatment of this patients autism. This frequency of ABA services is consistent with researchers, who reported that there is a strong relationship between treatment intensity and mastery of learning objectives, where higher intensity predicted greater progress. Thus, lowering the patients ABA therapy hours could be detrimental to his continued skill development and safety. Recent literature also noted that the COVID-19 outbreak has resulted in increased difficulties among patients with autism. Given these findings, the requested 40 hours per week of direct one-on-one ABA therapy (CPT 97153) is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous Panzyga [140 grams over five consecutive days (20 gm/30 gm/30 gm/30 gm/30 gm) followed by 60 grams over two consecutive days (30 gm/30 gm) monthly for six cycles]. Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain, which can include several different classes of medications. Colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. In an analysis of the efficacy and safety of IVIG for the treatment of autoimmune small-fiber polyneuropathy, Liu and colleagues report that IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and is safe and effective for rigorously selected small-fiber polyneuropathy patients with apparent autoimmune causality. Oaklander reports that a review of various studies regarding immunotherapy for distal small fiber polyneuropathy provides a rationale for treating carefully selected patients with immunomodulatory therapies. The author further notes that candidates for treatment should have symptoms consistent with small fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. Novak and colleagues report that small-fiber polyneuropathy appears to be associated with post-treatment Lyme disease and may be responsible for certain sensory symptoms. In this case, the patient has chronic, painful paresthesias secondary to small fiber neuropathy presumed to be secondary to Lyme disease. His symptoms have not been controlled with conventional medical therapy. Given that current medical literature notes that patients with presumed autoimmune small fiber neuropathy may improve clinically with IVIG and that an autoimmune mechanism may be triggered in patients with small fiber neuropathy secondary to Lyme disease, the requested services are medically indicated. Therefore, intravenous Panzyga [140 grams over five consecutive days (20 gm/30 gm/30 gm/30 gm/30 gm) followed by 60 grams over two consecutive days (30 gm/30 gm) monthly for six cycles] is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for the 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