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

A 62-year-old male enrollee has requested for a PET scan with CT attenuation (PET/CT scan) for evaluation of her atypical gastric cancer.  Findings:  Two physician reviewers found that PET/CT is likely to continue to be superior to any other imaging modality to detect early recurrent or metastatic disease in this case. There is adequate evidence of clinical utility to support the requested PET/CT scan.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech generating device, Accent 800 with WordPower (CPT E2510), Rehadapt Custom Mount (CPT E2512), and Symbol Stix, QRM Plate, and Spec Switch Accessories (CPT E2599). Per the American Speech-Language-Hearing Association (ASHA) recommendations, eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Morin and colleagues reviewed 18 multiple-baseline or multiple-probe experiments across 17 studies indicate that using high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. The records provided for review suggest that this patient with Lennox-Gastaut syndrome, developmental delays, epilepsy, and cortical visual impairment is not expected to develop oral language. The patient underwent a thorough evaluation by a provider who specializes in the evaluation of young patients for AAC devices. The provider noted that less technologically complex devices are inadequate for this patients communication needs. The patient has cortical visual impairment, which limits his options to devices that incorporate auditory scanning. The speech generating device, Accent 800 with WordPower and related accessories, is appropriate to enable the patient to effectively communicate wants and needs. The patient has demonstrated the ability to use the device and ongoing speech therapy using the device is planned. For these reasons, the requested speech generating device, Accent 800 with WordPower (CPT E2510), Rehadapt Custom Mount (CPT E2512), and Symbol Stix, QRM Plate, and Spec Switch Accessories (CPT E2599) is medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reconstructive surgery. Findings:  The physician reviewer found that Cosmetic physicians often encounter patients who are dissatisfied with an objectively descent postoperative result. A mismatch between doctors and patients perception of the outcome leads to their frustration and occasionally aggressive behavior. The author further states, Unrealistic expectations, minimal deformities, history of multiple cosmetic interventions, decisional disturbances (profile of maximizer), looking for a secondary gain, familiar disagreement, body dysmorphic disorder, depression, anxiety, and personality disorders have been found to correlate with postoperative dissatisfaction. Baslaim and colleagues reported that in 26 breast reductions, All patients were happy about the reduced breast heaviness, but their satisfaction with the breast shape and scars was variable: 19/26 (73.1%) were highly satisfied, 3/26 (11.5%) were satisfied, 2/26 (7.7%) found the results acceptable but were not satisfied, and 2/26 (7.7%) were completely dissatisfied.In this case, the patient underwent a breast reduction and has undergone several subsequent procedures. She has no functional complaints of pain. Photographs show minor asymmetry and flattening of the inferior pole of the right breast. Given that the breasts appear within the wide range of normal for a female, and within the range of normal after breast reduction surgery, the requested services are not medically indicated. Therefore, bilateral breast reconstructive surgery is not medically necessary for the treatment of this patients condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, breasts are not abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, and are within the wide range of appearance for normal female breasts. There records do not reflect functional complaints. Accordingly, the requested bilateral breast reconstructive surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome gene testing for medical evaluation of her family history of colon cancer.  Findings:  Two physician reviewers found that the requested testing is not likely to be more effective for this patient than other available options. The National Comprehensive Cancer Network (NCCN) guidelines for Lynch syndrome testing criteria indicate the patient must meet the Amsterdam criteria or the revised Bethesda guidelines. Both guidelines require at least one family member diagnosed with cancer before the age of 50. In this case, the patients relatives were diagnosed at approximately 50 years of age. As such, the requested HNPCC genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a LifeVest wearable cardioverter defibrillator for treatment of his non-ischemic cardiomyopathy. Findings:  Two physician reviewers found this patient was at high risk for sudden death given the severe LV dysfunction, known coronary artery disease and evidence of non sustainable ventricular tachycardia. A treatment plan consisting of optimal medical therapy to improve LV function is consistent with clinical guidelines and peer-reviewed medical literature (Chung, et al; Sadeghi, et al). Contingent on improvement in a patients LV function, an ICD may not be required. Based on a patients overall clinical condition, providers may recommend a wearable cardioverter defibrillator until either a permanent ICD is placed or improvement in LV function renders a wearable defibrillator unnecessary. Overall, a wearable cardioverter defibrillator plays an important role in reducing the risk of sudden death in this clinical setting. Therefore, the LifeVest at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Fentanyl transdermal system, 100 mcg, 15 patches per month (Please note: ten patches per month have been approved by the Health Plan.). On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has a history of chronic pain in the thoracic spine and hip, treated with one Fentanyl patch every 48 hours, totaling 15 patches per month. The records do not document any aberrant or drug seeking behavior, irregular Controlled Substance Utilization Review and Evaluation System (CURES) reports, or inconsistent urine drug screens. The provider notes that the patients current medication regimen is allows the patient to perform activities of daily living and work full time. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is medically indicated. Therefore, Fentanyl transdermal system, 100 mcg, 15 patches per month (Please note: ten patches per month have been approved by the Health Plan.), were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 anesthesiology with sub-specialty certification 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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for the medication, H.P Acthar Gel. The enrollee has a history of steroid induced diabetes mellitus type 2, and systemic lupus erythematosus (SLE). Her nephrologist is requesting approval of HP Acthar Gel due to worsening proteinuria, now in the nephrotic range.  She has had previous unsuccessful treatments including steroids, CellCept, Plaquenil, and cyclosporine. Her physician indicates a renal biopsy showed immunoglobulin A (IgA) nephropathy. Current treatments are not managing her symptoms so her physician has prescribed Acthar with a goal of managing proteinuria with nephrotic syndrome. A kidney biopsy done showed focal segmental glomerulosclerosis associated with lgA nephropathy and/or prior lupus nephritis. According the medical literature, studies in enrollees with IgA nephropathy emphasize the importance of optimal use of supportive care to include weight normalization; control of blood pressure and proteinuria; use of renin-angiotensin systemblocking agents; and dietary restriction of sodium and protein intake. If these measures fail to control the disease, next steps, in general, involve the use of immunosuppression. In this study, which did not include H.P. Acthar gel, continuing supportive care was compared to various immunosuppression regimens. Only the corticoid monotherapy with prednisone group showed a reduction in proteinuria at twelve months. Serious side effects included impaired glucose tolerance.  The data suggesting that H.P Acthar Gel can be used as an alternative to prednisone in enrollees with IgA nephropathy is lacking. The reports of Acthar gel in IgA are not reliable reports. There was a small study of five enrollees with IgA and only two showed a partial response. The makers of H.P. Acthar Gel, in their safety report on the drug, indicate common adverse reactions for Acthar are similar to those of corticosteroids and include a change in glucose tolerance. In conclusion, there is insufficient clinical information in the medical record to support H.P. Acthar Gel as medically necessary to treat the medical condition reported.  The enrollee has been treated with appropriate maximal non-immunosuppressive therapy with a persistence of proteinuria only. Any reports of a positive response to Acthar gel, have very limited clinical data that does not support the true clinical role of this medication in IgA nephropathy.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in nephrology 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

A request was made on behalf of a 15-year-old female enrollee for authorization and coverage of continued residential treatment for depression and alcohol dependence.  The health plan has denied this request.One physician reviewer performed a medical necessity Independent Medical Review.  The physician upheld the health plans denial on the basis that the enrollee did not have an active diagnosis of major depression, and therefore, the requested services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old male enrollee has requested physical therapy and occupational therapy for treatment of the enrollees cerebral palsy.  Findings:  Three physician reviewers found that the clinical and pre-clinical literature verifies the ability of the injured brain to retrain itself based on mechanisms of synaptic plasticity. Further, modern scientific data has demonstrated that cerebral palsy is not a static encephalopathy unresponsive to therapeutic modalities. For this reason, the skills training provided during PT and OT sessions can help re-pattern the nervous system with considerable benefit in patients with cerebral palsy. As numerous reliable studies have shown, the advantages of these treatment modalities are well documented in similar patient subsets with compromised normal brain function. Thus, the requested PT and OT sessions have been shown to be medically indicated for this patient and are not experimental or investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for NP-Thyroid and authorization and coverage for Armour Thyroid.In this case, the patient has a diagnosis of hypothyroidism that has been treated with desiccated thyroid extract (DTE) for many years with good clinical response. The patients medical history reflects that other preparations have proven ineffective or adverse to the patient in the past. Every patient is different, and it is clear that some need this combination of LT4+LT3, or DTE, to alleviate the symptoms of hypothyroidism. Studies have shown DTE to be safe and even beneficial when looking at cardiac, bone and other parameters. Under these circumstances, the NP-Thyroid purchased by the patient was medically necessary, and Armour Thyroid, the form of DTE that has provided the best response for the patient, is medically necessary going forward. Accordingly, the brand name NP-Thyroid purchased by the patient was medically necessary to treat the patients medical condition. In addition, the requested medication, brand name Armour Thyroid, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the medication at issue and requested medication were, and are, medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested a laser resurfacing procedure for the treatment of his acne scarring. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the proposed procedure is medically necessary. The requested laser resurfacing for acne scarring does not meet the definition of reconstructive surgery. The patients acne scars do not constitute an abnormal structure of the body. Even if the patients scars were considered an abnormal structure, it is not clear that laser resurfacing will offer more than a minimal improvement in the patients appearance. Furthermore, there is no evidence that the patients acne causes a functional impairment, which would render the proposed therapy medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old female has requested Rituxan therapy for treatment of her Sjogrens disease and neuromyelitis optica (Devics disease).    Findings:  Three physician reviewers found that the patient has a history of recurrent myelitis and optic neuritis in association with a connective tissue disorder most consistent with Sjogrens. She has had multiple severe attacks of myelitis leaving her with weakness and bladder issues, as well as recurrent loss of vision in both eyes with some residual optic neuropathy. Her disease has been characterized as neuromyelitis optica (Devics disease), but her neuromyelitis optica (NMO) antibody has been borderline. She has been treated with chronic oral Dexamethasone, high dose IV Solu-Medrol, intravenous immunoglobulin (IVIG), methotrexate, high dose CellCept, and most recently IV Cytoxan with control, but the medication had to be stopped due to congestive heart failure. She was hospitalized three weeks ago for recurrent bilateral loss of vision, and reportedly responded well to IVIG and her first course of Rituxan. It was requested that she finish the therapeutic protocol (1000mg IV for two courses separated by two weeks). She is now overdue for the second course as the Health Plan has denied the requested Rituxan treatment based on its status as an investigational therapy. This patient has a clinical syndrome consistent with NMO spectrum disorder. Approximately 35% of patients with this condition have negative antibody status. This is complicated by the patients underlying autoimmune disorder, which is likely contributing to her disease. The patient has recurrent disease despite highly aggressive therapy including three different immunosuppressant medications, IVIG, and high dose steroids with a variety of complications, including congestive heart failure. The literature regarding therapy with Rituxan supports its use in patients with refractory NMO, as this patient. The American Academy of Neurology (AAN) statement indicates that Rituxan may be considered for use, but they are unable to give a stronger recommendation based on the lack of placebo controlled studies. As NMO is a relatively rare disease, no large, double blinded, placebo controlled studies have been performed or are likely. Given the failure of multiple standard therapies to treat this patients autoimmune NMO spectrum disorder, the patients reported improvement after her first Rituxan dosing, and a literature supporting the use of this drug in this clinical setting, the requested Rituxan is more likely to be effective than standard therapy in treating this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested refitting of a left above elbow (transhumeral) prosthesis for treatment of the enrollee, who is an amputee. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  Residual limbs in amputees are known to change in size over time.  This is true for relatively newer amputations and more mature residual limbs.  This can be due to factors such as weight changes, increases in subcutaneous fat, muscular atrophy or muscular hypertrophy.  In this case, the patient underwent amputation.  He received his current prosthesis on the date indicated.  However, he has gained a significant amount of weight over a short period of time.  There is no discussion related to this weight gain to indicate why the patient has gained this weight and whether it is reasonably expected to have stabilized.  A definitive replacement socket without this clinical information is not medically indicated, as the new socket may be ill-fitting again very soon after fabrication.  All told, the requested refitting of a left above elbow (transhumeral) prosthesis is not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested genetic testing for arrhythmogenic right ventricular dysplasia for evaluation of his history of dilation of the right ventricular, fibrofatty tissue infiltration and arrhythmias.  Findings:  Three physician reviewers found that arrhythmogenic right ventricular dysplasia is an inherited cardiomyopathy involving the ventricular myocardium with fibrofatty replacement, leading ultimately to right ventricular dysfunction.  There is propensity for malignant ventricular arrhythmias with sudden cardiac death.   In 50% of arrhythmogenic right ventricular dysplasia cases, the disease is transmitted in an autosomal dominant fashion.  Genetic testing for this condition has about a 50% detection rate for the known mutations which have been associated with this disorder.  In addition to confirming the diagnosis of arrhythmogenic right ventricular dysplasia in patients with suspected disease, genetic testing allows for early identification and diagnosis of individuals at greatest risk for developing arrhythmogenic right ventricular dysplasia, prior to the expression of typical clinical manifestations.  If a pathogenic variant is identified in a preclinical individual, regular follow-up is indicated.  Fressart and colleagues concluded that genetic testing was strongly supported as a clinical tool in this clinical situation and also suggested its use had prognostic impact.   Overall, per the current medical literature, the requested genetic testing for arrhythmogenic right ventricular dysplasia is likely to be of greater benefit than other modalities for evaluating this patient.