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

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old enrollee has requested reimbursement for the Foundation One gene test for evaluation of the enrollees metastatic chordoma. Findings:  2/3 of the physician reviewers found that the Foundation One genomic testing of this patients recurrent tumor was an appropriate test in this clinical setting, and was more likely to lead to beneficial treatment than any available standard therapy. There is no available standard therapy for recurrent metastatic poorly differentiated chordoma in children. The standard treatment for chordoma is surgery and radiation although there are reports of responses to chemotherapy. This patient was treated with a broad range of standard chemotherapy prior to Foundation One testing. Thus, the Foundation One test was an important first step in finding a biologically plausible agent, and that this testing is consistent with standard practice for a patient in this situation. There is increasing evidence that tumor genome testing frequently yields targetable mutations and that drugs targeting these mutations can result in meaningful clinical responses. In a recent study of children with malignancies, of 91 children with sequenced tumors, genetic mutation findings resulted in a change in therapy in 23 children, and nine of those children had ongoing responses to therapy for 8-16 months. Given this support, the Foundation One gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in pediatric hematology and 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric hematology and 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric hematology and 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: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patient is diagnosed with major depressive disorder. The patients illness is causing significant functional impairment. The patient has trialed many medications. The patient previously responded well to a standard course of TMS. Although the data is limited, the reintroduction of TMS is not uncommon when patients relapse. According to the Clinical TMS Society, TMS should be reintroduced until remission is reachieved with a starting point of three to five sessions per week for one to three weeks. Thus, a time-limited re-trialing of TMS is appropriate in this case. It is reasonably expected that the patient will experience a similar benefit from the disputed service and there is no evidence to suggest that reintroduction of TMS would be unsafe. As such, TMS at the frequency of three to five sessions per week for three weeks followed by clinical re-evaluation is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee has requested a CT of the heart for an evaluation of his condition. Findings:  The physician reviewer found that the diagnostic procedure at issue is an appropriate test to diagnose serious pathology which can present with symptoms radiating to the back as listed by the treating physician. CT angiography was not ordered, and the presence of calcification in the left anterior descending is an incidental finding. The diagnostic procedure at issue represented a non-experimental, appropriate use of CT technology well within the standard of care to exclude disease for workup of this particular patients chest discomfort.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a three-year-old male diagnosed with autism at the age of 20 months. His treatment has consisted of an applied behavioral analysis program three hours per week, speech therapy three hours per week, and occupational therapy one hour per week. Occupational therapy has primarily been sensory based. The most current reports reflect gross motor skills within functional limits except for handling a ball and poor arm swing while running. Fine motor skills are within functional limits. Activities of daily living are delayed in dressing, especially for fasteners, though fasteners are not an age appropriate activity of daily living for a three-year-old child. The patient requires scheduled toileting. He has difficulty with circle time in group when other children sing.Language skills are age appropriate with receptive language when engaged and attending, but much of this appears to be from rote learning. The patients receptive vocabulary is within functional limits. His expressive language is still significantly delayed. The patients parents have requested authorization and coverage for continued speech therapy and occupational therapy services. The Health Plan has denied this request on the basis the requested services are not medically necessary for treatment of the patients condition.Review of the relevant medical literature reveals no data on individualized speech therapy in the treatment of autism. Given that pragmatic speech, auditory processing, social communication, and expressive speech are the primary deficits, group speech with normal peers and speech within the educational setting are more appropriate. This should be done as part of a coordinated interdisciplinary program.Furthermore, review of the literature regarding occupational therapy in autism reflects mixed findings especially with regard to specific therapies such as sensory integration therapy. All studies regarding sensory integration therapy are small scale and at least one of those studies reports no benefits.Though the submitted records indicate multiple physicians have recommended speech and occupational therapy for the patient, these therapies have been recommended in an educational context and do not imply such services are medically necessary.The only treatment validated through scientific research to be beneficial for treatment of autism is applied behavioral analysis (ABA). The gains achieved by autism patients in speech and communication are usually a product of an ABA program. Historically, ABA programs after the age of three have been offered through IEP and the Individuals with Disabilities Education Act. Deficits such as pragmatic speech, auditory comprehension, and expressive speech delay fall primarily under educational issues and coordination of care is required. Thus, treatment is best provided through the student IEP.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A forty-one year-old female with a possible autoimmune peripheral neuropathy is requesting reimbursement and prospective authorization of intravenous immune globulin (IVIG).  Reviewers Findings:  The reviewing physician found that there is a lack of credible evidence supporting the efficacy IVIG therapy in this context. Given the potentially serious risks the application of IVIG therapy cannot be recommended for a patient such as this one.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether the frozen shoulder procedure of the left shoulder provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. A review of the record indicates that the enrollee has a history of shoulder pain. She has undergone activity modification and physical therapy.Two out of three physician reviewers found that she underwent manipulation under anesthesia procedure that was a variation called the Oolo-Austin Trigenics Manual Capsular Dissection Procedure (OAT-MCD). There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this specific manipulative procedure for this patient. A recent extensive review of the literature notes that most patients (about 90%) will see complete resolution of symptoms with nonsurgical management.  Surgical intervention, including manipulation under anesthesia, with or without arthroscopic capsular release, is not recommended until after at least a 9 to 12 month failed trial of nonoperative treatment.Final Result: The reviewers determined that the requested procedure was not likely to have been 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 orthopedic surgery, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested Lazanda 100 mcg fentanyl nasal spray for treatment of the enrollees chronic interstitial cystitis. Findings:  The physician reviewer found that Lazanda 100 mcg fentanyl nasal spray is not medically necessary for treatment of this patients interstitial cystitis and chronic pain. Such doses are only indicated for malignant pain. The patient has chronic non-malignant pain. The current standard of care for chronic non-malignant pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy to address chronic pain. Consistent with these findings, the requested Lazanda 100 mcg fentanyl nasal spray is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zoll wearable cardioverter defibrillator vest for treatment of the enrollees dilated cardiomyopathy, myocarditis, and acute systolic congestive heart failure.  Findings: Two reviewers found that in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there is no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time, approximately 90 days has elapsed, when continued left ventricular dysfunction of 35% or less is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has passed has not been demonstrated to improve health outcomes (Hohnloser, et al; Steinbeck, et al). In addition, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). All told, the requested Zoll wearable cardioverter defibrillator vest is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a two-year-old female enrollee has requested applied behavioral analysis (floor time) therapy for up to 20 hours per week for treatment of the enrollees autism. Findings:  Three physician reviewers found that the data suggests that long-term, comprehensive ABA intervention leads to positive effects in terms of intellectual functioning, language development, acquisition of daily living skills and social functioning in children with autism. As such, ABA therapy is an accepted form of therapy and should be approved for the 20 hours a week as recommended for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the combination of carfilzomib and daratumumab infusions for treatment of the enrollees multiple myeloma. Findings: The physician reviewer found that the combinations of carfilzomib and daratumumab infusions are medically necessary for treatment of the patients medical condition. Daratumumab (Darzalex) is a monoclonal antibody directed against CD38. It was approved by the U.S. Food and Drug Administration (FDA) for the treatment of myeloma in patients who have progressed on proteasome inhibitor or immunomodulatory agents. A phase I trial showed that daratumumab with bortezomib/dexamethasone was a safe combination (Moreau, et al). Building on such results, a recent phase III, randomized clinical trial showed that daratumumab/bortezomib/dexamethasone had increased overall response rate and improved progression free survival compared with bortezomib/dexamethasone on its own (Palumbo, et al). Carfilzomib (Kyprolis) is an agent in the same class as bortezomib. Carfilzomib is an irreversible proteasome inhibitor that is approved by the FDA for the treatment of myeloma for patients that have progressed on one or more prior therapies. There is evidence in the medical literature showing responses in patients who have progressed on bortezomib therapy, an agent with a similar mechanism of action. In this case, the patient presents with aggressive myeloma with a need for urgent therapy. As such, the combination of carfilzomib and daratumumab infusions is medically necessary for treatment of the patients aggressive myeloma.Final Result: The reviewer determined that the requested medications are 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 with sub-specialty certification in medical oncology and hematology 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: Upheld

A 59-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was suffering from low back pain over a four day period of time.  There was no report of an acute increase in her pain on the date in question.  There also is no report of her having taken any over-the-counter medications such as ibuprofen and/or Tylenol in order to treat the pain at home.  It seems reasonable that she could have made an appointment to see her physician over the previous four days.  It is unlikely that failure to obtain immediate medical attention on the date in question would have resulted in any serious jeopardy to her health or serious dysfunction of any bodily organ.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for anesthesia services. A review of the record indicates the enrollee saw his physician for intermittent abdominal pain with occasional anal sphincter cramping with spasm. He did not report unintentional weight loss, nausea, or change in bowel habits.  History includes hypertension and hyperlipidemia. The enrollee underwent esophagogastroduodenoscopy and colonoscopy. Per the medical literature, monitored anesthesia care (MAC) is described as a specific anesthesia service for diagnostic or therapeutic procedures performed under local anesthesia along with sedation and analgesia, titrated to a level that preserves spontaneous breathing and airway reflexes. MAC alone or with local anesthesia accounts for a relatively high percentage of anesthesia services nationwide. MAC essentially comprises of three basic components: A safe conscious sedation, measures to allay patient's anxiety, and effective pain control.  Choosing the correct medications and doses depends upon an assessment of the individual patient and the degree of sedation required to adequately perform the intended procedure. Because the level of sedation required varies with patient characteristics and the procedure, it is important for the endoscopist to keep both of these considerations in mind when selecting the pre-procedure sedation plan. During endoscopic procedures performed with moderate sedation (formerly referred to as conscious sedation), the patient is able to make purposeful responses to verbal or light tactile stimulation. The patient underwent both an upper and lower endoscopy and achieving the appropriate level of relaxation is necessary. The patient would not be appropriate for the use of oral medication due to the possibility that the oral medications would not provide an appropriate level of relaxation since two procedures were performed. Full anesthesia would not be appropriate as the patient would then be too relaxed. The use of Monitored Anesthesia Care in this instance was appropriate. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Gastroenterology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 16 sessions of aqua therapy for treatment of her medical condition.   The physician reviewer found that the requested therapy is not medically indicated for the treatment of this patient. In this case, the patient has normal bilateral upper extremity strength which is required for continued independent functioning. Based on the documentation submitted for review, there has been no functional benefit with the patients prior aquatic treatments and there is no functional benefit expected with the treatments being requested. The patient can maintain her upper extremity strength through continued wheelchair use and, if needed, with a home exercise program using conventional equipment. Additional skilled aquatic therapy sessions are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested therapy 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 physical medicine and rehabilitation 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 physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has undergone physical therapy in the past.  She does not have any significant impairment that would preclude her from performing an independent exercise program going forward.  There are no documented exercises that she was performing in the formal therapy setting that she could not perform independently, or substitute with independent exercise.  There is a lack of proven benefit of passive modalities provided in a formal setting on a prolonged basis on health or functional outcomes in the setting of this patients conditions.  Palliative modalities such as topical heat can be applied independently by the patient without anticipation of a marginally significant difference in health or functional outcomes compared to modalities provided on a prolonged basis in the formal physical therapy setting.  No marginally significant benefit would be expected from the proposed ongoing formal treatment over an independent program.  While she may have many ongoing symptoms, her symptoms in general and her overall functional status are not expected to improve with the proposed physical therapy.  All told, the requested physical therapy is not medically indicated for the treatment of this patient. 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 physical medicine and rehabilitation 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.