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

The parent of an 8-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy (CPT code H2019) and 15 hours of supervision per month (CPT code H0032) and 5 hours of treatment planning per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. The medical communitys customary and usual prescription for an autistic child is ABA therapy. ABA therapy is well-documented as being an effective therapy to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. The efficacy of ABA as the only effective behavioral treatment has been documented by many authors (Vismara and Rogers).When reviewing ABA as effectively applied and continued with older children, there is limited literature substantiating its favorable effect on this continuing impaired population. Thus, the clinical circumstances of each patient must be considered to determine the appropriateness of continuing ABA therapy. In this case, there are several clinical features that are relevant. When ABA therapy was discontinued the patients behavioral control deteriorated and he became more aggressive. This would imply that the ABA therapy did have a positive effect on his personal skills and behavior. When reintroduced, over limited hours, the patient demonstrated improved social and behavioral skills. ABA services did have a positive although limited behavioral effect during the three months when it was reintroduced. However, ABA therapy has not substantially improved the patients overall communicative, social, and self-help skills during the nearly four years of treatment. Thus, the numbers of hours of ABA therapy should be adequate to prevent regression of the patients presently acquired skills; 2 hour daily should be adequate to prevent loss of his present abilities, along with daily school attendance. In conclusion, it is medically necessary for this patient to receive 10 hours per week of ABA therapy and 4 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested neuropsychological testing for an evaluation of the enrollees autism. Findings:  The physician reviewer found that this patient presents with symptoms of an autism spectrum disorder along with cerebral palsy. Neuropsychological testing is often indicated for both disorders to assist in developing or enhancing an appropriate treatment plan. The history also indicates the patient is regressing in school and additional testing could be helpful in the treatment process. Neuropsychological testing is likely to be of clinical value in this setting and is consistent with American Academy of Child and Adolescent Psychiatry guidelines for the Assessment and Treatment of Children, Adolescents and Adults with Autism and Pervasive Developmental Disorders. Neuropsychological testing in this setting is also supported by other standard clinical references such as Volkmars Handbook of Autism and Pervasive Developmental Disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found the patient has a normal IGF-1 level for pubertal stage and his adult height prediction of 68-68.5 inches is normal for US adult males. He is not known to have any morphological abnormalities of his pituitary gland and does not have evidence of pituitary dysfunction. The most likely cause of his fall-off in growth and delayed bone age is constitutional delay, not GH deficiency. His height velocity is expected to accelerate spontaneously with progression in pubertal development. All told, the requested Nutropin AQ NuSpin 20 mg is not supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees leiomyosarcoma.Findings:  There is support in the medical literature and in the guidelines for using PET for initial staging. The National Comprehensive Cancer Network guidelines state that PET scan maybe useful in tumors larger than 3 cm. This patients mass measured 3.5 x 2.8 cm. In addition, research has shown that PET can be useful in assessing grade and prognosis. Before giving this patient treatment options, it was critical to decide stage of the tumor, as the treatment for localized disease is different than that for stage 4 or metastatic disease.  The use of PET for leiomyosarcoma can provide information as to tumor grade and can be used to help assess treatment response in the future. The American College of Radiology guidelines state that PET could potentially avoid 20% of futile surgeries performed.  There is also literature that indicates that the results from PET may allow a small change in the management of patients using PET for initial staging of a sarcoma. In summary, the literature shows that PET can add information in terms of tumor aggressiveness as well as information as to the extent of metastasis. This information is helpful to assess the standardized uptake values on subsequent examinations. Accordingly, the PET scan performed was likely to have been more beneficial for the evaluation of this patients medication condition than the standard methods available.Final Result: Two of the three reviewers determined the services at issue were 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:  All three reviewers are board certified in diagnostic radiology 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

An enrollee has requested authorization and coverage for laparoscopic reversal Roux-en-Y gastric bypass and proceeding with laparoscopic loop duodenal switch.Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. Researchers have found that the evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Obesity is understood to be a chronic condition and patients may need more than one operative intervention. In this case, the patient is morbidly obese with a BMI that is greater than 40 kg/m2. The present request is for the reversal of the patients gastric bypass and conversion to a malabsorptive operation which has greater weight loss outcomes. The patient meets American Society for Metabolic & Bariatric Surgery reoperative guidelines with the completion of an updated multidisciplinary evaluation that did not reveal any obvious behavioral, dietary, medical or cardiac barriers to surgery. The patient has also failed ongoing dietary efforts with six months of supervised weight loss and net weight gain despite intervention. Under these circumstances, the requested laparoscopic reversal Roux-en-Y gastric bypass and proceeding with laparoscopic loop duodenal switch is medically necessary for treatment of the patients medical condition.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 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: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a BMI of 39 and a number of referenced comorbidities including hypertension, gastroesophageal reflux disease (GERD), and depression. A psychological evaluation recommended the patient receive psychotherapy. She is seeking authorization for a duodenal switch procedure. The Health Plan has denied this request.The Health Plans denial should be upheld. Based upon the patients history and psychological evaluation, the patient does not appear prepared for the lifestyle changes necessary for weight loss surgery to be successful. The patient should follow through on the recommended psychotherapy and undergo re-evaluation in approximately six to nine months. If at that time the patient is considered an appropriate candidate for weight loss surgery the Health Plans denial should be reconsidered. At that time the patient should also be re-evaluated by her bariatric surgeon.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoscopic plantar fasciotomy and micro revision of the calf tendon. The submitted documentation supports the medical necessity of the requested services. Plantar fasciotomy is offered to patients with recalcitrant plantar fasciitis. Endoscopic plantar fasciotomy and gastrocnemius recession/revision of calf tendon have become the surgical standard of care after the failure of conservative treatments for plantar fasciitis. In this case, the patient has recalcitrant plantar fasciitis. The submitted documentation reflects that the patient has tried and failed numerous conservative treatments, including physical therapy, icing, shoe gear modification, custom foot orthotics, anti-inflammatory medications, boot immobilization, night splinting, and stretching. Under these circumstances, the requested endoscopic plantar fasciotomy and micro revision of the calf tendon are medically necessary to treat 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 podiatry 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 patient has requested authorization and coverage for Sovaldi 400 mg once per day and Ribasphere 600 mg twice daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. .Findings:  The physician reviewer found that According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. However, per the guidelines, Epclusa is the only recommended first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin, without the adverse effects of ribavirin (Feld, et al; Foster, et al). Due to these trial results, Sovaldi and ribavirin are no longer recommended as first-line treatment for patients with genotype 2 hepatitis C. For these reasons, the requested Sovaldi 400 mg once per day and Ribasphere 600 mg twice daily for 12 weeks are not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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 internal medicine with sub-specialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees mixed receptive/expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Feldman & Messick). A meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than children who have no treatment. Review of the submitted documentation demonstrates that this patient was noted to have speech and language delay. A subsequent evaluation the following month did not reveal a delay; however, different tools were utilized to determine the patients abilities. The patient has an identified delay in receptive and expressive speech of greater than 50% per one evaluation and no identified delays in another evaluation. It is important to determine this patients current speech and language development. Given the discrepancy in the findings of the patients speech and language evaluations, he should undergo re-evaluation with an independent speech therapist to determine his current level of functioning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Early initiation of treatment may help avoid untoward complications from advanced disease, including liver failure and extrahepatic manifestations from hepatitis C.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Overturned

A 35-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. With regard to this patient, she presented with severe pain. This constitutes sufficient rationale for believing that an emergency medical condition exists, and is an acceptable reason for a prudent layperson to seek medical care emergently. Further, the date of service was a Sunday so a prudent layperson would have sought immediate care at the ED. The fact that the patients pain was resolving on its own and that she decided to leave against medical advice does not negate the appropriateness of her decision to seek medical care in the ED on the date of service in question. Thus, the patients situation meets the definition of emergency medical condition as set forth by California law.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested growth hormone therapy (Norditropin) for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  According to the U.S. Food and Drug Administration, growth hormone is indicated for treatment of severe idiopathic (non-growth hormone deficient) short stature when height is more than 2.25 standard deviations below the mean for age and sex.  Using an independent growth calculator, this patients height as of the said date was 2.18 standard deviations below the mean.  Based on bone age, his predicted height is 172.44 cm, or 0.68 standard deviations below the mean.  This patient does not meet U.S. Food and Drug Administration defined criteria for severe idiopathic short stature.  The current medical evidence does not support the requested therapy in this clinical setting.  All told, the requested growth hormone therapy (Norditropin) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male has requested coverage for Synvisc injections for treatment of the enrollees end stage right shoulder osteoarthritis.  Findings:  The physician reviewer found that overall, a review of randomized placebo controlled double blinded studies in reference to the shoulder does not support a positive clinical effect. In the article authored by Hseih and colleagues, the authors compared a cohort of 70 patients with adhesive capsulitis of the shoulder randomly placed into one group receiving hyaluronic acid injections with physical therapy and a second group receiving physical therapy alone. Both groups experienced improvements in pain, disability, and quality of life after treatments. No significant group effect was found for any outcome measurements. The authors concluded that intra-articular hyaluronate injection did not produce added benefits for adhesive capsulitis of the shoulder. The article authored by Colen and colleagues concluded that after pooling outcomes of different studies that there was statistical evidence for positive effect of intra-articular hyaluronic acid. However, they qualified this statement by stating that there is limited evidence that hyaluronic acid is superior to placebo and no evidence that intra-articular hyaluronic acid is better than corticosteroids or other conservative therapies. In the article from Kim and colleagues, 105 patients were allocated randomly into two groups. One group received hyaluronate and the other group received corticosteroids. The injections were performed into the subacromial space with ultrasound monitoring. The outcomes were assessed with the American Shoulder and Elbow Surgeons standardized shoulder assessment form. The authors reported that outcomes were similar between hyaluronate injection and corticosteroid.  All told, it is not medically necessary for this patient to receive Synvisc injections into the right shoulder for his advanced end stage osteoarthritis. An additional period of conservative care is likely to be beneficial, allowing adequate time for the exacerbation and inflammatory reaction to subside. The patient and the provider are discussing total shoulder arthroplasty, which would have greater risk, but would be appropriate definitive treatment. It should be noted that with a surgical procedure anticipated, repeated injections of either steroid or any other substance would increase a low risk of infection within the joint particularly in the face of a large non-biological implant. Consistent with these findings, the requested therapy is not medically necessary for treatment of the patients medical condition.