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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 15 hours per week of direct applied behavioral analysis (ABA) therapy, six hours per month of oversight and two units per month of family behavioral treatment of the autism. Findings: The physician reviewer found that ABA therapy at the frequency of 15 hours per week of direct ABA therapy, six hours per month of oversight and two units per month of family behavioral treatment were medically necessary for treatment of the patients ASD. The study by Reichow and colleagues shows that ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In this case, the patient has received ABA since his diagnosis which has been effective for teaching him skills including communication and adaptive skills. However he continues to have significant issues with elopement. In this clinical setting, the ABA providers recommendation of 15 hours per week of direct ABA therapy, six hours per month of oversight and two units per month of family behavioral treatment were and are medically necessary for treatment of the patients autism.Final Result: The reviewers determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that acupuncture treatment is a reasonable option for a patient with chronic pain. However, additional acupuncture should only be provided based on progressively greater, incremental objective gains. Moreover, passive care such as acupuncture should be combined with active care such as conditioning with an aerobic and stretching exercise program. Resolution of symptoms, intolerance, lack of measurable improvements or non-compliance with aerobic and strengthening exercises are reasons to discontinue treatment. Although the provider reported that prior acupuncture care as beneficial in improving this patients ability to perform activities of daily living, the records do not include specifics with pre- and post-acupuncture baselines for comparison purposes. The provider did not chart the total number of sessions completed or any measurable, progressive, significant, objective functional improvement to support additional acupuncture services. For these reasons, the requested acupuncture services are not medically necessary for 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 oriental 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

A 50-year-old female enrollee has requested a breast MRI for an evaluation of the enrollees condition. Findings:  The physician reviewer found that the use of MRI in this setting is not shown to have distinct advantage over other routine mammographic imaging. The breast MRI was not medically indicated for evaluation of this patient. The Health Plans denial was appropriate and consistent with the current state of the art of medical imaging.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a six-year-old female enrollee requested authorization and coverage of thalidomide for treatment of a recurrent germ cell tumor.  The health plan denied the enrollees request indicating that thalidomide is not medically necessary.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three- physician reviewers concluded that thalidomide is likely to be more beneficial for treatment of the enrollees recurrent germ cell tumor than any available standard therapy.  Because all three- physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of the enrollee, who has been diagnosed with breast cancer. Findings:  The physician reviewer found that this patient had a half-sister who died from ovarian cancer. There are no other known first-degree relatives affected with breast or ovarian cancer, but her paternal family history is incomplete, as is her ethnic background. This information could significantly alter the pre-test probability of being a mutation carrier. Furthermore, the criteria outlined by the American Society of Clinical Oncology recommends genetic testing when the individual has personal or family history features suggestive of a genetic cancer susceptibility condition, the test can be adequately interpreted, and the results will aid in diagnosis or influence the medical or surgical management of the patient or family members at hereditary risk of cancer. Based upon the information provided, the patient meets this criteria. All told, BRCA1 and BRCA2 genetic testing is medically indicated for evaluation of this patient, as it may assist in treatment planning.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested authorization and coverage for Tysabri injections for treatment of his multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  This patient has been diagnosed with relapsing remitting multiple sclerosis.  He has had three attacks within a short time span.  Tysabri is appropriate for the treatment of relapsing remitting multiple sclerosis, and this medication has been demonstrated as highly effective in this setting.  The U.S. Food and Drug Administration has approved Tysabri as monotherapy for the treatment of patients with this condition.  Generally, Tysabri is recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate multiple sclerosis therapy.  This patient has aggressive disease, and the current medical evidence supports the use of Tysabri in this clinical setting.  All told, the requested Tysabri injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested a positron emission tomography (PET) scan for medical evaluation of her Parkinsons disease. Findings:  Two physician reviewers found that his patient had early onset of Parkinsonian features, but had some atypical features such as lack of tremor, neuropathy, and behavioral issues that were not typical. She sought a second opinion and the provider clinically determined this may not be Parkinsons disease, but one of the Parkinsonian syndromes, specifically MSA-P and ordered a PET scan. In this case, the PET showed clear changes that confirm a Parkinsonian syndrome and not idiopathic Parkinsons disease. Therefore, the PET scan at issue was likely to be more beneficial in diagnosing this patients underlying condition than a standard neurologic assessment or other standard testing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for local anesthesia (as opposed to general anesthesia). In a study of 114 patients to evaluate the surgical and anesthetic aspects of histrelin implantation for the treatment of precocious puberty, Davis and colleagues report that while histrelin implantation is straightforward, removal presents technical challenges, and that local anesthesia, with possible nitrous oxide supplementation, is well tolerated. Eugster reports, Placing and removing the [histrelin implant] is a minor outpatient procedure easily accomplished by a pediatric surgeon using local anesthesia. In this case, the patient received an implant with local anesthesia due to her anxiety, and the provider has recommended removal of the implant as it is over a year old. Given that current medical literature supports local anesthesia in this clinical setting as safe and effective, the requested service is medically indicated. Therefore, local anesthesia (as opposed to general anesthesia) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 enrollees parent is requesting authorization and coverage for a special bed alarm-HCPCS: enuresis alarm, using auditory buzzer and/or vibration device x1.  The enrollee has Tourettes syndrome, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), anxiety and autism-like symptoms. His urologist indicates the enrollee has a history of possibly two episodes of epididymitis, as well as bedwetting. The most likely etiology for this condition is voiding dysfunction.  A follow-up note indicates the enrollee needed an authorization for diapers because he is unable to hold his urine and stool.  An enuresis alarm for the enrollee was prescribed. The enrollees parent indicates the alarm would wake the enrollee when wet and will help train him not to urinate in his sleep. Review of the record indicates while the enrollee exhibits nocturnal enuresis (bedwetting), he also has daytime urinary incontinence, fecal incontinence and lower urinary tract symptoms, such as urgency and postponement that require wearing diapers. According to a literature review, these incontinence symptoms associated with the enrollees nocturnal enuresis are consistent with the enrollees comorbidity, autism spectrum disorder. Findings: Literature support for an enuresis alarm device for nocturnal enuresis is limited to highly motivated individuals with primary monosymptomatic (a single principal symptom) nocturnal enuresis (PMNE) and family support. However, this is not the case for this enrollee. Unlike individuals with PMNE, this enrollee exhibits other lower urinary tract symptoms, such as daytime incontinence, urgency and holding maneuvers. He has multiple comorbidities, including ADHD and autism-like symptoms that limit his ability to cooperate with parental support and make the most effective use of the alarm device. Even for qualifying enrollees with PMNE, literature recommends short-duration treatment trials and/or intervals because of the high level of burden on the parents to support this treatment. While literature supports the superiority of an enuresis alarm over other pharmacologic treatment for PMNE, literature support for non-monosymptomatic nocturnal enuresis is lacking. This enrollees comorbidities compromise his ability to cooperate with the treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested single photon emission computed tomography (SPECT) scan for evaluation of his penile melanoma.  Findings:  Three physician reviewers found that it is generally accepted that sentinel lymph node excision is the most important diagnostic procedure for patients with melanoma.  This can be accomplished by injecting isotope in the periphery of the melanoma and then by obtaining either simple planar images, or by obtaining SPECT images.  Per the current medical evidence, SPECT imaging assists in determining the exact location and visualization of sentinel lymph nodes.  The purpose of the scan is to direct the provider to sample the appropriate node.  In sum, SPECT offers advantages over planar nuclear medicine imaging in identifying sentinel nodes and directing surgical excision.  Therefore, SPECT scan was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan 1600 mg medication for 10 days or more for treatment of the enrollees small intestinal bacterial overgrowth. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The records indicate that this patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. The results were sustained for several weeks after treatment. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86% responded to Xifaxan, and symptoms were reduced as well. The patient had a serum sickness syndrome with tetracycline, in the past.  For these reasons, Xifaxan 1600 mg for 10 days or more is supported as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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: Overturned

The patient has requested reimbursement for Euflexxa injections in both knees. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of significant benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, Euflexxa injections in both knees were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage for IDET. The health plan has denied this request indicating that IDET is considered investigational for treatment of the enrollees chronic low back pain.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni or Zepatier, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. There is a need for NS5A resistance testing prior to Zepatier in patients with genotype 1a. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is indicated and Zepatier is supported for use in this clinical setting. Thus, the requested Harvoni is not medically necessary for treatment of this patients hepatitis C virus. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a WalkAide System [functional electrical stimulator (FES) system]. There is a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing FES improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, researchers reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment is not medically indicated. Therefore, a WalkAide System (FES system) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested small bowel capsule endoscopy for evaluation of his recurrent small bowel obstruction.  Findings:  Two physician reviewers found that Katsinelos and colleagues evaluated the diagnostic yield of WCE in seventy-two patients with chronic (greater than three months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities. The overall diagnostic yield of capsule endoscopy was 44.4%. The authors concluded that, chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. There is literature support for use of WCE in diagnosing recurrent bowel obstruction, as in the case of intussusception, intestinal webs, and when other diagnostic studies have failed to localize source (Rosenbaum, et al). Singeap and colleagues described a series of 15 patients referred for WCE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies. Radiation enteritis, Crohns disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated. The authors concluded that surgery, with the removal of the retained capsule, was beneficial in identifying the location of, and treating, the underlying disease in these patients. All told, the contemporary medical literature supports use of WCE for evaluation in this patients case.