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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested six months of intravenous immunoglobulin (IVIG) therapy, or Rituxan infusions for treatment of her vasculitis and vasculitic neuropathy. The physician reviewer found that for the treatment of vasculitic neuropathy, the use of immunosuppressive agents is based on case reports or patient series. Most review articles use corticosteroids alone or in combination with cyclophosphamide, azathioprine or methotrexate. Most of the larger studies have used azathioprine in their patients with good responses. In this case, this patients records, clinical findings, and laboratory results do not support a diagnosis of vasculitic neuropathy. This patient has previously been treated with Imuran as well as oral and intravenous Cytoxan. However, the records do not document that the patient has been treated with the standard of care regimen consisting of high dose prednisone with or without cyclophosphamide. The medical records also do not demonstrate that the patient has tried or has a contraindication to treatment with corticosteroids or methotrexate. Her evaluation fails to demonstrate a systemic vasculitis or a primary rheumatological disorder causing her vasculitic neuropathy. As there is only evidence of improvement in primary systemic vasculitis and not peripheral vasculitis, the requested IVIG is not indicated. Should the patient not respond to prednisone, or continues to require long-term therapy, then either IVIG or Rituxan would be medically necessary. However, given the lack of documentation supporting an indication for IVIG or Rituxan, the requested therapies are not supported as medically necessary. Final Result: The reviewer determined that the requested therapies 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 internal medicine, rheumatology, and allergy and immunology 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 46-year-old male enrollee has requested a Single Photon Emission Computed Tomography (SPECT) scan, psychological testing, and interpretation for evaluation of his behavioral health conditions. Findings:  Three physician reviewers found that he underwent a Single Photon Emission Computed Tomography (SPECT) study. There was no alteration in diagnosis or in treatment intervention as a result of this study. The patient has requested reimbursement for this scan along with the associated services of psychological testing and interpretation. There is no supporting evidence that the SPECT study was of significant importance to the proper diagnosis or treatment of a behavioral health condition. This procedure has no recommended use for the patients listed diagnoses. Its primary usage is in movement disorders, brain tumor or stroke evaluation and seizure disorder. The use of functional imaging is not recognized as a mainstay modality and most resources agree that more research is necessary in evaluating the role SPECT may play in assessing and treating psychopathological disorders.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male with a history of a cleft lip and palate, which was treated by a cranial facial center. He has undergone reconstructive cleft lip/palate surgery. The records provided indicate the patient has an unrepaired cleft alveolar ridge, communication impairment, and otitis media with effusion. The patient has been seen at the cranial facial center five times and the cranial facial team performed all of the reconstruction surgery needed to date. The Health Plan indicates it is not medically necessary for the patient to continue to receive services from the same cranial facial team.Review of the submitted clinical records indicates the patient has a cleft lip/palate congenital deformity. Part of the deformity is Eustachian tube dysfunction with resultant middle ear effusions and resultant otitis media. The patient is in need of follow-up on a regular basis with an otolaryngologist. In addition, the patient has malocclusion deformities secondary to his cleft lip/palate congenital deformity. His occlusion will change as he grows and as his dentition changes toward permanent dentition. Malocclusion and maleruption of dentition are common with the patients congenital deformity and he will require distraction techniques as well as probable bone grafting after distraction has been completed. This will occur over multiple years. Therefore, the patient needs a dental specialist who can provide distraction techniques and will ultimately need bone grafting by a plastic surgeon or maxillofacial surgeon. Furthermore, the patient needs a speech therapist to evaluate and help with diction problems associated with muscular incompetence. This will change as the child develops and his bony distraction changes his degree of oral and nasal competence in terms of speech. The timing of these processes varies with the degree of nasopharyngeal incompetence and the amount of bony distraction needed. As long as the Health Plan has these specialists available, it is not medically necessary for the patient to return to the same facial cranial center where he has received treatment in the past. While the patient does need evaluation of the above health issues during the course of his growth to adulthood there is no evidence that these services are only available at the patients facial cranial center. As such, the requested referral is not medically warranted for the patients ongoing treatment. Based upon the information set forth above, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy (PBRT) initiated on 3/03/21 and forward for a total of 39 treatments.At issue is whether the PBRT initiated on 3/03/21 and forward for a total of 39 treatments was and/or are medically necessary to treat the patients medical condition.Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated proton beam therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by the American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed. Thus, the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. In conclusion, PBRT initiated on 3/03/21 and forward for a total of 39 treatments was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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 radiation 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: Upheld

Nature of Statutory Criteria/Case Summary: A 60-year-old male enrollee has requested authorization and coverage for acute inpatient physical rehabilitation for treatment of the enrollee, who is status post right cranioplasty for right skull defect following craniectomy for infection. Fulfills Findings:  The physician reviewer found that the records indicate that the patient has a history of glioblastoma multiforme. He had undergone multiple surgeries and had undergone extensive treatment, including multiple episodes of rehabilitation. The patient was near his baseline level of function prior to the surgery. Physical therapy noted that he was performing squat pivot transfers with minimum assistance. He was ambulating with a hemi-walker with contact guard assistance to minimum assistance, up to 30 feet.  Physical therapy notes reported that the patient had reached his maximum potential.  He was requiring assistance from family for his activities of daily living.  In the hospital after surgery, he was ambulating up to 15 feet at a time with minimum assistance.  He was transferring with minimum assistance.  This was essentially at the level he was at before surgery and when his therapist had indicated that he had reached maximum potential for progression. Acute inpatient physical rehabilitation is not medically necessary as treatment could be provided at a less intensive setting of care.  All told, acute inpatient physical rehabilitation is not medically necessary 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing for FH/Gene/Tier 2 analysis/hereditary leiomyomatosis and renal cell cancer (HLRCC) for evaluation of the enrollees risk for cancer. Findings: The physician reviewer found that this patient is at 50% risk of having inherited HLRCC as her father is known to have the condition. The family mutation is known to be N340K. As noted in the medical literature, HLRCC is a cancer predisposition syndrome. Patients with this condition are at risk for cutaneous leiomyomata, which are at risk for becoming leiomyosarcoma. Uterine leiomyomata are present in almost all females with HLRCC. These are also at risk for transformation to leiomyosarcoma. Renal cell carcinoma occurs in about 10%-16% of patients with HLRCC with a median age of detection at 44 years. Early diagnosis is important for those at risk for inheriting HLRCC. Genetic testing to determine if this patient has inherited the familial HLRCC will determine if further screening is necessary. Thus, single site genetic testing for the N340K mutation is medically necessary as patient is at 50% risk for having this mutation. However, full tier 2 testing is not medically necessary. Consistent with this finding, a portion of the testing at issue was medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that this portion of the testing at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in genetics 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 Lynparza (olaparib) 150 mg, twice daily. Olaparib is FDA approved for the maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in patients who are in a complete or partial response to platinum-based chemotherapy. This is also supported by the NCCN guidelines. This patient has received second line, platinum-based therapy and meets criteria. She was on a previous PARP (poly [ADP-ribose] polymerase) inhibitor for such a short amount of time that it would likely not be considered significant. The use of olaparib in this patient is reasonable and medically necessary. Therefore, Lynparza (olaparib) 150 mg, twice daily is medically necessary for this patient. Final Result: The reviewer 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, 12 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is supported by the peer-reviewed literature as medically necessary for children with autism spectrum disorder. ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. ABA has been helpful for this patient, as she has made progress in social, play and cognition skills. However, she continues to have maladaptive behaviors including non-compliance, biting and inappropriate grabbing. She is making slow progress with her goals, and has plateaued in other areas. A gradual reduction of services is indicated. As such, 35 hours per week of ABA therapy, 12 hours per month of supervision and two hours per month of parent training is medically necessary and appropriate based on her progress and significant decrease in maladaptive behaviors. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested a PET-CT scan for an evaluation of his adenocarcinoma of the gastroesophageal junction. Findings:  Two physician reviewers found that while it is intuitive that PET-CT scan could be useful for evaluation of unsuspected tumor recurrence, there are no well-recognized indications using large studies for the use of PET-CT in patients without suspected tumor recurrence after appropriate therapy.  Thus, based upon the evidence and literature to date, there is no proven indication of PET-CT in this patients circumstance. De Potter and colleagues state, Because of its poor sensitivity and low negative predictive value, FDG-PET is not suited for screening purposes in the follow-up of treated gastric cancer.  If a patient has symptoms suggestive of recurrence of gastric cancer or indeterminate findings on a conventional CT scan, then PET-CT scan may be appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for photodynamic therapy. Patients with multiple actinic keratoses can benefit from the use of field treatment with multiple modalities including 5-fluorouracil cream, imiquimod, ingenol mebutate, and photodynamic therapy. Current guidelines recommend 5-fluorouracil cream and imiquimod as first-line treatments for actinic keratoses. A recent comparison study reported the greatest efficacy from 5-fluorouracil cream over other modalities (Jansen, et al.). This patient presents with a history of basal cell carcinoma of the right cheek and recurrent actinic keratoses on his face. Although the patient achieved adequate results with photodynamic therapy in the past, there is a lack of data supporting retreatment with photodynamic therapy for retreatment in this clinical setting. Therefore, the requested photodynamic therapy is 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 dermatology 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 Harvoni for treatment of his hepatitis C virus.  Findings: The physician reviewer found that Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest American Association for the Study of Liver Diseases and Infectious Diseases Society of America (AASLD/IDSA) recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per current AASLD/IDSA guidelines, the medical appropriateness of therapy as proposed exists regardless of fibrosis score. According to the AASLD/IDSA guidelines, Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). As such, the proposed regimen of Harvoni is medically necessary for treatment of the patients medical condition. Final Result: The reviewer 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 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: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested artificial disc replacement surgery for treatment of her lumbar stenosis, spondylolisthesis, and radiculopathy.  Findings:  Three physician reviewers found that this patient presents with chronic low back pain. She has right lower extremity pain and numbness but no symptoms of a defined radiculopathy or sciatica. She has an abnormal MRI at L5-S1, but this has not been shown to be her pain generator. She has no evidence of instability, spondylolysis, infection, or fracture at L5-S1. In addition, L4-5 has not been shown to be abnormal or to have degeneration. She has undergone a discogram which was normal at L3-4 and with concordant pain L4-5. The provider indicates that the discogram was attempted at L5-S1 but not performed as the patient had severe pain. On the basis of the L4-5 finding and the severe pain with the attempt at L5-S1, the hybrid procedure artificial disc replacement at L4-5 and 360 fusion at L5-S1 is proposed. Valid discography requires three levels of injection, pressure measurements, post discogram computed tomography (CT) results with Modic/Dallas 4 of 5 findings. In the medical literature, Chou cautioned that discography should not be performed in patients with chronic non-radicular low back pain as a tool for diagnosing discogenic low back pain. Further, the procedure should not be performed by the surgeon. Resnick and colleagues noted that discography should not be used as a stand alone procedure prior to surgery. This patients records do not demonstrate that these criteria have been met. With regard to patient selection, Zigler and colleagues reported that a patient is a candidate for artificial disc replacement who has an anatomically abnormal disc which is clearly the pain generator in the face of normal adjacent levels. Since this patient has a normal L4-5 disc, abnormal L5-S1 and is about to undergo fusion, she is not a candidate for artificial disc replacement. All told, the requested surgical intervention is not likely to be more beneficial for treatment of the patients medical condition than conventional alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for posterior tibial nerve stimulation (PTNS). As discussed in the medical literature, PTNS is performed as a salvage procedure. According to the American Urological Association (AUA) incontinence guidelines, PTNS is considered to be an appropriate therapy for patient with intractable irritative lower urinary tract symptoms including frequency and urgency incontinence. However, there is a lack of data demonstrating superior health outcomes with PTNS as compared to the remaining available standard therapies. All told, the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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.