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

An enrollee has requested authorization and coverage for F5 (coagulation Factor V) genetic testing.Findings:  Two of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Studies of individuals with Factor V Leiden (FVL) indicate that the annualized risk for heterozygotes to have a thrombotic event is 0.49%. It is generally not recommended to test asymptomatic adult family members of individuals known to have a Leiden variant because there are no studies addressing benefit of treatment and the practical risk of thrombosis is low. However, in certain situations, there may be coexisting risk factors that would alter the recommendations in a particular case. In asymptomatic FVL carriers, standard antithrombotic prophylaxis should be recommended during risk situations such as surgery, immobilization, or trauma. Other coexisting risk factors that may influence duration of antithrombotic prophylaxis should be considered. These coexisting risk factors would include age, family history, overweight and obesity, and prolonged immobilization. In this case, the patient has a BMI that indicates that he is overweight/obese, and therefore, with this risk factor and his compelling family history, anticoagulation might be considered if he proves to be FVL positive. Therefore, while testing is not generally recommended, it has the potential to influence patient management in this case. Under these circumstances, F5 (coagulation Factor V) genetic testing is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in medical genetics and genomics, with primary specialty certification in clinical genetics and genomics. Physician reviewer 2 is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical genetics. All three physician reviewers 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

The parent of a 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the documentation provided fails to demonstrate that the patient cannot consolidate meaningful treatment gains in a less restrictive setting. There is no documentation of previous intensive family therapy or structured psychotherapeutic programming offered by intensive outpatient services or partial hospitalization. There is no evidence of a history of behavioral problems in the academic setting.  He had no legal history, but child protective services were in place. During his recent hospitalization and residential admission, the patient did well with medication changes and had not demonstrated inappropriate behaviors in the treatment milieu.  There is no evidence of a symptom complex that would require continued treatment in a 24-hour supervised setting at this time.  In conclusion, the patient has chronic issues of significance that demand comprehensive specialty care. However, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, continued residential treatment services are not medically necessary for the comprehensive specialty care that the patient requires.
Appeal type: Experimental/Investigational
Decision: Upheld

Physisican 1: The patient is a 56-year-old male with a history of Achilles enthesopathy. The patients provider indicates the patient has not achieved prolonged relief with NSAIDs, stretching, functional foot orthotics, and a Dynasplint. The patients provider believes extracorporeal shock wave therapy (ESWT) is indicated for this patient. The Health Plan has denied authorization for the requested therapy on the basis it is considered investigational for treatment of the patients condition. The Health Plans denial should be upheld. There is insufficient medical literature showing that ESWT for treatment of plantar fasciitis results in an improved clinical outcome. Furthermore, there is no literature to support ESWT for the treatment of Achilles enthesopathy. The patient is likely to experience greater benefit from standard therapies than from use of this unproven procedure. As such, I have determined that the requested therapy 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. Physician 2: The patient is a 56-year-old man with chronic foot pain. He has requested authorization and coverage for extracorporeal shock wave therapy (ESWT). The Health Plan has denied this request on the basis that ESWT is considered investigational for treatment of the patients condition. ESWT has not yet been shown to be efficacious for treatment of Achilles enthesopathy. There are no long-term studies demonstrating that ESWT will provide long-lasting relief in this clinical setting. Furthermore, it has been documented that ESWT can damage tissue and thus, risks clearly exist. As such, ESWT cannot be recommended at this time. I have determined that the requested therapy 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. Physician 3: The patient is a 56-year-old man who has been treated for left posterior heel pain with NSAIDs, function orthotics, physical therapy, and a Dynasplint. His diagnosis is Haglunds deformity with posterior calcaneal enthesopathy. After months of continued pain, a request for extracorporeal shockwave therapy (ESWT) was made. The Health Plan has denied this request on the basis that ESWT is considered investigational for treatment of the patients condition. ESWT has been approved by the Food and Drug Administration (FDA) for treatment of lateral epicondylitis and proximal plantar fasciitis. The application of ESWT to the posterior heel for treatment of insertional Achilles enthesopathy is an off-label use and is of unproven efficacy. There is no literature demonstrating that ESWT is more beneficial for treatment of the patients condition than surgical intervention. Accordingly, I have determined that the requested therapy 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy. The American Psychiatric Association has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. This patient was diagnosed with major depressive disorder by a non-Plan provider . Per the submitted documentation, the diagnosis of major depressive disorder is established. Based on the relevant medical records, coupled with the expanding peer-reviewed literature base, TMS represents a safe and appropriate treatment intervention for this case. The requested services are consistent with good medical practice and are reasonably expected to both improve the patients condition and prevent a more serious episode of illness. All told, TMS is medically necessary for the treatment of this patient. 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: Upheld

A 60-year-old female has requested annual DEXA scans for the evaluation of osteopenia.  Findings:  The physician reviewer found that it is generally recognized that DEXA measurements to ascertain the response to therapy for osteopenia or osteoporosis should not be done before completing two years of treatment, due to regression to the mean. Markers of bone resorption may be useful after three months of treatment. In this instance, the patient will not benefit from DEXA scanning at an interval of less than two years.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested weight management classes for treatment of her obesity.  Findings:  The physician reviewer found that the patient has demonstrated progress with the structured diet program with documented weight loss. Nutritional counseling is appropriate and medically indicated for the management of conditions for which nutritional intervention has been demonstrated to result in positive net health outcomes. These conditions include pre-diabetes, diabetes, eating disorders, cardiovascular disease and renal disease. The United States Preventive Services Task Force recommends dietary counseling for individuals with known risk factors for diet-related chronic diseases and concludes that such counseling is likely to improve health outcomes. This patient has conditions of hypertension, hyperlipidemia, impaired glucose tolerance and possible sleep apnea.  Structured medical nutrition therapy and lifestyle counseling serve as an essential component of the medical treatment of these specific disease states and should be the initial step in the management of these conditions.  All told, weight management classes from the date in question forward were and are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested a dual x-ray absorptiometry (DEXA) bone density scan for an evaluation of her osteopenia. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the patient met generally accepted criteria for a DEXA scan. There is no evidence that the patient was at high risk for osteoporosis. The Health Plans criteria for DEXA scan are medically appropriate and consistent with the standard of care in this setting. Given the patients young age and the absence of a history of vertebral fracture, glucocorticoid therapy or primary hyperparathyroidism, there was no clinical indication for the disputed DEXA scan. There is no peer-reviewed scientific literature to support the need for a repeat or follow-up DEXA scan in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrolle has requested a parathyroid scan for evaluation of her hypothyroidism and thyroid nodule. Findings:The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. The requested parathyroid scan is not clinically indicated or medically necessary in this patients case. A parathyroid scan is not utilized to make the diagnosis of hypoparathyroidism, but rather to localize for planned surgery. Unless there is a primary diagnosis of hypoparathyroidism and surgery is planned, the requested scan would not be of benefit. The Health Plans authorization for a second opinion with an in-Plan endocrinologist is medically reasonable and appropriate. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old man who has lost 130 pounds since undergoing weight loss surgery in 2002. The patient indicates he experiences rashes due to excess skin. He also complains of low back and testicular pain due to the weight of the pannus. The patient wishes to undergo surgical removal of the excess skin. The Health Plan has determined the requested procedure is not medically necessary.Though the patient complains of painful rashes due to an overhanging pannus, the submitted exam notes do not document a rash. In addition, there is no evidence medical therapies have been pursued as an alternative to surgical intervention. Furthermore, based upon the information provided, it appears the patients low back pain is multifactorial and pre-existing. Thus, the requested procedure would not be expected to improve this condition. Moreover, testicular pain is not documented in the patients physicians evaluations, nor is there documentation of this problem on the physical examination. Thus, there is insufficient evidence that the patients condition results in a functional deficit. As such, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 46-year-old female enrollee has requested for emergency services for treatment of her sudden onset of dizziness and nausea. Findings:  The physician reviewer found that a prudent layperson with an average knowledge of medicine who was experiencing dizziness and nausea would not expect the absence of immediate emergency care to jeopardize her health. The patients condition could have been safely evaluated and treated in an urgent care or private office setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment from 3/01/15 through 5/19/16.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There was no evidence of self-injurious behavior.  Per the medical records, the patient did not have suicidal or homicidal ideation.  He did not have any psychosis, mania, delusions, hallucinations, or agitation.  The patient was calm, cooperative, and participated in groups.  He was compliant with medications.  He has a supportive family. The patient had no comorbid medical problems necessitating 24-hour monitoring. The patient had received several months of inpatient and residential treatment learning coping skills which could have been practiced in a less restrictive environment in a home and school environment.  He continued to require treatment for his anxiety and depression, but this could have been done in a less restrictive environment. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested for a real-time remote 30 day heart monitor for treatment of the enrollees no sustained ventricular tachycardia (NSVT). Findings: Two physician reviewers found that in this circumstance if evaluation for recurrent no sustained ventricular tachycardia or other dysrhythmia is thought to be necessary then Holter monitoring for frequent symptoms or exertional symptoms or off-line self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations. In addition, off line auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias (Blomstrom-Lundqvist, et al; Crawford, et al). Continuous real-time monitoring by telemetry services is not indicated in this case, since off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry has not been shown to improve health outcome compared to standard monitoring techniques. Thus, the use of a real-time 30 day heart monitor is not likely to be more beneficial for treatment of the patients medical condition than 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 is 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: Overturned

A male enrollee requested Harvoni for 12 weeks for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Evidence supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy due to non-liver-related comorbid conditions. This patient already has advanced fibrosis based upon his FibroSURE test, and therefore, it is medically necessary to treat him to eradicate infection and prevent progression of his cirrhosis to a decompensated state, and also prevent complications of cirrhosis. Therefore, based upon this approval supported by large clinical trials, Harvoni is medically necessary for 12 weeks in this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his Aspergers syndrome.  Findings:  The physician reviewer found that ABA therapy has been widely used in the therapeutic intervention in autistic children. Studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (greater than 20 hours per week). In addition, studies have also been conducted looking at intensive ABA therapy versus standardized care. Comparing patients that received ABA therapy versus those who received standardized therapy, there is a statistical improvement in cognitive, language, and adaptive behavior skills in patients who have received ABA treatment. ABA therapy is superior to special education or standardized care in improving the outcome in patients with autism. On average, the children who received the behavioral treatment gained 17 IQ-points, 13 points in language comprehension, 23 points in expressive language and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, 1 point in language comprehension, 2 points in expressive language and zero points in adaptive behaviors in one study (Eikeseth, et al). Given the scientific data demonstrating that ABA is an accepted and appropriate modality for treatment of patients with autism spectrum disorder, ABA therapy is medically indicated and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a 57-year-old woman with a history of right elbow pain. Her physician recommended exercise, physical therapy, and ice for her pain, none of which provided relief. The patient then underwent extracorporeal shockwave therapy (ESWT), which was performed in September 2004. The Health Plan has denied reimbursement for these services indicating there is no evidence demonstrating ESWT is safe and effective for treatment of the patients elbow pain. ESWT is an unproven treatment for the condition of epicondylitis. The safety and efficacy of ESWT has not been established in the case controlled scientific literature. There is no evidence ESWT as compared to standard therapy is likely to result in a superior outcome. Therefore, I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An patient has requested authorization and coverage for a power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees late-onset cerebellar ataxia. The submitted documentation supports the medical necessity of the requested equipment. In this case, the patient has idiopathic progressive neuropathy and cerebellar ataxia with a history of repeated falls and impairment of gait and mobility. The patient is unable to self propel a manual wheelchair. He is unable to perform pressure reliefs and is at risk for pressure ulcers. He resides in a subacute facility and would be expected to receive assistance in terms of performing transfers to and from a wheelchair. The current medical evidence supports the requested equipment in this clinical setting. Therefore, the requested power wheelchair 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 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.