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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Cromolyn Sodium for treatment of the enrollees mast cell activation disorder. Findings:  The physician reviewer found that mast cell activation disorder is a form of mastocytosis which is caused by the presence of too many mast cells (mastocytes) and CD34+ mast cell precursors. Patients affected by mastocytosis are susceptible to itching, hives, and anaphylactic shock, caused by the release of histamine from mast cells. Cromolyn is a U.S. Food and Drug Administration (FDA) approved therapy for mastocytosis. Therefore, the patient is likely to benefit from the proposed medication. As such, Cromolyn Sodium oral concentrate provided was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was and 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the computed tomography (CT) scans of the head and cervical spine on an emergent or urgent basis. Findings:  The physician reviewer found the patient presented to the ER due to a closed head injury. Thus, the patient met prudent layperson criteria for immediate medical attention. However, the patient did not have symptoms of significant head injury such as loss of consciousness, vomiting, or neurologic deficit. Thus, there was no medical indication for a head CT scan. Additionally, the patient denied any neck pain and no cervical spine tenderness to palpation was present. Therefore, there was no indication for a CT scan of the patients cervical spine. In sum, the CT scans of the head and neck were not required on an emergent basis to screen and stabilize the patients medical condition. Moreover, the CT scans of the head and cervical spine were not required on an urgent basis. The patient presented without symptoms of significant head injury such as loss of consciousness, vomiting, or neurologic deficit, there was no medical indication for an urgent head CT scan. In addition, the patient denied neck pain and there was no evidence of cervical spine tenderness to palpation. Final Result: The reviewer determined that the services at issue were not required on an emergent or urgent basis to screen and stabilize the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found in this case, the patient was experiencing a recurrence of a previously established mental illness. There was no mention of an acute psychiatric syndrome such as suicidality, homicidal ideation, mania, psychosis or grave disability. Further, the patient was not being treated at the time which is significant as it appears that he previously did well on pro-serotonergic medication and had not optimized evidence-based treatments typically delivered in the outpatient setting.  Although often recurrent and debilitating in nature, OCD is not a life-threatening medical emergency. When a patient with OCD has a co-occurring acute psychiatric syndrome, the combination may result in an emergent condition necessitating specialty services from an emergency department or an acute inpatient psychiatric unit. However, the patient in this case was treated at the partial hospital level of care, which does not ordinarily provide emergency care. Moreover, a common exclusionary criterion for partial hospitalization is the presence of a psychiatric emergent condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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 54-year-old female enrollee has requested an MRI of the cervical spine for evaluation of her neck pain.  Findings:  The physician reviewer found that this patient has chronic neck pain and upper extremity tingling following an industrial injury 10 years ago. Her current neurologic examination does not show any significant neuropathic or myelopathic findings. Her provider indicates the patients symptoms and examination are compatible with carpal tunnel syndrome and the provider suggested electrical studies. Recent review of the patients previous MRI scan did not show any significant canal or cord compromise. The patient has not had any recent trauma, infection, cancer or surgery on her spine. Further, she is not a surgical candidate since she does not wish to pursue surgical intervention. As such, the patient does not meet accepted guidelines for MRI imaging including Milliman, American College of Radiology, American College of Occupational and Environmental Medicine and Bussieres criteria.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 14-year-old female enrollee has requested intensive in home and/or community-based behavior support for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the requested services are likely to be more efficacious for this patient than any available standard therapy. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Although most studies of applied behavioral analysis involve young children, there is evidence that the postnatal brain continues to develop particularly with respect to myelination of the prefrontal cortex throughout adolescence and well into the third decade. Thus, specific treatment, including applied behavioral analysis that encompasses cognitive therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry that has not been compromised by the underlying pathogenetic process. This approach, which does embrace the activities of daily living, will deliver therapeutic benefit to the portion of the patients central nervous system that retains plasticity.
Appeal type: Medical Necessity
Decision: Overturned

A 17-year-old female enrollee has requested for residential treatment for treatment of her major depression. Findings:  The physician reviewer found that the patient has clearly struggled with a mood disorder that heretofore has been considered that of major depression, and for which residential treatment was deemed necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cognitive behavioral therapy and a neuropsychological evaluation. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation and treatment of the enrollees autism and anxiety. A review of the record indicates that the enrollee has been diagnosed with autism and anxiety with dysfunctional behavior. Previous treatments had included applied behavior analysis (ABA), speech therapy, occupational and physical therapy, and medication therapy. The medical records indicate an abrupt change in staffing increased anxiety and increased inappropriate behaviors and new onset behavior of eating inappropriate substances. Current medication included Melatonin and Cetirizine daily. The enrollees provider has recommended cognitive behavioral therapy, a new order for Sertraline, and a referral to a psychiatrist including neuropsychological evaluation.Cognitive behavioral therapy has been shown to be a beneficial and effective treatment for children and adolescents with anxiety and autism, and is also determined by the reviewer to be medically necessary. Wood and colleagues followed 40 children ages 7-11 with anxiety and autism who were randomly assigned to 16 sessions of CBT or a three-month waitlist. The CBT model emphasized behavioral experimentation, parent-training, and school consultation. In intent-to-treat analyses, 78.5% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positive treatment response at post treatment, as compared to only 8.7% of the waitlist group. CBT also outperformed the waitlist on diagnostic outcomes and parent reports of child anxiety, but not childrens self-reports. Treatment gains were maintained at three-month follow-up. Based on the records provided for review, there is significant scattering in the patients abilities, and he is likely to respond well to CBT. An accurate evaluation of the patients language level and intellectual function will enable appropriate services to be tailored to his needs and abilities. For these reasons, the requested CBT and neuropsychological evaluation are supported as medically necessary for evaluation and treatment of this patients behavioral health issues. 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 pediatrics and neurology with special qualification in child neurology 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 62-year-old female enrollee has requested Botox injections for treatment of her condition of spasmodic torticollis.  Findings:  Three physician reviewers found that in 2008, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) conducted an evidence-based review of the safety and efficacy of Botulinum neurotoxin A (Botox) in the treatment of movement disorders including cervical dystonia (Simpson, et al). The authors noted that there were 7 Class I studies for cervical dystonia and based on these studies, Botox has been established as safe and effective for the treatment of cervical dystonia. Furthermore, the researchers recommended that Botox injections should be offered as a treatment option to patients with cervical dystonia as Botox is probably more efficacious and better tolerated in patients with cervical dystonia than standard alternatives with lesser grade evidence in support of its safety and utility.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male has requested PET/CT scans for evaluation of esophageal cancer.  Findings:  Three physician reviewers found that PET/CT scans have proven value in the initial staging and restaging of esophageal cancer. For this patient, a PET/CT scan following completion of radiation and chemotherapy will assist in treatment planning. If the repeat PET/CT scan shows no metastatic disease, the patient would be a candidate for surgical removal of the esophageal cancer. If the patient continues to have metastatic lymph nodes, surgery may not be appropriate. Medicare coverage criteria allow for staging and restaging PET/CT scans for patients with esophageal cancer. The previous PET/CT scan and the proposed scan are essential studies and medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser hair removal of the face, chest, stomach, genital area, buttocks, back, and thighs. The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that for some patients, certain interventions can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. The WPATH includes hair removal to help alleviate gender dysphoria by electrolysis, laser treatment, or waxing. This patient presents with gender dysphoria. Her providers have recommended laser hair removal to help her achieve an appearance more consistent with her gender identity. Given this support, the requested laser hair removal of the face, chest, stomach, genital area, buttocks, back, and thighs is medically necessary for 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 with expertise in transgender health 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: The patient has requested authorization and coverage for hyaluronan injections to the bilateral knees. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. The records document that this patient has severe bilateral knee pain. His symptoms have affected his quality of life and ability to perform activities of daily living. Imaging studies have revealed patellofemoral arthritis. He has tried and failed conservative treatments including NSAIDs and strengthening exercises. He is unable to tolerate NSAIDs. Total knee arthroplasties are not appropriate as the patients osteoarthritis involves only one of the three compartments. Consistent with the recommendations from the AAOS, the requested hyaluronan injections to bilateral knees are medically necessary for management 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 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 53-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) scans for evaluation of her irregular findings on mammogram.  Findings:  Three physician reviewers found that this patient presents with a positive family history of breast cancer in her sister who was diagnosed at 45 years of age. Using the Gail Model of breast cancer risk assessment this patients calculated lifetime risk is 14%. Applying the American College of Radiology (ACR) guidelines, screening breast MRI is appropriate for patients with a calculated risk of greater than 20% or with history of prior radiation to the chest region as a young adult. This patient has a calculated risk of less than 20% and has no documentation of previous radiation to the chest. As such, the patient does not meet the published guidelines for screening breast MRI. When a patient has a non-palpable mass that is suspicious, breast biopsy is the next appropriate study. The use of breast MRI to avoid biopsy is not medically appropriate. The ACR states that, MRI should not be used in lieu of biopsy of a mammographically, clinically, and/or sonographically suspicious finding. Moreover, this patient has had an abnormal mammogram with a BIRADS 5 category, which indicates that a biopsy is needed due to the high suspicion of cancer. For these reasons the requested diagnostic breast MRI is not medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee requested (certolizumab pegol) Cimzia syringe kit for medical reatment of the enrollees Crohns disease.  Findings:  The physician reviewer found that Cimzia is a pegylated tumor necrosis factor alpha (TNF-a) inhibitor that was U.S. Food and Drug Administration (FDA)-approved in April 2008 specifically indicated for reducing signs and symptoms of Crohns disease and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. In the medical literature, de Bie and colleagues noted that while not FDA-approved for use in the pediatric population, Cimzia has been used off-label to treat refractory pediatric inflammatory bowel disease. The authors also noted that despite the growing experience with these drugs in children with inflammatory bowel disease, optimal treatment strategies still need to be determined. Mahadevan and colleagues reported that scheduled infusions of infliximab (Remicade) are effective at inducing and maintaining remission. Given that this patients records do not demonstrate that he has been adequately treated with Remicade consistent with FDA recommendations, the requested Cimzia is not supported as medically necessary for treatment of the patients Crohns disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested authorization and coverage for a 64-slice CT angiography of the chest for evaluation of coronary artery disease.Reviewers' Findings:The three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary artery disease currently remains an unproven application of this technology.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Annovera birth control ring.Combined (estrogen-progestin) hormonal contraception is highly effective and available in multiple forms and formulations, including as a vaginal ring. In the United States, there are two commonly available combined hormonal contraceptive rings, the etonogestrel/ethinyl estradiol ring and the segesterone acetate/ethinyl estradiol ring. This second formulation is known commercially as Annovera. The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but do not require daily or weekly use. More specifically, Annovera is a one-year reusable segesterone acetate/ethinyl estradiol ring. The ring is worn for three weeks and removed for one week, and that pattern is repeated for a total of 13 cycles. Annovera is approved by the U.S. Food and Drug Administration. Given that the patient has already tolerated this medication well, and that the formulation of progesterone is different from the other options (segesterone versus etonogestrel), it is medically appropriate to continue this treatment for the patient. Therefore, Annovera birth control ring is medically necessary for the treatment of 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 obstetrics and gynecology 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 of Zepatier 50mg /100 mg one tablet by mouth daily for 16 weeks for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to the 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). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, treatment is needed regardless of fibrosis stage. As such, the request for Zepatier 50 mg /100 mg one tablet by mouth daily for 16 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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.