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

The parent of a 16-year-old male enrollee has requested  for continued social skills training group therapy for treatment of the enrollees Aspergers syndrome and obsessive compulsive disorder. Findings:  The physician reviewer found that the concept of social skills training group therapy is discussed in retrospective or case-controlled studies that are of small scale. At this time, is a notable lack of medical evidence-based peer review of the efficacy of social skills training in this setting. Reports of benefit stem primarily from descriptive and anecdotal literature, although the quantity and quality of research is increasing. Williams White, et al. concluded that the state of research about the effectiveness of social skills groups is still in its infancy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for human chorionic gonadotrophin (hCG) for treatment of the enrollees hypogonadotropic hypogonadism. Findings:  Two physician reviewers found that although this patients records support a diagnosis of partial empty sella syndrome and secondary hypogonadism, there is a lack of evidence of polycythemia as noted by the provider, which would be a contraindication for testosterone therapy. Further, the records provided for review do not include sufficient documentation that the patient has experienced side effects with testosterone therapy. Thus, although hCG treatment has a role for patients who desire fertility, the requested hCG therapy is not supported for use as a routine treatment for patients with secondary hypogonadism. Given the availability of standard options including dermal patches, the requested hCG 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 requested medication 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 endocrinology, diabetes, and metabolism 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement for InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollee has a history of cerebral palsy, Down syndrome, blindness, deafness, developmental delay, and seizures. His provider is requesting coverage for the InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollees provider indicates the enrollee is entirely dependent on others for his care and has a history of hospitalizations for respiratory illness. He has a continued need for a chest percussion device that keeps him from getting bronchitis and pneumonia. The enrollee also suffers from gastroesophageal reflux disease, (GERD) and recurrent aspiration pneumonia. He is treated with Keppra and recurrent antibiotics. He saw his medical specialist on nine occasions with a normal pulmonary exam. The medical literature, in an extensive review found that evidence for most respiratory interventions for young people with cerebral palsy is absent or weak. No controlled trials demonstrated significant effects on respiratory morbidity, owing to their scarcity, weak designs, and inadequate power. There is an urgent need for well-designed prospective controlled studies investigating prevention and management of respiratory disease in young people with cerebral palsy.  This is consistent with the lack of support for airway clearance devices in cystic fibrosis, which has been the area most studied with these devices. In a review of such devices in cystic fibrosis, while some areas showed better results with oscillating devices, there was also data suggesting a higher rate of exacerbations requiring antibiotics compared to use of PEP- positive expiratory pressure. The medical literature does not show gastroesophageal reflux disease (GERD) is an absolute contraindication for manual chest physiotherapy.  The record has insufficient evidence of failed manual chest physiotherapy.  Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the MoPath procedure level 7 test provided for evaluation of her pregnancy. Findings:  Three physician reviewers found that as noted by the American College of Obstetricians and Gynecologists (ACOG), a patient should be provided aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. The testing should be tailored to the most common conditions, those specific to the patient based on personal and family history, and those that are present in a higher rate in their specific ethnic group. It is not recommended that the patients are pan-tested for all possible genetic disorders. In this case, the provider found the patient to be at high risk for conditions including spinal muscular atrophy (SMA), glucose-6-phosphate dehydrogenase (G6PD), and methyltetrahydrofolate reductase (MTMHR) deficiency. Thus, testing for these conditions was therefore indicated. However, the MoPath 7 also includes rare conditions that this patient did not have an elevated risk for carrying. As such, the SMA, G6PD, MTMHR deficiency testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the MoPath procedure level 7 test provided was not likely to be more beneficial for evaluation of the patients medical condition than any standard testing.Final Review: All three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Two physician reviewers are board certified in obstetrics and gynecology and are actively practicing. One physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that the medical literature supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and increase in detection of small cancers and increase in overall diagnostic accuracy compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.  In sum, digital breast tomosynthesis performed was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female who underwent a vitrectomy for treatment of a macular hole. Following surgery, face down head positioning was required. The patients physician recommended the use of a vitrectomy support system to allow the patient to maintain the correct position for proper healing. The patient is requesting reimbursement for the vitrectomy support system. The Health Plan has denied the patients request indicating the equipment at issue was not medically necessary.Post-op face down head positioning is considered to be a very important part of the vitrectomy. Retinal specialists believe the success rate is higher if the patient maintains a high percentage of his or her time in a face down posture. Long periods of time with the bubble out of position increase failure rate and increase the possibility of lens damage with subsequent cataract formation. It is very difficult for patients to maintain a face down position without assistance. A device such as the vitrectomy support system is considered part of the therapy. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old male with hypertension, dyslipidema, and coronary artery disease (CAD). The submitted information indicates the patient has been successfully treated with Zocor (a statin) and Zetia for his dyslipidemia and coronary artery disease. Several years earlier the patient had been treated with Lipitor, which was discontinued because of joint and muscle pains. The Health Plan has denied coverage for Zocor indicating that no evidence has been provided that the patient has been unsuccessfully treated with two formulary statins. Current guidelines for the treatment of coronary artery disease include treatment of serum LDL to levels less than 100. In multiple clinical trials, statin therapy has been demonstrated to reduce the incidence of cardiac events in individuals with established coronary artery disease. Continued use of Zocor is medically appropriate in this case because the patient has achieved therapeutic goals while on Zocor. Furthermore, the patient has avoided previous statin associated side effects. Thus, use of Zocor is medically indicated given the patients clinical history.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 34-year-old woman with a history of an abnormal pap smear and genital/cervical warts.  Her provider has recommended treatment with cervical laser and biopsy.  The patient reportedly has a low pain tolerance and a history of hemorrhage after a previous procedure. Her provider is requesting authorization to perform the procedure under general anesthesia in the hospital setting.  The Heath Plan has denied this request based on a determination that general anesthesia and inpatient care are not medically necessary.There is no medical indication for the proposed procedure to be performed under general anesthesia.  The patient is medically stable with no significant past medical history.  General anesthesia for healthy patients (ASA Class I or II) may be indicated for a procedure of greater complexity, a higher level of preoperative anxiety or a greater need for a pain-free operative period.  A contraindication to local anesthesia might also require that a general anesthetic be administered.  In this particular case, the procedure is typically performed under local anesthesia with no sedation required.  The patient has no contraindications for pre-medication with Valium, Xylocaine, or cryo to the cervix.  The record provided does demonstrate the necessity of an inpatient procedure under general anesthetic.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old female enrollee has requested authorization  for the medication Byetta for treatment of her morbid obesity and diabetes.  Findings:  The physician reviewer found that the patient was denied Byetta because she did not fulfill the Health Plans requirement of a hemoglobin A1C of 6.5% or higher for authorization of Byetta. This is a morbidly obese patient who has been taking Amaryl, Actos and insulin. All three of these medications cause weight gain. In addition, Actos and insulin cause fluid retention. This patient already requires two different kinds of diuretics. Taking these medications will make it very difficult for this patient to lose weight.  The patient is likely to benefit greatly by taking Byetta and discontinuing Actos and insulin. She has already achieved great blood glucose control and weight loss with a trial of Byetta.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested real-time cardiac monitoring for evaluation of her mitral valve prolapse. Findings:  Two physician reviewers found that remote ambulatory long-term cardiac monitoring is now recognized and accepted as a useful diagnostic adjunct to detecting and characterizing underlying symptomatic and asymptomatic cardiac arrhythmias, for both risk assessment and to inform best management on a real-time basis.  In most settings, the information obtained is not easily or promptly ascertained using other diagnostic approaches. In this patient with significant arrhythmias detected at the time of stress testing, the services at issue were medically appropriate even absent test evidence for ischemia. It is true that the value of remote monitoring remains to be definitively established.  However, there is significant value in having diagnostic information available promptly on a real-time basis, especially when the patient is not in a position or location to bring recording equipment in for prompt analysis of symptomatic arrhythmias. Real-time cardiac monitoring is also beneficial when potentially more threatening arrhythmias may be asymptomatic and earlier awareness of them becomes clinically important for best patient management.
Appeal type: Urgent Care
Decision: Upheld

A 30-year-old male enrollee has requested for emergency services for treatment of his headache. Findings:  The physician reviewer found that The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and the gradual onset of headache symptoms over four days, would not reasonably expect the absence of emergency care to jeopardize their health. Although the patient was experiencing pain, his pain was not acute in onset.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested gastrointestinal (GI) tract wireless capsule endoscopy for evaluation of his history of GI bleeding lesions.  Findings:  Two physician reviewers found the request for a repeat capsule endoscopy is not consistent with the recommendations in the medical literature given the findings on the previous study. The standard practice is to follow the patient clinically for signs of recurrent or ongoing bleeding. This would include looking for melena and checking serial hemoglobin values. The records do not include evidence of ongoing bleeding that would require evaluation with an enteroscopy to assess and treat the ulcers. All told, the requested GI tract wireless capsule endoscopy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient reported fatigue, headaches, postnasal drip, and nasal congestion. The provider noted computed tomography (CT) of the sinuses revealed no mass, no acute fracture or dislocation, and no aggressive osseous lesions. The provider noted the patient has mild septal deviation and concha bullosa that does not obstruct her airway. The patient has requested authorization and coverage for concha bullosa reduction surgery. The Health Plan denied the request and reported the requested surgery is not medically necessary for the treatment of this patient. At issue in this case is whether concha bullosa reduction surgery is medically necessary for the treatment of the patients medical condition. Studies reported, A concha bullosa (CB) represents the presence of air cell in the turbinates, and the middle turbinate concha bullosa is a common nasal cavity anatomical variation. The authors also noted, Our findings show that the CB does not appear to give rise to chronic sinusitis, but the extensive type was more symptomatic than the bulbous or lamellar types. In this case, the patient has a history of headaches, fatigue, and postnasal drip. CT imaging showed a concha bullosa with no sinus disease. There was no documentation the patient had sinusitis or nasal obstruction. The medical evidence does not support the requested surgery in this clinical setting. Therefore, concha bullosa reduction surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 otolaryngology 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 Synthroid for treatment of her hypothyroidism.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Synthroid has been established. The documentation submitted for review demonstrates that the patient has had improvement in her symptoms when switched to brand name Synthroid. The patient reported jaw, back and neck pain and chest discomfort with generic levothyroxine. Hence, it is reasonable and medically necessary for this patient to be treated with Synthroid given improvement in her symptoms. For the reasons provided, the patients request for Synthroid is medically necessary. 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 endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for omeprazole suspension. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of intractable seizures, cerebral palsy and global developmental delay.Findings: According to the American Academy of Child and Adolescent Psychiatrys (AACAP) most up to date practice parameter on obsessive compulsive disorder (OCD), cognitive behavioral therapy is the first line of treatment for mild to moderate cases of OCD and the combination of cognitive behavioral therapy and medication is indicated for moderate to severe cases of OCD. Treatment resistance is considered when a patient has persistent OCD symptoms despite engaging in adequate treatment that is known to be effective. The patient in this case has a history of multiple medication trials and failure of treatment at the outpatient level of care. A research study on residential treatment for adolescents with OCD noted, Patients with complex comorbidity or previous unsuccessful treatment attempts may require more intensive monitoring, multimodal interventions, and greater intensity of treatment delivery than even intensive outpatient CBT provides...residential treatment provides a greatly increased number of hours of CBT provided per week...constant placement in the treatment setting and removal from direct contact with family members accommodating their symptoms, and around-the-clock staff monitoring and support to assist with ritual prevention, homework compliance, and other treatment targets. The patients treating provider at the residential facility noted that the patient required intensive support throughout her time at the residential facility due to the patients escalating anxiety when participating in exposures and response prevention.  Based on the patients clinical history, including psychiatric comorbidities and treatment resistant status, and current medical literature, the residential level of care was medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that 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 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: Medical Necessity
Decision: Overturned

The parents of a twelve year-old female with cystic fibrosis are requesting authorization for the Vest Airway Clearance System.  Reviewers Findings:The reviewing physician found that there is sufficient scientific evidence demonstrating that the Vest System is safe and effective for patients with cystic fibrosis.   The reviewing physician found that the Health Plan denial should be overturned.