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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occupational therapy in an aquatic setting for treatment of the enrollees autism and sensory integration disorder. Findings:  The physician reviewer found that the request for occupational therapy in an aquatic setting has not been established as medically necessary for treatment of the patients medical condition. Mortimer and colleagues examined the effectiveness of hydrotherapy on social interactions and behaviors in the treatment of children with ASD. The review found that Few studies have investigated the effect of hydrotherapy on the social interactions and behaviors of children with ASDs. The authors further state that studies that have been conducted were constrained by small sample size, lack of comparator, crude sampling methods, and the lack of standardized outcome measures. In addition, Getz reviewed 173 articles involving the use of hydrotherapy in children with neuromotor or neuromuscular impairments. The results demonstrated a substantial lack of evidence-based research evaluating the specific effects of aquatic interventions in this population. These findings suggest that the use of hydrotherapy for the treatment of autism has not yet been established as evidenced-based and is therefore not medically necessary. The patient appears to have had delays in several activities of daily living including fastening buttons, snaps and zippers and teeth brushing. The patient would likely benefit from occupational therapy services. Final Result: The reviewers 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested reimbursement for Applied Behavioral Analysis (ABA) therapy services, including social skills group therapy. While an autism diagnosis is a necessary component to access Applied Behavioral Analysis (ABA), it is only one component, and another necessary component is documentation outlining patient assessment results and course of treatment. Guidelines established by the Council of Autism Service Providers (CASP) highlight essential elements of ABA including direct observational data, a carefully constructed individualized and detailed behavior-analytic treatment plan, and treatment protocols. CASP guidelines also detail critical features of a treatment plan for service authorization. In this case, the patient has been diagnosed with autism, and the treatment in issue, ABA, is the most evidence based treatment for individuals on the autism spectrum. However, there is no documentation of the specific needs of the patient during the period under consideration, as the submitted records do not include a treatment plan for this period. Furthermore, the submitted records do not set forth direct observational information or include medical record documentation of ABA services that were provided to the patient during the period under consideration. Under these circumstances, Applied Behavioral Analysis (ABA) therapy services, including social skills group therapy, provided during the period under consideration were not medically necessary to treat the patients condition.Final Result: The reviewer determined that services at issue were not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed B.C.B.A., board certified in psychology, 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

The patient is a 51-year-old female with a body mass index (BMI) of 37.3. The patients comorbid conditions include bilateral degenerative joint disease of the knee and back pain. She wishes to undergo gastric bypass surgery and has obtained psychiatric clearance. The Health Plan has denied authorization for weight loss surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 37.3 and no significant comorbid conditions such as diabetes or hypertension, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, 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: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of the medication gleevec for the treatment of colo-rectal cancer that has metastasized to the lungs and liver.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication gleevec is not likely to be more beneficial for treatment of the enrollees Colo-rectal cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old woman who has plaque psoriasis that covered at least 50% of her body surface areas. Methotrexate, cyclosporine and phototherapy were ineffective or caused unacceptable side effects. She has received treatment with Raptiva since May 2005, which resulted in marked improvement with reduction in psoriasis to only 13% of her body surface area. The Health Plan has denied coverage for Raptiva on the basis that it is not medically necessary for treatment of the patients condition.Raptiva is a medically appropriate treatment for moderate to severe psoriasis resistant to other forms of treatment. Raptiva therapy resulted in remarkable improvement in this patients condition. In addition, methotrexate, cyclosporine and phototherapy were ineffective or caused unacceptable side effects. Given the patients documented response to Raptiva and her poor response to other therapies, continuation of Raptiva is medically reasonable and indicated. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male has requested coverage for L4-L5 lumbar spinal fusion (CPT 20930, 22612 and 22840) and laminectomy for treatment of his spondylolysis and severe facet disease at L4-L5.  Findings:  The physician reviewer found that while fusion of the lumbar spine is frequently performed, the indications for this procedure are not clearly defined (Sonntag and Carciano). Fusion may be indicated in specific pathologies, such as mechanical instability associated with localized destruction from tumor, trauma, or infection, but low back pain without an explainable pathomorphologic correlation or functional deficit is not an indication for fusion (Aebi). There must be evidence of instability with progressing neurological impairment in order for fusion to be considered medically necessary. In this case, evidence of instability is not well documented. Although the provider describes a 4mm movement in the study, no listhesis is described by the radiologist in the radiology report of the same study. All told, there is inadequate objective evidence provided of spinal instability in this patient and therefore the medical necessity of L4-L5 lumbar spinal fusion in addition to laminectomy is not established.
Appeal type: Medical Necessity
Decision: Overturned

A three-year-old female enrollee has requested for speech therapy for treatment of her articulation disorder. Findings:  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior. In particular, speech sound disorder not only greatly reduces intelligibility, but it has also been associated with later reading disability. As noted by Nelson and colleagues, speech and language development is considered by experts to be related to school success and is a useful indicator of a childs overall development and cognitive ability. They noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. It is clear that speech disorders must be taken very seriously, and intervention should be timely and comprehensive. The literature supports the efficacy of speech therapy intervention for patients like this patient. In a large meta-analysis looking at studies of children with primary speech and language delay/disorder, Law and colleagues concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary deficits.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.Findings:  The physician reviewer found that the documentation submitted for review indicates the patient has a history of an inpatient admission in April 2015 with a primary diagnosis of bipolar disorder, most recent episode depressed, severe without psychotic features and an intensive outpatient program admission in May 2015 with a primary diagnosis of unspecified bipolar disorder. The record indicates that the patient has been treated with Geodon which is not a typical augmentation therapy or monotherapy agent for major depressive disorder. Given that the records support a history of bipolar disorder and lack of peer-reviewed literature supporting TMS for patients with bipolar disorder, the request for TMS treatment is not indicated. In addition, the patient had a Montgomery-Asberg Depression Rating Scale (MADRS) score of 42 indicating severe depression. 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 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

A 63-year-old female enrollee has requested for removal of skin spots for treatment of her skin spots with diagnosis of actinic keratosis.   Findings:  The physician reviewer found that in the medical literature, Berlin noted that actinic keratoses are precancerous lesions that can transform to skin carcinomas. Seborrheic keratoses are benign skin lesions that may represent a cosmetic problem. The actinic keratosis lesions are a form of early skin cancer that should be removed to avoid further transformation into skin carcinomas. Consistent with these considerations, removal of the patients actinic keratosis lesions, not the non-inflamed seborrheic keratoses, are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old male who has end-stage COPD requiring continuous supplemental oxygen. He is receiving long-term treatment with steroids and frequent treatment with oral antibiotics. The patient is also Hepatitis C positive.  The record indicates the patient has been evaluated for a single lung transplant at two transplant centers and both determined he was not a candidate due to his Hepatitis C status. The patient then consulted with the Cleveland Clinic, which apparently has accepted him as a single lung transplant candidate. This is a patient with end stage lung disease who also has hepatitis C. At issue is whether the patient is a candidate for a lung transplant.  Three reasons were stated as to why the patient may not be a candidate despite meeting all other criteria to be listed as a candidate.  The prime reason is the presence of Hepatitis C in the patient.  A secondary reason, related to the Hepatitis C is a question raised regarding the patients status to receive immunosuppressive therapy. The third was a specific reason at the Cleveland Clinic, that being a lack of social support.The mere presence of Hepatitis C is not a contraindication for receiving a lung transplant.  As described by the enclosed information from the Cleveland Clinic, they have performed lung transplants in more than ten patients with Hepatitis C and have reported their favorable results.   In a survey of UNOS lung transplantation facilities published in 1999, 72% of programs considered Hepatitis C seropositive patients for transplantation.  55% of the programs then accepted lungs from seropositive donors (Cotler, Jensen, and Kesten).  In a more recent publication, Hartwig, et. al. recommended that more programs use Hepatitis B and C positive donors as a means to increase the available organs for lung transplantation.There is no evidence in the record presented that provides a concern regarding immunosuppressive therapy. Patients with Hepatitis B, Hepatitis C, HIV and liver diseases receive transplants. Modulating the dose of immunotherapy may be required. Patients who have liver disease including Hepatitis C are currently receiving kidney, liver, and heart transplants.  The patient has stated, and it would be true if the patient has been listed, that the concern about social support is no longer valid. The decision of whether a given patient is a candidate is determined by the individual transplant center and their specific protocols.  The patient has been accepted by one such transplant center. The transplantation of lungs to patients with Hepatitis C is not experimental or investigational in general and not for the Cleveland Clinic. The experience of the Cleveland Clinic has been reported and is positive for lung transplantation in patients such as this patient.  Based upon the information set forth above, I have determined that the requested procedure is medically necessary and appropriate for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an eight-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD) who has recently been treated with EEG biofeedback therapy. The parents request for reimbursement for the biofeedback therapy has been denied on the basis that the therapy was not medically necessary for treatment of the patients ADHD.To date, there is insufficient evidence supporting the use of biofeedback therapy for the treatment of ADHD. Randomized controlled group studies are needed in order to provide an accurate estimate of the percentage of patients who demonstrate gains. Convincing, statistical results of such studies have not been published to date. Meanwhile, pharmacological treatment is quite successful for most patients. Though children would be better served with non-pharmacological methods, until statistically valid results supporting the efficacy of biofeedback therapy are obtained from large numbers of patients, accepted pharmacological treatment should be utilized. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for whole exome sequencing (WES) for his treatment of cerebellar ataxia, spasticity, dystonia, and tremor of unknown cause.Findings: Three physician reviewers found that the medical studies do not support the requested services in this clinical setting. At this time, whole exome sequencing WES has been reported to be diagnostic in 26% of patients. This patient has already had testing of the genes most commonly associated with ataxia, with no genetic cause found. As such, in this patients case, whole exome sequencing (WES) is not likely to provide an additional benefit in finding a diagnosis, especially as his providers feel a structural etiology may be involved. Accordingly, the documentation provided does not indicate that whole exome sequencing (WES) would be beneficial for this patient as a clinical test. Therefore, WES is not likely to be more beneficial than other methods for the evaluation of this patients medical condition. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in medical genetics and genomics 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 patient has requested authorization and coverage for proton beam therapy. There are currently inadequate high quality clinical outcomes published in the peer-reviewed medical literature to support the long-term safety and efficacy of proton beam therapy for the management of potentially resectable head and neck cancer, as compared to standard of care photon-based radiation therapy. Proton beam radiotherapy is the subject of ongoing prospective randomized clinical trials in this patients clinical setting, for which this patient may be eligible for enrollment. The American Society for Radiation Oncology (ASTRO) does not recommend proton beam therapy in this patients setting outside the context of a clinical trial. The National Comprehensive Cancer Network (NCCN) guidelines support the use of photon-based radiotherapy in the form of intensity modulated radiation therapy (IMRT) for management of this patients invasive squamous cell carcinoma of the tongue base. All told, the requested proton beam 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 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: An enrollee has requested Sovaldi for treatment of the enrollees chronic hepatitis C virus genotype 3a.  Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. The recommendations apply regardless of fibrosis stage. The guidelines do not recommend Sovaldi with ribavirin any longer for genotype 3. This is based on the significantly higher effectiveness of two other regimens (Nelson, et al; Foster, et al). For these reasons, Sovaldi for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees homozygous 9p21. Findings:  Two physician reviewers found that the patient had dyslipidemia and reported homozygous for 9p21 associated with increased cardiovascular risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), myeloperoxidase, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Two physician reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.