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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 25 hours per week of direct one-to-one applied behavior analysis (ABA) services (CPT 97153). This patient has made considerable progress. His Vineland 3 scores have all improved since baseline, with an adaptive behavior composite score of 72. This score places him within two standard deviations of the mean, or the moderately low range. Overall, this is an improvement compared to baseline, an indication that the gap between the patient and his same-aged peers is gradually closing. Further, the patient has several goals listed in the treatment plan involving reduction in problem behavior. However, the treatment plan has listed the severity of the behaviors in the low range, with the exception of elopement. These behaviors have also decreased over previous treatment periods, indicating the patient continues to make progress, albeit with fewer treatment hours. A letter from the provider indicated that since the treatment was reduced at the start of the year, there was a relatively small spike in problem behavior likely due to the addition of several new peer contexts that he could not access before due to the frequency and intensity of his problem behavior. Considering this information, the patient is responding to treatment, his goals do not reflect a need for greater intensity, and the patient has not demonstrated a need for a greater intensity of service delivery. The Health Plan has authorized 20 hours per week of direct one-to-one ABA services, which is appropriate given this patients progress and remaining goals. Thus, the requested 25 hours per week of direct one-to-one ABA services (CPT 97153) are not medically necessary for treatment of this patients autism. 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 psychology and is a board certified behavior analyst 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

Physician 1:  The patient is a 36-year-old female with cervical pain and swelling at the base of the neck. The etiology of her pain is not known. The patient reports that after two prolotherapy sessions she experienced improvement in her symptoms. She has requested authorization for six prolotherapy sessions, which the Health Plan has denied on the basis that the therapy is considered experimental.There are many different protocols of prolotherapy with no current obstructive data to define the dose, ingredients or frequency of injections to obtain tightening of ligaments. Additionally, the safety of prolotherapy is unknown. Furthermore, the patient has not exhausted standard therapies such as myofascial release, trigger point injections, electrical stimulation, etc. Therefore, 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. The Health Plans denial should be upheld.Physician 2:  The patient is a 36-year old female with neck pain of unknown etiology. She reports that treatment with medications, physical therapy, massage and acupuncture did not provide long-term relief. The patient believes prolotherapy has been helpful and therefore requests authorization and coverage for the therapy. The Health Plan has denied this request. The peer-reviewed literature has not clearly demonstrated the safety or effectiveness of prolotherapy from a basic science or clinical outcomes standpoint when compared to placebo in randomized, controlled trials. Prolotherapy is not a generally accepted medical intervention and not among the standard of care interventions for chronic neck pain. 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. The Health Plans denial should be upheld.Physician 3:  This patient is a 36-year-old female with a history of chronic neck pain for over one year for which she has had various physical therapy and chiropractic treatments. The neurology evaluations, and MRI and other studies have not shown definite pathology. At issue is coverage of prolotherapy by the Health Plan.A critical review of prolotherapy in the treatment of osteoarthritis, neck pain and other musculoskeletal conditions reveals that the clinical efficacy of the therapy remains inconclusive.  Although the patient reported pain relief, the use of prolotherapy for pain control is still considered investigational and it is not consistent with the current standard of care. There is no reliable evidence demonstrating that prolotherapy is more effective than standard care. Therefore, 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: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for Botox injections for treatment of his condition.   Findings:  Two physician reviewers found that the Botox treatment pattern does not address the usual muscles for dystonia, but rather are more typical of sites used for treatment of migraine. The medical records do not address the frequency, severity or qualities of the patients pain, nor does it address the response to various treatments, including Botox. There is insufficient evidence to support the diagnoses of oromandibular dystonia or chronic migraine.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 has requested authorization and coverage for a Synvisc-One injection to the left knee. The patient has been diagnosed with left knee osteoarthritis. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent benefit from a prior viscosupplementation injection. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection to the left knee is medically necessary for the treatment of this patientFinal 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cystic fibrosis gene analysis. The American College of Obstetricians and Gynecologists (ACOG) states that, complete analysis of the CFTR gene by DNA sequencing is not appropriate for routine carrier screening. The ACOG noted that, this type of testing generally is reserved for patients with cystic fibrosis, patients with negative carrier screening result but a family history of cystic fibrosis. In this case, with an affected mother, gene sequencing is also appropriate. Other forms of single gene mutation or panel testing would have likely missed the important mutation in this patient. Therefore, the cystic fibrosis gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the cystic fibrosis gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the cystic fibrosis gene analysis 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most 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 nonliver-related conditions. The guidelines report that patients with cirrhosis such as this patient are highest priority for therapy. Per the guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Furthermore, the AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 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: Overturned

The parent of a one-year-old male enrollee has requested for magnetic resonance spectroscopy (MRS) for evaluation of the enrollees microcephaly, developmental disorder and possible metabolic disorder. Findings:  Two physician reviewers found that performing a MRS is a reasonable diagnostic test, in keeping with best medical practices, in order to rule in or out this condition.  There are a number of well-recognized biochemical abnormalities that can arise from impaired mitochondrial metabolism in the central nervous system.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested a CT angiogram for his chest pain.   Findings:  Three physician reviewers found that other approved alternatives could have been considered such as stress echo or single photon emission computed tomography (SPECT) imaging. In addition, there is no documented data to suggest a change in outcomes in this subset of patients. Currently, the CT angiogram is not a substitute for cardiac catheterization or nuclear SPECT imaging. The CT angiogram is not supported by the American Heart Association and a consensus statement in 2006 stated that the test is not ready for widespread use at the time. Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, and the need to use contrast, potentially nephrotoxic dye, as well as the radiation exposure. Furthermore, the clinical trials have been small.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule.Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Final Result: Three reviewers determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A forty-one year-old male with a right submandibular adenoid cystic carcinoma is requesting authorization for neutron beam therapy.Reviewers Findings:  Two of the reviewing physicians found that neutron beam therapy in this clinical setting is medically appropriate and indicated and is likely to result in a better outcome for this patient.  The third reviewing physician found that there is no evidence neutron beam therapy is more efficacious than external beam irradiation with photons and electron beam irradiation boost.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a monthly injection of Simponi 50 mg for treatment of the enrollees psoriatic spondylitis. Findings:  The physician reviewer found the request for a monthly injection of Simponi 50 mg is not medically necessary for treatment of the patients medical condition. According to the records submitted for review, there is a lack of documentation demonstrating that the patient has tried and failed both Humira and Enbrel. Based on the medical records provided for review and lack of failure of Humira or Enbrel, the requested medication is not supported as medically necessary for treatment of the patients psoriatic spondyloarthropathy. 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 rheumatology 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

An 18-year-old male enrollee has requested laser treatment (photodynamic therapy) for treatment of his acne.   Findings:  Three physician reviewers found that riddle and colleagues performed a review of 21 clinical trials and noted the benefit of photodynamic therapy in the reduction of inflammatory lesions and a significant improvement in acne.  However, the authors noted that further studies are needed before a consensus protocol can be established.  Pierard-Franchimont and colleagues concluded that the relative effectiveness compared with other treatments is unconfirmed.  A split-face study of 44 patients using photodynamic therapy was performed by Orringer and colleagues. The authors found only 30% of patients were deemed responders to this treatment with respect to improvement in inflammatory lesion counts, while only 7% of patients responded in terms of non-inflammatory lesion counts. Further studies are required to increase knowledge and clinical usefulness of this treatment method. In this patients case, the requested services are not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and substance use treatment program services for treatment of his polysubstance abuse and anxiety. Findings:  The physician reviewer found that the progress notes indicate the patient did not have recent intensive treatment prior to the RTC services at issue. The progress notes report that he did not have any suicidal ideation, psychosis or homicidal ideation. He was cooperative in treatment and was progressing in the residential treatment plan. According to the American Society of Addiction Medicine (ASAM) criteria for level of placement, this patient was a candidate for intensive outpatient program (IOP) services. The patients emotional/behavioral or cognitive conditions and complications suggest the patient had a risk rating score of 1 indicating mild issues that are stable. In addition, the patients recovery/living environment suggest the patient had a risk rating of 1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores in the 0 to 2 range. This overall risk rating recommends the patient be treated with IOP services for nine or more hours of service per week. IOPs allow individuals to remain in their own homes and communities, which may improve their adjustment to community life. Researchers noted that IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. Public and commercial health plans should consider IOP treatment as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness. 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 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 parents of a ten year-old male with short stature are requesting reimbursement for previous Growth hormone (GH) therapy and authorization for continued treatment with GH therapy.Reviewers Findings:  The reviewing physician found that it would seem probable that the patient has a constitutional delay in growth and is likely to gain a normal height without assistance.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for excision of a skin lesion for treatment of her benign cherry angioma.  Findings:  The physician reviewer found that Messenger and colleagues note that other lesions can mimic cherry hemangiomas and that treatment of these superficial lesions can be as simple as shave excision followed by electrodessication. Removal of a benign skin lesion may be medically necessary when the lesion has one or more of the following characteristics: bleeding, intense itching, and pain. Removal may be further medically indicated if the lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.