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

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested reimbursement for 40 hours per week of applied behavioral analysis (ABA) therapy. Studies show that, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the current medical literature and this patients clinical history and presentation, comprehensive ABA therapy was appropriate. However, there is a lack of objective data to suggest 40 hours of ABA would have led to more gains than 30 hours per week. Moreover, recent research on ABA therapy frequency suggests moderate gains can be made with less intensive services in some individuals. In this case, the goals targeted during the 2017 authorization period do not demonstrate that the patient exhibited behaviors or deficits in skills warranting 40 hours per week of medically necessary ABA therapy. All told, the 40 hours per week of ABA therapy were not medically necessary for treatment of the patients medical condition.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 a board certified psychologist 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: Medical Necessity
Decision: Upheld

A male enrollee with a diagnosis of plantar fasciitis and hypertension. An examination dated reported that the patient complained of pain to the second and third toes and the right foot when walking. The patient is noted to be using orthotics currently as well as ice as needed for pain. The patients plantar fascia is noted to be stable according to the examination. There was no physical exam of the foot during the office visit. X-rays of right foot that were taken revealed no fracture or joint space abnormality. The soft tissues are normal. The patient has used orthotics for roughly six years according to a note written by the patient. He advised that for six years he has received new orthotics for plantar fasciitis, which inhibited his normal comfortable ambulation. It has been recommended that patient obtain a new pair of custom orthotics. This has been denied by the health plan as not medically necessary. At issue is whether orthotics are medically necessary for treatment of this patients medical condition. There are certain foot structures that require orthotic therapy in order to maintain a neutral position, therefore deferring the onset of plantar fasciitis. However, there is no biomechanical examination to advise that this patient has such a foot structure. Current medical documentation does not support the need for orthotics in this clinical setting. It has been recommended that the patient obtain a new pair of orthotics for a diagnosis that was made over six years ago. However, there is no documentation that a physical examination has been performed on the foot within the past year. There is no biomechanical evaluation of the foot and no current radiographic abnormality of the foot. Due to the lack of medical documentation and medical evaluation of this patients foot, the requested orthotics are not medically necessary for treatment of this patients medical condition.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 podiatry 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 72-year-old male enrollee has requested Harvoni 90/400 mg. for treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD and IDSA guidelines further state, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. Therefore, regardless of fibrosis score, per guideline recommendations, the requested Harvoni medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 Units injected twice a week. The American College of Rheumatology (ACR) guideline recommends methotrexate (MTX) with or without a tumor necrosis factor inhibitor (TNFi) as the next treatment in those who have failed MTX alone. There are also multiple studies demonstrating the efficacy and safety with TNFi in treating moderate to severe rheumatoid arthritis (RA). Further, there is evidence that a second TNFi may be effective in patients who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. Given safety data and efficacy rates, a second TNFi with or without MTX is recommended over tofacitinib. At this time, the guidelines recommend a trial of two different TNFi prior to trying another agent. Moreover, the guidelines do not recommend Acthar Gel for the treatment of RA. There are a few small studies demonstrate efficacy of Acthar Gel, but further studies are necessary prior to its routine use. In this case, the records fail to demonstrate that the patient is refractory to all standard RA treatments. As such, the request for Acthar Gel 80 Units injected twice a week is not medically necessary for treatment of this patients RA.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 subspecialty certifications in allergy and immunology and 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: Urgent Care
Decision: Overturned

A 30-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that this patient had a recent history of being treated for a urinary tract infection (UTI) with complaints of rapid onset bladder spasm and gross hematuria prior to admission to the emergency department. The patient reported her pain level at 9 on a scale of 1 to 10 at triage. The emergency physician did a urinalysis which showed evidence of pyuria and hematuria. She was discharged with a diagnosis of cystitis (UTI) and provided a prescription for Macrobid and pain medicine. This case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. The patient rated her pain as 9 of 10 on initial presentation in association with gross hematuria. The patients pain level or the blood in urine alone would have been a sufficient basis for a layperson to consider this patients condition to be an emergency. She had a history of urinary tract infections including pyelonephritis and had been told in the past by a medical professional to seek immediate medical attention for similar symptoms to prevent progression to pyelonephritis. Thus, a prudent layperson would have been appropriately concerned for her imminent health under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. 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 anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for genetic testing to determine if he has a form of trisomy 8. Since 2010, chromosomal microarray (CMA) has been recognized as standard of care for assessment of individuals with neurodevelopmental disorders, including autism spectrum disorders and intellectual disability. While the specific test requested to identify potential mosaic trisomy 8 is not described in the provided records, CMA would be the recommended and the most sensitive test to evaluate for this and other potential genetic causes of this patients neuropsychiatric concerns. More recently, it has been recognized that genetic diagnoses identified in those with neurodevelopmental disorders by CMA can impact recommended management. An enrollee has requested authorization and coverage for genetic testing to determine if he has a form of trisomy 8. Since 2010, chromosomal microarray (CMA) has been recognized as standard of care for assessment of individuals with neurodevelopmental disorders, including autism spectrum disorders and intellectual disability. While the specific test requested to identify potential mosaic trisomy 8 is not described in the provided records, CMA would be the recommended and the most sensitive test to evaluate for this and other potential genetic causes of this patients neuropsychiatric concerns. More recently, it has been recognized that genetic diagnoses identified in those with neurodevelopmental disorders by CMA can impact recommended management. Henderson and colleagues found that positive (abnormal) results of CMA had management implications for more than half of patients (54.5%), including in 42.1% of those with isolated neurodevelopmental disorders. The medical evidence supports genetic testing in this clinical setting. Therefore, genetic testing to determine if the patient has a form of trisomy 8 is medically necessary. found that positive (abnormal) results of CMA had management implications for more than half of patients (54.5%), including in 42.1% of those with isolated neurodevelopmental disorders. The medical evidence supports genetic testing in this clinical setting. Therefore, genetic testing to determine if the patient has a form of trisomy 8 is medically necessary.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested for Lyrica for treatment of her migraine headaches. Findings:  The physician reviewer found that there is insufficient data demonstrating the efficacy or long-term safety of Lyrica for chronic headache conditions. To date, there has only been one small open-label trial demonstrating its potential. This data has not been confirmed with a randomized clinical trial. There are multiple therapies that have class A or B evidence supporting their use for treatment of headaches.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for five hours per week of intervention using the PLAY project intervention model. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that for an individualized ABA treatment plan, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. Solomon and colleagues report that PLAY project therapy is based on a developmental, individual differences, and relationship-based (DIR) theoretical framework, operationalizing DIR through a structured approach that includes coaching, modeling, and video feedback. However, there is an overall lack of research on DIR based therapies to establish its efficacy. Current evidence-based practices for the management of patients with autism do not include PLAY project therapy or DIR- based therapies. In this clinical setting, given the limited evidence in current medical literature on the effectiveness of PLAY project therapy, the requested services are not medically indicated. In this patients case, five hours per week of intervention using the PLAY project intervention model are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, five hours per week of intervention using the PLAY project intervention model are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Positron Emission Tomography (PET) with concurrently acquired Computed Tomography (CT) Scan.Findings: Two out of three physician reviewers found that the current medical evidence does not support the requested service in this clinical setting. NCCN and ACR guidelines state that PET/CT is not useful in Stage 1 noninvasive parotid tumor follow up or initial stage imaging. PET/CT is more useful with invasive tumors that are T3/T4. These guidelines recommend follow up imaging in Stage 1 by CT and MRI. A study by researchers also describes the limited benefit of PET/CT in detecting head/neck cancer recurrence after initial treatment. This study also suggests that negative 3-month scans led to no significant differences in subsequent survival outcomes in patients whose recurrences were detected through PET/CT versus those with clinically detected recurrences. In this case, although there was some question of positive margins, the patients follow up radiation oncology consultation stated that the margins were close though negative. The patient also did not require radiation therapy due to her low staging. Her tumor pathology was low grade mucoepidermoid. Under these circumstances, NCCN and ACR guidelines indicate that further imaging with CT or MRI is more appropriate than PET/CT. PET/CT is more useful with invasive tumors that are T3/T4, though the patient does not fit this criterion. Accordingly, the requested Positron Emission Tomography (PET) with concurrently acquired Computed Tomography (CT) Scan is not likely to be more beneficial than any other available standard treatments for the patient's medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology, and interventional radiology and diagnostic radiology, and is actively practicing. Physician reviewer 3 is board certified in diagnostic radiology 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: Upheld

The parent of a six-year-old male has requested Tomatis Listening Therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS).  Findings:  Three physician reviewers found that Tomatis Listening Therapy falls into the category of auditory integration training. It uses electronically modified voice and music to ameliorate auditory processing deficits and improve concentration. According to the current literature, including a systematic review of existing studies, there is insufficient evidence to support the use of Tomatis Listening Therapy in this patient population (Sinha, et al.). One recent brief report stated, the results reflect a lack of improvement in language using the Tomatis Method for children with autism. (Corbett, et al.) In sum, the peer-reviewed literature does not currently support use of the Tomatis Listening Method as an efficacious treatment modality for children with autism spectrum disorders. Therefore, the proposed therapy is not likely to be more beneficial than other available therapies for treatment of this patients PDD-NOS.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the F5 (coagulation factor V) hereditary hypercoagulability gene analysis.  Deep vein thrombosis and pulmonary embolism may be caused by hereditary thrombophilias. In the clinical setting of increased risk, complications may be prevented by appropriate interventions. There is strong medical evidence supporting factor V Leiden testing in this patients case. The testing as ordered was appropriate in order for preventative measures to be implemented for this patient to help prevent potential complications. Given this support, the F5 (coagulation factor V) hereditary hypercoagulability gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three reviewers determined that 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 overturned. Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested a continuous glucose monitor for treatment of her type 1 diabetes.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested equipment in this patients case.  Per the submitted records, this patient has wide glucose fluctuations.  The current medical evidence indicates that an insulin pump with continuous glucose monitoring can improve diabetes management, especially by avoiding hypoglycemia.  There is sufficient evidence indicating that consistent use of a continuous glucose monitor benefits patients with type 1 diabetes.  The requested equipment is likely to result in improved control of the patients glucose levels.  All told, the requested continuous glucose monitor is medically indicated for the treatment of this patient.