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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing performed. The Health Plan has denied this request indicating that the requested testing was not medically necessary for treatment of the enrollees autism; attention deficit hyperactivity disorder (ADHD); cognitive deficits; learning disability; sensory processing disorder; motor deficits; and speech and language disorder. At issue in this case is whether the requested neuropsychological testing provided was medically necessary for treatment of the enrollees medical condition.Determining the neurocognitive profile through neuropsychology testing is medically necessary in the care of individuals with autism, ADHD and accompanying comorbidities for several reasons. To begin, neuropsychology testing can be used to identify core processing speed deficits and executive functioning errors. This information can then be used to better understand how to proceed pharmacologically, and also provides valuable baseline information which can be used to gauge treatment effect as noted by colleagues. Not only does neuropsychology testing inform pharmacotherapy, but can also be used as therapy itself. Colleagues reported in a recent study on neuropsychology testing, frontal/executive programming was used in individuals with autism, and was shown to be effective in improving impaired executive functioning in autism spectrum disorder patients and may also lead to improvements in some aspects of social functioning. Lastly, the use of neuropsychology testing in individuals with an autism spectrum disorder (ASD) and comorbid ADHD demonstrate significant clinical heterogeneity. In a recent study, significant differences in the neuropsychological characteristics of children with ASD + ADHD compared to those with ASD only was observed. Children with ASD + ADHD showed higher symptoms of anxiety, worse working memory, and less empathy. This suggests that having ADHD brings further challenges to individuals with ASD and may negatively impact their management and outcome. Utilizing this information allows for more targeted pharmacotherapy, effecting clinical outcomes as indicated by colleagues. It is for these reasons that neuropsychology testing was medically necessary in this case. Final Result: The reviewer determined that the requested services 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per 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. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. However, the published literature and AASLD/IDSA guidelines do not support Harvoni over Viekira Pak in this case. Thus, the requested Harvoni for eight weeks is not supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested a chemotherapy regimen to include nine visits/injections of Herceptin for treatment of her metastatic clear cell ovarian cancer. Findings:  Two physician reviewers found that Herceptin has been approved by the Food and Drug Administration (FDA) for the adjuvant treatment of HER2-overexpressing breast cancer. It has not been FDA approved for the treatment of ovarian cancer. Nor is Herceptin included in expert consensus panel recommendation for patients with recurrent ovarian carcinoma. Currently, there is a paucity of data concerning the use of Herceptin in ovarian cancer. Large scale phase three and four studies are lacking at this time. As a result, there is insufficient outcome data demonstrating that Herceptin is likely to be of any clinical benefit in this setting. The peer-reviewed clinical literature does not support the use of Herceptin in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested continued treatment with Aciphex 20mg for the treatment of his severe laryngopharyngeal reflux disease. Findings:  The physician reviewer found that the Health Plan has formulary proton pump inhibitors (omeprazole, Prevacid and Nexium) that are at least as potent and efficacious as Aciphex. The Health Plans requirement that the patient attempt an eight-week course of two of the three formulary proton pump inhibitors (omeprazole, Prevacid and Nexium) is a reasonable requirement for assessing the effect of such medication. The submitted medical records do not demonstrate that the patient has tried the preferred proton pump inhibitors for eight weeks. As such, the patient should attempt appropriate trials of two of the formulary proton pump inhibitors as recommended by the Health Plan. If the patient does not respond to the preferred proton pump inhibitors, then treatment with Aciphex 20mg would be medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested medication is likely to prevent further development and progression of fibrosis.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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

A 24-year-old female enrollee has requested a vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Three physician reviewers found that the literature lacks significant peer-reviewed papers reporting results on long-term randomized studies comparing sleeve gastrectomy to other procedures. Lap-band is universally accepted as the safest surgical procedure for morbid obesity, with studies showing excellent long-term results. Lap-band allows for the stomach to remain intact and the band pressure can be adjusted as needed without operative procedure. The 2007 American Society for Metabolic and Bariatric Surgery (ASMBS) statement reviewed sleeve gastrectomy results by many authors, but the follow-up up data are limited to three years. Lap-band has shorter operative time, less morbidity, less severe complications, shorter hospital stay and longer follow-up data available.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested thigh/lower body lift for the treatment of her excess skin condition. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the requested surgery is medically necessary for this patient. There is no evidence of a chronic functional problem that has failed to respond to conservative therapy. Furthermore, it does not appear the requested procedure is reconstructive in nature. The patient has generalized skin laxity consistent with her history of massive weight loss, which does not constitute an abnormal structure of the body. Additionally, the requested procedure would not improve function or create a normal appearance to the extent possible as the patient would still have obese thighs with cellulite and lipodystrophy. Finally, the requested surgery would offer no more than a minimal improvement in the appearance of the patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this 17-year-old male was admitted to residential treatment facility because of aggression and threatening behavior at home. On the mental status examination by the treating psychiatrist he was not found to have any active suicidal or homicidal ideation, mood disorder or psychosis which was requiring 24-hour supervision and monitoring care. This patient did have a substance abuse issue however, the records do not document that he exhibited symptoms of withdrawal or imminent withdrawal which required the residential level of care. Further, the patient was not described as showing any significant psychiatric symptoms or withdrawal risks which required this level of care. Thus, applying the treatment guidelines from the American Society of Addiction Medicine (ASAM) and the American Psychiatric Association (APA), this patient could have been treated in a lower level of care such as a partial hospitalization program or intensive than outpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections (100 units, 50 units per axilla). The records document that this patient has a history of moderate-to-severe primary axillary hyperhidrosis that is rated a score of 3 of 4 on the hyperhidrosis disease severity scale (HDSS). Per the clinic notes, and the providers letter, the patients condition is causing significant functional impairment. The patients provider has recommended continued treatment with Botox injections in the axillae. As noted in the medical literature, the treatment of patients with severe and/or refractory primary axillary hyperhidrosis must be individualized based on patient history, clinical findings, and the recommendations in the current guidelines (Gorelick and Friedman). The U.S. Food and Drug Administration (FDA) has approved Botox for the management of patients with primary axillary hyperhidrosis who have not obtained adequate relief of symptoms with topical agents. Recent literature supports treatment with Botox for patients with axillary hyperhidrosis with a score of 3 of 4 on the HDSS (McConaghy and Fosselman.). Moreover, this patient has reportedly experienced adequate clinical relief with prior Botox injections in the axillae (Nawrocki and Cha). Given the functional impairment caused by the patients condition and its severity, Botox is appropriate for treatment of the patients moderate-to-severe hyperhidrosis. Therefore, the requested Botox injections (100 units, 50 units per axilla) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 VESIcare 10 mg for treatment of the enrollees urinary urgency. Findings:  The physician reviewer found that there is sufficient support in the medical literature and in the documentation provided for the requested medication in this clinical setting. Treatment of this patients condition with VESIcare was not approved on the basis that the patient had not tried and failed the formulary alternatives. However, the records show that this patient has trialed and failed multiple medications. Instead, this patient had responded to treatment with VESIcare. It is not unusual for patients who have been diagnosed with interstitial cystitis and refractory irritative urinary symptoms to fail multimodal therapy. 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 urology 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 reimbursement for transurethral prostatic thermoablation procedure. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the services at issue in this clinical setting. The transurethral prostatic thermoablation procedure is a novel technique to treat male urinary symptoms secondary to BPH due to an enlarged prostate. The technology uses water vapor (steam) therapy to create necrosis within the transitional zone, which eventually shrinks the prostate, thereby improving urinary symptoms. A recent sham-controlled trial showed improved storage and voiding symptoms after the thermal therapy procedure. The symptoms remained significantly improved over 24 months.  However, current medical literature does not support improved efficacy of this procedure over first line therapy like transurethral resection of prostate. In addition, long term outcomes for transurethral prostatic thermoablation are largely unknown. As such, the medical necessity for the transurethral prostatic thermoablation procedure performed has not been established in this patients case. 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 urology 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 authorization and coverage for mitral valve repair with MitraClip and one day hospital stay.Findings:  Two of the three physician reviewers found percutaneous mitral valve repair using the MitraClip device has been approved by the U.S. Food and Drug Administration for high risk patients with degenerative or other primary mitral valve regurgitation. Researchers evaluated both functional and degenerative mitral regurgitation patients who were at high risk for surgical mitral valve repair. Excellent outcomes for the device were demonstrated. Per researchers, percutaneous mitral valve repair may be indicated for severely symptomatic patients with chronic severe primary mitral regurgitation who have favorable anatomy for the repair procedure but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal medical therapy. This patient does not exhibit severe symptoms. His symptoms would be considered only Class II. In addition, his Society of Thoracic Surgeons (STS) score does not classify him as prohibitive surgical risk. In sum, the requested mitral valve repair with MitraClip and one day hospital stay are not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee requested ultrasound therapy for medical treatment of her temporomandibular joint pain.Findings:  Two physician reviewers found that the requested services are likely to be more beneficial than other available treatment options.   This patient has undergone both surgical and non-surgical modalities to treat her ongoing temporomandibular joint pain.  Per the current medical evidence, ultrasound therapy used in conjunction with physical therapy is an important adjunct in pain relief.  The requested ultrasound therapy can be utilized in the management and treatment of this patients temporomandibular joint pain as an adjunct with combined modalities.  Thus, the requested ultrasound therapy is likely to be more effective than other alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a pre or very early adolescent enrollee has requested Nutropin AQ NuSpin for treatment of the enrollees idiopathic short stature.  The submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. Per the records, the patient has normal bone age, normal growth factors, normal peak GH response to provocative testing, and no known morphological abnormalities of the pituitary gland or midline brain structures. Thus, these measurements do not support that he demonstrates classic GH deficiency.  Using the Bayley-Pinneau height prediction method, the estimated adult height for this patient is within two standard deviations of his genetic target height and not short enough to warrant a trial of GH therapy for idiopathic short stature. Moreover, the Pediatric Endocrinology Society guidelines (Wilson, et al) state that a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.  However, this patient does not meet most of these criteria. All told, the requested Nutropin AQ NuSpin is not medically indicated for the treatment of this patient.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 pediatrics with sub-specialty certification in pediatric 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: Upheld

A 67-year-old male enrollee has requested for a coronary angiogram with percutaneous coronary intervention for treatment of his triple vessel coronary artery disease.  Findings:  The physician reviewer found that based on the records provided for review, the patient is a 67-year old male with diabetes, provokable silent ischemia on stress testing and three-vessel coronary disease with preserved ventricular function on angiography. The coronary lesions identified are described as amenable to bypass surgery.  In this setting, current guidelines recommend coronary bypass surgery over coronary angiogram with percutaneous coronary intervention due to improved long-term outcomes with bypass surgery in this select group. There is no documentation that coronary artery bypass surgery is either contraindicated in this patient or is associated with excessive increased risk. For patients who do not wish to undergo coronary bypass surgery, aggressive medical therapy is a reasonable alternative approach and is comparable to the requested procedure. Therefore, since coronary artery bypass surgery is the preferred treatment option in this setting and because there is an additional alternative of continued aggressive medical therapy, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the right breast (CPT 77058) for an evaluation of her abnormal mammogram. Findings:  Three physician reviewers found that the Breast Imaging Reporting and Data System (BIRAD), developed by the American College of Radiology, provides a standardized classification for mammographic studies. This system demonstrates good correlation with the likelihood of breast malignancy. The BIRAD system informs physicians about key findings and identifies appropriate follow-up and management. Review of the submitted evidence demonstrates that the patient had an MRI exam which revealed an abnormality classified as BIRAD 3, which calls for short interval follow-up (six-months). This abnormality, foci of enhancement, was only seen on the MRI exam; as such, MRI is the only modality that is appropriate to use for follow-up. Since the patients last MRI occurred over six-months ago, a repeat MRI is indicated at this time.