Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 25-year-old male enrollee has requested an osteochondral allograft and a meniscal allograft for the treatment of his left knee pain. Findings:  Two physician reviewers found that the submitted clinical evidence demonstrates that the patient is an appropriate candidate for osteochondral allograft and meniscal allograft. The presence of instabilities or misalignments are relative contraindications to the proposed procedures unless they are combined with corrective osteotomies. Although there is no final comment as to the alignment of the limbs by the patients orthopedist, the patients radiologist does state that there is satisfactory alignment. The patients knee is also stable; there is no discussion of any anterior cruciate insufficiency. While the literature to date is lacking in terms of long-term data on outcomes and risks associated with the proposed procedures, there is sufficient evidence demonstrating that this is the best treatment option available in this particular setting. Upon review of the entire clinical situation, especially considering this patients age of 25, total knee replacement or hemi-arthroplasty is not an acceptable alternative procedure. The evidence-based literature and the cumulative expert opinion support a decision that the planned procedures are likely to be superior to any available standard therapy in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested an EBCT coronary artery scan for an evaluation of his cardiovascular risk. Findings:  Three physician reviewers found that the medical records provided indicate that the patient has high cholesterol. The patient is reportedly under stress and has a family history of heart disease, although the age of onset is not provided. At this time, none of the available literature states that EBCT coronary artery scan is superior to standard testing, namely nuclear stress testing. Rather, this is an additional testing option. Although EBCT for evaluation of coronary artery disease is becoming a more frequently used modality, it was not likely to be superior to alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an additional ten (10) hours per week of applied behavioral analysis (ABA) therapy (a total of 25 hours per week for treatment of the autism spectrum disorder.   Findings:  The physician reviewer found that the efficacy of ABA therapy in improving maladaptive behaviors in patients with autism is well supported in the peer-reviewed literature. Granpeesheh and colleagues assessed the effects of age and treatment intensity in behavioral outcomes for children with autism. The authors concluded that Our data indicated that the number of treatment hours and the childs age showed a linear relationship with the number of mastered behavioral objectives. The highest age group (7-12 yrs) did not show significant relationship between treatment hours and number of behavioral objectives mastered. Participant in this age group showed a relatively flat line in that approximately 17 behavioral objectives were mastered each month regardless of if the child was receiving high or low treatment hours. In this case, the patient started ABA therapy at 13 years of age. Although the primary goals of treatment in the areas of aggression and compliance were not met, the patients overall performance has remained steady. In addition, aggression occurred at a range of 0 to 1.0 per hour over a three month period. The Health Plans authorization of 15 hours per week is medically reasonable in this clinical setting. All told, the request for an additional ten (10) hours per week of ABA therapy (a total of 25 hours per week) are not medically necessary for treatment of the 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 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 anterior lumbar interbody fusion at L4-S1 for treatment of his degenerative disc disease at L4-5 and L5-S1.   The physician reviewer found that overall there is a lack of evidence from controlled trials that spinal fusion alone is effective for treating acute low back pain in the absence of spinal fracture, dislocation or spondylolisthesis with instability. In this case, there is no degenerative spondylolisthesis documented and there is no evidence of instability. In addition, there is no radicular pain below the knee or objective findings of radiculopathy in the lower extremities. Moreover, the imaging studies do not show any nerve root compression. All told, the evidence based guidelines do not support the requested fusion from L4 to S1 as medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Findings: This patients records document a history of obesity, hypercholesterolemia, and a family history of coronary artery disease. The patient started treatment with Wegovy with reported satisfactory results as evidenced by loss of 19 pounds. The provider has recommended continued treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk. Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying. Ozempic and Wegovy are both brand name products containing the same active ingredient, semaglutide. Given this support, the requested Wegovy is medically necessary for 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 subspecialty certification in endocrinology, diabetes, and metabolism 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 gene testing for evaluation of her medical condition. Findings:  Three physician reviewers found that, although pharmacogenomic testing shows promise, it is not being widely used in clinical practice at this time.  In this case, it does not appear the results of the testing would have been helpful in the treatment of this patient.  Specifically, the medications she is currently receiving have low genetic impact, indicating that she should respond to them in the standard way.  Furthermore, the submitted clinical notes do not describe how this testing would affect the patients medical treatment.  Therefore, the superior efficacy of gene testing has not been established.  Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in psychiatry 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Latuda for treatment of her behavioral health condition. Findings:  The physician reviewer found that Latuda is an atypical antipsychotic agent initially approved by the United States Food and Drug Administration (FDA) for the treatment of schizophrenia, subsequently Latuda gained an additional indication for the treatment of bipolar illness. Although Latuda has demonstrated preliminary positive outcomes for mixed depression, the lack of additional well-designed, adequately-powered replicative studies demonstrating safety and efficacy tempers the value of these initial findings. Further, Latuda is not FDA approved for major depressive disorder nor recommended by the most recently published clinical practice guideline for treatment of unilateral depressive illness. Considering that the patient has not been treated with and failed well-established augmentative strategies, such as buspirone, quetiapine, olanzapine-fluoxetine, lithium or thyroid hormone, the requested Latuda is not medically necessary for treatment of this patients medical condition. 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested therapy. ABA therapy is the standard of care in the therapeutic intervention of autistic children and the documentation submitted for review has confirmed a diagnosis of autism. According to the physicians Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Therefore, ABA therapy is medically necessary and should be provided for this patient.Final Result: Two reviewers determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Upheld

A 58-year-old female has requested coverage for herpes zoster (shingles) vaccine for treatment of her suppressed immune system status post chemotherapy and radiation therapy.  Findings:  The physician reviewer found that recommendations from the Centers for Disease Control (CDC) indicate that the herpes zoster vaccine is indicated for all patients ages 60 and over. In addition, the Advisory Committee on Immunization Practices (ACIP) statement notes that the vaccine is not recommended for patients under age 60 because there is little data about use in this age population. Further, there are no conditions under which CDC recommends administration of vaccine to those under 60 years of age including patients who are immunocompromised or being treated for malignancies, as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested an MRI of the lower extremities (feet/ankles) for evaluation of her bilateral foot pain. Findings:  Two physician reviewers found that this patient has disabling bilateral foot pain.  Her underlying diagnosis is consistent with unknown connective tissue disorder.  Her symptoms may reflect plantar fasciitis, but also could reflect other inflammatory conditions.  MRI is the best imaging choice with which to evaluate this patient in order to obtain a diagnosis and allow the clinicians to form a treatment plan which may be of benefit for her.  No other imaging test will offer as much information.  All told, the requested MRI of the lower extremities is likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old female has requested coverage for a past positron emission tomography/computed tomography (PET/CT) scan for evaluation of her status post stage 2B breast cancer.  Findings:  Two physician reviewers found that the patient has a BRCA-1 genetic mutation, and was found to have triple negative invasive ductal carcinoma of the breast four years ago. Two out of 13 axillary lymph nodes were positive for tumor. The patient underwent a bilateral mastectomy and bilateral salpingo-oophorectomy. She has undergone a PET/CT scan in the past. She presented in the past year with new hip pain.  A PET/CT scan was performed as a restaging tool since the patients hip symptoms were new. The Health Plan denied the PET/CT indicating that the National Comprehensive Cancer Network (NCCN) guidelines do not recommend PET/CT for restaging of breast cancer.The use of PET/CT in the restaging of breast cancer is the subject of debate in some centers with many oncologists advocating its use for restaging of breast cancer particularly when new symptoms develop. This patient has a history of triple negative breast cancer with positive lymph nodes discovered at surgery. With a new onset of hip pain, the obvious concern would be of osseous metastasis and restaging at this stage would be reasonable. The National Oncology PET Registry (NOPR) recommendations allow for coverage of PET/CT scans in breast cancer patients where new treatment is contemplated if recurrence or metastasis develops. This policy was adopted by the Centers for Medicare & Medicaid Services (CMS) in April 2009 at which time the utility of PET scans was broadened significantly. In addition, the Health Plans medical policy regarding PET scans states under the category of breast cancer Positron Emission Tomography is considered medically necessary for the subsequent treatment (restaging and recurrence) of breast cancer. All told, the PET/CT scan at issue was medically reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old male has requested a continuous glucose monitoring system (CGMS) for type I diabetes.  Findings:  Three physician reviewers found that although there are no substantial studies to demonstrate the utility of continuous glucose monitoring in preventing severe hypoglycemia, clearly the warning system would be helpful during the patients hypoglycemic or hyperglycemic episodes. Frequent finger-stick blood glucose monitoring cannot be performed at sufficient intervals to avoid severe hypoglycemia, particularly at night. Given the patients clinical history, it was determined that the requested equipment is likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for Xolair for treatment of her asthma. Findings:  The physician reviewer found that the FDA approved indications for Xolair include moderate to severe persistent asthma in patients who have a positive skin test or in-vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and a pre-treatment total IgE level of 30 or greater.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old man with a well-documented diagnosis of very symptomatic chronic urticaria. Treatment with Benadryl, Claritin, Allegra, and other over-the-counter antihistamines was ineffective. Treatment with Zyrtec was effective. The patient experienced immediate relief of his symptoms with Zyrtec. The patient wishes to continue use of Zyrtec. The Health Plan indicates the submitted information does not demonstrate that Zyrtec is medically necessary for treatment of the patients urticaria.Zyrtec is medically necessary for treatment of the patients condition. The submitted information indicates the patient is currently using Zyrtec and is stable on the medication with no adverse effects.  In addition, there is evidence that Zyrtec has proven effective for this patient. Furthermore, there is documented evidence that other antihistamines have not been effective. Continued use of Zyrtec is medically reasonable and appropriate and indicated in this case. Therefore, I have determined that 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: Overturned

The parent of a two-year-old male enrollee has requested coverage for speech therapy services for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that a literature review by Goldstein examined empirical studies evaluating speech and language intervention procedures applied to children with autism. The author found that speech and language therapy incorporating sign language, discrete-trial training, and milieu teaching procedures have been used successfully to expand the communication repertoires of children with autism. For these reasons, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested sclerotherapy for treatment of his varicose veins. Findings:  Two physician reviewers found that bleeding from a ruptured varicose vein can be quite significant, and interruption of the offending vein is indicated. A review of the medical literature reveals that obliteration of a vein can typically be achieved by surgical excision or chemical ablation (sclerotherapy). Rigby and colleagues concluded that there was insufficient data to recommend the use of surgery over sclerotherapy, or vice versa, due to similar outcomes. The patient and provider in this instance chose sclerotherapy due to time constraints and the patients work concerns. Given the immediacy of the need for treatment, this was a medically reasonable and appropriate option. Therefore, in this clinical setting, sclerotherapy was more beneficial for the patients medical condition than available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for a Zoll LifeVest (wearable cardioverter defibrillator). The enrollee has a complex medical history, including multiple gastrointestinal issues, hyperthyroidism, chronic pain, long Q-T syndrome and bradycardia. The enrollee was admitted to an inenrollee unit due to a syncopal episode. She was started on nadolol and was provided a Lifevest. This enrollee does have a history of confirmed long QT interval type 1, which has been asymptomatic. She has a complicated past medical and past surgical history and has been taking some medications with syncope listed as a side effect. Literature does not support the use of the Zoll LifeVest in this setting.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for extracorporeal shock wave therapy for treatment of her plantar fasciitis.  Findings:  Two physician reviewers found that while ESWT for treatment of chronic proximal plantar fasciitis is FDA approved, the effective rates quoted in the medial literature (50-65%) are considerably lower than other available alternatives. Other treatment options that have not been exhausted by this patient include: local steroid injections to the heel; custom orthotics; physical therapy including phonophoresis and ultrasound; and possibly endoscopic plantar fasciotomy. These treatments generally carry a 90% cure rate; therefore, ESWT is not likely to be more effective for treatment of the patients plantar fasciitis than standard treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for partial hospitalization program (PHP) services. Applying the Community Psychiatrists Level of Care Utilization System to determine the necessary and appropriate level of care for adults, this patient does not meet the criteria for PHP services. The patient has a composite score of 10. This correlates with treatment in a community-based outpatient clinic setting. Therefore, PHP services are not medically necessary for the 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 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.