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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a full treatment plan for 10 hours per week of direct applied behavioral analysis (ABA) therapy, 12 hours per month of supervision and four hours per month of parent training. Findings:  The physician reviewer found that 1n this case, the medical necessity for continued ABA services has been established. The medical literature supports a higher intensity of ABA treatment for children with autism . The correlation between treatment outcomes and treatment intensity is well documented. The Health Plans authorization of 26 hours per month, which is approximately 6.5 hours per week of direct ABA therapy, eight hours per month of supervision and two hours per month of caregiver training, is less than what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient has made progress in many areas as evidenced by the progress reports over the last several years, but he continues to demonstrate impairment in several skills such as transitions and accurately interpreting the meaning of casual conversation. These persistent struggles are making it increasingly difficult for him to be successful in more generalized environments such as college. For the reasons provided, the patients request for a full treatment plan for 10 hours per week of direct ABA therapy, 12 hours per month of supervision and four hours per month of parent training is medically necessary for treatment of the patients autism. Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for drug metabolism for evaluation of his medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient has mixed hyperlipidemia.  There is no indication for genetic testing for response to statin medications.  The testing will not add any clinically significant information to the care of this patient.  There are drugs for which genetic testing is appropriate.  However, first-line medications used in the treatment of lipid disorders are not in this category.  All told, genetic testing for drug metabolism was not likely to have been of greater benefit than other methods of evaluating this patient.  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 reviewers are board certified in internal medicine 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

A 63-year-old male enrollee has requested Zetia 10 mg. for treatment of his coronary artery disease.  Findings:  The physician reviewer found that it is a clinically reasonable treatment decision to attempt and reduce LDL cholesterol to less than 70 mg/dl in patients with known atherosclerotic coronary artery disease (CAD). In the medical literature, Taylor and colleagues conducted the HALTS trial to compare Zetia versus extended release niacin in patients with elevated Framingham risk scores, diabetes or known CAD. The authors concluded that the addition of Zetia did not meaningfully affect carotid intimal thickness. Likewise, other studies with Zetia have failed to demonstrate a change in outcomes. In addition, standard therapies are available (LaRosa and colleagues) who demonstrated a reduction in atherosclerotic events with high dose (80 mg) atrovastatin versus low dose (10 mg) atrovastatin. In this study, the target LDL in the high dose group was approximately 70 mg/dl, and 100 mg/dl in the low dose group. Although no difference in mortality was demonstrated, there was a difference in event rates. Moreover, the side effect profile in the high dose group was completely satisfactory. With regard to this patient, there is no stated compelling clinical reason not to try atrovastatin 80 mg before proceeding to combination therapy with Zetia. His records provide no specific indication for Zetia that could not otherwise be addressed with high dose monotherapy with a statin. Therefore, the requested medication has not been shown to be medically necessary for the management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parents of a patient has requested authorization and coverage for immunotherapy/allergy shots, one a week for 52 weeks (two sets). Findings:  The physician reviewer found that candidates for immunotherapy are patients whose symptoms are not controlled adequately by medications and avoidance measures or those experiencing unacceptable adverse effects of medications. The selection of allergens for immunotherapy is based on clinical history, the presence of specific immunoglobulin E (IgE) antibodies, and allergen exposure. According to the American Academy of Allergy, Asthma and Immunology (ACAAI), allergen immunotherapy extracts should be prepared individually for each patient. Individualized patient extracts allow for customized treatment specific to the patients identified allergen sensitivities and reduce the risk of allergen cross-contamination. Additionally, the provider must specify the starting immunotherapy dose, the target maintenance dose, and the immunotherapy schedule. The immunotherapy build-up schedule entails administration of gradually increasing doses during a period of approximately 28 weeks. After a patient completes the build-up dose, the patient enters the maintenance dose. This patients clinical documentation includes evidence of skin testing showing findings correlated with seasonal and perennial allergic rhinitis. All told, the requested immunotherapy/allergy shots, one a week for 52 weeks (two sets), are supported as medically necessary for treatment of this patients allergic rhinitis.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 internal medicine with subspecialty certification in allergy and immunology 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 21-year-old female enrollee, who has a mitochondrial disorder with gastrointestinal, cardiac and muscular manifestations, has requested authorization for single proton emission computed tomography (SPECT) scanFindings:  Three physician reviewers found that SPECT scanning was not likely to add any clinical value to the management of the patients condition. SPECT scan does not address the elements of differential diagnosis and would not be expected to impact the patients treatment. SPECT scan is of unproven efficacy in this context and it is not standard of care for patients such as this one.
Appeal type: Experimental/Investigational
Decision: Upheld

A 78-year-old male enrollee requested percutaneous tibial nerve stimulation (CPT code 64566) for medical treatment of his urgency and frequency incontinence.  Findings:  Three physician reviewers found that PTNS is not indicated or effective for the treatment of post-radiation urinary tract symptoms and nocturia. PTNS is indicated for overactive bladder symptoms that have failed anticholinergic therapy, behavior modification and pelvic floor exercises. This patients records do not document a clinical indication for treatment with PTNS. Therefore, the requested PTNS (CPT code 64566) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Keytruda infusions. This patient presents with metastatic breast cancer to liver status post tumor ablation. The provider noted concern for lymphangitic spread on recent computed tomography (CT) imaging. The patients provider has recommended treatment with carboplatin, gemcitabine, and Keytruda. The U.S. Food and Drug Administration (FDA) has approved Keytruda for the treatment of locally recurrent unresectable or metastatic triple-negative breast cancer in combination with chemotherapy in patients whose tumors express PD-L1, defined as having a combined positive score (CPS) of 10 on testing. The records provided for review do not include documentation of PD-L1 for this patient. Moreover, there is no report of the microsatellite instability (MSI), mismatch repair (MMR), or tumor mutational burden (TMB) status to support treatment with Keytruda. Without these markers, there is a lack of support for treatment with Keytruda. Therefore, the requested Keytruda infusions are not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the 3D breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. While it is acknowledged that there is a lack of long term studies as of yet proving increased survival rates when tomosynthesis is added to the routine screening mammographic views, the technique has become popular among providers due to the associated decrease in callbacks and increased rate of detection of small cancers. For this reason, the addition of 3D breast tomosynthesis to the usual mammographic films is considered more beneficial for the patient than digital mammography without tomosynthesis.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: Reviewers 1, 2, and 3 are 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: Medical Necessity
Decision: Upheld

The parents of a three-year-old male have requested  intensive reflex integration (Masgutova-based) therapy for treatment of his autism.  Findings:  The physician reviewer found that the literature does not support the use of an alternative treatment modality such as intensive reflex integration (Masgutova-based) therapy for the treatment of autism. Accepted therapies in this setting include speech therapy, occupational therapy, physical therapy, and applied behavioral analysis. These modalities have been shown to be effective in treating behaviors associated with autism spectrum disorders (Warren, et al.; Rogers, et al.; and Meyers, et al.). Methods that are based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. At this time, the benefit of intensive reflex integration has not been established in this patient population. There are no peer-reviewed, evidence-based studies that support this form of treatment for autism and therefore, the treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old female who underwent a bariatric procedure with resultant massive weight loss. She is seeking authorization and coverage for removal of excess skin of the arms, breasts, thighs, abdomen, buttocks, and back. The Health Plan has authorized the removal of the abdominal panniculus for intertrigo but indicates a medial and lateral thigh lift, buttock lift, brachioplasty, and mastopexy are not medically necessary for treatment of the patients medical condition. The medical records and photographs submitted support the medical necessity for a mastopexy. There is documented evidence of intertrigo of the breast area that has been refractory to conservative management. Thus, a mastopexy is medically warranted to relieve the patients functional impairment. However, breast augmentation is considered cosmetic in this case and is not medically necessary. Furthermore, the submitted records and photographs do not provide compelling documentation of medical necessity for medial and lateral thigh lift, buttock lift, and brachioplasty. The patients skin problems in these areas do not appear to be significant. As such, these procedures are cosmetic in nature and not medically necessary for treatment of the patients medical condition.Based upon the information set forth above, I have determined that although the requested mastopexy is medically necessary for treatment of the patients medical condition, the requested medial and lateral thigh lift, buttock lift, and brachioplasty are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested growth hormone therapy (Norditropin) for treatment of the enrollees growth hormone deficiency.  Findings:  The physician reviewer found that growth hormone deficiency is suspected in children with moderate to severe growth failure. A definitive diagnosis is typically made when there is little to no response of growth hormone to provocation testing. IGF-1 levels should be used in conjunction with bone age determination because there is overlap of IGF-1 values for growth hormone deficient and normally developing children during infancy and early childhood. Although this patient could have hypopituitarism (growth hormone deficiency), it has not been adequately documented based on current recommendations for diagnosis. His height as of the said date was greater than 2.5 standard deviations below the mean, which supports a diagnosis of severe idiopathic short stature. According to the FDA, growth hormone is indicated for treatment of severe idiopathic (non-growth hormone deficient) short stature when the patients height is more than 2.25 standard deviations below the mean for age and gender. Thus, recombinant growth hormone therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 25 visits of intensive outpatient program (IOP) services provided and forward. Findings:  The physician reviewer found that the 25 visits of IOP services were not and are not medically necessary for the treatment of the patients medical condition. According to the documentation submitted for review, the patient has been documented as making progress with the treatment already provided in IOP. The clinical records submitted for review do not support continuation at the proposed level of intervention. The patient is scheduled to begin a specialized preschool program through his school district  and will receive two 30 minute sessions of speech therapy per week, together with occupational therapy and ABA therapy. These services are medically appropriate to meet the patients medical needs without the implementation of further IOP services.Final Result: The reviewer determined that the services at issue were not and 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 and neurology with special qualification in child neurology 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

A 48-year-old male has requested a WalkAide functional electrical stimulator (FES) for treatment of his foot drop status post cerebral vascular accident (CVA).   Findings:  The physician reviewer found that the patient is is reported to have residual hemiparesis since a prior stroke, with foot drop for the last 21 years. He has a mechanical heart valve due to prior endocarditis and is maintained on Coumadin. He has used an ankle foot orthosis (AFO) for several years. A trial of WalkAide functional electrical stimulator (FES) has been completed, with reported marked improvement in walking speed by 57%. At baseline, the patient is active, ambulatory, but has difficulty walking on uneven surfaces, ramps and stairs. In a six-minute timed walk, he covered 100 yards, but with the WalkAide device he covered 500 yards, without taking breaks. This patient has brain injury due to stroke with residual spasticity and foot drop. The patients foot drop continues to impair his gait despite use of an AFO. The peer-reviewed medical literature shows that foot drop gait is known to be inefficient, with increased fatigue and slowed walking speed. Research on the use of a FES has shown potential benefit in speed of walking, oxygen uptake, and physiological cost in patients with spasticity from chronic central nervous system lesions, as occur in multiple sclerosis, stroke, traumatic brain injury, or spinal injury. Studies have also shown potential for neural plasticity, with functional gains maintained after discontinuation of FES. Consistent with this support, the requested WalkAide FES is a reasonable addition to standard rehabilitation efforts to recover better gait. Further, a trial of the WalkAide FES demonstrated benefits beyond standard therapy with an AFO for this patient. As such, the requested WalkAide FES is more likely to be beneficial in treating this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a panniculectomy for the treatment of her abdominal fold/bulge. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. There is no documentation of the patients abdominal pannus nor of her excess fat and skin. There is no evidence of skin infections, intertrigo or rashes. While the provider mentions a budge in the abdomen, there is no evidence of a hernia due to defects created by utilization of the rectus abdominis. Thus, there is no evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. As such, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. With regard to general concepts of medical necessity, again there is no evidence documenting the patients abdominal pannus. There is no documentation of excess fat and skin with pictorial documentation of skin infections, intertrigo or rashes. The patient had a computed tomography (CT) scan, which according to her physicians note, showed that she may have fat necrosis along the lower portion of her TRAM reconstruction and there appears to be a very limited abdominal wall recon. No loss of functioning was documented which would necessitate a panniculectomy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the testing serum infliximab (Remicade) levels and antibodies to infliximab (Anser IFX assay) for evaluation of her Crohns disease. Two physician reviewers found that assessing measurements of infliximab levels and antibodies with the Anser IFX assay remains unproven. In general, infliximab levels correlate inversely with disease activity. However, the target level of infliximab necessary to achieve clinical benefit remains unknown. There is a lack of controlled data which have identified the optimal drug level. Antibodies are often transient and may not be neutralizing in some patients. Further, therapeutic levels likely vary between patients. Based on these findings, the testing serum infliximab levels and antibodies to infliximab (Anser IFX assay) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two 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 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: Overturned

A 62-year-old male enrollee has requested for excision (mastectomy) along with suction-assisted lipectomy for treatment of his bilateral gynecomastia. Findings:  Two physician reviewers found that treatment of gynecomastia has shifted from a purely open excisional treatment versus some type of lipectomy (suction-assisted versus ultrasonic) or some combination of both. Standard treatment as documented in the above references generally reserves severe cases for the solely open approach. Liposuction is not considered investigational and is standard of care.  It is well accepted in the plastic surgery field.