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

The parent of a three-year-old male enrollee has requested speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the standard of care in the medical community would be to continue to provide speech therapy in this setting. A report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. According to the authors, People with ASDs [autism spectrum disorders] have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Thus, the lack of success of the patients prior speech therapy should not be a barrier to further speech therapy. Additionally, the paper by Turner and colleagues is a controlled study comparing autistic children who did and did not receive speech therapy. Those children who did receive therapy by the age of 2 had far greater communication skills by the age of 9 than those who did not receive speech therapy. Further, the report, of the Speech and Language Association states that all autistic children can benefit from speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male has requested past and future coverage for continued treatment from UCLA Neuropsychiatric Hospital (NPH) Early Childhood Partial Hospital Program (PHP) for treatment of his autism and behavioral health issues.  Findings:  The physician reviewer found that a review of the medical records indicates this young patient continues to display unsafe behavior, aggression toward others, self injurious behavior and psychotic symptoms. He is currently in a partial hospitalization program (PHP). The progress reports and treating providers summary indicate the patients maladaptive behavior has improved while in the PHP, and specifically his head banging has decreased from 7 times per day to 2 times per week. However, he continues to display significant level of aggression and unsafe behavior and requires intensive staff intervention and hands-on parent training. Given the severity of the patients symptoms as documented in the medical records, and given his positive response to treatment, continued treatment at the PHP level of care is clinically appropriate. This conclusion is consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) and community standards of care as noted in the peer reviewed literature including the American Psychiatric Association (APA).
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested Botox injections for treatment of her migraines. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine headaches, there is ample literature supporting its use in a subset of headache patients.  In this particular case, the patient has been resistant to multiple standard therapies for headache.  In addition, she has had a reported significant benefit from prior Botox use. To discontinue this medication may cause significant impairment and clinical worsening for this patient.  In this patients case, Botox injections are likely to be the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Actemra (tocilizumab) injections. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. Intervention with tocilizumab is medically indicated in this patients case. The records demonstrate that this patient has increased risk for reduced allograft chronic rejection. There is morbidity risk associated with allograft failure. The presence of DSAs are a negative long term predictor for allograft survival. Treatment with tocilizumab has been used with ABO-incompatible transplantation. Tocilizumab is indicated in that its pro-inflammatory mechanism of action has benefits in reducing DSAs. Therefore, in this patients case, Actemra (tocilizumab) injections are medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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 Epclusa for 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. The medical evidence supports the requested medication regimen in this clinical setting. All told, Epclusa for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her condition. Findings:  The physician reviewer found that the enrollee's symptoms warrant evaluation with MRI of the lumbar spine. The referring physician, the patients treating surgeon, has detailed knowledge of the anatomy and neuroanatomy of concern. An MRI of the lumbar spine is medically indicated for evaluation of this patient. Referral from a primary care physician or orthopedic surgeon is not medically warranted.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for the anesthesia service performed during an endoscopy/colonoscopy for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient is an American Society of Anesthesiologists (ASA) II with only moderate systemic disease. He has no medical history of the cardiac or pulmonary systems and he does not have a documented history of difficulty or problems with anesthesia. Severe Crohns disease does not render the patient at increased risk for endoscopy or colonoscopy and does not require MAC services for the procedure. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for estrogen Femring 0.10 mg for treatment of her menopausal symptoms. Findings:  The physician reviewer found that menopausal symptoms vary from patient to patient and their treatment often requires a tailored approach. Multiple treatment routes are available, including oral, transdermal, transvaginal. The treatment route depends on the patients tolerance, reaction and medical history, and is tailored to provide the least risk profile. In this case, the patients provider reports that she needed increasing doses of Estrogel in order to control her symptoms. In order to decrease her hormone exposure and decrease her symptomatology, she was changed from a gel formulation to the ring. However, the documentation does not support that any other medications were tried on the formulary before switching from the gel to the ring. Given that there is no documented intolerance or contraindication to the formulary preferred medications, the request for estrogen Femring 0.10 mg is not medically necessary for treatment of the 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 obstetrics and gynecology 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

The parent of a two-year, nine-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient. Specifically, the patient should receive five hours of speech therapy per week. In addition, a complete and detailed speech and language evaluation should be performed by an independent therapist for an accurate diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested osteochondral allograft transplantation for the ankle and its associated services (codes 20680, 20690, 20692, 20902 and 27700) for treatment of her ankle pain. Findings:  Three physician reviewers found that although ankle arthrodesis remains the standard treatment for ankle arthritis, the associated problems have led to interest in other approaches, such as joint replacement and allograft transplantation. Short-terms results of allograft transplantation have been encouraging, but longer follow-up is needed to confirm these initial results. Follow-up radiographs have shown narrowing and sclerosis, even in cases with good clinical status. A high failure rate has been reported to be associated with this procedure.  At this time, the superior efficacy of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested radiofrequency ablation of arrhythmogenic foci in the pulmonary vein for treatment of her history of palpitations.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  The records do not support a diagnosis of atrial fibrillation.  The clinical notes suggest supraventricular tachycardia rather than atrial fibrillation.  Ablation procedures are not recommended for incidental asymptomatic paroxysmal supraventricular arrhythmias.  Based upon the medical records, this patient does not meet the standard criteria for ablation.  Ablation procedures have risk of serious complications and should be performed only after a link between the particular arrhythmia and the patients symptoms has been established.  Thus, the requested radiofrequency ablation of arrhythmogenic foci in the pulmonary vein is not likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient with autism will continue to benefit from intensive ABA therapy and has shown impressive gains in all domains since the start of treatment. The American Academy of Pediatrics (AAP) recommends a minimum of 25 hours per week of ABA therapy per week for children with autism. As this is the standard of care for patients with autism, 25 hours per week of ABA therapy is medically necessary for the management of this patients behavioral issues associated with autism.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year-old male has requested non-emergency medical transportation for treatment of his deformational plagiocephaly.   Findings:  The physician reviewer found that the requested non-emergent medical transport to primary care, subspecialty, therapy, and diagnostic appointments, specifically physical therapy and the orthotic clinic involved in creating the helmet for positional cranial molding is not medically necessary. The letter submitted by the provider describes his plan of care for the patient. However, there is no indication that the patients medical condition limits his ability to take private or public transportation. Further, the records do not include documentation of any impaired mobility, as the only mention of special equipment is the helmet to help correct the patients positional plagiocephaly. All told, the requested non-emergent medical transportation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male enrollee has requested an automatic external cardioverter defibrillator for evaluation of his ventricular tachycardia.  Findings:  The physician reviewer found that based on review of the available records, the patient has documented exertional ventricular tachycardia in addition to inducible sustained ventricular tachycardia on electrophysiology study that required cardioversion for termination. This diagnosis is a Class I indication for an implantable cardioverter defibrillator. However, the patient wanted to delay the implant until he sought a second opinion and other possible treatment options. In the medical literature, it is clinically reasonable and appropriate in this high-risk situation to have the patient wear an external defibrillator. The standard criteria for an external wearable defibrillator were also met since the patient also met the requirements for an implantable defibrillator. In this case, the wearable external defibrillator was intended as a bridge to an implantable defibrillator only during a period of delay while the patient pursued a second opinion and other treatment options. For these reasons, the medical necessity of the LifeVest used by this patient during this timeframe has been established as medically necessary and should be reimbursed.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old female with a body mass index (BMI) of 41. She has multiple comorbidities. The patient has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. Her provider has recommended that she undergo a duodenal switch procedure. The Health Plan has denied coverage for the requested procedure citing a lack of medical necessity. The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Accordingly, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested substance abuse facility services for teens for treatment of the enrollees substance use disorder. Findings: The physician reviewer found that this young patient presents with a history of alcohol dependence. Her parent has requested coverage for treatment at a residential treatment facility for the patients substance abuse. However, a recent psychiatric evaluation failed to suggest that this patient has any symptoms of an overt mood disorder including any suicidal or homicidal thoughts, intent or plan. In addition, the patient has not shown any signs of imminent alcohol withdrawal. Applying the American Society of Addiction Medicine (ASAM) criteria for a residential treatment facility care, this patient is a candidate for evaluation for treatment at a lower level of care, as she does not require medical monitoring for her substance abuse. Although the patient does not require residential treatment at this time, she is an appropriate candidate for evaluation for a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay testing for evaluation of the enrollees cutaneous melanoma. Findings:  The physician reviewers found that in thick melanoma tumors, like in this patients case, the standard of care is to do a wide local excision with possible sentinel lymph node dissection and base any further treatment on these results. Options for adjuvant treatment include immunotherapy, targeted therapy, BRAF and MEK inhibitors and chemotherapy. The standard protocol, based on National Comprehensive Cancer Network (NCCN) guidelines for a thick tumor, does not include a workup with molecular testing. Currently, the testing has shown some impressive results in predicting risk of metastasis. However, there is no set change in treatment protocol based on the findings. The standard protocol would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. Clinical studies which show that the results of the molecular testing will make a difference in the treatment or morbidity/mortality are lacking at this time. It is for this reason that the DecisionDx-Melanoma testing is considered experimental or investigational for patients with thick melanoma tumors. Since this test does not provide a benefit more than the established tests as to outcomes and treatment options, the DecisionDx-Melanoma assay provided was not likely to have been more effective in the evaluation of this patients medical condition than any available standard therapy. Final Result: All 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: Physician reviewers number one, two, and three are board certified in dermatology and 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

A 43-year-old female enrollee has requested for panniculectomy and abdominoplasty/diastasis repair for treatment of her diastasis of the abdomen.  Findings:  The physician reviewer found that noted by Oneal and colleagues in the medical literature, there is inadequate scientific data to support that abdominal pain can be related to abdominal muscle diastasis but muscle plication may be expected to improve a functional problem in some patients. There was insufficient documentation of a significant abdominal pannus causing any functional deficit. The photographs provided demonstrate a diastasis of the rectus muscles without a significant lower abdominal pannus. However, the documentation does not clearly indicate that a panniculectomy was actually performed and therefore it was not medically necessary to be done during the same procedure as the abdominoplasty.