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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulsed radiofrequency of the right knee. As discussed in the peer-reviewed medical literature, pulsed radiofrequency is not supported as a safe and effective treatment for knee pain. A study found a small-randomized trial that concluded; further clinical trials need to be undertaken, with a larger sample size, in order to demonstrate the efficacy of this technique. Researchers noted that adverse vascular events have been reported and the long-term efficacy and adverse events are still largely unknown. All told, the requested pulsed radiofrequency of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: One reviewer found that the requested pulsed radiofrequency of the right knee is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three 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: One reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha SureClick Auto-Injector. Findings:  The physician reviewer found that this patient has established coronary artery disease (CAD) and his goal LDL should be 70. He is on maximally tolerated statin therapy of rosuvastatin at 20 mg. His Lpa is elevated and he is being referred for Repatha therapy to lower LDL further and also to lower Lpa. Clinical notes specifically reference lowering the patients lipoprotein (A) (Lpa), which is the reason given for not adding ezetimibe, as this would not significantly lower his Lpa. Although the patients Lpa may be used as an additional risk factor to assess the need for statin therapy under current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, and there is some data that PCSK-9 inhibitors are effective at lowering Lpa, the current data is limited and short-term. Further, the current ACC/AHA clinical guidelines do not currently target Lpa lowering as a goal for therapy. In addition, Lpa levels have not been shown to affect recurrent ischemic events in patients after acute coronary syndromes. The ACC/AHA guidelines recommend LDL lowering to a goal of 70 in patients with established disease, using both maximally tolerated statin therapy and ezetimibe in combination. If the patients LDL goal is not reached with this combination therapy, PCSK-9 inhibitors can then be considered for use to lower LDL to goal of less than 70. This patients records do not document an adequate trial of multi-drug therapy with maximal statin and ezetimibe, prior to consideration of Repatha SureClick. All told, the requested Repatha SureClick is not supported as 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 internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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 52-year-old female enrollee has requested for sacroiliac joint injections for treatment of her sacroiliitis. Findings:  Two physician reviewers found that there is no strong scientific data supporting the efficacy or necessity of sacroiliac joint injections for therapeutic relief. A study by Hansen and colleagues found that the evidence supporting therapeutic intraarticular sacroiliac joint injections is limited.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested a 12 week course of Harvoni for treatment of her 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. Therefore, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy.Findings:  Three physician reviewers found that the medical evidence has not demonstrated the superior efficacy of the services at issue over standard available therapy, photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure. Thus far, this does not appear to translate into actual decreased clinical side effects. The retrospective study by Sheets and colleagues showed that gastrointestinal toxicity was actually higher with proton beam therapy, although this has not been confirmed by other studies to date. Cancer control rates are also reportedly similar between photons and protons. National Comprehensive Cancer Network guidelines noted that no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Thus, proton beam therapy provided was not likely to have been more efficacious than other treatment options.Final Result: The reviewers determined that the services at issue were 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 radiation oncology 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: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested laparoscopic sleeve gastrectomy for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the requested laparoscopic sleeve gastrectomy is medically necessary for treatment of the patients medical condition. The National Institute of Health (NIH) consensus guidelines recommended that bariatric surgery should be considered for patients who have a BMI greater than 40, or a BMI greater than 35 in association with major comorbidities such as severe sleep apnea, Pickwickian syndrome, and obesity related comorbidities. According to the documentation submitted for review, the patient presents with clinically severe obesity with a BMI of 37 and comorbid conditions that include fatty liver disease, sleep apnea, GERD and shortness of breath. The patient has tried multiple dietary approaches with only moderate success. In addition, she completed a psychological evaluation which reported that she is a good candidate for surgery. Based on the documentation submitted for review, the patient meets the accepted criteria for bariatric surgery. As such, the requested laparoscopic sleeve gastrectomy is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old female with a history of bronchospasm and dyspnea. She had a motor vehicle accident approximately one year prior and underwent various surgeries. She has a history of rib fracture and lung collapse. Pulmonary functions tests performed in April 2005 revealed a normal arterial blood gas pH of 7.34/PC02 41/PO2 86 on room air. Spirometry revealed a FVC of 87%, FEV1 of 79%, and the FEV1/FVC ratio was 74%. The DLCO was reduced at 53% and when adjusted to lung volumes the DL/VA was 68% of predicted value. There was no significant improvement after bronchodilators. According to a letter dated August 2005 from the patients pulmonologist the patient was found to have mild asthma and started on Advair 100. Her physical examination was normal. The pulmonologist said the decreased DLCO was due to atelectasis. He also stated that the dyspnea was largely due to anxiety and deconditioning. The patient was referred for pulmonary rehabilitation.The Health Plan denied coverage for the requested therapy indicating the patient does not have moderate to severe COPD. Pulmonary rehabilitation for patients with COPD is well established and accepted as a means of enhancing standard therapy in order to alleviate symptoms and improve quality of life. This is according to the position statement from the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) published in 1997. The paper concludes lower extremity training resulted in improvement in exercise tolerance, dyspneas, and subjective quality of life measures, but upper extremity training, ventilatory muscle training (VTM) and psycho-behavioral interventions did not result in added benefit. The evidence is based on patients with COPD (due to emphysema or chronic bronchitis); its role in the treatment of asthma is speculative.According to the patients pulmonologist, the patient has mild asthma and is being treated with the lowest dose of Advair. He states that the patients decreased DLCO may be due to atelectasis, but there is no radiographic evidence of this. Furthermore, the patients ABG is normal despite a decreased DLCO. It appears a cardiopulmonary exercise test is the next appropriate step in order to determine the cause of the patients dyspnea and should take place prior to consideration of pulmonary rehabilitation.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pediatric occupational therapy services within 15 minutes of the enrollees residence by car.   Juvenile idiopathic arthritis is a chronic rheumatologic disease in childhood that presents with peripheral arthritis. Treatment is aimed at elimination of active disease, normalization of joint function, preservation of normal growth, and prevention of long-term joint damage. Medications include corticosteroids, non-steroidal anti-inflammatory agents, anti-rheumatic drugs, and biologic agents. Hand and wrist related symptoms are relatively common in children with juvenile idiopathic arthritis. Unless treated, these symptoms can significantly limit participation in both leisure and school activities. A combination of pharmacologic and non-pharmacologic therapies is essential in preventing functional limitations. This patient has significant joint pain limiting his ability to travel distances without pain and/or frequent breaks. Thus, it is medically necessary and appropriate to locate therapists within a tolerable distance. The family has identified a qualified provider of occupational therapy within a 15-minute car ride, within the range of tolerability for this patient. Therefore, pediatric occupational therapy services within 15 minutes of the patients residence by car are medically necessary for the 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 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

The parent of a 3-year-old male enrollee has requested 2 hours per week of speech therapy in-home for treatment of the enrollees autism. Findings:  The physician reviewer found this patient is significantly below age expectations in language and motor skills.  The patients parent requests to have 2 hours per week of in-home service for speech therapy as the patient previously received in-home therapy from the indicated center, however these types of service are different. Infant stimulation programs are best performed in a home setting while speech therapy is best utilized in a clinic. Thus, the patient will be best served in a clinic, not at home. In addition, based upon the patients most recent speech and language evaluation, a frequency of, one hour per week of speech therapy, as authorized by the Health Plan is medically appropriate at this time. The medical necessity of the requested 2 hours per week of speech therapy in-home has not been established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation (RFA). In this case, the patient has cervical spine magnetic resonance imaging (MRI) findings of degenerative joint disease at the C5-6 and C6-7 levels, which correlates with her current complaint of neck pain radiating to the shoulder blades, but not into the forearms or hands. Her physical examination findings are positive for tenderness over the right cervical facet joints of C4-6. Her provider reports the patient has undergone multiple RFA treatments to the cervical spine, which have all provided excellent relief. The current evidence-based medical guidelines advise that repeat diagnostic blocks are not required in patients who have already received previous RFA procedures if a repeat procedure is being planned to a segment of the spine that has already successfully been treated. In this case, the patient has had this procedure before with excellent results and is requesting a repeat of the procedure. Therefore, the requested RFA is medically necessary for treatment of this patients neck pain.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 anesthesiology with subspecialty certification in pain management 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: A female enrollee has requested authorization and coverage for enteral formula (Ensure nutritional drinks). The Health Plan has denied this request indicating that the requested nutritional drink is not medically necessary for treatment of the enrollees irritable bowel syndrome. A review of the record indicates that the enrollee has been diagnosed with somatoform disorder; gastritis; fibromyalgia; anxiety; weight loss; post-traumatic stress disorder; anorexia; gastroduodenitis without bleeding; and irritable bowel syndrome without diarrhea. A visit note, reported the enrollee presented with weight loss and abdominal pain. The enrollee reported a visit in the emergency room, for abdominal pain and nausea. The enrollee reported severe constipation and daily laxative use and takes a laxative every time she eats solid food. The enrollees weight at this visit is 99 pounds, height 5 feet 3 inches and body mass index (BMI) is 17.5. The provider recommends following up with a psychiatrist; continue Maxalt and ondansetron; follow up with gastroenterology; and smaller more frequent meals; Ensure; and protein shakes. At issue in this case is whether the requested enteral formula (Ensure nutritional drinks) is medically necessary for treatment of the enrollees medical condition. Ward notes that patients with irritable bowel syndrome may benefit from exclusion of gas-producing foods; a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs); and in select cases, lactose and gluten avoidance. The patient has a diagnosis of irritable bowel syndrome with constipation. There is no documentation of a trial of standard dietary intervention for irritable bowel syndrome or documentation of other medical management of irritable bowel syndrome. Therefore, the use of an enteral formula is not medically necessary.Final Result: The reviewer determined that the requested nutritional drink 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 family 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: Experimental/Investigational
Decision: Overturned

A 26-year-old male enrollee has requested a positron emission tomography (PET) with computed tomography (CT) skull to thigh (CPT code 78815) for medical evaluation of his primary mediastinal germ cell tumor. Findings:  Three physician reviewers found that AFP measurements play a central role in the diagnosis and follow-up of patients with non-seminomatous germ cell tumor. This patients most recent AFP values demonstrate an increase from 3.9 to 9.8. He has undergone multiple courses of chemotherapy, as well as surgical resection and radiation therapy, thus restaging at this time is appropriate. However, CT performed without PET may not be able to distinguish malignant tumor from benign components such as post-radiation fibrosis. PET/CT adds a metabolic component that is not offered by CT alone and is more useful than CT alone in assessing the aggressiveness of the malignancy and identifying active malignancy. For these reasons, the requested PET/CT is likely to be more beneficial than other standard imaging techniques in guiding this patients further care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that in this clinical setting, 30 hours per week of ABA therapy, 10 hours per month of supervision and one visit per week of parent training is medically necessary for treatment of the patients autism. The patient has received high level ABA therapy for a number of years. According to the documentation submitted for review, the patient has met some motor and language goals, but has not met many of the social goals. The patient continues to require a high level of ABA services due to his maladaptive behaviors that include aggression, non-compliance and whining. In addition, the progress reports show an increase in maladaptive behaviors. The Health Plans authorization of 10 hours per week of ABA therapy is not clinically indicated for this patient. Decreasing ABA hours from 40 hours per week to 10 hours per week will likely lead to a return of previous behaviors and a loss of skills. Therefore, 30 hours per week of ABA therapy, 10 hours per month of supervision and one visit per week of parent training (CPT 0370T) is medically necessary for treatment of the patients autism.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.