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 four corner fusion surgery with compression FT screws for treatment of the enrollee who has a history of left wrist pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case. A study indicated that four corner fusion had been shown to be a reliable option of treatment of wrist arthritis. They concluded that four corner fusion using headless retrograde headless screws demonstrated a low complication rate and high fusion rate, and could therefore be considered a reliable surgical technique. Another study concluded that four corner fusion, including with headless compressive screws, is a reliable wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation. The researchers concluded that four corner arthrodesis using headless compression screws was comparable to or better than the results of previously published techniques. This technique exploits the theoretical advantages of strong compression between carpals while avoiding a screw head sized hole in the lunate articular cartilage and preserving the dorsal capsular ligament attachments to the triquetrum. This patient presented with constant intense left wrist pain for over one year with markedly limited range of motion. The patient had been diagnosed with a non-union fracture and left wrist end stage (bone on bone) osteoarthritis. The patient failed to improve despite over the counter anti-inflammatories, activity modification, physical therapy, and prior PIN. Current evidence based peer reviewed literature support the use of four corner fusion with headless compression screws with comparable or better results in terms of fusion rate, pain relief, grip strength, and satisfactory range of motion. Therefore, a four corner fusion surgery with compression FT screws is medically necessary for treatment of this patients medical condition. 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 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: Upheld

A 58-year-old male enrollee has requested for a knee scooter for treatment of his mobility needs. Findings:  The physician reviewer found that there is nothing in the record to indicate that the patient had formal training by a physical therapist for ambulation to determine what type of walking assist device would best accommodate the non-weight-bearing status of his left lower extremity. The standard options are crutches, walker or a wheelchair. An assessment by a home health care professional would also be helpful to help facilitate his convalescence.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that the scientific literature is clear when it comes to superior long-term outcome of the duodenal switch operation when compared to other procedures. The benchmarks measured include, weight loss, resolution of co-morbidities and lack of any significant differences between their complications when specifics are compared. The duodenal switch operation does not have metabolic side-effects that are worse than that of the gastric bypass operation.In-fact, gastric bypass patients have a higher failure rate and worse nutritional profile long-term than that of the duodenal switch patient. Furthermore, the resolution of diabetes is far superior with the duodenal switch than that of the gastric bypass.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested group social skills therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that social skills groups are indicated for children with autism spectrum disorders. However social skills groups are primarily indicated for school age children who are not receiving applied behavior analysis (ABA) services. The primary goals of the social skills groups are social competence, social communication and emotion recognition. In this case, parental concerns include non-compliance, repetitive behaviors, disruptive and aggressive outburst behaviors and public behavior. The requested intervention is not designed to address aggression and non-compliance. Reichow and colleagues (2012) found improvements in communication, cognitive skills, social skills and adaptive skills through the use of ABA.  In reviewing the additional information provided for review, there is a lack of evidence demonstrating that the patient is ready for a social skills group. Once she is more compliant with most adult directions, does not have outbursts and obtains basic conversational skills to be able to respond appropriately in a group then a social skills group may be indicated. In general, many children with autism spectrum disorders in the school age do benefit from social skills groups.  However, there are some basic social skills that need to be learned in a one-on-one setting prior to engaging in social skills groups. Re-evaluation by developmental pediatrician or ABA team for readiness to engage in a social skills group should be done in the near future.  In this case, the most appropriate way to address the parental concerns is through ABA. At this time the goals of building social skills should occur through ABA.  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 and 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 authorization and coverage for Epclusa for 24 weeks for treatment of the enrollees hepatitis C virus genotype 1b.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. However, the AASLD/IDSA guidelines state that patients who fail an NS5A inhibitor such as Harvoni should have testing for NS5A and NS3 resistance-associated variants and these are not provided. The guidelines also state that patients who fail an NS5A inhibitor such as Harvoni should be treated with a 24-week regimen, and that ribavirin should also be included in all cases, based on clinical studies. Epclusa is never recommended without ribavirin after failure of an NS5A inhibitor such as Harvoni. 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 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: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested a Harmony prenatal test for evaluation of her pregnancy.  Findings:  Three physician reviewers found that The American College of Obstetricians and Gynecologists (ACOG) has recommended that women, regardless of maternal age be offered prenatal assessment for aneuploidy either by screening or invasive prenatal testing. Cell free fetal DNA is one option that can be used as a primary screening test in women at increased risk of aneuploidy (ACOG, No.545). At risk of aneuploidy includes, maternal age of 35 years or older, fetal ultrasound findings indicating an increased risk of aneuploidy, and history of prior pregnancy with a trisomy. In this case, the patient is not at an increased risk. There is a lack of scientific evidence demonstrating the clinical value of cell free fatal DNA testing for individuals who are not at an increased risk. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollee's chronic hepatitis C virusl genotype 1a.Findings: The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Consideration for eight week therapy in patients with baseline viral load of less than six million IU/mL is based on post-hoc analysis of treatment naive patients in the ION-3 trial, resulting in an uncontrolled comparison (Kowdley, et al). The AASLD/IDSA guidelines state that these results are not generalizable and that treatment duration of less than 12 weeks should be done with caution. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chemotherapy, immunotherapy and a procedure to clear the obstruction in the enrollees bile duct for treatment of the enrollees hepatocellular carcinoma. Findings: The physician reviewer found that this patient has a history of hepatocellular carcinoma.  She has requested coverage for chemotherapy, immunotherapy and a procedure to clear the obstruction in her bile duct.  However, the current medical evidence does not suggest that chemotherapy, immunotherapy, or biliary surgical intervention will reverse the current situation. There is a lack of support for the requested services in this patients case. 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 internal medicine with sub-specialty certification in medical oncology 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 47-year-old female enrollee has requested Avastin therapy for treatment of her glioblastoma.  Findings:  Two physician reviewers found that there has been increasing interest in the use of endothelial (vascular) growth receptor inhibitors such as Avastin in the treatment of brain tumors. Avastin has been found to be useful, along with chemotherapy, in lung and colon cancer. As yet, however, there is no convincing data to indicate that Avastin, by itself or in combination with the proposed CCNU chemotherapy, will prolong survival or offer significant clinical benefit. Accordingly, the use of Avastin in the treatment of brain tumors must be considered investigational and of no proven clinical value.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 180 cans of Ensure every 30 days for treatment of the enrollee who has a history of substantial gum loss. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested liquid diet. There is no medical documentation to support that this patient is having a problem maintaining his weight or that he is malnourished. In general, treatment of an underweight or malnourished patient should be directed at the underlying cause as well as dietary modification. The initial step in improving nutrition is to add high calorie foods to the diet and lift any dietary restrictions.  Nutritional supplements are recommended if the patient does not regain or maintain his or her weight despite adjustments in meal preparation and diet. There is no recent documentation to support that the patient is malnourished. The documented BMI does not suggest that the patient is underweight. There is no documentation that he would be unable to tolerate a standard liquid or soft diet instead of three cans of Ensure daily. Therefore, 180 cans of Ensure every 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested liquid diet is not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition. Findings: Two physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient.  Final Result: Two of the 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 with sub-specialty certification in cardiovascular disease 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

The parent of a two-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that the literature on the subject of ABA is clear that this treatment is not considered experimental and is rapidly becoming the treatment of choice for young patients with autism spectrum disorders. Moreover, numerous studies have established that ABA has a role in the treatment of autistic patients with documentation of improved health outcomes. This patient has been diagnosed with autism and is almost 3 years of age. Thus, he is an appropriately identified patient to receive the requested ABA service. The articles referenced consistently show that ABA is an effective intervention for autism in early childhood such that it is expected to provide this patient with better results than alternative treatment modalities. Given the patients level of deficits and the recommendations by his providers for 25 hours of ABA therapy per week, the requested services should be provided at the requested frequency.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested Oxycontin 40 mg, oral 12-hour SR tablets (8 tablets 4 times a day) for treatment of his chronic hip pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Oxycontin 40 mg, oral 12-hour SR tablets (8 tablets 4 times a day) is not medically necessary. The patient has chronic non-malignant pain. The current standard of care in this clinical setting is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. Furthermore, high dose opioids are associated with a high risk of dependence and tolerance; therefore are not recommended (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would therefore be in the best interest of this patient to wean off opioids and continue in a multidisciplinary program. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for high frequency chest wall oscillation device. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the device at issue in this clinical setting. Patients who are diagnosed with bronchiectasis often have mucus plugging and pulmonary infections. However, while high frequency chest wall oscillation devices for chest physical therapy have been available for many years, their efficacy over routine chest physical therapy have not been established. There is a lack of multicenter, randomized, controlled, and long term clinical outcome studies documenting the safety and efficacy of this device in patients diagnosed with pulmonary disease. There is a lack of objectively documented studies to indicate that the device at issue decreases the progression of any disease, decreases the number of pulmonary admissions or decreases the length of stay of an admission in any disease. The subjective improvement of a patients condition should not be a substitution for randomized, controlled, clinical trials to prove its safety and efficacy. While the patients symptoms may have improved with this device, there is a lack of documentation that the device at issue would improve the long term functional outcome of this patients condition.  Final Result: The reviewer determined that the device at issue was not and 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 sub-specialty certification in pulmonary 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 a similar medical condition.