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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of her osteoarthritis of the knee. Findings:  The physician reviewer found that evidence based medical studies conclude that hyaluronic acid is the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids (Bannuru et al). Kotevoglu and colleagues conducted a randomized controlled clinical trial comparing the effectiveness of different molecular weight hyaluronan solutions in the treatment of knee osteoarthritis. The hyaluronic acid groups performed better than placebo. Evidence based medical guidelines and peer-reviewed literature support the use of hyaluronic acid injections for this patients condition. She presented with significant and function-limiting right knee pain. Clinical exam findings were consistent with imaging evidence of tri-compartmental osteoarthritis. There was evidence of reasonable and/or comprehensive non-operative treatment and failure, including aspiration and intra-articular steroids. She was intolerant to oral anti-inflammatory medications and Tylenol was insufficient. A series of Supartz injections was performed previously with documented reduction in pain. Given the efficacy of the Supartz injections, a repeat course of the therapy is medically appropriate and indicated at this time. Therefore, the services at issue were and are medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a blood pressure monitoring device. This patient presents with potential end organ disease from hypertension with CKD and proteinuria. Management of hypertension is critical in preventing ongoing renal injury. Researchers ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. The authors noted that ambulatory blood-pressure data provide a more comprehensive assessment of blood pressure over the course of a day and have been reported to better predict health outcomes than blood pressure measured in the clinic (clinic blood pressure) or at home. This patient has well-documented attempts to measure her blood pressure in the clinic and at home. Therefore, the requested blood pressure monitoring device is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for hippotherapy. A review of clinical studies and research indicates that hippotherapy is a subset of animal assisted therapies that uses the characteristic movements of a horse to provide carefully graded motor and sensory input. The goal is to improve neurological function and sensory processing which can then be generalized to daily activities for patients with a variety of disabilities, including autism. However, a study found that the effectiveness of hippotherapy remains unsupported. Researchers evaluated all equine assisted activities and therapies, and found three studies suitable for meta-analysis. The authors reported the results of the meta-analysis indicated no statistically significant differences compared to control groups. The authors concluded that further research is needed. According to the National Autism Centers National Standards Project, behavior based techniques, such as applied behavioral analysis (ABA) therapy, are recommended for patients with autism. All told, the requested hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Findings:  Three physician reviewers found hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Final Result: The reviewers determined that hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Credentials/Qualifications: Physician reviewers 2 and 3 are board certified in psychologist and board certified behavior analyst,and are actively practicing. Physician reviewer 1 is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Two of the 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers is 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 the Botox injection.As noted in the medical literature, intrapyloric injection of Botox is not recommended for patients with gastroparesis. Although observational studies suggest that injection of Botox into the pylorus can improve both gastric emptying and symptoms by inhibiting pylorospasm, randomized trials have failed to demonstrate an improvement in symptoms as compared with placebo. All told, the Botox injection rendered was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Botox injection provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Botox injection provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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 authorization and coverage for  proton beam therapy (CPT 77520, 77522, 77523, and 77525). This patient presents with a history of prostate cancer with recent recurrence. A prostate biopsy on 3/15/20 showed involvement of the prostate gland bilaterally by a combination of a Gleason 3+3 and 3+4 adenocarcinoma. The patients provider has recommended proton beam therapy in lieu of standard IMRT and other standard treatment modalities. Proton beam radiation therapy for prostate cancer in a patient previously treated with radiotherapy to the pelvis has not been demonstrated to be superior to prostatectomy or IMRT. Per the American Society for Radiation Oncology (ASTRO), the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. A systematic review by Verma and colleagues evaluated available evidence regarding proton beam therapy re-irradiation. The authors investigated patients with central nervous system, head/neck, lung and gastrointestinal malignancies. The authors noted, Based on the limited existing data, proton beam therapy is a notably safe re-irradiation modality for effective salvage of recurrent disease. It is important to note that this systematic review did not evaluate re-irradiation in the setting of prostate cancer. At this time, there is a lack of evidence supporting re-irradiation with proton beam therapy for this patient with prostate cancer. Thus, the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: 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: Upheld

The patient has requested authorization and coverage for bilateral mastectomy. Researchers noted that in hypothyroidism and hyperthyroidism, gynecomastia is commonly resolved after euthyroid state restoration. The American Society of Plastic Surgeons (ASPS) recommend breast biopsy when malignancy is suspected. There should be unilateral or bilateral gynecomastia present that has persisted for more than three months after pathological causes ruled out and three months of unsuccessful medical treatment. Moreover, the patient should have symptoms such as pain and discomfort due to the distention and tightness from the hypertrophied breast. Based on the available documentation, malignancy is not suspected. Bilateral gynecomastia is present, but pathological causes have not been ruled out. There is no report of pain or tenderness due to the distention and tightness from the hypertrophied breast. Based on the medical information received for review, bilateral mastectomy is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Bilateral gynecomastia is a developmental abnormality. There is no pain or tenderness, so functional issues are not present. The requested surgery would achieve a more normal appearance. However, the requested surgical intervention is not supported since the medical records do not include documentation that pathologic causes have been ruled out. For these reasons, the requested bilateral mastectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a replacement battery for her spinal neuro-stimulator and a pain pump to regulate morphine dose for treatment of her post lumbar spine surgery syndrome and lower extremity compartment syndrome. Findings:  The physician reviewer found that the spinal cord stimulator is clinically supported for treatment of the patients medical condition. The patient indicated that the device has provided pain relief but that currently the battery needs replacement. A randomized controlled study by Deer and colleagues supports the efficacy of spinal cord stimulation (SCS) in treating failed back surgery syndrome and complex regional pain syndrome. Taylor and colleagues note that spinal cord stimulation was effective in reducing pain irrespective of the location of the chronic pain. This review also supports SCS as an effective pain relieving treatment for chronic low back pain with predominant leg pain with or without a prior history of back surgery. As such, the requested replacement battery for the patients spinal neuro-stimulator is medically necessary for treatment of the patients medical condition. On the other hand, the requested intrathecal pump or the pain pump is not clinically supported in this case. The medical records do not indicate findings of spasticity for which the device may be indicated nor do the records show a terminal condition for which palliative care is needed.  Moreover, the documentation shows no indication of intolerance or failure of oral opioids being taken for the noted pain condition to support the need to deliver such medications intrathecally. A paper by Hayek and colleagues notes a lack of controlled studies showing benefit of intrathecal opioids for non-cancer pain.  Such use may be considered in patients with demonstrated failure of or intolerance to oral administered opioids. Thus, the request for a replacement battery is medically necessary for treatment of the patients medical condition but the request for a pain pump is not medically necessary.  Final Result: The reviewer determined that the requested replacement battery is medically necessary for treatment of the patients medical condition but the request for a pain pump is not medically necessary. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in neurology with sub-certification 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 ablation of the left great saphenous vein (GSV) and bilateral sclerotherapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee's medical condition. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting. The classical and standard treatment regimen for varicose veins due to GSV incompetence and varicosities is to offer conservative therapy as first line options. If the patients succeed with conservative therapy, no further intervention would be required. However, if they fail, then ablation or removal of the axial veins and interruption of significant non-axial accessory varicosities would be indicated. This patient has documented left GSV insufficiency but the records provided do not document a trial and failure of conservative therapy. This patient may require further therapy if conservative measures fail, and once the patient completes conservative therapy, the patient should be reevaluated. However, currently, the medical necessity for ablation of the left GSV and bilateral sclerotherapy has not been demonstrated for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lenalidomide (Revlimid). Findings:  Two physician reviewers found that cutaneous involvement in systemic lupus erythematosus (SLE) is common and characterized by a chronic relapsing course. Although most patients respond to the standard first-line therapy of topical steroids and anti-malarials, approximately 30-40% of patients will be refractory to these regimens. For this significant minority, there is no consensus algorithm on treatment. One agent, thalidomide, is a potent immunomodulatory medication that has multiple effects on the immune system. Thalidomide has shown marked efficacy in several case series of refractory cutaneous SLE. Revlimid, a thalidomide analogue, has shown greater potency and a more favorable side effect profile when compared to thalidomide. As Revlimid is more potent than thalidomide, it achieves responses at lower doses. This patient has been treated with and failed first-line therapies. However, the patients condition improved while on thalidomide, which was discontinued due to side effects, and then with Revlimid without untoward events. Given these findings, the requested Revlimid is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. One reviewer found that Revlimid is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology 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: Overturned

The parent of a 16-year-old female enrollee has requested 40 hours per month of applied behavioral analysis (ABA) (code H2019) and 10 hours per month of supervision (code H0032)for treatment of the enrollees autism.  Findings:  The physician reviewer found that notwithstanding, there is limited literature examining the effectiveness of ABA as applied to teenagers and adults. However, Reichow and Volkmars article concludes that social skills can be improved by ABA therapy even in teenagers. In this patients case, she is still attending school with an aide by her side and her more complex communications are presumably partially carried on by a picture exchange system. From the age of 9 years to the present, her language has improved from age equivalency of 3 years to approximately a 6 12 year age equivalency. In March 2013 testing indicated her major deficiencies were in community and socialization skills. The patients self-help skills are close to normal. This patients primary deficits are her marked immaturity in interpersonal skills and socialization. Thus, it is medically necessary that the patient continue to receive ABA services in order to improve her interpersonal/socialization skills and allow her to be functional in society. The requested frequency of 40 hours per month of ABA therapy and 10 hours per month of supervision is excessive for purposes of achieving these goals. ABA services at a frequency of 12 hours per month of ABA therapy and 2 hours per month of supervision are sufficient to address the patients deficits in interpersonal/socialization skills and therefore are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested coverage for speech therapy.Findings:  The physician reviewer found that the patients speech-language disorder is significant and is attributable to his autism spectrum disorder. The patient requires ongoing speech-language therapy. Continuing therapy will allow the patient to maximize his functional abilities and to prevent behavior problems associated with frustration at being unable to express himself. The patient should continue to receive speech therapy for a six-month period. At the end of the six-month period, the patient should be re-evaluated by his providers to determine if continued speech therapy is indicated.