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

The parent of a 17-year-old female enrollee has requested applied behavioral analysis (ABA) therapy and ABA supervision for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is currently 17-years-old and presents with significantly delayed language, daily living and socialization skills. Based upon the documentation provided, it appears she has been receiving at least one hour daily of ABA therapy for approximately the specified timeframe. The submitted progress reports do not demonstrate the patient has made significant functional progress with ABA therapy. There is a lack of evidence that the patients behaviors or social skills have improved beyond the level that would be anticipated by maturation despite the specified timeframe of ABA therapy. Individuals who benefit from ABA therapy generally exhibit gains in behavior within a two-year period. Therefore, continuation of ABA therapy at a frequency of 8 hours of therapy per week and 4 hours of supervision per month is not medically necessary. Two hours of ABA therapy per week and 1 hour per month of supervision is sufficient to maintain the patients current performance level and therefore is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male enrollee has requested authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees behavioral issues. Findings:  The physician reviewer found that early intervention services are medically necessary for children diagnosed with autism spectrum disorder. Colleagues studied children enrolled in a multidisciplinary team approach, similar to the proposed IOP program in this case. The authors reported that the children demonstrated significant gains in overall functioning that was sustained on follow evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long-term independence. In addition, the use of cognitive behavioral therapy has been shown to be beneficial in the treatment of children with autism, successfully addressing common problems such as feeding difficulties. Given the support in the peer-reviewed literature demonstrating the benefit of early intervention in children with autism, coupled with the patients resistance to transitions and rigidity, outburst behaviors and tantrums, the request for IOP services is medical necessary for treatment of the 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for abdominoplasty surgery. The enrollee has a history of diabetes, hypertension, high body mass index, and lumbar radiculopathy. He was evaluated by a plastic surgeon for an abdominal panniculectomy. Medical records show a physical examination revealed a large, hanging abdominal pannus covering the entire mons pubis. The surgeon determined the risks of surgery outweighed the benefits. The records do not support the enrollee has a significant functional impairment secondary to the excessive abdominal pannus. The records do not support recurrent infections that are not manageable with optimal medical therapy. The abdominoplasty surgery was deemed not medically necessary in various encounter notes. Literature describes abdominoplasty as a procedure to reduce excess skin and fat around the abdomen and strengthen the muscles of the abdominal wall, resulting in a visually pleasing abdomen. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of the keloid scar on the right ear lobe. Keloids arise after a disruption of skin integrity following superficial or deep injuries. Keloids are composed of mainly type III (early) or type I (late) collagen. Some of the symptoms include pruritus, tenderness, and pain. Although keloids have an aggressive growth pattern, they are generally benign tumors, as development of malignant cells in a keloid is rare. Tissue bulk can cause functional problems, and some keloids are symptomatic with associated itching and/or pain. In addition to symptoms such as tenderness, pain, and burning, keloids may lead to sleep disturbances, anxiety, depression, and disruption of daily activities. In addition, the cosmetic defect can progress to produce severe deformities and functional impairment that negatively impact the patients quality of life. Intradermal, extradermal, or systemic therapies may be used, although combination regimens are the most effective in treating keloids and preventing recurrences. The records provided for review document the presence of a symptomatic right ear lobe keloid measuring 2 cm. The patient reports that the keloid causes discomfort. Thus, the requested removal of the keloid scar on the right ear lobe is medically necessary. Moreover, the requested procedure is reconstructive in nature. The patients condition constitutes an abnormal structure of the body caused by disease. The requested removal of the keloid scar on the right ear lobe will create a normal appearance to the extent possible with more than a minimal improvement in the appearance of the patient. Given these findings, the requested removal of the keloid scar on the right ear lobe is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 reimbursement for advanced lipoprotein testing. There is a lack of clinical studies in current medical literature demonstrating that advanced lipoprotein testing adds significant actionable information to what is already known from a basic fasting lipid panel, or that therapies to correct novel lipoprotein abnormalities, such as lipoprotein(a) and apolipoprotein (apo) B have any effect on cardiovascular outcomes such as myocardial infarction, stroke, or death. In this clinical setting, there is insufficient evidence to support the use of the service at issue, particularly given this patients low risk of atherosclerotic cardiovascular disease (ASCVD). Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 reviewer 1 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in interventional cardiology and in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested lumbar spinal fusion surgery for treatment of his axial pain with radicular symptoms.  Findings:  The physician reviewer found that at issue in this case is the medical necessity of a lumbar fusion. Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option #1 would argue against a fusion in this patient as he would be undergoing a primary disc excision. Option #2 also argues against a fusion as the patient does not have evidence of lumbar spinal deformity or instability at any level.  Option #3 could possibly apply to this patient as he does complain of axial low back pain, but it is unclear which level(s) is the origination of the patients pain. Finally, options #4 and #5 do not apply to this patient as he has not as yet had a primary surgery and does not have evidence of recurrent disc herniation at these levels. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL). Findings:  The physician reviewer found that  alopecia areata is a common form of immune-mediated alopecia and that current treatment options mostly include non-specific broad immunosuppressants that are administered either locally or systemically, with first-line therapies involving the use of intralesional and topical steroids. However, such therapies are only approved for short-term use due to side effects. The authors further note that immunosuppressive agents such as methotrexate, cyclosporine, and azathioprine lack adequate evidence from randomized controlled studies to support their use and therefore tend to require very close patient follow-up due to potentially severe immunosuppression that may result. The authors explain that contact immunotherapy involving the use of squaric acid dibutyl ester and diphenylcyclopropenone has produced inconsistent results. Dillon reports that although several therapies for alopecia areata have been developed and tested, there is no specific treatment that has been approved, leading to the availability of many off-label conventional treatment options, with very limited responses, including the emerging use of Janus kinase (JAK) inhibitors. Cho and colleagues report a small but growing body of literature supporting the use of dupilumab as an effective treatment option for alopecia areata among a subset of patients with atopic dermatitis. In this case, notes reported that the patient had failed all first, second, and third line therapies including topical corticosteroids, intralesional steroids, tofacitinib, methotrexate, and prednisone. The records note that the patient is achieving improvement in her alopecia as well as her atopic dermatitis on dupilumab. Therefore, Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL) is 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 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

A 50-year-old female has requested a repeat MRI of the lumbar spine for the evaluation of back pain.  Findings:  The physician reviewer found that there is no medical necessity for a repeat MRI in this case. The submitted documentation does not reveal any evidence of a neurological deficit on physical exam. Furthermore, the patients two previous MRI studies did not show significant degeneration or severe stenosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.Findings:  Three physician reviewers found that patient has gastroesophageal reflux disease (GERD) based on pH recording, and he has not benefited to a significant degree from use of acid suppression treatment. In prelude to surgical intervention for GERD, researchers noted that it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. The authors concluded that upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has undergone much of this pre-operative assessment. However, this patient has multiple contraindications to performance of the transoral incisionless fundoplication procedure including Barretts esophagus, hiatal hernia of greater than 2 cm, and a body mass index (BMI) over 35. For these reasons, the requested procedure is not likely to be more beneficial than available standard therapy for treatment of patients medical condition. Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial than available standard therapy for treatment of patients medical condition.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: Medical Necessity
Decision: Upheld

The patient is a 19-year-old male with a congenital condition with components of cerebral palsy-type neuromuscular disorder. He is wheelchair bound, and a request has been made for a custom, lightweight power-assisted vehicle (POV). He has a lightweight wheelchair that is approximately four years old and is in need of frequent repairs. The patients mother indicates the patient has right wrist chronic tendonitis, which is exacerbated by propelling the wheelchair. The physical therapist confirms this overuse history. The patients mother feels the patient needs some type of powered wheelchair because he is in college and has to negotiate terrain that is uneven and hilly. She states that the college makes power scooters available, but that is not a viable option for the patient because he is prone to tip out a power scooter and is unable to transfer to desk or toilet.The patients primary care physician has supported the patients request stating that a POV will allow the patient to manually propel and will provide assistance when needed to push long distances and up ramps and inclines, etc. The patients physical therapist indicated the patients power was 4/5 in the upper extremities and he had pain at end of range of motion. An evaluation in April 2004 indicated the patient was able to stand with maximum support. Another evaluation performed in June 2004 did not give any description of power, ability to transfer, etc. The Health Plan has denied coverage for the requested equipment on the basis that it is not medically necessary for the patients mobility. The Health Plan has authorized a repair evaluation of the patients current wheelchair along with any necessary repairs. In addition, a mobility evaluation has been authorized. The Health Plan utilizes criteria similar to Centers for Medicare and Medicaid (CMS) for determining appropriateness of a POV. It is considered DME to be used for purposes within the home. The Health Plan requires that the patient be unable to operate a manual wheelchair, demonstrate ability to operate POV controls, and be able to safely transfer in and out of the POV. It has not been demonstrated that the patient meets these criteria. He appears capable of operating a manual wheelchair, and has not shown his ability to transfer from a POV. There is no objective evidence that the patient would be able to transfer from chair to desk and toilet in the requested device. Also, the POV has been requested for use in the community and medical necessity criteria requires use in the home. The Health Plans recommendation that a mobility evaluation be performed to assist in better determining whether the patient meets criteria for a POV is medically reasonable and appropriate. As such, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. High-dose corticosteroid therapy is the mainstay of treatment for acute exacerbations of multiple sclerosis (MS). Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel, an adrenocorticotropic hormone (ACTH), for the treatment of exacerbations of multiple sclerosis in adults. Other therapies include plasmapheresis, generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids or ACTH, and intravenous immunoglobulin (IVIG), sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but for which there is no consistent evidence regarding use in relapse management. Ross and colleagues state that Acthar Gel, May be considered as an alternative treatment of MS relapses. In our experience, reasons for using ACTH include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids. In a randomized, open-label, crossover study evaluating 18 patients with MS treated with subcutaneous Acthar Gel and intravenous methylprednisolone (IVMP), Bell and colleagues report that preliminary results suggest that fewer drug-related adverse effects occurred with Acthar Gel than intravenous methylprednisolone for treatment of MS exacerbations. In a randomized, rater-blinded trial evaluating 23 patients randomized to ACTH or IVMP experiencing breakthrough disease in relapsing forms of MS while on disease modifying therapy with interferon , Berkovich and colleagues found that over 15 months, the cumulative number of relapses per patient was 0.08 with ACTH versus 0.80 with IVMP. In this case, the patient has MS with acute exacerbations. Given that current medical literature supports the use of Acthar Gel in this clinical setting, with less adverse effects and comparable efficacy and treatment outcomes to intravenous corticosteroid therapy, the requested medication is medically indicated. Therefore, Acthar Gel is medically necessary for the treatment of this patient.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.