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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continued applied behavioral analysis (ABA) therapy for treatment of the autism.  Findings: The request for continued ABA therapy at the frequency of 40 hours per week has been established as medically necessary for treatment of the patients autism. Mohammadzaheri and colleagues compared two intervention conditions, a naturalistic approach, Pivotal Response Treatment (PRT) with an adult-directed ABA approach on disruptive behavior during language intervention in the public schools. The study found that ABA was effective to decrease disruptive behaviors in school age children. In addition, ABA is one of the best therapies to address aggression and self-injury. In this case, the patient has maladaptive behaviors that have considerable safety implications due to elopement, self-injury and tantrum. There is a lack of records showing that the patients maladaptive behaviors are at a safe level. As such, a decrease in ABA hours is not indicated at this time. Therefore, based on the records submitted for review, 40 hours per week of ABA services is medically necessary for treatment of the patients autism.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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) services provided, and 40 hours per week of ABA therapy going forward. The presenting information supports the ABA services already provided, and 40 hours per week of ABA therapy going forward, as medically necessary for treatment of this patient. Specifically, the records document interfering behaviors, low Vineland-3 scores, and a large scope of goals identified in the treatment plan. The patients rate of interfering behavior highlights that while the patient has made significant improvements, the patient has yet to meet the final goal. These behaviors are socially unacceptable, making access to other treatment areas, such as social interaction, difficult to achieve. Findings: the physician reviewer found that the patients overall composite and daily living scores are more than two standard deviations from the mean, while her communication and social scores are two standard deviations from the mean. Her motor scores are a relative strength, but still over one standard deviation from the mean. In age equivalents, the patient is more than two years behind in some areas, but almost four or more years in all other areas. According to the Behavior Analyst Certification Board (BACB), dosage is dependent upon goals of treatment, specific patient needs, and response to treatment. The goals listed in this patients treatment plan highlight 27 goals and seven interfering behaviors. The number of goals listed is appropriate for the requested service intensity. The BACB highlights a reduction in service intensity should align with discharge and transition planning. As the patient has not acquired the skills to meet the criteria for discharge, a step down in services is not warranted. Therefore, ABA services provided, and 40 hours per week of ABA therapy going forward, were and are medically necessary for the treatment of this patient. 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 psychology, a licensed behavioral analyst, 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 patient has requested reimbursement for the single photon emission computed tomography (SPECT) scans of the brain for evaluation of the enrollees atypical depression, brain fog and cloudy thinking. Findings:  The physician reviewers found that single photon emission computed tomography (SPECT) is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body. Advances in neuroimaging techniques such as SPECT represent an exciting, and potentially useful, expansion of the collective knowledge base. However, the available data has not demonstrated a meaningful correlation between clinical diagnoses and specific brain activity patterns. This patient had not exhausted standard treatments available to treat her condition including serotonin-norepinephrine reuptake inhibitors or monoamine oxidase inhibitors, which represent classes of medications commonly used to treat atypical depression. Further, her antidepressants had not been augmented with agents such as buspirone, lithium, aripiprazole, quetiapine or thyroid hormone. Finally, there was no evidence that the patient had failed evidence-based non-pharmacologic interventions, such as cognitive behavioral therapy, psychodynamic psychotherapy or interpersonal therapy. In sum, considering the relevant peer-reviewed literature and current practice standards, the SPECT scans of the brain provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three reviewers determined that the diagnostic procedures at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer numbers one, two, and three are board certified in psychiatry and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested continued skilled nursing facility (SNF) rehabilitation services including physical and occupational therapy for treatment of her medical condition status post multiple fractures. Findings:  The physician reviewer found that this patient sustained clavicular, rib and pubic ramus fractures. As recommended by the medical literature, these injuries are typically managed non-operatively (Anderson; Denard, et al.; Hill, et al.). As of the date in question, the patient had progressed to a level of function where further care could be provided at a less intensive level of care such as home health care as planned. The patients records document that she has been medically stable. Further, her pain has been well controlled and her leg edema has improved. She has multiple chronic medical issues, but these issues can be followed on an outpatient basis without an expectation of a significant difference in health or functional outcomes. There are no reported skilled nursing issues in that the patient is on an oral diet and oral or inhaled medications and is not reported to require complex wound care or other skilled nursing services. From a functional standpoint, she is able to walk household distances and perform ADLs at the standby assist level. The patients needs as of the date in question onward were and are custodial in nature; the medical necessity of SNF services beyond this date has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested residential psychiatric services for the treatment of the enrollees anxiety and attention deficit disorders. Findings:  The physician reviewer found that the patient does not meet medical necessity criteria for residential level of care during the timeframe in question. This determination is based on the medical records reviewed wherein there is no documentation to support that the patient was at any time in imminent risk of harm to herself or others. Additionally, there is no documentation to show the patient had any symptom or behavior that needed 24-hour monitoring. This patient does have emotional and mental health issues, but these could have been effectively and safely treated at a less restrictive level of care. There is no documentation to support that the patient was actively psychotic, or unable to take care of herself. The level of care provided was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested a positional (stand up) thoracic spine MRI for an evaluation of her low back pain. Findings:  Three physician reviewers found that there is a lack of controlled studies which have demonstrated clear benefit of an upright MRI in long-term results based upon this technique. The small body of literature seems to address the utility of the technique in the lumbar spine, but even in this area there is a lack of evidence that the depiction of findings on the erect study versus the standard supine study are necessarily related to the patients symptoms. Currently, there is a lack of data comparing the two techniques in the thoracic spine.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542).Findings:  Two of the three physician reviewers found the infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542) was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The service at issue is a quantitative monitoring assay designed to measure infliximab and antibodies to infliximab levels, intended to provide insight into factors contributing to a patient's loss of response and to guide treatment decisions. There is insufficient evidence in current medical literature to determine the role of measurement of antibodies to infliximab and how the use of the test results in improved health outcomes compared to other accepted diagnostic tests. Lee and colleagues note in a meta-analysis that the presence or absence of anti-infliximab antibodies did not affect the rates of clinical remission and that the prevalence of anti-infliximab antibodies depended on the regimen of infliximab administration and the use of immunosuppressants. The authors further noted that patients who tested positive for anti-infliximab antibodies were at an increased risk of infusion reactions but had similar rates of remission compared with patients who tested negative for anti-infliximab antibodies. The authors concluded that further analysis is required to determine whether loss of response is dependent on the titre of anti-infliximab antibodies. In this case, given that visit notes reported that the patient was in remission, results from the service at issue would not have changed the management of his treatment regimen as dose escalation would not have been indicated in this clinical setting. Therefore, the infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 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 parent of a 15-year-old male enrollee has requested  gynecomastia surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the current medical evidence, surgical management of gynecomastia should be reserved for severe and refractory cases.  Pruthi and Jones noted that nonsurgical interventions and medical therapies be considered as initial therapy for adolescents with a breast mass or breast hypertrophy.  The clinical documentation submitted for review indicated the patient had the condition for at least five years.  However, there was a lack of documentation indicating nonsurgical interventions and medical therapies had been considered as an initial therapy.  There is a lack of support for the requested gynecomastia surgery in this patients case.  All told, the requested gynecomastia surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 20-24 acupuncture sessions. Current evidence suggests that most acupuncture therapies, including acupuncture combined with other therapies, are effective in decreasing pain and in improving physical function. Research found that acupuncture might be efficacious in terms of pain relief and reduction of muscle irritability in myofascial pain syndrome patients. The data support an initial trial of five to six acupuncture sessions in combination with a conditioning program of aerobic and strengthening exercises. Future treatment based on improvements in objective measures may justify an additional six sessions. Peer-reviewed medical literature indicates that passive care with acupuncture should be combined with active care such as a home exercise program. Additional acupuncture treatments should occur based on progressively greater, incremental objective gains. In this case, prior acupuncture sessions were reported as beneficial in reducing the patients symptoms. However, the records do not document the number of sessions completed and specific measurable, sustained, and objective functional improvement obtained with previous acupuncture. Moreover, the request for 20-24 sessions of acupuncture exceeds the current recommendations. The records do not document a reduction in medication intake or work restrictions, or an improvement in performing activities of daily living directly attributable to prior acupuncture. All told, the requested 20-24 acupuncture sessions are not medically necessary for treatment of this patient. 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 oriental 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

A 43-year-old male enrollee has requested surgical vein stripping for treatment of his varicose veins.  Findings:  The physician reviewer found that general practice guidelines in the specialty of vascular surgery dictate that symptomatic varicose veins warrant invasive treatment when there are complications such as bleeding, ulceration or recurrent thrombophlebitis or there are chronic symptoms which are severe enough to interfere with activities of daily living. Additionally, the symptoms must be refractory to at least three months of conservative therapy inclusive of prescription compression stockings. Treatment of the great saphenous and small saphenous veins by ligation, division and stripping is warranted only when reflux is demonstrated in these veins by duplex ultrasound. In this instance, there is insufficient documentation that the patients symptoms interfere with his activities of daily living and the use of an Ace wrap is not equivalent to prescription compression stocking use. Finally, no reflux was demonstrated in the great saphenous or small saphenous veins of the right leg.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of her risk of cardiac disease. Findings:  Three physician reviewers found that guidelines for the management of cardiac risk 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 (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (A), C-reactive protein (CRP), high sensitivity CRP, 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. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification 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: Overturned

A 56-year-old female enrollee requested Copaxone 40mg injections, three times per week for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage.  The patient has been diagnosed with relapsing-remitting multiple sclerosis, and Copaxone 40mg, three times per week has been prescribed.  Per the current medical evidence, the requested medication dosage has been demonstrated to be safe and well-tolerated in this clinical setting.  All told, Copaxone 40mg injections, three times per week are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  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. This applies regardless of fibrosis stage or viral load. Per the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. These guideline 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. The guidelines indicate patients with diabetes are high priority for therapy. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni 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: Experimental/Investigational
Decision: Overturned

A 33-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her Castlemans disease.  Findings:  Two physician reviewers found that there is sufficient medical literature supporting the use of a PET scan in this clinical setting. The study by Szturtz and colleagues stresses the significance of full-body PET/CT scanning during staging and treatment response evaluation. Moreover, Pelosi and colleagues state that based on the results of previous case reports and on those of the present study, Castleman's disease has a high glucose metabolic activity. Thus, the use of a PET scan is considered appropriate in order to stage or restage the disease and to evaluate the response of the disease to treatment. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested service is likely to be more beneficial than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage for the medication Procarin. The health plan has denied this request indicating that Procarin is considered investigational for treatment of the enrollees multiple sclerosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested medication is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.