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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of his 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks, or with Harvoni for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety with either medication.  However, there is a lack of head-to-head trials showing that Viekira Pak is superior to Harvoni, which is the Health Plans alternative.  For these reasons, although treatment of hepatitis C is necessary in this case, the requested treatment with Viekira Pak is not supported as medically necessary for the treatment of this patients hepatitis C infection.   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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Myriad genetic blood test for evaluation of the enrollee, who has a family history of breast cancer. Findings:  Thwo physician reviewers found that BRCA genetic testing is a well-accepted form of testing for breast and ovarian cancer susceptibility, and there are a series of possible clinical decisions that can be made on the basis of BRCA testing. The medical evidence supports BRCA genetic testing for a woman, without a personal history of breast cancer, if she has a first-degree or second-degree relative diagnosed with breast cancer below the age of 45. In this patients case, her aunt was diagnosed with breast cancer below the age of 45. However, this patient was evaluated with a 25-gene panel which includes many genes of unknown clinical implications. Therefore, the panel is of questionable clinical benefit. Although many of the genes in the panel are of ongoing interest, these genes as yet cannot be used for clinical decision making.  Therefore, the BRCA genetic testing portion of the services at issue was likely to have been more efficacious than other methods of evaluating this patient. The medical records fail to demonstrate the superior effectiveness of the remainder of the services at issue. Final Result: The reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: Reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested endovenous chemical ablation (ultrasound-guided vein injection) of the left leg for the treatment of her varicose veins. Findings:  The physician reviewer found that this patient has poor valvular function which constitutes an abnormal structure of the body. This venous insufficiency is caused by a disease process. The requested services will be performed to assist the patient with normal activities of living, thus improving function. Furthermore, although the services are intended to improve function, more than minimal improvement in appearance will result as a byproduct of the treatment. Therefore, the proposed services should be considered reconstructive surgery as defined by California law. Moreover, the proposed services are medically necessary to treat the patients functional problems. The patient does not have typical venous insufficiency associated with an incompetent saphenous system. Rather, there is some reflux at the level of the knee feeding directly into a very large, refluxing branch. There is also a degree of lesser saphenous reflux. This anatomical situation does not lend itself to traditional treatment plans. The patient has completed conservative management. Thus, endovenous chemical ablation (ultrasound-guided vein injection) of the left leg is medically necessary for treatment of the large, palpable branches.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested a pneumatic vest airway system (the Vest Airway Clearance System) for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that persistent bacterial bronchitis (PBB) is a clinically diagnosed condition characterized by the following: chronic wet cough lasting more than four weeks, resolution of the cough following antibiotic therapy, and absence of other conditions that could be responsible for the cough. Children with PBB are often misdiagnosed with asthma, although PBB and asthma may coexist. Treatment is based on eradicating the bacteria with antibiotics and measures to improve cough effectiveness and keeping the airways free of infection to allow healing (Chang and colleagues). Manual chest physiotherapy (CPT) is one way in which to facilitate airway clearance. Children with recurrent PBB should undergo evaluation for bronchiectasis and its causes. There is some concern that PBB may be antecedent to bronchiectasis. CPT, while effective initially, can become less so as a child grows. It is also undesirable in patients with gastroesophageal reflux (as this patient has), as the positioning required may exacerbate this condition. High-frequency chest wall oscillation (HFCWO) such as the Vest Airway Clearance System was developed to improve airway clearance in those patients where the normal mucociliary transport system has failed (e.g., chronic bronchitis, bronchiectasis, cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. Research confirms the utility of these systems in airway clearance. In stable outpatients with cystic fibrosis, high-frequency oscillation and chest physiotherapy were found to have comparable augmenting effects on expectorated sputum weight without changing PFTs or oxygen saturation (Scherer and colleagues). Systems such as the Vest Airway Clearance System are now clinically established as appropriate therapy for patients with airway clearance problems. Although it has been best studied in patients with cystic fibrosis, its use has been expanded to include a wide variety of patients with similar difficulties. It is therefore medically necessary and appropriate to provide the VACS therapy system to this patient to facilitate his mucus clearance, particularly in light of his GERD.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested for chemoembolization of liver metastasis for treatment of his metastatic colon cancer.   Findings:  Three physician reviewers found that the scientific evidence suggests that chemoembolization of liver metastasis greater than 5 cm is investigational in nature. Furthermore, there is no peer-reviewed literature demonstrating that chemoembolization confers additional benefit over standard therapy in patients with metastatic colon cancer. Given the paucity of data regarding the use of chemoembolization in this particular setting, its superiority remains unproven.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Rituxan for medical treatment of her immune thrombocytopenic purpura. Findings:  The physician reviewer found that Rituxan is medically appropriate in this clinical setting.  Per the current medical evidence, Rituxan is the standard next option in this patients case.  Other interventions could potentially cause disruption of her chronic myeloid leukemia therapy, causing relapse.  All told, the requested medication Rituxan is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a seven-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that despite the therapy addressing the patients fine motor deficits, the findings emphasize the realm of sensory integration and its dysfunction. The therapists interventions focused on sensory integration therapies rather than several other mainstream therapies for ASD. Sensory Integration Disorder (SID) originated in the OT literature and is specific for that discipline. However, there is limited data to support the efficacy of sensory therapy for the treatment of ASD. There is no empirical data to support sensory integration treatment and it should not be viewed as a primary intervention strategy in children with ASD.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test for evaluation of the enrollees pineal pilocytic astrocytoma with aggressive features. Findings: All three physician reviewers found that there is a lack of support in the medical literature as to the superior efficacy of the services at issue in this clinical setting. Prospective randomized clinical trials, which compare the strategy of targeted treatment to standard of care therapies, are needed in order to demonstrate the clinical utility of this gene test. The available medical literature, as to its clinical utility, consists of a small number of uncontrolled studies, and nonrandomized controlled trials. The evidence is not sufficient to make conclusions as to its efficacy and clinical utility when compared to standard options. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested osteochondral knee allograft for the treatment of her knee pain. Findings:  The physician reviewer found that the requested osteochondral knee allograft is medically appropriate and reasonable. Given the patients young age and high activity level, arthroplasty should not be considered. Microfracture has also failed. All told, osteochondral knee allograft is likely to be the most efficacious procedure in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin for the treatment of Short Stature. Findings:The physician reviewer found that baseline profiles and a bone age x-ray were considerably delayed by years vs. chronological age.  At the then current height, the final adult height estimate was far greater than the mid parental target height; actually, over 2 standard deviations above the genetic mean. The baseline labs were all normal including thyroid tests and the IGF-1 level was approximately the mean for age/gender.  Given the reassuring final height estimate, no therapeutic interventions were initiated at the time.  The enrollee was seen again and demonstrated sub-optimal interval height velocity with height deceleration.  A repeat set of labs confirmed the normal IGF-1. At this time the decision was made to start growth hormone therapy and the enrollee did well, without adverse effects with the therapy.  There are notes indicating treatment was provided for years.  As per the medical literature, Idiopathic Short Stature is an FDA defined condition where the child is below the 1st percentile and evidence at the time of treatment suggests an adult height below the first percentile.  Data in this case does not document that this criterion is met. The patients starting height was not below the 1st percentile and his bone age predicted a very normal adult height. The requested treatment with Nutropin AQ Nuspin was not appropriate.    Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Endocrinology and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis who presented for a breast examination. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, she has breasts that have been described as being extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service 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 1, 2, and 3 are board certified in diagnostic radiology 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 an eight-year-old female enrollee has requested neuro/biofeedback therapy for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that in 1997, the use of neuro/biofeedback for the treatment of ADHD was reviewed extensively by the American Academy of Child and Adolescent Psychiatry as part of the process of defining treatment parameters. There was no evidence to support the efficacy of this therapy at that time and current literature on the subject has not risen to the level of controlled, double-blind, research-centered, clinically-based, reproducible studies. The use of neuro/biofeedback is, at best, investigational and it is not medically indicated for the treatment of ADHD.
Appeal type: Experimental/Investigational
Decision: Overturned

A 19-year-old male enrollee has requested growth hormone therapy (Genotropin) for the treatment of his Prader Willi Syndrome (PWS) and adult growth hormone deficiency. Findings:  Two physician reviewers found that while growth hormone (GH) tests may not be as useful in PWS as in other disorders because of the confounding effect of obesity in these individuals, the use of GH therapy is well established. As noted in the references, there is evidence that GH is an approved therapy to maximize stature in patients with PWS. The records provided for review show no evidence that this patients growth plates have closed which lends even more support to the contention that he is likely to benefit from GH therapy. All told, the use of growth hormone therapy for treatment of patients with PWS is a medically appropriate indication, and the patient is an appropriate candidate for continued therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for arthroplasty (total joint replacement) of the right ankle. Nationally recognized evidence based medical guidelines recommend total ankle replacement surgery only for very limited indications. This patient presents with constant right ankle pain, grade 3/10 at rest and grade 8-10/10 with weight bearing. Pain interferes with activities of daily living and work ability. Clinical exam findings have documented painful limited range of motion and crepitus consistent with x-ray findings of end-stage post-traumatic right ankle osteoarthritis, reportedly bone-on-bone. He has had worsening pain despite long-term conservative treatment. The patients body mass index is 31. There are no guideline contraindications documented in the medical records. Current evidence based medical guidelines for total joint replacement in the ankle have been met. Therefore, the requested arthroplasty (total joint replacement) of the right ankle is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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:  An enrollee has requested Sovaldi and Ribasphere for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 guidelines, treatment-naive patients with hepatitis C, genotype 2 infection should be treated with daily Sovaldi and ribavirin for 12 weeks.  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 2 regardless of fibrosis stage.  All told, the requested Sovaldi and Ribasphere are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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: Overturned

A 30-year-old female enrollee has requested diagnostic testing (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile) for evaluation of her pregnancy. Findings:  The physician reviewer found that per the submitted documentation, this patient had a high-risk pregnancy. Her high-risk conditions included polyhydramnios, cholestasis of pregnancy with elevated liver enzymes, and elevated bile salts. The patient had symptoms of itching which is very typical with cholestasis of pregnancy. She underwent diagnostic testing (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile).The medical community has been paying increasing attention to cholestasis of pregnancy, which is a potentially serious pregnancy-related liver disorder. The primary symptom of intrahepatic cholestasis of pregnancy is severe itching. The itching generally progresses in severity, and may develop to the point that it interferes with a womans daily activities, including sleep. Although the itching sensation can be present on any part of the womans body, it is most commonly felt on the palms of the hands or the soles of the feet. There is an increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy and polyhydramnios. The patient started to receive biweekly fetal testing as well as kick counts. On the date in question, the patient had a follow-up growth scan and antenatal testing which included an amniotic fluid index and biophysical profile. The timing since her previous sonogram to check growth was appropriate, and the patient received the biophysical profile as part of her biweekly antenatal assessment for cholestasis of pregnancy and polyhydramnios. These are considered standard of care. The fetus is monitored closely during the pregnancy to ensure normal fetal development is taking place. In this patients case, the diagnostic testing provided (99211 for office visit, 76815 for ultrasound and 76818 for fetal biophysical profile) were medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested sensory integration and praxis therapy for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that sensory integration and praxis therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Sensory integration therapy has a robust medical literature as to its long-term value.  A meta-analysis of 27 medical journal articles concluded that sensory integration therapy is effective for the developmentally disabled child. In addition, researchers reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. Given the above, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in neurology with special qualification in child neurology 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.