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

The parent of a 14-year-old male enrollee has requested 86 hours per month of direct intervention applied behavioral analysis (ABA) therapy and 11 hours per month of program supervision for treatment of the enrollees high functioning autism.  Findings:  The physician reviewer found that based on the submitted documentation, this patients major dysfunction is his behavior.   The patients parents have expressed concern over the patients aggressive behavior and potential to injure himself and others and his inappropriate interactions with strangers. At the age of six he was prescribed medication to control aggressiveness and impulsivity. At the age of 11, the recommendations at the conclusion of an extensive psychological evaluation were psychiatric intervention and his parents learning operant behavioral management. The patients math and reading skills are in the average range for age. Although he has a profound speech delay, he is receiving speech therapy to address this issue. While the patient continues to present with severe aggressive and oppositional defiant behaviors, the Health Plan has authorized 20 hours per month of direct intervention ABA therapy and two hours per month of program supervision. The requested frequency of 86 hours per month of direct ABA therapy and 11 months per month of program supervision is excessive for treatment of the patients behavioral issues, and thus, is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 15 stereotactic beam radiation therapy (SBRT) treatments. The National Comprehensive Cancer Network (NCCN) guidelines on the management of lung cancer endorse the routine use of local therapy in patients with EGFR mutated lung cancer who have oligoprogression. In a phase 3 study in patients with EGFR metastatic lung cancer, Wang and colleagues demonstrated a benefit from consolidative radiotherapy to sites of involvement in patients with metastatic disease. In this case, the patient has a single site of progressive disease without other sites of progression or development of distant metastases. Given that the patient meets criteria for oligoprogression, the patient is likely to benefit from local radiation to sites of involvement. Therefore, 15 SBRT treatments are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested 15 SBRT treatments are 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 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 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 is a 35-year-old female requesting authorization for a bariatric surgery consultation. She has a body mass index (BMI) of 36.9. She reports chronic heartburn, back pain and knee pain, and her provider noted a family history of diabetes. The patient also reports that she has tried various dietary weight loss programs, medications and exercise without successful long-term weight reduction. The patients provider has recommended a consultation with a bariatric surgeon for consideration of weight reduction surgery.The patient does not meet the recommendations set forth by the NIH for consideration of weight loss surgery. These criteria are based on the relative risks associated with an operative intervention at a particular BMI versus the risks associated with a non-operative approach. Given the patients BMI and comorbidities, non-surgical methods are likely to be more beneficial for this patient. Therefore, I have determined the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cooling device for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the limited evidence currently available was insufficient to draw definitive conclusions on the effective of cryotherapy for outcomes other than immediate postoperative pain reduction compared to no cryotherapy. There was a need for well-designed, good quality randomized trials to answer other questions related to this intervention. This patient underwent left knee arthroscopic surgery for a diagnosis of medial meniscus tear, positive lateral meniscus tear, and subchondral cyst.  There is support for the use of cryotherapy in the immediate postoperative period following knee surgery.  However, there is a lack of large volume, long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs, for knee arthroscopic surgeries. Final Result: Two of three reviewers determined that the device 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 number one, two, and three are board certified in orthopedic surgery and actively practicing. The reviewers are 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 patient is a 17-year-old male who was diagnosed as having pervasive developmental disorder and Aspergers disorder at the age of 12 years. Prior to his admission to the residential treatment center, the patient was in juvenile detention for about seven months, where he attempted suicide twice; the last attempt occuring in November 2005. The patient was admitted to residential treatment in July 2006. A review of weekly treatment updates dated in July 2006 and August 2006, along with group therapy and individual therapy notes shows no indication the patient is actively or imminently suicidal or homicidal, nor that he is psychotic. The patients symptoms and behavior appear to be are under good control and his behavior has not been described as aggressive, agitated or out of control. The record indicates the patient is compliant with the prescribed treatment plan. The patients parent has requested reimbursement and continued authorization for residential treatment services provided from July 2006 onward.  The Health Plan denied the request based on a determination that the services were/are not medically necessary.A detailed and intensive review of the clinical record, including documentation from the patients psychiatrist and individual therapist and the weekly group therapy updates, does not show the patient was at imminent risk of harm to himself or to others. There is no documentation indicating the patient was actively psychotic, that he demonstrated out-of-control/aggressive behaviors or that his medical or emotional status required 24-hour monitoring. The patient could have been effectively treated in a less restrictive setting from July 2006 onward.Based upon the information set forth above, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Epclusa 400/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to 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 conditions.  This applies regardless of fibrosis stage.  In treatment-naive, genotype 2 patients, therapy is recommended with Epclusa, or Sovaldi with Daklinza, which is on the formulary.  There is a lack of controlled head-to-head comparison data to show that Epclusa is superior to Sovaldi with Daklinza.  Both Sovaldi and Daklinza can be crushed to deliver through a gastrostomy tube if needed.  The current guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ingrezza capsules. Findings: There is a difference between oromandibular dystonia and tardive dyskinesia. ONe study reports that Ingrezza is the first treatment approved by the U.S. Food and Drug Administration (FDA) for the treatment of  tardive dyskinesia. Another study reports that Ingrezza significantly improved tardive dyskinesia in patients with underlying schizophrenia, schizoaffective disorder, or mood disorder. The American Psychiatric Association (APA) practice guidelines for the treatment of patients with schizophrenia support the use of vesicular monoamine transporter type 2 (VMAT2) inhibitors for moderate-to-severe tardive dyskinesia together with antipsychotics. In this case, there is disagreement on the patients diagnosis. The records note that one provider states that the patient has tardive dyskinesia, possibly related to a dental procedure but without a clear mechanism of injury. There is a lack of evidence in current medical literature of tardive dyskinesia being caused by a dental procedure, and the records did not include documentation of past neuroleptic/antipsychotic exposure that would cause tardive dyskinesia. The patients other providers have diagnosed the patient with dystonia. Given that further investigation of the patients diagnosis with specialty consultation is required and as Ingrezza is not supported as appropriate for the medical management of dystonia, the requested medication is not medically indicated. Therefore, Ingrezza capsules are not medically necessary for the treatment of this patient.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 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested a dermatology consultation for treatment of the enrollees rash.   Findings:  The physician reviewer found that the medical notes indicate that the lesions are increasing in size and number. The patients primary care physician recommended the consultation with a dermatologist for evaluation. The primary care physician does not offer a diagnosis, etiology, or treatment plan in the submitted records. Given that a referral to a skin specialist is thought necessary by the patients provider and a treatment plan has not been implemented, the requested dermatology consultation is medically reasonable in this case. The evolving eruption as described warrants evaluation by a dermatology specialist. Pigmentation of the legs can represent a number of diagnoses which should be evaluated by a dermatologist (Hogeling, et al. and Pimentel, et al.).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested porcine xenograft for treatment of her medical condition. Findings:  Three physician reviewers found that biological dressings, such as cadaver allografts and porcine skin xenografts are utilized to treat partial thickness burns. These dressings provide temporary wound coverage until full healing can be achieved. Burns can be treated with topical medication such as Sulfamylon or with biologic dressings such as xenografts. A biologic dressing is not expected to survive on a partial thickness burn, but is used instead to protect and sterilize the burn and prevent progression to a full thickness burn. According to the American Burn Association on the surgical management of the burn wound and use of skin substitutes Xenograft (pigskin) is used at many institutions in the same manner as allograft. Necrosis in the zone of stasis (the damaged but potentially viable area of thermally injured tissue surrounding irreversibly necrotic skin) could be avoided by optimal treatment of the wound with a biologic dressing such as xenograft. Thus application of xenograft on a debrided mid-dermal burn might prevent/obviate the need for excision and autografting. In sum, the porcine xenograft is supported by evidence published in the peer reviewed medical literature. Therefore, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in plastic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for a SpaceOAR hydrogel procedure. Findings:  The physician reviewer found that Karsh and colleagues note that the SpaceOAR system creates distance between the prostate and the rectum, so that the rectum is out of the radiation treatment field. The authors note that spacer application has a high technical success rate and significantly reduces the rectal radiation dose. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve the sparing of the adjacent rectum. In this case, records noted that magnetic resonance imaging (MRI) reported a total prostate size of approximately 52 cc, and that a prostate biopsy reported Gleason 3+3 disease. The patient had an elevated PSA of 21.4. The providers recommendation of SpaceOAR placement to improve sparing of the adjacent rectum is supported by current medical literature. Therefore, a SpaceOAR hydrogel procedure 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 SpaceOAR hydrogel procedure 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 service 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 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: Overturned

Nature of Statutory Criteria/Case Summary:An female enrollee has requested authorization and coverage for E2300 power seat elevation system, E2301 power standing and K0108 power elevating leg rest for treatment of the enrollees nemaline rod myopathy. Findings:  The physician reviewer found that nemaline rod myopathy is an extremely rare muscle disorder with profound weakness of all muscle groups including the limbs, face and neck muscles. In general, the symptoms do not improve as the child ages, but they may plateau in weakness, and tend to regress with increasing weakness and failure of the heart muscle.  According to the documentation submitted for review, the patient is scheduled to start kindergarten. The record demonstrates that the patient has the capability to electrically propel the wheelchair. The upright position in school, will be very useful in elevating the patient to tables, platforms and preventing continuous sitting. There is a significant literature concerning the value of the standing position in children and adults who are unable to walk. In addition, the patient is likely to have a psychological boost of being eye level with her peers. In addition, there is evidence that the standing position aids in increasing bone density and improves cardiac function. Also, given that progressive heart disease is an ongoing problem in patients with nemaline myopathy, the standing position will aid in reducing the risk of heart disease. As such, the request for E2300 power seat elevation system, E2301 power standing and K0108 power elevating leg rest has been established as medically necessary for treatment of the patients medical condition. 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 pediatrics and neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastopexy and abdominal body contouring. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The requested surgeries appeared to be for the purpose of removal of excess skin and tissues of the subcutaneous nature per the progress notes. The surgeries were performed in the abdomen, buttocks and breast tissue area along with a surgery for breast prosthesis. The progress notes and photographs indicate that the patient had breast tissue prior to surgery. The surgeries did not appear to be for the purpose of creation of breasts, but rather cosmetic alteration of current breast tissue as well as cosmetic alteration of excess skin tissue due to weight loss. The progress notes indicate that the patient presented for elective cosmetic-type surgery. The submitted documentation does not indicate that the patient specifically reported that her body size and shape was contributing to her gender dysphoria. It is also noted that the patient is continuing to receive hormone therapy which will contribute to redistribution of tissue as well.  Therefore, mastopex and abdominal body contouring were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with expertise in the treatment of gender dysphoria 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 Cartiva Synthetic Cartilage Implant. This patient presented with persistent and worsening left great toe pain with a diagnosis of hallux rigidus status post prior bone spur surgery at the left first MPJ without sustained pain relief. Clinical examination findings were consistent with imaging evidence of severe first MPJ arthritis. The records included documentation of failed reasonable and comprehensive non-operative treatment including activity modification, taping, and shoe wear modification. He underwent decompression arthroplasty with Cartiva Synthetic Cartilage Implant on the first MPJ of the left foot. Evidence-based medical literature supports the use of the Cartiva Synthetic Cartilage Implant as an option in this patients medical condition to maintain first MPJ motion.  Given this support, the Cartiva Synthetic Cartilage Implant was 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 Cartiva Synthetic Cartilage Implant was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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.