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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for Norditropin Flexpro (somatropin) injection pen. The enrollee has CHARGE syndrome. She is status post cleft palate repair, status post ventricular septal defect repair, and she is tracheostomy and gastrostomy tube-dependent. She has additional diagnoses of developmental delay, myopia and sensoroneural hearing loss.  The enrollee was evaluated for short stature. Records show the enrollees height velocity over the previous 15 months was 6.1 centimeters per year.  A bone age x-ray showed a skeletal age of 11 years at a chronological age of 10 years three months, and open epiphyses, which predicts an adult height of 51 inches. The enrollee has a pretreatment height less than or equal to -2.25 standard deviations.  The enrollees height velocity and bone age would not allow the enrollee to reach a normal adult height. The enrollee therefore met idiopathic short stature criteria.  The request is consistent with generally accepted standards of medical practice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee requested graft product, Veritas collagen matrix for medical treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. In this case, there is no description of inframammary fold malposition, rippling, capsular contracture or implant malposition to justify the necessity of revision surgery.   If the tissues were thin enough for ADM to be medically indicated there would be visible rippling in the photo provided and a description of such a condition in the medical records. Moreover, Veritas is non-cross-linked bovine pericardium and AlloDerm is non-cross-linked human dermis. In animal studies there is significant loss of tensile strength in the non-cross-linked prosthetics such as Veritas and AlloDerm as compared with the cross-linked materials like Permacol at six months. Therefore, there is a lack of proven advantage of Veritas over other materials in the medical literature. Thus, the requested services are not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Hoyer lift and a full electric bed allowing for reverse Trendelenburg position. The provider reports that this patient has specific positioning needs due to her hemiparesis, immobility, and susceptibility for skin and soft tissue breakdown. Intermittent weight measurement is reasonable for monitoring her general health status. However, these measurements can be performed in the providers office or other institutional setting. There is no indication in the available records that this patient requires frequent weight measurements at home. Thus, the requested scale attachment for a Hoyer lift is not medically necessary for this patient based on the available records. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 insertion of a lumbar artificial intervertebral disc for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. In this case, the patient presents with chronic radicular lower back pain. Given the multilevel degenerative disease noted on imaging and findings suggestive of nerve root compression, the requested insertion of a lumbar artificial intervertebral disc is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his low back pain.   Findings:  Three physician reviewers found that the use of artificial disc replacement has not yet been adequately supported by Level I and Level II studies of sufficient duration to resolve current outstanding issues concerning the use of this technology. It is known through studies of knee and hip total replacement that there is a predictable need for revision over time and the same sequence of events is likely following total disc replacement.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for 120 hours per month of direct applied behavior analysis (ABA) services and 24 hours per month of supervision for treatment of the autism spectrum disorder. Findings:  The physician reviewer found the request for 120 hours per month of direct ABA services and 24 hours per month of supervision are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient has made slow progress in many areas of his skill acquisition goals. The patient continues to require a high level of support to transition appropriately. Failure to master these skills puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. In addition, several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA services for children with autism and the clinical documentation supporting a higher level of support for this patient, the requested services are medically 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 parent of a 16-year-old male enrollee has requested  for Somatropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that this patient does not have data supporting an abnormally poor height velocity based on measurements obtained over 1 year of time. Further, it is difficult to ascertain the accuracy of his height prediction but it does not appear to be less than 63 inches and is not evidenced with a complete growth chart, concomitant bone age radiographs, and height measurements. For these reasons, the medical necessity of the requested GH therapy has not been established in the records provided for review.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa intra-articular injections for both knees. In the peer-reviewed medical literature, researchers reported on a meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Intraarticular hyaluronic acid can provide improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has been demonstrated to be safe and effective. This patient has been treated with multiple conservative treatments, including Tylenol and meloxicam, for osteoarthritis in the past without substantial relief. Moreover, this patient has experienced relief with prior viscosupplementation injections. All told, the requested Euflexxa intra-articular injections for both knees are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 Comprehensive Liquid Biopsy. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 Comprehensive Liquid Biopsy was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 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 reimbursement and prospective authorization and coverage for an intrathecal pump and medications. The Health Plan has denied this request indicating that the service at issue was not and is not medically necessary for treatment of the enrollees back pain.  Findings:  The physician reviewer found that the records indicate the patient has been stable for several years with an intrathecal (IT) pain pump with morphine, clonidine, and bupivacaine, with little fluctuation, the ability to still work and adequate pain control after several surgeries with recurring neurocompressive lesions in the lumbar spine. She has done well using little oral methadone and no other oral medications. She has followed up regularly to have her pump refilled on time with only small incremental changes in the dosages as needed and frequently no changes. An IT system runs on the premise of direct delivery of the medications to the spinal space with rapid transit to the cord and brainstem, sites of ascending pain pathways, and into the thalamus and cortex and higher processing centers (Belverud, et al). The presence of a catheter is compatible with MRI, spinal cord stimulation, and re-operation should it become needed. Further, the patient is able to manage with less medication and fewer systemic side effects as detailed by Cohen and Dragovich. Given that this patient has been in pain since the mid 1990s with failed back surgery syndrome and has done well for years with IT pain management, the service is clinically indicated for this patient (Tomycz, et al). At this time, cessation of the patients IT pump could precipitate extreme withdrawal and make her pain nearly impossible to control with equivalent oral medications The patient is productive, employed, and enjoys stable and reasonable pain control with no reported problems with her IT system. For these reasons, the requested coverage for past medication and IT pump refills and prospective approval for reasonable refills and medication as recommended by her pain physician has been established as medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks 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 (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 guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below six million IU/mL can be treated with Harvoni for eight 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 1 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for eight weeks 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness. In addition, the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals. Final Result: The reviewers 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

The parent of a 10-year-old female enrollee has requested speech therapy, physical therapy and occupational therapy for treatment of the enrollees pervasive developmental disorder and Rett syndrome.  Findings:  The physician reviewer found that the role of speech therapy in autistic spectrum disorders (ASD) is well published in the medical literature. This patient has features along the autism spectrum per the submitted medical records. Numerous citations recommend or demonstrate evidence for speech therapy for children with autism (see references number 1-3). While there have been few studies offering a direct comparison of methods, many experts believe that children with ASD benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors. In this particular case, the patient clearly exhibits a diagnosis for which the standard of care is speech therapy. The patient has been receiving speech therapy with a picture exchange system, a modality that has demonstrated effectiveness (Millar, et al.). Continuation of speech therapy is medically appropriates and necessary for this patient. Furthermore, while the evidence basis has not yet been clearly established, most experts in Rett syndrome agree that a program of physical and occupational therapy minimizes the feeding difficulties and physical contractures that result from this disorder (Sharpe). Occupational therapy is also directed at purposeful use of the hands.  Case series have shown a decrease in stereotypical hand-wringing and increased socialization with such therapy. All told, speech therapy, physical therapy and occupational therapy are medically appropriate and in accordance with generally accepted professional standards of practice in this setting. The patient meets medical necessity criteria for these therapies given the severity of the neuromotor involvement and the gravity of her diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female has requested eight additional outpatient mental health therapy sessions for treatment of her depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with affective disorders. Current practice in this country is focused on succinct evidence-based treatments, particularly in the acute phase of the illness. This concept is effectively captured in the following excerpts from the American Psychiatric Association (APA) clinical practice guideline, Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the provider and patient rated scales at regular intervals. If four to eight weeks of treatment do not yield at least moderate improvement (greater than 20% diminution in symptoms) the provider should thoroughly review and reappraise the treatment plan. In this particular case, the patient is diagnosed with depressive disorder not otherwise specified. She has received supportive therapy which rather has successfully buoyed her functionality and quality of life. However, cast upon her history of chronic family dysfunction is an acute parent-child relational problem. Thus, aggressive, time-limited treatment, with well defined therapeutic goals and ideally family involvement, will likely improve the patients condition. Such a therapeutic course represents a safe, reasonable, and appropriate intervention consistent with good medical practice in the United States. Consistent with the APA guidelines, the requested additional eight sessions are medically necessary for treatment of the patients medical condition.