Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parents of an enrollee have requested reimbursement for the laboratory allergy testing services provided by Foundation Labs on 4/21/20. Findings:  The physician reviewer found that Bernstein and colleagues state that testing for the most common allergenic foods usually detects most suspected food hypersensitivity, although more tests may be required depending on the clinical situation. Many clinicians test with a limited panel of commonly allergenic foods when food allergy is suspected and there is no clear-cut history of symptoms occurring after exposure to specific foods. Exhaustive testing to the 200 or so foods available for skin or specific immunoglobulin E (IgE) testing in patients presenting with anaphylactic reactions is rarely indicated. The primary tools available to evaluate patients adverse reactions to foods include history (including diet records), physical examination, prick/puncture skin tests, serum tests for food specific IgE antibodies, trial elimination diets, and oral food challenges. The general aims of diagnosis are to determine if food is causing the disorder under evaluation and, if so, to identify specific causal food(s). A proper diagnosis will allow the patient to receive instructions regarding avoidance of problematic food. The current literature and Allergy Practice Parameter Guidelines that address immunoglobulin G (IgG) diagnostic testing, which includes IgG food sensitivity and IgG subclass testing, notes that neither of these tests are considered clinically useful, relevant, or a valid method for evaluating for food allergy or food intolerance that may be contributing to an allergic condition. In this case, the superior efficacy of the services at issue has not been established. There is a lack of published peer-reviewed literature, scientific evidence, or professional standard guidelines supporting the safety and efficacy of Tolerance Induction Program. Therefore, the laboratory allergy testing services provided by Foundation Labs on 4/21/20 was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings: Three out of three physician reviewers found that the laboratory allergy testing services provided by Foundation Labs on 4/21/20 were not likely to have been more beneficial for the enrollee than any available standard therapy.Final Result: The reviewers determined that the requested services were not likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in allergy and immunology and is actively practicing. The reviewers are experts in the treatment of the
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested Botox injections for treatment of his palmar hyperhidrosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. The patients condition of palmar hyperhidrosis has been resistant to conventional therapies. The patients symptoms are described as severe and chronic with the medical records indicating that the patient has failed therapy with aluminum chloride topically, salt water iontophoresis, and glycopyrrolate at high doses. These are all considered to be the standard of care for treatment of hyperhidrosis (Hoorens and Ongenae). Other than botulinum toxin injection, thoracic sympathectomy is the only other treatment option available and this is an invasive procedure with potential serious complications. Given that the patient has failed all standard therapies, it is reasonable to consider therapy with botulinum toxin injection. Mannava and colleagues note that the use of botulinum toxin injection for palmar hyperhidrosis has been evaluated and found to be a successful treatment. In conclusion, given that the patient has failed the conventional therapies, the requested Botox injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees medical condition. Findings: Two physician reviewers found that ABA services at the frequency of 30 hours per week are not indicated in this clinical setting. Spreckley and Boyd noted that a nonsystematic review in their meta-analysis concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each childs strengths and weaknesses and family circumstances, was essential for young children with autism to make gains. In this case, the patient is in a home school program and therefore is already having a school day of at least six hours based on his grade level and taking into account the special education status. The request for 30 hour per week of ABA is excessive and may be detrimental of the desired effect. Therefore, based upon the medical literature and the documentation submitted for review, 20 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition.Final Result: Two reviewers determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  All three reviewers are board certified in child neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male patient of 37 years of age has had chiropractic care over the span of a year for neck and back pain. The patient states the chiropractic care provides relief of his pain and requests continued authorization and coverage. The Health Plan denied future chiropractic services citing a lack of medical necessity.The medical records reviewed consisted of progress notes and a single page request for treatment authorization. The information provided did not include a detailed case history, initial examination or patient intake forms. The patient does feel the chiropractic care benefits him, but a review of the record does not have supporting documentation illustrating medical necessity for continuing chiropractic care. The actual clinical condition and status of the patient relative to the treatment received cannot be ascertained from the existing record. As such, the effectiveness of treatment is uncertain and the need for continued care is not substantiated.  Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee requested applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism.   Findings:  Three physician reviewers found that regarding the medical necessity for ABA therapy for this patient, the requested ABA services are medically necessary based on overall evaluation of the literature, including positive and negative analyses. Behavior during development, in the setting of a multifactorial disease process that gives rise to autistic spectrum disorder, is too complex for a one size fits all approach. Specific treatments, including ABA, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with ASD. All told, the requested ABA therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested Mirena Intra-Uterine Device (IUD) for the treatment of her menstrual disorder. Findings:  The physician reviewer found that this patient has not received adequate relief from her dysmenorrhea from oral contraceptive pills, hormonal pens, or narcotics. Her symptoms are severe and quite debilitating. As the above cited studies indicate, intra-uterine devices have been shown to be successful in the treatment of menstrual disorder. These devices can decrease the need for surgeries.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral removal of gynecomastia. Findings:  The physician reviewer found that based on review of the medical records provided the procedure is not medically necessary. The patient complains of pain after his first surgery for gynecomastia. However, breast pain was not noted during the most recent providers examination. The primary complaint on that date was breast enlargement. In addition, the patient does not have any documented functional limitations related to the enlarged breasts or require treatment with conservative measures to relieve breast pain. All told, the requested bilateral removal of gynecomastia is not medically necessary for treatment of this patients medical condition. Further, the requested bilateral removal of gynecomastia is not supported as reconstructive in nature. The presence of enlarged breasts is an abnormal structure of the body. However, in this patient, the most likely etiology is obesity and lipomastia. While surgery can be considered for this patients condition to address a functional deficit, the surgery has not been recommended due to a functional limitation. Moreover, the requested surgery is not likely to make a more than minimal improvement in the patients appearance. The patient has already undergone one procedure to address this issue, and there is a lack of rationale to support a repeat procedure. Furthermore, weight loss is appropriate in this patient prior to consideration of surgery, as weight loss alone may resolve the breast enlargement. Thus, in this patient with a BMI over 39 kg/m2, weight loss prior to consideration for repeat surgery is advisable. Given these findings, the requested bilateral removal of gynecomastia is not medically necessary and is not reconstructive in nature for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested surgery is not medically necessary and is not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 57-year-old female enrollee has requested physical therapy (PT) services for the treatment of her cervical and left hand pain. Findings:  The physician reviewer found that the patient is a 57-year-old female who required surgery. She underwent cervical discectomy and fusion. The patient was prescribed physical therapy postoperatively. This type of postoperative treatment was indicated and medically necessary. The therapist provided modalities not available at home and provided numerous benefits that are used in conjunction with home exercises and medication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous glucose monitoring system. Both the medical literature and the submitted documentation support the medical necessity of the requested CGM system. In 2016, the American Association of Clinical Endocrinologists published a consensus statement favoring the use of CGM on patients with diabetes. The statement indicates that CGM improves glycemic control and reduces hypoglycemia. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes. CGM alerts patients to impending or actual low or high glucose values and thereby facilitates prompt action and prevention of hospitalizations. Multiple studies cited in the statement have documented the superiority of CGM in improving HbA1c levels by decreasing hypoglycemia and hyperglycemia. In a study published in 2016, HbA1c levels were significantly lower in patients using CGM than those not using CGM. This is regardless of whether patients administered insulin via a pump or multiple doses of insulin.  A 2012 meta-analysis of 10 trials compared real-time continuous glucose monitoring to self-monitoring blood glucose. Four studies compared a sensor-augmented pump with multiple doses of insulin and self-monitoring blood glucose. The results of the meta-analysis supported the superiority of continuous glucose monitoring in both comparisons in terms of HgA1c reduction without increased risk of hypoglycemia.In this case, the patient is at risk for diabetes-related complications due to uncontrolled hyperglycemia. With proper use of a CGM system and the guidance of her endocrinologist, the patient will be able to make better decisions about her diabetes self-management with the insulin pump. The patient will be able to improve her HbA1c level close to goal with less risk of hypoglycemia. Therefore, the requested continuous glucose monitoring (CGM) system is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested device 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 subspecialty certification in endocrinology, diabetes, and metabolism, 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 62-year-old male enrollee has requested Orthovisc injections for treatment of his bilateral degenerative joint disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services.  Rutjes and colleagues conducted a systematic review to evaluate the benefits and risks of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults, and they concluded that viscosupplementation is associated with a clinically irrelevant benefit.  Viscosupplementation is also associated with a risk for adverse events.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 46-year-old female enrollee has requested reimbursement for the graft procedure, Graffix Core for treatment of the enrollees hallux limitus, right foot. Findings:  The physician reviewer found that It is well-established in the medical literature that the Grafix Core graft is effective for use in patients with non-healing diabetic foot ulcers. However, the medical literature does not support the use of the Grafix Core graft for application over denuded cartilage. Further studies must be performed to evaluate the efficacy of amniotic membrane and stem cell membranes over diseased cartilage. Based on the available documentation and current peer-reviewed medical literature, the application of the graft procedure, Grafix Core provided on 5/30/17 was not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.  Final Result: All three 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: Medical professional reviewer number one is board certified in podiatry 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.Medical professional reviewer number two is board certified in podiatry 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.Medical professional reviewer number three is board certified in podiatry 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 63-year-old female enrollee has requested  for compression stockings for treatment of her lymphedema. Findings:  The physician reviewer found that is a complication from lymph node removal due to her cancer. Compression stockings increase tissue pressure which promotes filling of lymph vessels. Compression stockings are standard treatment for lymphedema and the patient is symptomatic. Compression stockings are the appropriate medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epidiolex 100 mg. Currently, Epidiolex is the only U.S. Food and Drug Administration (FDA) approved medication for use as adjunct therapy in patients with Dravet syndrome or Lennox-Gastaut syndrome (LGS). However, the trials evaluating the safety and effectiveness of Epidiolex only evaluated patients with these two specific seizure disorders. Epidiolex has not yet been critically evaluated for use in any other form of epilepsy, nor has it been evaluated for use as monotherapy. A query of clinical trials reveals that there are multiple ongoing studies involving Epidiolex to evaluate its efficacy and safety in other seizure disorders. This patient has a seizure disorder, but there is no documentation of LGS or Dravet syndrome. Given the absence of published literature available to support the use of Epidiolex for patients with seizure disorders other than LGS and Dravet syndrome, the requested drug Epidiolex 100 mg is not supported as medically necessary for treatment of this patients medical condition. 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 with subspecialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: A 59-year-old female enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) for evaluation of the enrollees back pain. Findings:  The physician reviewer found that The records provided for review do not include any documentation depicting a significant change in symptoms since the patients MRI. In addition, there are no red flags to support an indication for a repeat MRI of the lumbar spine absent flexion extension x-rays and a repeat course of physical therapy. Given the lack of change in symptoms, a course of recent physical therapy, or findings on extension x-rays suggesting cause for concern, the requested lumbar spine MRI without dye is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 an enrollee has requested reimbursement and prospective authorization and coverage for 17.2 hours per month of direct applied behavioral analysis (ABA) therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training for treatment of his autism.  Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients parents are requesting continued coverage of ABA therapy to address emotional regulation, impulse control, and compliance. A treatment plan has been developed that is consistent with the patients essential health needs such as daily living and communication and consistent with the diagnosis of autism. Based on the support in the peer-reviewed literature and clinical documentation submitted for review, the medical necessity of 17.2 hours per month of direct ABA therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training provided from 11/7/16 forward was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 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.