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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Hizentra home infusions (13 grams administered by a nurse), (12 grams administered by a nurse), and (25 grams self-administered), and future for Hizentra 25 gram self-administered home infusions every 14 days for one year. Dysautonomia refers to any disorder associated with dysfunction of the autonomic nervous system. There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN). Clinical manifestations of SFPN may include postural tachycardia syndrome, orthostatic intolerance or hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, or neurogenic bladder. Intravenous immunoglobulin (IVIG) is considered a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In one study, 55 patients with confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that their results provide Class IV evidence that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Subcutaneous immunoglobulin (SCIg) therapy has also been used successfully for patients with immune deficiency syndromes. One review showed that SCIg is more effective than IVIG in improving patient reported outcomes in autoimmune neuromuscular disease in terms of muscle strength maintenance, improvement overall strength and quality of life, as well as patient satisfaction. In this case, the patient has autoimmune autonomic SFPN. Based on the current medical literature, patients with autoimmune SFPN may improve clinically with immunoglobulin treatment administered subcutaneously or intravenously. Given this support, Hizentra home infusions (13 grams administered by a nurse), (12 grams administered by a nurse), and (25 grams self-administered), and future Hizentra 25 gram self-administered home infusions every 14 days for one year were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested neurofeedback treatments once or twice weekly, monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice a week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions for treatment of her medical condition.  Findings:  The physician reviewer found that there is a lack of sufficient support in the peer-reviewed literature for neurofeedback treatments in this clinical setting. The study by Choobforoushzadeh and colleagues assessed the use of neurofeedback in 24 patients with MS. Although the results at two-month follow-up were positive, larger studies with long-term follow-up are needed to confirm these findings. There is currently a lack of medical literature supporting neurofeedback for the treatment of the cognitive effects of MS. In addition, neurofeedback treatments are not the standard of care in this clinical setting. Therefore, the request for neurofeedback treatments once or twice weekly has not been established as medically necessary for treatment of the patients MS.   However, monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions were and are medically necessary for treatment of the patients medical condition. Young and colleagues performed study of 95 adult ADHD patients, already treated with medication (MED), who were randomly assigned to receive treatment of 15 sessions of cognitive behavioral therapy. The authors concluded that the study provides evidence for the effectiveness of cognitive behavioral therapy for ADHD symptoms. In this case, the patient presents with a longstanding history of MS, depression, anxiety and ADHD. Cognitive rehabilitation has been shown to be effective in the treatment and management of the patients medical conditions when used together with medications. Therefore, the monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice a week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions were and are medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested Botox scalene injections for the treatment of her cervical myofascial pain. Findings:  Three physician reviewers found that Botox is not approved for the treatment of myofascial pain syndrome. In addition, there is little to data to support the efficacy of Botox for myofascial. Given the patients previous benefit, another scalene block should be considered. There is no evidence that Botox would be as or more beneficial than another scalene block.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for speech therapy for treatment of the enrollees severe mixed receptive and expressive language disorder. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of speech therapy. The review by colleagues state that It is currently estimated that about 30% of children with autism spectrum disorder remain minimally verbal, even after receiving years of interventions and a range of educational opportunities. Children with autism often have difficulty developing the communicative intent and desire to communicate effectively. A picture exchange communication system (PECS) systems or speech generating devices paired with interactions around desired objects is likely to be more effective in obtaining functional communication than speech therapy. In this case, the KSPT diagnostic test showed that he has a bit more functional oral movement in the percentile than he actually uses in speech sound production, which is in the percentile. This data shows that he has more oral movement skills for speech than he utilizes. Speech therapy for treatment of the patients oral movement is not likely to lead to the functional gains. For the reasons stated, speech therapy provided was not and is not medically necessary in this clinical setting. Final Result: The reviewer determined that the therapy at issue was not and 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested for diagnostic cardiac catheterization. Findings:  The physician reviewer found that American College of Cardiology (ACC) guidelines for the diagnoses and management of patients with stable ischemic heart disease note that a coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicate a high likelihood of severe coronary artery disease. In this case, while nuclear stress test images demonstrated only apical reversible ischemia, the electrocardiographic findings of significant ST-segment depression in five leads are very significant. In a study on the  role of exercise stress test induced ST-segment elevation, Russo and colleagues reported that ST-segment depression in five or more leads was the only independent predictor of left main or proximal left anterior descending coronary disease. In this case, the requested service, prior to elective major orthopedic surgery, to further define his coronary anatomy and risk is medically indicated.  Therefore, diagnostic cardiac catheterization is medically necessary for the evaluation of this patient.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 internal medicine with sub-specialty certification in cardiovascular disease 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 Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the medical necessity of Norco is not established. The patient presents with non-malignant chronic pain which will often worsen or recur as a result of opioid rebound. The long-term use of high-dose short-acting opiates such as Norco has been shown to result in induced tolerance and abnormal pain sensitivity. Based upon the submitted records, the patient has a history of opioid treatment without documentation of improved function or attempted weaning.  Therefore, the requested Norco is not medically necessary for treatment of the 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 anesthesiology with sub-specialty certification in pain management 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 three-year-old male enrollee has requested speech therapy two times per week (one hour each session) and occupational therapy two times per week (one hour each session) for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on the available medical literature, the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. In support of the need for occupational therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy and occupational therapy are standard of care modalities for patients with autism. Given the documented deficits associated with his diagnosis of autism, it is medically necessary for this patient to receive speech therapy and occupational therapy at the requested frequency.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent for treatment of his medical condition. Findings:  The physician reviewer found that PCSK9-inhibitors are a new class of medication that has been shown to reduce cardiovascular events when used in combination with statin medications. However, there is a lack of long-term data on the use of PCSK9 inhibitors and thus the potential for long-term adverse effects is unknown. Also, current guidelines do not recommend the addition of a PCSK9 inhibitor such as Praluent in the setting of LDL less than 100mg/dl while on statin therapy. Moreover, a recent trial has shown outcome improvement with Zetia added to a statin in this setting, a medication that does have longer term follow up with a proven safety profile compared to PCSK9 inhibitors. Overall, given the unknown long-term risks of PCSK9 inhibitors; the modest reduction in LDL required in this case; and the proven benefit with the addition of Zetia, the addition of Zetia is a preferred approach compared to the addition of Praluent. As such, based on available studies and the documentation provided, the use of Praluent is not 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 physician reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 33-year-old male enrollee has requested Delzicol for treatment of his ulcerative colitis. Findings:  The physician reviewer found that in this patients case, his colitis is no longer in remission but is active. Thus, Delzicol per FDA indication is the appropriate treatment in this clinical setting. Furthermore, based strictly on FDA-indication, Delzicol and Apriso are not equivalent medications, and the latter cannot be substituted for the former in treatment of this patients medical condition. Therefore, the medical necessity of the medication at issue has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. In this particular case, the patients alcohol use was central to her daily routine and contributed to significant impairment across multiple functional domains.  Her daily over-consumption of alcohol strained relationships, and often culminated with belligerence and blackouts. The patient also had co-occurring psychiatric issues. If discharged on the first date of service in dispute, the patient was likely to have promptly relapsed, while community-based treatment would have been inadequate at the time.  Per the records, she feared relapse and craved alcohol. Throughout her stay, the patient was actively engaged in treatment, including mindfulness training, family counseling and education, and aftercare preparation to develop a more empowering environment to sustain sobriety. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards for a case of this severity and facilitated transition to service delivery in a less restrictive setting.  Additionally, the services provided were reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma and dyspnea. Findings:  The physician reviewer found that Based on the information provided, patient has mild to moderate asthma based on a forced expiratory volume-1 (FEV-1) that has been stable over the past two years and lack of reported parameters in terms of daily symptoms, limitation to exercise, nocturnal awakenings, or albuterol use. Further, the patient was not reported to have any asthma exacerbations or use of systemic steroids. Overall, the benefit shown by bronchial thermoplasty is primarily related to reduction in asthma exacerbations, use of systemic steroids, hospitalizations, and lost days of work with some mild improvement in quality of life. However, bronchial thermoplasty has not been demonstrated to result in a reduction in FEV-1. Thus, the requested bronchial thermoplasty is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested procedure is 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 reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary disease 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in pulmonary disease 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary disease 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 47-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis of the knee. Findings:  The physician reviewer found that the efficacy of viscosupplementation in treating osteoarthritis of the knee is generally accepted in appropriate patients and as part of a comprehensive treatment strategy. It is most effective in patients with mild to moderate disease, and is not effective in patients with more severe involvement. The question of the efficacy of repeated series of injections remains unclear.  In patients with a previous beneficial course of therapy, there is evidence of response, and other reports have been encouraging. However, there are also reports of an increased frequency of problems associated with repeated series of injections. Studies of this question are in progress, but the results have not yet been published.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of his medical condition.   Findings: Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone.  Three dimensional digital breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue.  Given this support, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had the exam been done with two dimensional imaging alone.  Accordingly, breast tomosynthesis  was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two 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:  All three physician reviewers 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.