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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laser refractive surgery. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who was diagnosed with bilateral myopia and astigmatism.Findings:  There is a lack of support for the services at issue in this clinical setting.  Photorefractive keratectomy/laser refractive vision correction is an elective procedure that reshapes the cornea to eliminate or reduce the need for glasses or contact lenses.  The submitted documentation noted that the patient wore glasses and contact lenses to correct his vision prior to the surgery.  He reported that he experienced dryness while wearing contact lenses; however, the services at issue were elective and not medically necessary. The standard treatment for myopia and astigmatism is correction by glasses or contact lenses. The documentation provided did not demonstrate the patient was not able to correct his vision with glasses or contact lenses. Accordingly, the laser refractive surgery was not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 ophthalmology 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 35-year-old male enrollee has requested laser treatment for his rosacea.  Findings:  The physician reviewer found that the patients condition does not constitute an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor, or disease. Further, the requested therapy is not being requested to improve function. Although the requested therapy is being requested to create a normal appearance to the extent possible, the records do not indicate that the requested procedure will likely result in a more than minimal improvement in the patients appearance. Therefore, the requested therapy is not reconstructive in nature for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lower back fusion surgery with related hospital stay. The submitted documentation does not support that the requested services are medically necessary. American Association of Neurological Surgeons (AANS) criteria and National Imaging Associates (NIA) criteria for lumbar fusion identify a number of indications for which lumbar spinal fusion is appropriate, none of which are presented in this case. AANS guidelines further note that there is currently a lack of high-quality Level I evidence to support the use of lumbar fusion for patients with chronic low back pain without stenosis or without spondylolisthesis. In this case, the patient has chronic low back pain but no symptoms or signs of a lumbar radiculopathy. He has no localizing features to his pain and he has no symptoms or signs to implicate the L4-5 level as his pain generator, nor any level of his spine. The patients MRI shows no evidence of adjacent segment disease nor of nerve root compression. Furthermore, there is no documentation of failed conservative management such as physical therapy, injections, analgesics, a back brace, cognitive therapy, or activity modification. There is no correlation of his imaging with his clinical condition. Under these circumstances, lower back fusion surgery with a related hospital stay are not medically necessary to treat 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 neurological surgery. 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 46-year-old female has requested Botox injections for treatment of migraine headaches.  Findings:  Three physician reviewers found that Botox can be beneficial in some patients with migraine and chronic headache; however, it does not have literature support as a first-line agent. Although this patient has tried a few abortive therapies, her use of standard prophylactic agents is not documented. Anticonvulsants, beta-blockers, calcium channel blockers and tricyclic antidepressants have all been shown to be effective therapies for migraine. It does not appear that the patient has been given an adequate trial of these medications. If she fails to respond to the standard prophylactic medications, then Botox therapy might be appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that a review of the recent peer-reviewed literature indicates that MEG and magnetic source imaging can play an important role in epilepsy mapping. While the procedures are not widely used, their use in select patients with intractable seizure activity has allowed physicians to determine if a patient is appropriate for epilepsy surgery and to provide detailed mapping for pre-surgical planning. In the past, the gold standard for epilepsy mapping was the use of intracranial electrodes. There is risk associated with any surgical procedure and  particularly with brain surgery. MEG is a safer, non-invasive means of obtaining the same information as would be obtained from intracranial EEG (ICEEG).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollee, who has a history of micropapillary carcinoma of the thyroidFindings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Final Result: Three reviewers determined that the testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing. Findings:  The physician reviewer found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells.  At this time, there is a lack of convincing evidence that the assay adds to our decision making ability, or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular profiling.   A study noted this ongoing research as well as the serious limitations of such studies. A randomized trial did not demonstrate significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment.  Finding the presence of a mutation does not guarantee that a treatment directed at this mutation will produce a clinically beneficial response.  In sum, FoundationOne gene testing performed  was not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: The reviewers 2 of 3  determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 & 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

The parent of a ten-month-old male enrollee has requested Synagis for treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  The physician reviewer found that while the patient does not meet strict AAP criteria for RSV prophylaxis based on gestational age and the specified risk factors, he has other risk factors that increase his likelihood of morbidity and mortality from RSV infection. It is therefore appropriate that he receive palivizumab for the duration of the 2006-7 RSV season.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy at this time.  The current medical literature has noted a positive effect of speech and language therapy interventions for children with expressive vocabulary and expressive phonological difficulties.  However, the submitted medical records do not support speech therapy in this patients case.  An initial speech evaluation was not submitted for review.  A current speech evaluation with appropriate standardized speech assessments is needed to determine current speech delay and articulation disorder.  Absent this information, the medically necessity of speech therapy cannot be established.  All told, the requested speech therapy is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606). The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter-defibrillators (ICDs) in this group of patients. Current medical literature supports the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular (LV) dysfunction with an ejection fraction of less than or equal to 35%, along with guideline directed medical therapy. Kutyifa  and colleagues report that results from 2,000 patients enrolled in the Prospective Registry of Patients Using the Wearable Defibrillator (WEARIT-II) registry demonstrated that a wearable cardioverter defibrillator can be safely used to protect patients during the period of risk assessment prior to ICD placement. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend the use of a LifeVest  within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure with severely reduced ejection fraction, to allow for the potential improvement in the ejection fraction, which may occur spontaneously and with optimal medical therapy, thus obviating the need for an ICD. In this case, a discharge summary dated 3/10/21 reported that the patients ejection fraction was 20%, and the LifeVest prescription was within the 90-day window of an initial diagnosis of congestive heart failure. In this clinical setting, the LifeVest was likely to have been more beneficial than any other available standard therapy in preventing sudden death due to a lethal arrhythmia. Therefore, the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device was likely to have been 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 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is 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 57-year-old man who has requested authorization for continued group psychotherapy. The submitted records indicate the patient received outpatient group psychotherapy from October 2002 through December 2003. The Health Plan denied authorization and coverage for continued group psychotherapy in September 2003.There is not sufficient evidence that continued group psychotherapy is medically necessary. Furthermore, the submitted evidence does not demonstrate that group psychotherapy was medically necessary after September 2003. Unlimited group psychotherapy is not medically indicated in most clinical situations. There should be a defined end point or treatment plan with specific goals. The patient should be evaluated by a psychiatrist and a treatment plan should be formulated. The patient may have symptoms that would respond to pharmacotherapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested Synvisc injections for treatment of his ankle pain and osteoarthritis. Findings:  Three physician reviewers found that Synvisc injections for the treatment of this patients left ankle degenerative joint disease is likely to be more beneficial than any available alternative as he has already tried and failed other conservative measures. From the medical records, a total ankle replacement is planned, and this patient requires pain relief until that surgery is performed. Degenerative joint disease of the ankle is essentially similar to degenerative joint disease of the knee, and their pain-producing mechanisms are similar. There are studies which have shown that Synvisc (hyaluronic acid) is safe and effective for the treatment of pain associated with ankle osteoarthritis. In addition, this patient had a positive trial of Synvisc in the past.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient was diagnosed with a cm paravisceral aortic aneurysm. In this case, the patients condition was emergent. In general, there is no way to know when an aneurysm will rupture. These lesions are best repaired at centers with experience, and by an endovascular route, if possible. In this clinical setting, it was best to wait for the ZFEN graft. Thus, the services in dispute were for emergency care. Given the serious nature of the patients aneurysm, the patient received emergency medical services for an emergency medical condition on the dates of service in dispute. Final Result: The reviewer determined that the patient receives emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in vascular 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested coverage for 35 hours of direct applied behavioral analysis (ABA) per week. The enrollee was diagnosed with autism spectrum disorder (ASD) and has been receiving applied behavioral analysis (ABA) services with a Board Certified Behavior Analyst (BCBA).Findings: the physician reviewer found that  currently receives 35 hours of ABA services per week. He also receives occupational therapy and speech therapy. His behaviors include vocal stereotypy, non-compliance, elopement, self-injurious behavior, and wrist clapping. Upon re-assessment, there are several behaviors identified as challenging which were targeted with associated goals for improvement, with primary concerns noted at the enrollees elopement, active non-compliance, and self-injury, as well as the repetitive behaviors of vocal stereotypy (severity level two) and wrist clapping (severity level two).  The enrollee has made tremendous progress and met goals by mastering hundreds of exemplars across various domains including those of adaptive curriculum, language curriculum, cognitive curriculum, social curriculum, play curriculum, executive function curriculum. In these domains, additional goals are continually made to continue to forge additional progress for the enrollee. The ABA progress report shows his behaviors have improved in safety awareness, in some language and social skills, and with increased interest in food preparation. Based on review of the records, with the improvement of various core autism symptomology, the ability of the enrollee to engage more fully with other typical peers both socially and academically, and the much decreased risky behaviors, the medical necessity for the current level of 35 hours per week of ABA services is not supported. Historically, the enrollee has had seven years of intensive ABA, and particularly has received more intensive ABA services over the past year, and has followed generally accepted treatment guidelines for gold-standard ABA services and exceeded such guidelines. Per generally accepted practice guidelines, it is recommended that youth enrollees begin receiving intensive services prior to three years/36 months of age in order to obtain the potential long-term benefits of early intensive ABA services.  This enrollee began receiving services regularly since the age of two years of age and without any notation of disruption in such services.  Based on his progress, the hours can now safely be reduced without any substantial anticipated decrease in progress either short or long-term.  Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for a speech therapy assessment and continued speech therapy. Based on his current testing scores, this patient continues to require speech therapy for articulation, but no longer requires speech therapy for pragmatic language, expressive language or any other language areas. The testing does not indicate that an additional speech therapy assessment is needed at this time. Based on his current scores, he requires individual speech therapy once per week for one hour, but does not require group speech therapy. The research on articulation disorder indicates that individual speech therapy is helpful for this patients current speech and language deficits. His testing demonstrated typical and age appropriate speech skills for pragmatic language and all other areas. His ABA can provide therapy for social communication problems that involve pragmatic issues. Thus, the requested speech therapy assessment is not medically necessary while individual speech therapy once per week for articulation disorder is medically necessary. Final Result: The reviewer determined that a portion of the requested services 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 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.